Mats Berg

Rosacea: Current state of epidemiology

Case definitions are critical in epidemiologic research. However, modern disease indicators must now consider complex data from gene-based research along with traditional clinical parameters. Rosacea is a skin disorder with multiple signs and symptoms. In individuals, these features may be multiple or one may predominate. While studies on the epidemiology of rosacea have previously been sparse, there has been a recent increase in research activity. A broader body of epidemiological information that includes a greater variety of countries beyond Northern Europe and general population-based demographics is needed. As there are operational issues in current case definitions of rosacea subtypes--rationalization and standardization--universal consistent applications in future research is also imperative. Further improvement in disease definition combining new research information along with clinical pragmatism should increase the accuracy of rosacea case ascertainment and facilitate further epidemiological research.

Prevalence of rosacea in the general population of Germany and Russia - The RISE study

There is an unmet need for general population‐based epidemiological data on rosacea based on contemporary diagnostic criteria and validated population survey methodology.

Psoriasis and stress: a prospective study.

Background  Psoriasis is generally thought to be worsened by stress. This presumption has been supported primarily by retrospective studies using questionnaires. No controlled prospective study on this issue has been performed.

Comparison of Moisturizing Creams for the Prevention of Atopic Dermatitis Relapse: A Randomized Double-blind Controlled Multicentre Clinical Trial

Atopic dermatitis (AD) affects adults and children and has a negative impact on quality of life. The present multicentre randomized double-blind controlled trial showed a barrier-improving cream (5% urea) to be superior to a reference cream in preventing eczema relapse in patients with AD (hazard ratio 0.634, p = 0.011). The risk of eczema relapse was reduced by 37% (95% confidence interval (95% CI) 10-55%). Median time to relapse in the test cream group and in the reference cream group was 22 days and 15 days, respectively (p = 0.013). At 6 months 26% of the patients in the test cream group were still eczema free, compared with 10% in the reference cream group. Thus, the barrier-improving cream significantly prolonged the eczema-free time compared with the reference cream and decreased the risk of eczema relapse. The test cream was well tolerated in patients with AD.

Possible gender differences in the quality of life and choice of therapy in acne

Background  Acne is a very common skin disease that has major impact on the patients’ quality of life. Although the disease has been extensively studied we still need more knowledge of factors influencing the decisions for choice of therapy.

Hand eczema and health-related quality of life : a comparison of EQ-5D and the Dermatology Life Quality Index (DLQI) in relation to the hand eczema extent score (HEES)

Health‐related quality of life (HRQoL) is associated with the extent and severity of hand eczema. We still lack a consensus about which HRQoL instrument to use as the standard, and how to measure the extent and severity of hand eczema.

Neuronal changes in psoriasis exacerbation

Background The nervous system contributes to inflammatory skin diseases.

Shortcomings in rosacea diagnosis and classification

In 2002, the National Rosacea Society (NRS) proposed a provisional classification for rosacea based on the clinical knowledge of that time and on morphological features. Explicit was the intent that this was ‘a framework that could be readily updated and expanded as new discoveries were made’. That scheme posited primary and secondary criteria for diagnosis and division into four subtypes, representing common clinical patterns of presentation, and one variant. It also helped to increase recognition of rosacea as a disease and to guide research. Subsequent incorporation of this paradigm in epidemiological, pathophysiological and translational research has provided for greater standardization in rosacea reporting. Now, after more than a decade of using this scheme in research and clinical practice, it should be re-evaluated to incorporate current scientific knowledge and address shortcomings in guiding diagnosis and classification of rosacea. Unequivocal diagnoses can be challenging in the absence of an absolute gold standard (histology in malignancy; reduced ejection fraction in congestive heart failure; positive bacterial blood cultures in sepsis). Accuracy of a diagnostic test is based on the proportion of true results of the test (true positive, or sensitivity; and true negative, or specificity) in a population. In rosacea, where there are multiple potential symptoms and signs which may be present in varying permutations in individual patients, the crux of diagnostic criterion determination must address two issues: which feature(s) is/are essential (without which the condition cannot be present) and is this finding unique to the condition? In assessing diagnostic criteria, the goal is to seek those with a high true-positive rate (that is, a high proportion of those with the criterion truly have the disease – referring to sensitivity) and true-negative rate (a high proportion of those who do not have the criterion do not have the disease – referring to specificity). In the clinical paradigm, diagnosis is optimized by excluding other conditions that can present similarly, the differential diagnosis. The NRS classification requires reappraisal based on these considerations. The presence of one or more of the following four primary features in a centrofacial distribution was defined by the NRS as indicative of rosacea: flushing (transient erythema), nontransient erythema, inflammatory papules and pustules and telangiectasia. Thus, each should be evaluated as a critical criterion. Is flushing independently diagnostic of rosacea in the absence of other features? Can it be accurately distinguished from emotional blushing, cancerous (neuroendocrine tumours) or postmenopausal flushing? While some authors aver to distinguishing these variations of blushing, the accuracy of these assertions is unknown. Using inflammatory papules and pustules as a primary feature implies that their sole presence indicates rosacea. If so, the counterargument is that they are also the feature of many other conditions, the most relevant in the age context of rosacea being adult acne, folliculitis, pityriasis folliculorum (demodicosis) and perioral/periorificial dermatitis. Is the sole presence of centrofacial inflammatory papules/pustules diagnostic of rosacea? Centrofacial telangiectasia are ubiquitous in adults as examination for telangiectasia at alar creases will readily demonstrate. Using the current classification, almost all adults would have rosacea based on telangiectasia. Of the primary features, we concur that centrofacial erythema may be the sole requisite criteria for rosacea. Nevertheless, diagnosis using this feature should depend on the severity. Lesser degrees of centrofacial erythema may not be adequately diagnostic in certain societal contexts. This may also be an inappropriate diagnostic criterion for very dark skin where erythema or redness is not readily visible. Adjunctive features may be more appropriate in this cohort, although epidemiology and acceptance for rosacea in skin of colour continues to be debated. Could this be one reason for the reported paucity of rosacea from regions with dark populations? The primacy of clinical criteria for case finding was demonstrated by a recent histological and molecular analysis demonstrating differences between erythematotelangiectatic rosacea (ETR) and telangiectatic photoageing. This study relied solely on clinical criteria for differentiation: those for the latter included telangiectasia and prominent feature(s) of photodamage (atrophy, premalignant or malignant neoplasms, facial wrinkling, dyspigmentation and/or poikiloderma), while those for the former were transient erythema (flushing), nontransient erythema and/or facial telangiectasia. We are uncertain why phyma should be considered a secondary feature of rosacea, implying that it is nondiagnostic of rosacea. There is no stated rationale for these very distinct changes not being a primary feature. Phyma has few mimics (lymphoma, rhinoscleroma, blastomycosis, nonmelanoma skin cancer, sarcoidosis), but none are completely identical with phymata, even clinically. The latter can be distinguished by clinical evaluation and biopsy, as required. Ocular rosacea is a collection of signs and symptoms without a sense of diagnostic prioritization. Similar to the diagnostic hallmarks of cutaneous rosacea, what are the essential clinical criteria for diagnosis of ocular rosacea? Along this line, why is ocular rosacea included as a subtype but not granulomatous rosacea or rosacea conglobata?

Development and Evaluation of a Rosacea Screening Instrument (Rosascreen)

Background: There are no current instruments to facilitate population screening for rosacea. Objective: To develop and evaluate a screening instrument for rosacea applicable for population surveys. Methods: A rosacea-specific screening instrument (Rosascreen), consisting of a subject-completed questionnaire and screening algorithm, was developed based on current diagnostic criteria for rosacea. Three iterations were pilot tested and refined for clarity and sensitivity in adult outpatients with and without rosacea. Results: Three subject groups were consecutively evaluated with iterations of the questionnaire at each centre (overall N = 121). The final version had a sensitivity of 93% to 100% for key diagnostic criteria, and use of the algorithm had a sensitivity of 100% for detection of rosacea and specificity of 63% to 71%. Most subjects found the questionnaire easy to understand and complete. Conclusion: Rosascreen, a subject-completed questionnaire and diagnostic algorithm, is a highly sensitive screening instrument that may facilitate estimation of rosacea prevalence in general populations.

Cost-effectiveness evaluation of clobetasol propionate shampoo (CPS) maintenance in patients with moderate scalp psoriasis : A Pan-European analysis

Background  Scalp psoriasis is a difficult to treat and usually chronic manifestation of psoriasis. The CalePso study showed that CPS (Clobex® Shampoo) in maintenance therapy of scalp psoriasis (twice weekly) significantly increases the probability of keeping patient under remission during 6 months, compared with vehicle (40.3% relapses vs. 11.6% relapses, ITT).