The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review

Authors

  • Martin Schaller Department of Dermatology, Universitatsklinikum Tuebingen, Tuebingen, Baden-Württemberg, Germany
  • Thomas Dirschka
  • Sol-Britt Lonne-Rahm
  • Giuseppe Micali
  • Linda F. Stein Gold
  • Jerry Tan
  • James Del Rosso

DOI:

https://doi.org/10.2340/actadv.v101.356

Keywords:

rosacea, stinging, burning, management, symptom, invisible

Abstract

Rosacea, a chronic condition usually recognized by its visible presentation, can be accompanied by invisible symptoms, such as burning and stinging. The aim of this review is to gather the most recent evidence on burning and stinging, in order to further emphasize the need to address these symptoms. Inflammatory pathways can explain both the signs and symptoms of rosacea, but available treatments are still evaluated primarily on their ability to treat visible signs. Recent evidence also highlights the adverse impact of symptoms, particularly burning and stinging, on quality of life. Despite an increasing understanding of symptoms and their impact, the management of burning and stinging as part of rosacea treatment has not been widely investigated. Clinicians often underestimate the impact of these symptoms and do not routinely include them as part of management. Available therapies for rosacea have the potential to treat beyond signs, and improve burning and stinging symptoms in parallel. Further investigation is needed to better understand these benefits and to optimize the management of rosacea.

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References

Schaller M, Almeida L, Bewley A, Cribier B, Del Rosso J, Dlova B, et al. Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel. Br J Dermatol 2020; 182: 1269-1276.

https://doi.org/10.1111/bjd.18420 DOI: https://doi.org/10.1111/bjd.18420

Steinhoff M, Harper J, Gieler U, Tan J. The BMJ Hosted Content 2020. Beyond the visible: rosacea and psoriasis of the face [accessed March 2021]. Available from: https://hosted.bmj.com/rosaceabeyondthevisible.

Jansen T, Plewig G. Rosacea: classification and treatment. J R Soc Med 1997; 90: 144-150.

https://doi.org/10.1177/014107689709000308 DOI: https://doi.org/10.1177/014107689709000308

Schaller M, Kemény L, Havlickova B, Jackson J, Ambroziak M, Lynde C, et al. A randomized phase 3b/4 study to evaluate concomitant use of topical ivermectin 1% cream and doxycycline 40-mg modified-release capsules, versus topical ivermectin 1% cream and placebo in the treatment of severe rosacea. J Am Acad Dermatol 2020; 82: 336-343.

https://doi.org/10.1016/j.jaad.2019.05.063 DOI: https://doi.org/10.1016/j.jaad.2019.05.063

Tan J, Steinhoff M, Bewley A, Gieler U, Rives V. Characterizing high-burden rosacea subjects: a multivariate risk factor analysis from a global survey. J Dermatolog Treat 2020; 31: 168-174.

https://doi.org/10.1080/09546634.2019.1623368 DOI: https://doi.org/10.1080/09546634.2019.1623368

Tan J, Steinhoff M, Bewley A, Gieler U. The BMJ Hosted Content 2018. Rosacea: beyond the visible [accessed March 2021]. Available from: https://hosted.bmj.com/rosaceabeyondthevisible.

Del Rosso J, Tanghetti E, Webster G, Stein Gold L, Thiboutot D, Gallo R. Update on the management of rosacea from the American Acne & Rosacea Society (AARS). J Clin Aesthet Dermatol 2019; 12: 17-24.

Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, et al. Standard classification of rosacea: report of the national rosacea society expert committee on the classification and staging of rosacea. J Am Acad Dermatol 2002; 46: 584-587.

https://doi.org/10.1067/mjd.2002.120625 DOI: https://doi.org/10.1067/mjd.2002.120625

Del Rosso J, Tanghetti E, Baldwin H, Rosrigues D, Ferrusi I. The burden of illness of erythematotelangiectatic rosacea and papulopustular rosacea: findings from a web-based survey. J Clin Aesthet Dermatol 2017; 10: 17-31.

Scharschmidt T, Yost J, Truong S, Steinhoff M, Wang K, Berger T. Neurogenic Rosacea: a distinct clinical subtype requiring a modified approach to treatment. Arch Dermatol 2011; 147: 123-126.

https://doi.org/10.1001/archdermatol.2010.413 DOI: https://doi.org/10.1001/archdermatol.2010.413

Del Rosso J, Thiboutot D, Gallo R, Webster G, Tanghetti E, Eichenfield L, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, Part 1: A status report on the disease state, general measures, and adjunctive skin care. Cutis 2013; 92: 234-240.

Tan J, Almeida L, Bewley A, Cribier B, Dlova N, Gallo R, et al. Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol 2017; 176: 431-438.

https://doi.org/10.1111/bjd.15122 DOI: https://doi.org/10.1111/bjd.15122

Lonne-Rahm S, Fischer T, Berg M. Stinging and rosacea. Acta Derm Venereol 1999; 79: 460-461.

https://doi.org/10.1080/000155599750009915 DOI: https://doi.org/10.1080/000155599750009915

Del Rosso J, Gallo R, Kircik L, Thiboutot D, Baldwin H, Cohen D. Why is rosacea considered to be an inflammatory disorder? The primary role, clinical relevance, and therapeutic correlations of abnormal innate immune response in rosacea-prone skin. J Drugs Dermatol 2012; 11: 694-700.

Rainer B, Kang S, Chien A. Rosacea: Epidemiology, pathogenesis, and treatment. Dermatoendocrinol 2017; 9: e1361574.

https://doi.org/10.1080/19381980.2017.1361574 DOI: https://doi.org/10.1080/19381980.2017.1361574

Steinhoff M, Buddenkotte J, Aubert J, Sulk M, Novak P, Schwab V, et al. Clinical, cellular, and molecular aspects in the pathophysiology of rosacea. J Investig Dermatol Symp Proc 2011; 15: 2-11.

https://doi.org/10.1038/jidsymp.2011.7 DOI: https://doi.org/10.1038/jidsymp.2011.7

Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000Res 2018; 7: 1885.

https://doi.org/10.12688/f1000research.16537.1 DOI: https://doi.org/10.12688/f1000research.16537.1

Forton F, Seys B. Density of Demodex folliculorum in rosacea: a case-control study using standardized skin-surface biopsy. Br J Dermatol 1993; 128: 650-659.

https://doi.org/10.1111/j.1365-2133.1993.tb00261.x DOI: https://doi.org/10.1111/j.1365-2133.1993.tb00261.x

Bonnar E, Eustace P, Powell F. The Demodex mite population in rosacea. J Am Acad Dermatol 1993; 28: 443-448.

https://doi.org/10.1016/0190-9622(93)70065-2 DOI: https://doi.org/10.1016/0190-9622(93)70065-2

Forton F, Germaux M, Brasseur T, De Liever A, Laporte M, Mathys C, et al. Demodicosis and rosacea: epidemiology and significance in daily dermatological practice. J Am Acad Dermatol 2005; 52: 74-87.

https://doi.org/10.1016/j.jaad.2004.05.034 DOI: https://doi.org/10.1016/j.jaad.2004.05.034

Forton F. Papulopustular rosacea, skin immunity and Demodex: pityriasis folliculorum as a missing link. J Eur Acad Dermatol Venereol 2012; 26: 19-28.

https://doi.org/10.1111/j.1468-3083.2011.04310.x DOI: https://doi.org/10.1111/j.1468-3083.2011.04310.x

Casas C, Paul C, Lahfa M, Livideanu B, Lejeune O, Alvarez-Georges S, et al. Quantification of Demodex folliculorum by PCR in rosacea and its relationship to skin innate immune activation. Exp Dermatol 2012; 21: 906-910.

https://doi.org/10.1111/exd.12030 DOI: https://doi.org/10.1111/exd.12030

Lacey N, Russell-Hallinan A, Zouboulis C, Powell F. Demodex mites modulate sebocyte immune reaction: possible role in the pathogenesis of rosacea. Br J Dermatol 2018; 179: 420-430.

https://doi.org/10.1111/bjd.16540 DOI: https://doi.org/10.1111/bjd.16540

Schaller M, Gonser L, Belge K, Braunsdorf C, Nordin R, Scheu A, et al. Dual anti-inflammatory and anti-parasitic action of topical ivermectin 1% in papulopustular rosacea. J Eur Acad Dermatol Venereol 2017; 31: 1907-1911.

https://doi.org/10.1111/jdv.14437 DOI: https://doi.org/10.1111/jdv.14437

Del Rosso J. Topical ivermectin: Data supporting dual modes of action in rosacea. J Clin Aesthet Dermatol 2017; 10: 39-42.

Koller B, Müller-Wiefel A, Rupec R, Korting H, Ruzicka T. Chitin modulates innate immune responses of keratinocytes. PLoS One 2011; 6: e16594.

https://doi.org/10.1371/journal.pone.0016594 DOI: https://doi.org/10.1371/journal.pone.0016594

Forton F, De Maertelaer V. Erythematotelangiectatic rosacea may be associated with a subclinical stage of demodicosis: a case-control study. Br J Dematol 2019; 181: 818-825.

https://doi.org/10.1111/bjd.17817 DOI: https://doi.org/10.1111/bjd.17817

Cardwell L, Alinia H, Tuchayi S, Feldman S. New developments in the treatment of rosacea - role of once-daily ivermectin cream. Clin Cosmet Investig Dermatol 2016; 9: 71-77.

https://doi.org/10.2147/CCID.S98091 DOI: https://doi.org/10.2147/CCID.S98091

Berardesca E, Farage M, Maibach H. Sensitive skin: an overview. Int J Cosmet Sci 2013; 35: 2-8.

https://doi.org/10.1111/j.1468-2494.2012.00754.x DOI: https://doi.org/10.1111/j.1468-2494.2012.00754.x

Van Zuuren E. Rosacea. N Engl J Med 2017; 377: 1754-1764.

https://doi.org/10.1056/NEJMcp1506630 DOI: https://doi.org/10.1056/NEJMcp1506630

Schaller M, Pietschke K. Successful therapy of ocular rosacea with topical ivermectin. Br J Dermatol 2018; 179: 520-521.

https://doi.org/10.1111/bjd.16534 DOI: https://doi.org/10.1111/bjd.16534

Addor F. Skin barrier in rosacea. An Bras Dermatol 2016; 91: 59-63.

https://doi.org/10.1590/abd1806-4841.20163541 DOI: https://doi.org/10.1590/abd1806-4841.20163541

Zhou M, Xie H, Cheng L, Li J. Clinical characteristics and epidermal barrier function of papulopustular rosacea: A comparison study with acne vulgaris. Pak J Med Sci 2016; 32: 1344-1348.

https://doi.org/10.12669/pjms.326.11236 DOI: https://doi.org/10.12669/pjms.326.11236

Del Rosso J, Levin J. The clinical relevance of maintaining the functional integrity of the stratum corneum in both healthy and disease-affected skin. J Clin Aesthet Dermatol 2011; 4: 22-42.

Dirschka T, Tronnier H, Fölster-Holst R. Epithelial barrier function and atopic diathesis in rosacea and perioral dermatitis. Br J Dermatol 2004; 150: 1136-1141.

https://doi.org/10.1111/j.1365-2133.2004.05985.x DOI: https://doi.org/10.1111/j.1365-2133.2004.05985.x

Levin J, Miller R. A guide to the ingredients and potential benefits of over-the-counter cleansers and moisturizers for rosacea patients. J Clin Aesthet Dermatol 2011; 4: 31-49.

Picardo M, Eichenfield L, Tan J. Acne and rosacea. Dermatol Ther (Heidelb) 2017; 7: 43-52.

https://doi.org/10.1007/s13555-016-0168-8 DOI: https://doi.org/10.1007/s13555-016-0168-8

Yuan C, Ma Y, Wang Y, Qian C, Hocquet D, Zheng S, et al. Rosacea is associated with conjoined interactions between physical barrier of the skin and microorganisms: a pilot study. J Clin Lab Anal 2020; 34: e23363.

https://doi.org/10.1002/jcla.23363 DOI: https://doi.org/10.1002/jcla.23363

Wollina U. Recent advances in the understanding and management of rosacea. F1000Prime Rep 2014; 6: 50.

https://doi.org/10.12703/P6-50 DOI: https://doi.org/10.12703/P6-50

Baldwin H, Santoro F, Lachmann N, Teissedre S. A novel moisturizer with high sun protection factor improves cutaneous barrier function and the visible appearance of rosacea-prone skin. Cosmet Dermatol 2019; 18: 1686-1692.

https://doi.org/10.1111/jocd.12889 DOI: https://doi.org/10.1111/jocd.12889

Tan J, Berg M, Gallo R, Del Rosso J. Applying the phenotype approach for rosacea to practice and research. Br J Dermatol 2018; 179: 741-746.

https://doi.org/10.1111/bjd.16815 DOI: https://doi.org/10.1111/bjd.16815

Gallo R, Granstein R, Kang S, Mannis M, Steinhoff M, Tan J, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018; 78: 148-155.

https://doi.org/10.1016/j.jaad.2017.08.037 DOI: https://doi.org/10.1016/j.jaad.2017.08.037

Sannino M, Lodi G, Dethlefsen M, Nisticò S, Cannarozzo G, Nielsen M. Fluorescent light energy: treating rosacea subtypes 1, 2, and 3. Clin Case Rep 2018; 6: 2385-2390.

https://doi.org/10.1002/ccr3.1891 DOI: https://doi.org/10.1002/ccr3.1891

Chen H, Lai W, Zheng Y. Rosacea in acne vulgaris patients: subtype distribution and triggers assessment - a cross-sectional study. J Cosmet Dermatol 2021; 20: 1889-1896.

https://doi.org/10.1111/jocd.13762 DOI: https://doi.org/10.1111/jocd.13762

Schaller M, Almeida L, Bewley A, Cribier B, Dlova N, Kautz G, et al. Rosacea treatment update: recommendations from the global ROSacea COnsensus (ROSCO) panel. Br J Dermatol 2017; 176: 465-471.

https://doi.org/10.1111/bjd.15173 DOI: https://doi.org/10.1111/bjd.15173

Del Rosso J, Thiboutot D, Gallo R, Webster G, Tanghetti E, Eichenfield L, et al. Consensus recommendations from the American acne & rosacea society on the management of rosacea, Part 2: a status report on topical agents. Cutis 2013; 92: 277-284.

Asai Y, Tan J, Baibergenova A, Barankin B, Cochrane C, Humphrey S, et al. Canadian clinical practice guidelines for rosacea. J Cutan Med Surg 2016; 20: 432-445.

https://doi.org/10.1177/1203475416650427 DOI: https://doi.org/10.1177/1203475416650427

Del Rosso J, Jackson M, Johnson S, Harvey A, Chavda R. Effect of combination therapy on visible/non-visible symptoms, and disease burden associated with severe rosacea: results from a post-hoc analysis of a randomized controlled trial. SKIN J Cutan Med 2020; 4: s56.

https://doi.org/10.25251/skin.4.supp.55 DOI: https://doi.org/10.25251/skin.4.supp.55

Webster G, Schaller M, Tan J, Jackson J, Kerrouche N, Schäfer G. Defining treatment success in rosacea as "clear" may provide multiple patient benefits: results of a pooled analysis. J Dermatolog Treat 2017; 28: 469-474.

https://doi.org/10.1080/09546634.2017.1343435 DOI: https://doi.org/10.1080/09546634.2017.1343435

Allergan. RHOFADE® (oxymetazoline hydrochloride) 1% Cream Prescribing Information [accessed 2021 Mar]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/208552s000lbl.pdf.

Galderma. MIRVASO® (brimonidine tartrate) 3 mg/g Gel Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/5303/smpc.

Foamix. ZILXI® (minocycline) 1.5% Foam Full Prescribing Information [accessed 2021 Mar]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2020/213690s000lbl.pdf.

Leo Laboratories Ltd. FINACEA® (azelaic acid) 15% Gel Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/240/smpc.

Thiboutot D, Thieroff-Ekerdt R, Graupe K. Efficacy and safety of azelaic acid (15%) gel as a new treatment for papulopustular rosacea: results from two vehicle-controlled, randomized phase III studies. J Am Acad Dermatol 2003; 48: 836-845.

https://doi.org/10.1067/mjd.2003.308 DOI: https://doi.org/10.1067/mjd.2003.308

Leo Laboratories Ltd. SKINOREN® (azelaic acid) 20% Cream Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/285/smpc#:~:text=Topical%20treatment%20of%20acne%20vulgaris.&text=Skinoren%20Cream%20should%20be%20applied,for%20the%20entire%20facial%20area.

Leo Pharma Inc. FINACEA® (azelaic acid) 15% Foam Prescribing Information [accessed 2021 Mar]. Available from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/207071s000lbl.pdf.

Galderma. SOOLANTRA® (ivermectin) 10 mg/g Cream Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/medicine/30353.

Galderma. SOOLANTRA® Ivermectin 10 mg/g Cream Australia Prescribing Information [accessed 2021 Mar]. Available from: https://www.galderma.com/au/sites/g/files/jcdfhc266/files/inline-files/Soolantra%20PI.pdf.

ADVANZ Pharma. ZYOMET® (metronidazole) 0.75%w/w Gel Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/512/smpc.

Galderma. EFRACEA® (doxycycline monohydrate) 40 mg Modified release hard capsules summary of product characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/medicine/22268.

Pfizer Ltd. VIBRAMYCIN-D® (doxycycline monohydrate) 100 mg Hard Capsules Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/4063#gref.

Roche Products Ltd. ROACCUTANE® (isotretinoin) 20 mg Soft Capsules Summary of Product Characteristics [accessed 2021 Mar]. Available from: https://www.medicines.org.uk/emc/product/6470/smpc.

Del Rosso J. The use of moisturizers as an integral component of topical therapy for rosacea: clinical results based on the assessment of skin characteristics study. Cutis 2009; 84: 72-76.

Draelos Z. Noxious sensory perceptions in patients with mild to moderate rosacea treated with azelaic acid 15% gel. Cutis 2004; 74: 257-260.

Williamson T, Cameron J, McLeod K, Turner B, Quillen A, LaRose A, et al. Concerns and treatment satisfaction in patients being treated with azelaic acid foam for rosacea. J Drugs Dermatol 2019; 18: 381-386.

https://doi.org/10.25251/skin.2.supp.35 DOI: https://doi.org/10.25251/skin.2.supp.35

Williamson T, Cheng W, McCormick N, Vekeman F. Patient preferences and therapeutic satisfaction with topical agents for rosacea: a survey-based study. Am Health Drug Benefits 2018; 11: 97-106.

Stein Gold L, Kircik L, Fowler J, Tan J, Draelos Z, Fleischer A, et al. Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol 2014; 13: 316-323.

Galderma R&D, LCC. RD.06.SRE.18170 and RD.06.SRE.18171. Data on file.

Stein Gold L, Kircik L, Fowler J, Jackson J, Tan J, Draelos Z, et al. Long-term safety of ivermectin 1% cream vs azelaic acid 15% gel in treating inflammatory lesions of rosacea: results of two 40-week controlled, investigator-blinded trials. J Drugs Dermatol 2014; 13: 1380-1386.

Wolf JE, Del Rosso JQ. The CLEAR trial: results of a large community-based study of metronidazole gel in rosacea. Cutis 2007; 79: 73-80.

Taieb A, Ortonne JP, Ruzicka T, Roszkiewicz J, Berth-Jones J, Peirone M, et al. Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol 2015; 172: 1103-1110.

https://doi.org/10.1111/bjd.13408 DOI: https://doi.org/10.1111/bjd.13408

Taieb A, Khemis A, Ruzicka T, Barańska-Rybak W, Berth-Jones J, Schauber J, et al. Maintenance of remission following successful treatment of papulopustular rosacea with ivermectin 1% cream vs. metronidazole 0.75% cream: 36-week extension of the ATTRACT randomized study. J Eur Acad Dermatol Venereol 2016; 30: 829-836.

https://doi.org/10.1111/jdv.13537 DOI: https://doi.org/10.1111/jdv.13537

Published

2021-10-31

How to Cite

Schaller, M., Dirschka, T., Lonne-Rahm, S.-B., Micali, G., Stein Gold, L. F., Tan, J., & Del Rosso, J. (2021). The Importance of Assessing Burning and Stinging when Managing Rosacea: A Review. Acta Dermato-Venereologica, 101(10), adv00584. https://doi.org/10.2340/actadv.v101.356