1. Applying the phenotype approach for rosacea to practice and research
J. Tan,1 M. Berg,2 R.L. Gallo,3 J.Q. Del Rosso4
1. Department of Medicine, Western University, Windsor, Ontario, Canada; 2. Department of Dermatology, Uppsala University, Uppsala, Sweden; 3. Department of Dermatology, University of California-San Diego, La Jolla, CA; 4. Department of Dermatology, Touro University Nevada, Henderson, NV.
British Journal of Dermatology 2018; doi: /bjd

2. Jerry Tan

3. Introduction What’s already known?
Rosacea diagnosis and classification have evolved from a subtype to a phenotype approach
Adoption of the phenotype approach has begun, but more widespread adoption and support across the field is required to ensure a complete transition

4. Objective
To identify challenges to implementation of a phenotype approach across clinical practice, interventional research, epidemiological research and basic science in rosacea
To make practical recommendations to facilitate assessment, management and research progression inclusive of the individual experience of disease

5. Methods
A panel of four dermatologists defined the framework for possible recommendation categories pertaining to clinical practice, interventional research, epidemiological research and basic science in rosacea
A literature search was performed to assess the current approach to rosacea practice and research within these four areas
Hits were limited to articles published between April 2015 and December 2017 to cover the period after publication of the most recent Cochrane systematic review on interventions for rosacea1
The authors then identified challenges to implementation of a phenotype approach based on the literature search results and their experience in the field
They consolidated and refined their recommendations through discussion
1. Van Zuuren EJ, et al. Cochrane Database Syst Rev. 2015;(4):CD003262

6. Summary of recommendations (1 of 2)
Clinical practice
Interventional research
Update language on diagnosis and classification
Support core stakeholder meeting to develop international communications plan
Educate patients and Health Care Professionals to improve awareness and understanding
Demonstrate proven clinical value of phenotyping; reinforce the shortcomings of subtyping
Develop simple clinical tools for physician– patient use*
Establish standardised clinical and patient- reported measures
Produce best-practice examples of phenotype use
**applicable to all skin pigment types.

7. Summary of recommendations (2 of 2)
Epidemiological research
Basic science
Facilitate longitudinal epidemiology studies on the potential for fluctuation of features
Include regional groups from all continents in studies for representation of all skin pigment types
Highlight the need for national initiatives to support research
Extend clinical practice updates to basic science
Reinforce the idea of phenotype variation over time
Interrogate existing data to identify:
Specific pathophysiological factors
The treatments with largest/fastest impact on disease

8. Supplementary info: Clinical checklist for use with patients
This checklist is intended to be an ongoing record of a patient’s rosacea phenotype, to help monitor changes in disease features and their response to treatment
It is free to download via the supporting information and should be completed together with the patient at each consult
Available at: wiley/original_supplements/6e80396a5b0691a350c1e f94577de132736a4d1d398c77bd40dee4c/bjd16815-sup-0001-SupInfo.docx

9. Discussion
The authors support the phenotype approach in rosacea across clinical practice, interventional and epidemiological research, and basic science
Several of these strategies span multiple areas, which reflects the need for an integrated approach to ensure consistent and comprehensive uptake
Since audit and feedback lead to small but potentially important improvements in professional practice,1 it is important to measure effectiveness of the phenotype approach as it becomes more widely used, to:
Enable sharing of successes to promote a virtuous circle of uptake
Identify areas for improvement, which could include:2
Medical record audit
Computerised databases
Health practitioner questionnaire/interview
Ivers N, et al. Cochrane Database Syst Rev. 2012:CD
Hakkennes S, Green S. Implement Sci 2006;1(1):29.

10. Limitations
This is an evolving field of inquiry, so future advances may inform both modification of signs and symptoms, and subsequent adjustment to suggested tools and language updates
Even given an objective tool, the severity of some signs can be subjective
E.g. Some cultures may consider persistent mild centrofacial erythema presenting as ‘rosy cheeks’ to be a normal or healthy variation
Persistent centrofacial erythema can be of limited use as a definitive diagnostic feature in dark skin phototypes, which will require specific guidance from future work to ensure consistent diagnosis and classification across the patient spectrum

11. The transition to a phenotype approach in rosacea is underway; however, there is still significant work to be done to ensure a comprehensive uptake
These practical recommendations are intended to indicate the next steps in this process, with the goals of:
Improving our understanding of the disease
Facilitating treatment developments
Ultimately improving care for patients with rosacea
Conclusions

12. Conclusions What does this study add?
This study offers practical guidance for clinical practice, interventional and epidemiological research, and basic science, to help overcome challenges and facilitate comprehensive uptake of the phenotype approach in rosacea
Conclusions What does this study add?

13. Co-authors M. Berg (left), R. L. Gallo (right), J. Q
Co-authors M. Berg (left), R. L. Gallo (right), J. Q. del Rosso (not shown)

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