- Email: [email protected]
Epidemiologic aspects of rosacea
918 Letters
J AM ACAD DERMATOL NOVEMBER 2005
NOTES
& COMMENTS
Epidemiologic aspects of rosacea To the Editor: Rosacea is a common, chronic facial dermatosis of uncertain etiology and variable progression, characterized by nontransient erythema and acute flares of papules and pustules, with concentration on the central area of the face. There is a paucity of epidemiologic studies, especially with regard to gender and age distribution.1 In this cross-sectional study of rosacea (19952002) in an outpatient setting of a general state hospital dermatologic teaching clinic (N = 615), diagnosis was made on the basis of history, clinical criteria, and/or laboratory criteria when appropriate. The overall denominator and reference population consisted of 50,237 outpatients (aged 35 days-96 years) consecutively examined by experienced dermatologists. All cases were entered into the study only at first referral with the aid of Access database: male patients numbered 20,909 (41.6%); female patients, 29,328 (58.4%). The Mantel-Haenszel x2 stratified analysis was used in an attempt to eliminate any confounding effects from demographic and
health-seeking behavior characteristics of the respective catchment area population (Table I).2 The median age was 59 years for male patients (range, 14-95 years) and 48 years for female patients (range, 8-89 years). Overall both sexes were equally affected by the disease (relative prevalence, 1.22%). Rosacea has been previously reported to affect both sexes equally only once3 and at a higher rate (2%) among more fair-skinned British outpatients.4 Traditional opinions about female preponderance resulted from a Swedish office employee population (rosacea cases, n = 81) in which the elderly were underrepresented.5 Mild disease often appears in women after the age of 35 years when the frequency of ‘‘hot flushes’’ and flushing increases.6 In our analysis, which was stratified by gender and age, 3 distinct periods in rosacea prevalence distribution were disclosed (Table I, subtotals). In the first period ( # 35 years of age) both sexes were equally affected at rather low rates. In the second (36-50 years), although frequencies significantly increased in both sexes, a clear and most significant female
Table I. Prevalence of rosacea by gender, age, and frequency of clinical type (1995-2002) Men Age (y)
N/exam
R (%)
# 20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 [80 Total
6497 1804 1380 1258 1029 1095 1053 1012 963 1376 1295 1072 558 517 20,909
7 6 6 21 6 7 10 34 20 19 34 26 22 10 228
Subtotals* A: # 35 B: 36-50 C: [50
10,939 3,177 6,793
40 (0.4)y 23 (0.7)y,z 165 (2.4)z
(0.1) (0.3) (0.4) (1.7) (0.6) (0.6) (0.9) (3.3) (2.1) (1.4) (2.6) (2.4) (3.9) (1.9) (1.1)
Women ET/PP
N/exam
R (%)
5/2 6/0 3/3 14/7 3/3 5/2 8/2 26/8 13/7 13/6 29/5 22/4 14/8 8/2 169/59
7685 2574 2042 2005 1975 1889 1872 1595 1570 1831 1756 1284 693 557 29,328
16 6 21 19 44 46 45 31 20 51 48 21 8 11 387
28/12 16/7 125/40
14,306 5,736 9,286
62 (0.4)§ 135 (2.3)§ 190 (2.6)
(0.2) (0.2) (1.0) (0.9) (2.2) (2.4) (2.4) (1.9) (1.3) (2.8) (2.7) (1.6) (1.2) (1.9) (1.3)
Significance ET/PP
P value; OR; 95% CI
12/4 3/3 12/9 15/4 35/9 34/12 29/16 24/7 14/6 33/18 32/16 15/6 7/1 9/2 274/113
e e e e W: \.001; 3.9; 1.6-10.2 W: \.001; 3.9; 1.7-9.4 W: \.001; 2.6; 1.2-5.5 M: = .03; 1.7; 1.04-3.0 e W: \.01; 2.0; 1.2-3.6 e e M: = .002; 3.5; 1.5-8.6 e e
42/20 98/37 134/56
e W: \10ÿ9; 3.3; 2.0-5.3 e
e, Equal prevalence; CI, confidence interval(s); ET, erythematotelangiectatic type; M, male preponderance; N/exam, number of patients examined; OR, odds ratio; PP, papulopustular type; R, total number of rosacea cases; W, female preponderance. *Comparisons within the groups: y P = .01; OR, 2.0; 95% CI, 1.1-3.4. z P \ 10ÿ9; OR, 3.4; 95% CI, 2.2-5.4. § P \ .10ÿ9; OR, 5.5; 95% CI, 4.0-7.5.
Letters 919
J AM ACAD DERMATOL VOLUME 53, NUMBER 5
preponderance was noted both overall and for each of the 5-year age-group strata. The third period ([50 years) was characterized by the highest and equally distributed overall rates in both sexes (Table I). In male patients, rosacea detection rates increased abruptly after 50 years of age and reached peak prevalence with the 76- to 80-year age group (3.9%). In female patients, this abrupt increment occurred significantly earlier (after 35 years of age), and prevalence remained constant thereafter, peaking at the 61- to 65-year age group (2.8%) (Table I). Rosacea detection rates for both sexes presented a significant (x 2; P \ .0001) seasonal variation: winter, 1.4%; spring, 1.5%; summer, 0.7%; autumn, 1.0% (data not shown). The association between the degenerative processes of skin aging and exposure to winter-related aggravating factors along with improvement of some rosacea cases after sun exposure might explain why higher prevalence rates were detected in winter and in more or less elderly age groups.1,6 By disease type, erythematotelangiectatic rosacea (n = 443, 72%, 95% CI 68.5-75.5) always predominated over papulopustular rosacea (n = 172, 28%, 95% CI 24.5-31.5) independently of age, sex, or both (x 2 analysis, Table I, subtotals). The frequencies of these disease types do not differ statistically with the Swedish series data, representing a constant finding.5 As expected,1 rhinophyma (male patients, n = 10; female patients, n = 4), when separately analyzed, was predominantly associated with male gender (P = .02, odds ratio 4.2, 1.2-18). Kyriakos P. Kyriakis, MD, MPH Ioulios Palamaras, MD Sofia Terzoudi, MD Smaro Emmanuelides, MD Charalambos Michailides, MD Georgia Pagana, MD Department of Dermatology & Venereology West Attica General Hospital ‘‘St. Barbara,’’ Athens, Greece Correspondence to: Kyriakos P. Kyriakis, MD, MPH Koumanoudi str 52 Athens 11474 Greece E-mail: [email protected]
REFERENCES 1. Blount WB, Pelletier AL. Rosacea: a common, yet overlooked, condition. Am Fam Physician 2002;66:435-40. 2. Rothman KJ. Stratified analysis. In: Modern epidemiology. Boston (MA): Little Brown; 1986. pp. 177-239.
3. Marks R. Concepts in the pathogenesis of rosacea. Br J Dermatol 1968;80:170-7. 4. Neves H. Incidence of skin diseases 1952-1965. Trans St John’s Hosp Dermatol Soc 1966;52:255-71. 5. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol 1989;69:419-23. 6. Wilkin JK. Rosacea: pathophysiology and treatment [editorial]. Arch Dermatol 1994;130:359-62. doi:10.1016/j.jaad.2005.05.018
Sun protection factor content and warning statements for sunless tanning products: An examination of retail outlets and the Internet To the Editor: Despite rising trends in melanoma, many Americans continue to tan and feel that they look better after being out in the sun.1,2 As a safer alternative to sun-induced tanning, the American Academy of Dermatology has advocated self-tanning lotions, and anecdotal reports indicate a growing use of sunless tanning products. The Food and Drug Administration has addressed the concern of inadequate sun protection afforded by sunless tanning products by mandating that all suntanning preparations containing no sunscreen have a warning label.3 We sought to determine whether sunless tanning products are currently labeled to reflect sun protection factor (SPF) content and if labels on the bottles of sunless tanning products without sunscreen display the required FDA warning. Sunless tanning products sold both in retail stores and on the Internet were examined. A search for retail venues where sunless tanning products might be sold in metropolitan Boston was performed. This search was replicated through the 50 most commonly sought Internet sites for information on sunless tanning products. Each brand of sunless tanning product was checked to determine whether any level of SPF was mentioned on the product labeling and whether there was a warning pertaining to the inadequacy of sunless tanning products in protecting against sun damage. Drug, specialty, and retail stores in the greater Boston area were visited in June 2004 to evaluate the SPF level and warning label on sunless tanning products. A local department store, a grocery store, two specialty beauty supply stores, and two pharmacy/convenience stores were visited. A search was conducted in June 2004 using the Google search engine and keywords such as ‘sunless tanning products’ and ‘sunless tanning.’ Information was gathered on 53 sunless tanning products sold in stores in the Boston area. Of these 53 products, 44 offered no sun protection (83%). The SPF in the remaining products was due to added
J AM ACAD DERMATOL NOVEMBER 2005
NOTES
& COMMENTS
Epidemiologic aspects of rosacea To the Editor: Rosacea is a common, chronic facial dermatosis of uncertain etiology and variable progression, characterized by nontransient erythema and acute flares of papules and pustules, with concentration on the central area of the face. There is a paucity of epidemiologic studies, especially with regard to gender and age distribution.1 In this cross-sectional study of rosacea (19952002) in an outpatient setting of a general state hospital dermatologic teaching clinic (N = 615), diagnosis was made on the basis of history, clinical criteria, and/or laboratory criteria when appropriate. The overall denominator and reference population consisted of 50,237 outpatients (aged 35 days-96 years) consecutively examined by experienced dermatologists. All cases were entered into the study only at first referral with the aid of Access database: male patients numbered 20,909 (41.6%); female patients, 29,328 (58.4%). The Mantel-Haenszel x2 stratified analysis was used in an attempt to eliminate any confounding effects from demographic and
health-seeking behavior characteristics of the respective catchment area population (Table I).2 The median age was 59 years for male patients (range, 14-95 years) and 48 years for female patients (range, 8-89 years). Overall both sexes were equally affected by the disease (relative prevalence, 1.22%). Rosacea has been previously reported to affect both sexes equally only once3 and at a higher rate (2%) among more fair-skinned British outpatients.4 Traditional opinions about female preponderance resulted from a Swedish office employee population (rosacea cases, n = 81) in which the elderly were underrepresented.5 Mild disease often appears in women after the age of 35 years when the frequency of ‘‘hot flushes’’ and flushing increases.6 In our analysis, which was stratified by gender and age, 3 distinct periods in rosacea prevalence distribution were disclosed (Table I, subtotals). In the first period ( # 35 years of age) both sexes were equally affected at rather low rates. In the second (36-50 years), although frequencies significantly increased in both sexes, a clear and most significant female
Table I. Prevalence of rosacea by gender, age, and frequency of clinical type (1995-2002) Men Age (y)
N/exam
R (%)
# 20 21-25 26-30 31-35 36-40 41-45 46-50 51-55 56-60 61-65 66-70 71-75 76-80 [80 Total
6497 1804 1380 1258 1029 1095 1053 1012 963 1376 1295 1072 558 517 20,909
7 6 6 21 6 7 10 34 20 19 34 26 22 10 228
Subtotals* A: # 35 B: 36-50 C: [50
10,939 3,177 6,793
40 (0.4)y 23 (0.7)y,z 165 (2.4)z
(0.1) (0.3) (0.4) (1.7) (0.6) (0.6) (0.9) (3.3) (2.1) (1.4) (2.6) (2.4) (3.9) (1.9) (1.1)
Women ET/PP
N/exam
R (%)
5/2 6/0 3/3 14/7 3/3 5/2 8/2 26/8 13/7 13/6 29/5 22/4 14/8 8/2 169/59
7685 2574 2042 2005 1975 1889 1872 1595 1570 1831 1756 1284 693 557 29,328
16 6 21 19 44 46 45 31 20 51 48 21 8 11 387
28/12 16/7 125/40
14,306 5,736 9,286
62 (0.4)§ 135 (2.3)§ 190 (2.6)
(0.2) (0.2) (1.0) (0.9) (2.2) (2.4) (2.4) (1.9) (1.3) (2.8) (2.7) (1.6) (1.2) (1.9) (1.3)
Significance ET/PP
P value; OR; 95% CI
12/4 3/3 12/9 15/4 35/9 34/12 29/16 24/7 14/6 33/18 32/16 15/6 7/1 9/2 274/113
e e e e W: \.001; 3.9; 1.6-10.2 W: \.001; 3.9; 1.7-9.4 W: \.001; 2.6; 1.2-5.5 M: = .03; 1.7; 1.04-3.0 e W: \.01; 2.0; 1.2-3.6 e e M: = .002; 3.5; 1.5-8.6 e e
42/20 98/37 134/56
e W: \10ÿ9; 3.3; 2.0-5.3 e
e, Equal prevalence; CI, confidence interval(s); ET, erythematotelangiectatic type; M, male preponderance; N/exam, number of patients examined; OR, odds ratio; PP, papulopustular type; R, total number of rosacea cases; W, female preponderance. *Comparisons within the groups: y P = .01; OR, 2.0; 95% CI, 1.1-3.4. z P \ 10ÿ9; OR, 3.4; 95% CI, 2.2-5.4. § P \ .10ÿ9; OR, 5.5; 95% CI, 4.0-7.5.
Letters 919
J AM ACAD DERMATOL VOLUME 53, NUMBER 5
preponderance was noted both overall and for each of the 5-year age-group strata. The third period ([50 years) was characterized by the highest and equally distributed overall rates in both sexes (Table I). In male patients, rosacea detection rates increased abruptly after 50 years of age and reached peak prevalence with the 76- to 80-year age group (3.9%). In female patients, this abrupt increment occurred significantly earlier (after 35 years of age), and prevalence remained constant thereafter, peaking at the 61- to 65-year age group (2.8%) (Table I). Rosacea detection rates for both sexes presented a significant (x 2; P \ .0001) seasonal variation: winter, 1.4%; spring, 1.5%; summer, 0.7%; autumn, 1.0% (data not shown). The association between the degenerative processes of skin aging and exposure to winter-related aggravating factors along with improvement of some rosacea cases after sun exposure might explain why higher prevalence rates were detected in winter and in more or less elderly age groups.1,6 By disease type, erythematotelangiectatic rosacea (n = 443, 72%, 95% CI 68.5-75.5) always predominated over papulopustular rosacea (n = 172, 28%, 95% CI 24.5-31.5) independently of age, sex, or both (x 2 analysis, Table I, subtotals). The frequencies of these disease types do not differ statistically with the Swedish series data, representing a constant finding.5 As expected,1 rhinophyma (male patients, n = 10; female patients, n = 4), when separately analyzed, was predominantly associated with male gender (P = .02, odds ratio 4.2, 1.2-18). Kyriakos P. Kyriakis, MD, MPH Ioulios Palamaras, MD Sofia Terzoudi, MD Smaro Emmanuelides, MD Charalambos Michailides, MD Georgia Pagana, MD Department of Dermatology & Venereology West Attica General Hospital ‘‘St. Barbara,’’ Athens, Greece Correspondence to: Kyriakos P. Kyriakis, MD, MPH Koumanoudi str 52 Athens 11474 Greece E-mail: [email protected]
REFERENCES 1. Blount WB, Pelletier AL. Rosacea: a common, yet overlooked, condition. Am Fam Physician 2002;66:435-40. 2. Rothman KJ. Stratified analysis. In: Modern epidemiology. Boston (MA): Little Brown; 1986. pp. 177-239.
3. Marks R. Concepts in the pathogenesis of rosacea. Br J Dermatol 1968;80:170-7. 4. Neves H. Incidence of skin diseases 1952-1965. Trans St John’s Hosp Dermatol Soc 1966;52:255-71. 5. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol 1989;69:419-23. 6. Wilkin JK. Rosacea: pathophysiology and treatment [editorial]. Arch Dermatol 1994;130:359-62. doi:10.1016/j.jaad.2005.05.018
Sun protection factor content and warning statements for sunless tanning products: An examination of retail outlets and the Internet To the Editor: Despite rising trends in melanoma, many Americans continue to tan and feel that they look better after being out in the sun.1,2 As a safer alternative to sun-induced tanning, the American Academy of Dermatology has advocated self-tanning lotions, and anecdotal reports indicate a growing use of sunless tanning products. The Food and Drug Administration has addressed the concern of inadequate sun protection afforded by sunless tanning products by mandating that all suntanning preparations containing no sunscreen have a warning label.3 We sought to determine whether sunless tanning products are currently labeled to reflect sun protection factor (SPF) content and if labels on the bottles of sunless tanning products without sunscreen display the required FDA warning. Sunless tanning products sold both in retail stores and on the Internet were examined. A search for retail venues where sunless tanning products might be sold in metropolitan Boston was performed. This search was replicated through the 50 most commonly sought Internet sites for information on sunless tanning products. Each brand of sunless tanning product was checked to determine whether any level of SPF was mentioned on the product labeling and whether there was a warning pertaining to the inadequacy of sunless tanning products in protecting against sun damage. Drug, specialty, and retail stores in the greater Boston area were visited in June 2004 to evaluate the SPF level and warning label on sunless tanning products. A local department store, a grocery store, two specialty beauty supply stores, and two pharmacy/convenience stores were visited. A search was conducted in June 2004 using the Google search engine and keywords such as ‘sunless tanning products’ and ‘sunless tanning.’ Information was gathered on 53 sunless tanning products sold in stores in the Boston area. Of these 53 products, 44 offered no sun protection (83%). The SPF in the remaining products was due to added