This pooled analysis incorporating data collected from a total of 1624 subjects in seven recent studies, using four questionnaires, confirms that erythema of rosacea significantly affects patients’ HRQoL. All HRQoL instruments have conceptual limitations; hence we chose to incorporate validated generic (EQ5D is very widely used in health economic analyses) and dermatology-specific (DLQI was the first HRQoL instrument and is the most widely used) questionnaires based on the quantity of available data for comparison with other diseases. Furthermore, to obtain a better sense of what it is like to live with erythema of rosacea, we also included the rosacea-specific PSLQ and redness-specific FRQ questionnaires, albeit non-validated questionnaires.
The EQ5D highlighted pain/discomfort and anxiety/depression as the main drivers of reduced HRQoL in rosacea subjects. Overall, the mean EQ-5D scores (VAS 74.0 and index score 0.859) were similar to values reported for other severe conditions. For comparison, a systematic literature review of HRQoL in psoriasis reported mean EQ-5D VAS scores ranging from 50.7 to 75.1 and mean EQ-5D utility index scores from 0.52 to 0.9 [17]. The authors concluded that these values for patients with psoriasis corresponded to the same level of deterioration in HRQoL as for patients with other serious chronic diseases, e.g., cardiovascular disease.
The relatively low EQ-5D HRQoL score for erythema of rosacea may reflect the fact that all the EQ-5D population subjects (100%) had self-perceived severe erythema, which was confirmed for around half of them (51.1%) by a clinician’s assessment. Indeed, PSA severe subjects had a worse mean DLQI score than moderate PSA subjects (8.6 vs 6.0). Furthermore, a systematic review exploring HRQoL in patients with cutaneous rosacea identified an association between negative impact on HRQoL and disease severity [7].
Symptoms/feelings was the most impacted DLQI domain. Overall, the mean DLQI total score of 6.2 points indicates a moderate influence of erythema of rosacea on HRQoL. This value is very similar to that in existing literature since a review on 10 years of experience with the DLQI reported a mean of means of 6.7 for rosacea/rhinophyma [18]. This score is lower than the mean of means reported for psoriasis (8.8) or acne (11.9), but higher than the scores for Darier’s disease (5.9) or Hailey–Hailey disease (6.1) [18]. Two previous studies in subjects exclusively with erythematotelangiectatic rosacea reported comparable DLQI scores of 5.6 and 7.8 [9, 10].
The subjects without lesions (EQ5D VAS of 72.3; EQ5D single index score of 0.83; DLQI total score of 7.4) appeared to have even worse HRQoL than subjects with ≥1 inflammatory lesion (EQ5D VAS of 78; EQ5D single index score of 0.92; DLQI total score of 6.3); patients may thus be most concerned about the persistent redness or erythema of rosacea rather than the presence of inflammatory lesions.
Results of the non-validated disease-specific PSLQ and redness-specific FRQ confirmed the results observed with the validated questionnaires. Rosacea was shown to affect work life and social life using the PSLQ (subjects mostly with moderate redness). An even larger effect on work and social life was observed with the FRQ in subjects with PSA severe redness. Similarly, a large-scale international survey showed that erythema of rosacea can lead to stigmatization, as well as having an impact on emotional and psychological well-being [19].
Treatments for the persistent redness of rosacea, e.g., brimonidine 0.33% gel (3.3 mg/g) [11–14, 20, 21] and laser and intense-pulsed light [9, 10], have been reported to improve patients’ HRQoL [22]. However, despite the availability of effective treatments, many rosacea patients are underdiagnosed, misdiagnosed and undertreated [15]. It appears that patients do not always seek medical advice [23], may be unable to successfully convey the impact on HRQoL and/or clinicians may overlook the psychological impact. A possible explanation for this may be that physicians have limited time during a consultation for effective communication and do not encourage patients to express their views [24, 25].
The use of HRQoL instruments in clinical practice, combined with effective patient–physician communication, should help facilitate dialog between physicians and patients, so that treatment decisions can be based on the patient’s priorities and preferences informed by best medical evidence [25–28].
Recommendations have been developed to help the introduction of HRQoL tools into clinical practice and new technology may be able to address many of the practical problems associated with measuring HRQoL in clinical practice [28].
A possible limitation of this meta-analysis is that it was not from a systematic review of the literature. However, it was a pooled analysis of seven existing studies and included published and unpublished data that met our incorporation criteria (data from one of the four questionnaires) to avoid publication bias. It is noteworthy that the EQ5D and FRQ data were from a single study (n = 92 subjects), in which the maximum number of lesions allowed was limited to five [11]. Although subjects participating in clinical studies may not be representative of the general population [11–14] (except for subjects in the epidemiological study [15]), an advantage of these subjects is that they all had a confirmed diagnosis of rosacea.