rosacea

Introduction

Chronic episodic skin disorder of unknown etiology.

Etiology

• idiopathic
• postulated causes
  • genetic predisposition
  • hypertension
  • Demodex folliculorum mites
  • gastrointestinal disease
• risk factors
  • predisposition to flushing
    • dietary & environmental precipitation
      • hot liquids, spicy foods, alcohol, chemical irritants
    • menopause
    • vasodilator drug therapy
  • exposure to sunlight & heat
  • stress & strong emotions

Epidemiology

• onset between ages 30 & 50
• fair-skinned individuals
• women affected 3 fold more than men
• 5% of US population, > 13 million cases in US

Pathology

• overexpression of kallikrein-5 cleaves cathelicidin thus producing clinical manifestations of rosacea
• increased gene expression relative to dermatoheliosis & controls of:
  • matrix metalloproteinase-1
  • matrix metalloproteinase-3
  • matrix metalloproteinase-9
  • calcitonin gene-related peptide
  • substance P
  • collagen type I
  • collagen type III
  • decorin
• erythema of rosacea consists of inflammation & vasodilation rather than vasodilation alone
• hyperreactivity of the innate immune system
• histopathology
  • variable
  • a combination of findings may support diagnosis of rosacea

* histopathology images

Clinical manifestations

• intermittent, but progressively more severe episodes
• mild episodes may include erythema & scattered telangiectasias lasting hours to days
• more severe episodes may include all features of the disease & last for weeks
• erythema, telangiectasias, papules & pustules occur on the forehead, cheeks, chin nose & glabella after an episode of flushing (central facial)
• flushing is often induced by ingestion of hot liquids, spicy foods, alcohol,
• exacerbated by
  • exposure to sunlight & heat
  • stress & strong emotions
• comedones are generally absent
• chronic inflammation, connective tissue hypertrophy & diffuse sebaceous gland hypertrophy is characteristic of severe rosacea
• phymas, rhinophyma
• ocular involvement (50%)
  • blepharitis
  • conjunctivitis (images)
  • iritis & keratitis considered complications

* images

Laboratory

• no definitive laboratory tests
• biopsy not routinely indicated

Complications

• iritis
• keratitis
• increased risk of Parkinson's disease (RR=1.71)
  • RR=2.03 if ocular rosacea
  • risk normalized by treatment with tetracycline

Differential diagnosis

• acne vulgaris
• perioral dermatitis
• seborrheic dermatitis
  • rosacea may accompany seborrhea
• contact dermatitis
• lupus erythematosus
  • cutaneous lupus erythematosus
  • systemic lupus erythematosus
  • lupus spares the nasolabial folds
  • papules, pustules & flushing supports diagnosis of rosacea
• carcinoid flush
• cutaneous tuberculosis
• amyotrophic dermatomyositis
  • heliotrope rash, Gottron papules, photosensitive facial poikiloderma
• dermatoheliosis (photoaging)
  • centrofacial location of redness, flushing, sensory change, & involvement of the nose suggest rosacea
  • no finding definitively distinguishes the two

Management

• general
  • may respond to treatment, but generally not curable
  • treatment is symptomatic; response may take 6-12 weeks
  • avoidance of triggers (precipitating factors)
• pharmacologic agents
  • topical agents
    • topical antibiotics have little effect on erythema & telangiectasias
      • topical metronidazole* (0.75%) MetroGel) BID
      • topical tetracycline 0.5-2% BID
      • topical erythromycin 0.5-2% BID (Erycette)
      • topical clindamycin 0.5-2% BID (Cleocin-T)
    • drying agents applied BID
      • benzoyl peroxide
      • sulfacetamide plus sulfur-containing lotions
        • Rosula Gel, Clenia cream or wash
      • azelaic acid 15-20% (Finacea Gel, Finevin)
    • hydrocortisone 1%
      • may be useful in reducing erythema & edema
      • fluorinated steroid should not be used
      • prolonged use causes rebound worsening of rosacea symptoms
      • MKSAP19 advises to avoid glucocorticoids
    • topical calcineurin inhibitors
      • topical tacrolimus
      • topical pimecrolimus
    • topical permethrin
    • topical ivermectin
  • systemic agents
    • systemic antibiotics
      • indications
        • effective for pustular rosacea - eye manifestations
      • tetracycline
        • 250 mg PO QID until symptoms diminish
        • then taper to 250-500 mg/day
        • continue therapy for at least 6 months
        • indefinite therapy may be required
      • doxycycline 40 mg QD only FDA-approved oral therapy
      • minocycline (Emrosi)
      • macrolide if tetracycline is ineffective
        • erythromycin 500-1000 mg QD
        • azithromycin
        • clarithromycin
      • metronidazole 250 mg BID, as a 1st line agent or if tetracycline is ineffective
    • isotretinoin (13-cis-retinoic acid) (Accutane)
      • 0.5-1.0 mg/kg/day for 15-20 weeks
      • low-dose 0.1-0.2 mg/kg/day may take longer than standard dose, but fewer adverse effects
      • minidose 2.5-5 mg QD
        • up to 6 months therapy may be necessary
        • adverse effects are minimal
      • indicated for rosacea refractory to therapy with antibiotics & topical steroids
• physical modalities
  • telangiectatic vessels may be treated with superficial electrodesiccation or laser surgery
  • rhinophyma may be treated with CO2 laser surgery, dermabrasion, or electrosurgery
• ophthalmology consultation for eye involvement
  • doxycycline
  • dexamethasone ophthalmic
  • artificial tears
  • eyelid hygiene
• diet
  • avoid foods that may cause vasodilation & thus facial flushing
  • i.e. hot liquids, alcohol, coffee, tea, spicy foods
• environmental control
  • avoid extremes of weather
    • wind
    • heat
    • cold
  • avoid prolonged sun exposure
• patient education
  • avoid tobacco
  • use mild, non-drying soap
  • use sunscreen
  • stress management may be helpful

* treatment of choice

Notes

• spironolactone mitigates risk of rosacea (it is not FDA-approved to treat rosacea)

More general terms

• sebaceous gland disease
• chronic skin disease

More specific terms

• lupus miliaris disseminatus faciei; facial idiopathic granulomas with regressive evolution (LMDF, FIGURE)

Additional terms

• Demodex folliculorum
• phyma
• rhinophyma
• sebaceous gland

Patient information

rosacea patient information