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Rosacea

Rosacea is a common chronic condition characterized by facial erythema, telangiectasia, coarseness of skin and papulopustular eruptions. The etiology of rosacea is unknown.


Presentation

The disease has a wide range of symptoms and signs, but rarely do patients go through each stage of rosacea. Variable erythema and telangiectasia is seen on cheeks and forehead. Inflammatory papules and pustules are seen mainly on the nose, the forehead, and the cheeks. Rarely, the neck and the upper part of the chest are involved.

In severe cases, thickened and disfigured noses (rhinophyma) are seen due to prominent sebaceous glands. Patients may complain of drying and peeling of the skin. Ocular lymphedema may be outstanding but is not seen commonly. Usually, rosacea does not cause any scarring.

Sometimes rhinophyma is the only presenting symptom and no other signs of rosacea are seen. Lymphedema can be predominant in periorbital area and sometimes be the only presenting symptom.

Ocular rosacea can be associated with conjunctival infection, and, rarely ever with chalazion and episcleritis.

Rosacea fulminans (pyoderma faciale) is a rare complication which is identified by the formation of nodules and abscesses with development of a sinus tract along with systemic signs.

A rare granulomatous type of rosacea (acne agminata/lupus miliaris disseminatus faciei) can present with inflammatory erythematous or flesh-colored papules spread symmetrically on the upper part of the face, especially around the eyes and nose. This type of rosacea may be associated with scarring and sometimes do not respond to regular treatment.

Blepharitis
  • We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea.[ncbi.nlm.nih.gov]
  • A 14-year-old girl presented with discrete papules and pustules on both cheeks with blepharitis and conjunctivitis.[ncbi.nlm.nih.gov]
  • Case 1 is a 10-year-old boy with 2 years of recurrent bilateral blepharitis, repetition chalazion, conjunctival hyperemia, and corneal ulcers, without response to topical antibiotics or topical and systemic steroids.[ncbi.nlm.nih.gov]
  • RESULTS: 17 patients (89.5%) suffered from blepharitis, 15 patients (78.9%) from conjunctivitis, twelve patients (63.2%) from chalazia/styes and nine female patients (47.4%) from corneal involvement.[ncbi.nlm.nih.gov]
  • It may be linked with other skin disorders ( acne vulgaris, seborrhea ) or eye disorders ( blepharitis, keratitis ).[medlineplus.gov]
Red Eye
  • We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea.[ncbi.nlm.nih.gov]
  • A persistent burning feeling, red eyes and light sensitivity suggest the more severe problem of rosacea keratitis. This rare complication can lead to with blindness without treatment.[aocd.org]
  • Rosacea Symptoms May Also Include Any Combination of the Following: Burning or stinging sensation to the skin Elevated red plaques Dry appearance to the skin Fluid under the skin - edema Burning or itching eyes, eyelid inflammation, styes, red eyes Skin[acne.org]
Flushing
  • Medications to reduce flushing Nutraceuticals targeting flushing, facial redness and inflammation may be beneficial.[web.archive.org]
  • Rosacea is a chronic skin disorder, characterized by persistent painful facial flushing and often accompanied by papules and pustules.[ncbi.nlm.nih.gov]
  • Triggers that cause episodes of flushing and blushing play a part in its development.[en.wikipedia.org]
  • Cutaneous flushing and facial erythema are common dermatologic conditions that elicit a wide differential diagnosis that includes rosacea, seborrheic dermatitis, photodermatitis, connective-tissue diseases, carcinoid syndrome, and mastocytosis.[ncbi.nlm.nih.gov]
  • Rosacea usually follows a pre-rosacea stage that involves flushing only.[doi.org]
Acne Vulgaris
  • Unlike acne vulgaris, rosacea is typically localized commonly over the central face (i.e. medial cheek, nose, forehead, and chin). Acne Vulgaris vs.[stanfordmedicine25.stanford.edu]
  • Rosacea, also referred to as acne rosacea, is different from acne vulgaris, which normally affects younger people.[acne.org]
  • Acne vulgaris is perhaps the disorder most commonly mistaken for rosacea, but redness and spider-like veins are not observed in patients with acne. Blackheads and cysts, however, are seen in acne patients, but not in those with rosacea.[medical-dictionary.thefreedictionary.com]
  • It may be linked with other skin disorders ( acne vulgaris, seborrhea ) or eye disorders ( blepharitis, keratitis ).[medlineplus.gov]
Eruptions
  • We report a case of a rosacea-like eruption in a 39-year-old woman occurring after the use of pimecrolimus cream for 12 months for atopic dermatitis.[ncbi.nlm.nih.gov]
  • This report describes a patient with a rosacea-like eruption as a unique clinical presentation of T-cell prolymphocytic leukemia.[ncbi.nlm.nih.gov]
  • The causative role of Demodex folliculorum should be considered in immunocompetent children with rosacea or rosacea-like refractory eruptions. In such cases, treatment with ivermectin can be beneficial.[ncbi.nlm.nih.gov]
  • Rosacea fulminans, previously known as pyoderma faciale, is a rare disease occurring almost exclusively in young women characterized by the sudden eruption of coalescing papules and pustules, and large cystic nodules limited to the face.[ncbi.nlm.nih.gov]
  • The diagnosis should be established by excluding other granulomatous disorders and rosacea-like eruptions such as sarcoidosis, tuberculosis, and lupus miliaris disseminatus faciei.[ncbi.nlm.nih.gov]
Acneiform Eruption
  • […] definition An acneiform eruption occurring mostly in middle-aged adults and appearing generally on the forehead, cheeks, nose, and chin.[dermis.net]
  • Steroid-induced acneiform eruption Steroid-induced acneiform eruption is not a variant of rosacea and can occur as an inflammatory response in any patient during or after chronic corticosteroid use.[rosacea.org]
  • eruptions Perioral dermatitis Diagnosis Physicians experience a challenge when diagnosing rosacea because of the numerous ways it can present itself.[acne.org]
  • eruption Folliculitis Uncommon Lupus erythematosus Dermatomyositis Drug reaction, e.g. isoniazid Sarcoidosis Demodicosis (mange) Source: References 1, 4, 6 Clinical manifestations The presence of at least one of the following primary features indicates[ncbi.nlm.nih.gov]
Facial Skin Lesion
Facial Redness
  • Physicians are often presented with patients complaining of facial redness and difficult to control rosacea.[ncbi.nlm.nih.gov]
  • Brimonidine sulfate and oxymetazoline HCL were both recently approved by the FDA for the management of facial redness. These agents, however, are costly, and not all patients respond to the medication.[ncbi.nlm.nih.gov]
  • MEDLINE was searched using the key search terms "rosacea," "rhinophyma," "metronidazole," "Helicobacter pylori," and "facial redness."[ncbi.nlm.nih.gov]
  • From the only FDA-approved oral rosacea treatment, to a highly effective topical cream and the only gel for the persistent facial redness of erythema, we have treatment options that may be right for you.[rosaceafacts.com]
Red Nose
  • Symptoms may include: Redness of the face Blushing or flushing easily A lot of spider-like blood vessels (telangiectasia) of the face Red nose (called a bulbous nose ) Acne-like skin sores that may ooze or crust Burning or stinging feeling in the face[medlineplus.gov]
  • nose (common in men) In addition, rosacea often affects the eye and eyelid.[uclahealth.org]
  • nose (almost only seen in men) In addition, rosacea often affects the eye and eyelid.[urmc.rochester.edu]
  • More common in men, rhinophyma is characterized by a bulbous, enlarged red nose and puffy cheeks. Thick bumps can also develop on the lower half of the nose and cheeks. This type of rosacea is relatively uncommon.[div.net.au]
Rash of the Nose
  • Other conditions that can be mistaken for rosacea include: ( 9 ) Lupus Acne Seborrheic dermatitis ( scalp eczema ) Lupus is a chronic inflammatory autoimmune condition that can cause a reddish skin rash over the nose and face, usually in a butterfly shape[everydayhealth.com]

Workup

The diagnosis is made clinically. Sometimes a skin biopsy is done to rule out other cutaneous diseases, like lupus or sarcoidosis. The typical history and visible signs are more than sufficient to diagnose a case of rosacea.

Normal Chest X-Ray
  • CBC, urinalysis, renal function tests, liver function tests, serum electrolytes, and blood sugar were all normal. Chest X-ray and ECG revealed no abnormality. Serology for syphilis and HIV, and mantoux test were negative.[ncbi.nlm.nih.gov]
Demodex Folliculorum
  • The causative role of Demodex folliculorum should be considered in immunocompetent children with rosacea or rosacea-like refractory eruptions. In such cases, treatment with ivermectin can be beneficial.[ncbi.nlm.nih.gov]
  • The microorganisms that have been associated include Helicobacter pylori, Demodex folliculorum, Staphylococcus epidermidis, and Chlamydia pneumonia; all the studies have been inconclusive.[ncbi.nlm.nih.gov]
  • The microorganisms that have been associated include Helicobacter pylori, Demodex folliculorum, Staphylococcus epidermidis, and Chlamydia pneumonia ; all the studies have been inconclusive.[doi.org]
  • Patients with papulopustular rosacea have a higher density of Demodex folliculorum mites on their faces than normal subjects but the role, if any, of their mites in initiating inflammation is disputed.[ncbi.nlm.nih.gov]
Chlamydia
  • The microorganisms that have been associated include Helicobacter pylori, Demodex folliculorum, Staphylococcus epidermidis, and Chlamydia pneumonia; all the studies have been inconclusive.[ncbi.nlm.nih.gov]
  • The microorganisms that have been associated include Helicobacter pylori, Demodex folliculorum, Staphylococcus epidermidis, and Chlamydia pneumonia ; all the studies have been inconclusive.[doi.org]
  • The role of Chlamydia pneumoniae in the etiology of acne rosacea: response to the use of oral azithromycin. Cutis. 2007;79(2):163–167. Rebora A. The management of rosacea. Am J Clin Dermatol. 2002;3(7):489–496. Torresani C, Pavesi A, Manara GC.[web.archive.org]

Treatment

Prior to any therapy, it is better to identify and avoid the triggering factors that flare up the patient's rosacea. These factors can be different for every individual. In some patients, it is seen that regular facial massage helps in reduction of lymphedema. Fairly high doses of prednisolone (30-60 mg/d) followed by oral isotretinoin helps in treatment of rosacea fulminans.

All patients with rosacea should use a broad-spectrum sunscreen that protects against both UV-A and UV-B rays on a daily basis [4]. 

Laser treatment can be done to treat enlarged or dilated blood vessels or remove surplus nose tissue in cases of rhinophyma.

Cosmetic change of rhinophyma can be done by various techniques like mechanical dermabrasion, carbon dioxide laser peel, and surgical shave.

The first line of treatment is generally topical metronidazole. Topical azelaic acid, sulfacetamide products, and topical acne medications are frequently used. Antibiotics are also very effective in both ways i.e. orally or topically, and for ocular rosacea, they are generally the first-line therapy. Some people also recommend using retinoids for treating rosacea [5] [6] [7].

Medicines that help in reducing the flushing like beta-blockers, clonidine, naloxone, ondansetron, and selective serotonin reuptake inhibitors can also help in treating rosacea.

In some patients who complain of rosacea that worsens with their hormonal cycles, oral contraceptive therapy can be beneficial.
Dapsone is helpful for patients who cannot take isotretinoin [8] and is used in cases of severe refractory rosacea.

Prognosis

Development of rosacea is different for every individual, depending on various factors like genetics, skin sensitivity, skin complexion, amount of time spent in sunlight without sunscreen, intake of alcohol and spicy foods, and exposure to extreme temperatures. With the help of suitable treatment and avoidance of triggering factors, rosacea can be controlled.

Etiology

The etiology of rosacea is unknown. Different aggravating factors leading to incidents of flushing and blushing play a role in developing rosacea.

Various factors like vasculature, climatic exposures, pilosebaceous systems abnormalities, dermal matrix degeneration, chemicals and consumed agents, microbial organisms, reactive oxygen species (ROS), increased neoangiogenesis, ferritin expression, and dysfunction of antimicrobial peptides (AMPs), may also lead to its development [1].

Epidemiology

It primarily affects people of northwestern European descent. Although it affects both the sexes, women are three times more prone to it as compared to men. 30-60 years is the most vulnerable age to suffer from rosacea.

Sex distribution
Age distribution

Pathophysiology

As the exact cause of rosacea is unknown, following are the theories that explain the development of this skin condition:

  • Vasculature: High amount of blood flowing through the vessels of face and numerous blood vessels that are nearer to the facial surface might be the cause of redness and flushing related to rosacea.
  • Climatic conditions: Harsh climatic conditions harm the cutaneous blood vessels along with the dermal connective tissue. Hence we know the reason why rosacea is prevalent on the face and flares up in spring due to the solar irradiation exposure.
  • Dermal matrix degeneration: Rosacea leads to the damage of endothelium and deterioration of the dermal matrix.
  • Chemicals and ingested agents: Spicy foods, alcohol, and hot beverages are generally considered as triggering factors for flushing in rosacea patients. Also, medications like amiodarone, topical steroids, nasal steroids, and increased dosage of vitamins B-6 and B-12, can also lead to flares in rosacea patients.
  • Inflammation: An inflammatory infiltrate present in either perivascular or a perifollicular area or present in both the places may also lead to rosacea.
  • Microbial organisms: Demodex species (mites generally seen human hair follicles) might lead to development of rosacea. Research suggests that Demodex has preference for rosacea afflicted areas of the skin like nose and cheeks [2].
  • Ferritin expression: Iron acts as a catalyst in converting hydrogen peroxide to free radicals that cause injury to the tissues by destroying cell membranes, proteins, and DNA. Skin biopsy of the patients with rosacea when immunohistochemically analyzed, showed significant rise in number of ferritin-positive cells in diseased individuals in comparison to controlled individuals. Also, raised ferritin positivity correlated with more progressive subtypes of rosacea. Hence, marked release of free iron from proteolysis of ferritin can cause oxidative damage to the skin, which can also speed up the development of rosacea [3].
  • Reactive oxygen species: In the beginning of an inflammatory process, the neutrophils release the reactive oxygen species (ROS), which are considered to play a vital role in the inflammation that is associated with rosacea.

Prevention

Rosacea cannot be prevented but the symptoms can be controlled by knowing and avoiding the common triggering factors [9] [10] like hot drinks, exercise, alcohol, spicy foods, emotions, caffeine, sunlight, extreme heat or cold. These factors increase the blood flow and lead to dilation of small blood vessels of the facial skin. It is necessary to identify one’s own trigger factors and pay special attention towards avoiding them.

Summary

Rosacea is a common chronic skin condition characterized by symptoms of facial erythema (redness) and a wide range of clinical signs, like telangiectasia, roughness of skin, and an inflammatory papulopustular eruption looking like acne.

Age is no bar for rosacea affection. Rosacea can be divided into four types, of which three affect the skin and the last one affects the eyes.

Patient Information

Rosacea is a chronic inflammatory skin disease manifested as widespread redness and red boils generally over the forehead, cheeks, and nose. It is commonly seen in females of the reproductive age group and is easily diagnosed just by seeing.

As there is no way of preventing rosacea, measures can be taken to reduce the symptoms and their frequency of development. The first and foremost step is avoiding the triggering factors. Then comes, taking care of the skin in general by cleansing and moisturizing your face regularly. Prefer facial products that do not burn, sting, irritate or cause redness when use. One must develop a habit of washing face with lukewarm water and a mild soap.

One must avoid alcohol and acetone based products like toners, scrubs, etc. as they tend to dehydrate the skin. Hydroxy acids and tretinoin like Retinon A have good chances of sensitizing your skin to sun and thereby worsening rosacea. Patients must make it a norm to use broad spectrum sunscreens and sun blockers daily and generously for protecting your face [4]. Use sunscreens that have SPF factor of 30 or more.

During winter patients must take extra care of face by using a scarf or ski mask to protect it. In case one wants to use makeup, one can go for green-tinted foundation creams and powders as they are designed specially to prevent redness of the skin.

References

Article

  1. Laquer V, Hoang V, Nguyen A, Kelly KM. Angiogenesis in cutaneous disease: part II. J Am Acad Dermatol. 2009 Dec;61(6):945-58; quiz 959-60.
  2. Bonnar E, Eustace P, Powell FC. The Demodex mite population in rosacea. J Am Acad Dermatol. 1993 Mar;28(3):443-8.
  3. Tisma VS, Basta-Juzbasic A, Jaganjac M, et al. Oxidative stress and ferritin expression in the skin of patients with rosacea. J Am Acad Dermatol. 2009 Feb;60(2):270-6.
  4. Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24;352(8):793-803.
  5. Ceilley RI. Advances in the topical treatment of acne and rosacea. J Drugs Dermatol. 2004 Sep-Oct;3(5 Suppl):S12-22.
  6. Ertl GA, Levine N, Kligman AM. A comparison of the efficacy of topical tretinoin and low-dose oral isotretinoin in rosacea. Arch Dermatol. 1994 Mar;130(3):319-24.
  7. Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Dermatol Venereol. 2005 May;19(3):273-85.
  8. Baldwin HE. Systemic therapy for rosacea. Skin Therapy Lett. 2007 Mar;12(2):1-5, 9.
  9. Greaves MW, Burova E. Flushing: causes, investigation and clinical consequences. J Eur Acad Dermatol Venereol. 1997;8:91-100.
  10. Higgins E, du Vivier A. Alcohol intake and other skin disorders. Clin Dermatol. 1999 Jul-Aug;17(4):437-41.

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Last updated: 2017-08-09 18:17