The Diagnosis And Management of Rosacea
Rosacea is a chronic recurrent inflammatory skin condition affecting primarily the central areas of the face with ocular involvement in 50 per cent of patients. It is relatively common and it has been estimated to affect approximately 14 million people in the US.
The cause of rosacea has not yet been established. Genetic factors, environmental, vascular, inflammatory factors, bacteria and micro-organisms have all been considered as possible contributors or causes.
The majority of patients with rosacea are aged between 30 to 60 years old. It affects more women than men. The prevalence of rosacea is highest among fair-skinned individuals, especially those of Celtic origin, and has not been diagnosed as often in dark skinned individuals although recent research indicates that darker skinned individuals may be more commonly affected than previously believed.
As rosacea affects the face, and because of the common misconception that the development of rosacea may be linked with alcohol abuse, it has a significant psychosocial impact and therefore diagnosis and management are critical.
The diagnosis of rosacea is based on the clinical features. Symptoms and signs include facial flushing, persistent centrofacial erythema, inflammatory papules and pustules, telangectatic vessels and hypertrophy of the sebaceous glands with fibrosis. Ocular changes can range from mild blepharitis and conjunctivitis through to sight threatening keratitis. Typically, rosacea follows a pattern of remission and flares of symptoms. There is often an overlapping of symptoms, however, in the majority of patients a particular clinical picture of rosacea dominates.
This allows rosacea to be classified into four subtypes:
Subtype 1 is termed Erythrematotelangiectatic. Patients in this group have troublesome flushing and persistent central facial erythema. Telangectatic vessels are present. Flushing is exacerbated by spicy foods, alcohol, hot drinks, temperature change, exercise and emotional stress. The differential diagnosis includes lupus erythematosus, chronic actinic damage, and photosensitivity. If flushing is severe carcinoid syndrome, phaeochromocytoma and polycythaemia may need to be considered.
. Papulopustular rosacea (subtype 2) is characterised by erythematous dome-shaped papules and small pustules on the central face with a background erythema. Sometimes oedema can occur. In contrast with acne, patients with rosacea do not have comedones (whiteheads and blackheads) and scarring of the skin does not occur.
Phymatous rosacea is subtype 3. It is rare and most commonly seen in men. It results from hyperplasia of the sebaceous glands and connective tissue and is characterised by distorted thickened skin and surface nodules. It is most commonly seen on the nose (rhinophyma).
Ocular rosacea (subtype 4) is common but is frequently overlooked. It has been estimated to be present in 50 per cent of patients with rosacea. Symptoms range from mild irritation to burning and stinging to blurred vision. Patients can have blepharoconjunctivitis, chalaia, hordeola, and very rarely keratitis, with potential visual loss.
These subtypes are useful in the guidance of therapy. The severity of each subtype can be graded as 1(mild), 2 (moderate) or 3 (severe).
Management of rosacea includes avoidance of exacerbating factors, medications to suppress the inflammatory lesions and the use of surgery or laser therapy for phymatous disease and telangectasias. Treatment is guided by the predominant subtype of rosacea the patient has.
Patients with rosacea have sensitive skin, so mild cleansers and emollients are advised. All patients with rosacea should apply sunscreens daily to prevent the development of facial photodamage that will exacerbate the redness of rosacea. Patients should attempt to identify aggravating factors to flushing and avoid these, and be advised that effective cosmetic coverage can neutralise erythema. Accurate patient information can be accessed via groups such as the National Rosacea Society () and American Academy of Dermatology () that have websites.
Erythematotelangectatic rosacea is difficult to treat. Where telangiectatic vessels are significant pulsed dye laser therapy, which causes selective photothermolysis, can be employed. This results in coagulation of the superficial vessels without associated dermal damage.
Topical and systemic antibiotics are the principal treatments for papulopustular rosacea. Topical metronidazole is both antibacterial and anti-inflammatory, and application twice daily results in less erythema and a reduction in inflammatory lesions. Topical metronidazole should be used with caution in women of child bearing age who are not taking oral contraception as it potentially can be absorbed and has mutagenic side effects.
Sodium sulfacetamide (antibacterial) and sulfur (keratolytic) topically can be used. Azelaic acid (antibacterial, anti-inflammatory) top- ically is comparable in efficacy to topical metronidazole. Topical erythromycin (antibacterial; anti-inflammatory) is another effective therapy.
Systemic agents, with or without concurrent topical treatment, are indicated in moderate to severe (grades 2 and 3) papulopustular rosacea.
Systemic agents such as oxytetracycline, doxycycline, erythromycin and minocycline, are most frequently used. Treatment should be for four to 12 weeks. Once systemic treatments are ceased, topical therapy is then continued to maintain a remission.
Rhinophyma is uncommon. Grades 2 and 3 rhinophyma can be effectively treated with surgical excision, electrosurgery or CO2 – laser therapy.
Ocular rosacea is common and usually mild. It is treated with good eyelid hygiene and warm compresses, artificial tears and topical application of metronidazole gel to the eyelid margins. Grades 2 and 3 may require treatment with systemic antibiotics. Referral to an ophthalmologist should be made if symptoms are persistent or severe.
Summary:
• Rosacea is a common condition with a significant psychosocial impact.
• Rosacea can be classified into subtypes which guide effective therapy.
• All patients should apply sunscreen daily and, where possible, avoid exacerbating factors.
• Erythematotelangiectatic rosacea is best managed with sun protection and possibly carbon dioxide laser treatment for prominent telangectasias.
• Papulopustular rosacea is usually treated with topical agents and/or systemic antibiotics.
• Phymatous rosacea is uncommon. Effective therapies include surgery and laser therapy.
• Ocular rosacea can be managed with eyelid hygiene, artificial tears and topical metronidazole. Persistent or severe symptoms should prompt referral to an ophthalmologist.
• Patient can access accurate information on websites such as the National Rosacea Society or the American Academy of Dermatology .
Dr Maeve McAleer, Dermatology Senior House Officer, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin
The cause of rosacea has not yet been established. Genetic factors, environmental, vascular, inflammatory factors, bacteria and micro-organisms have all been considered as possible contributors or causes.
The majority of patients with rosacea are aged between 30 to 60 years old. It affects more women than men. The prevalence of rosacea is highest among fair-skinned individuals, especially those of Celtic origin, and has not been diagnosed as often in dark skinned individuals although recent research indicates that darker skinned individuals may be more commonly affected than previously believed.
As rosacea affects the face, and because of the common misconception that the development of rosacea may be linked with alcohol abuse, it has a significant psychosocial impact and therefore diagnosis and management are critical.
The diagnosis of rosacea is based on the clinical features. Symptoms and signs include facial flushing, persistent centrofacial erythema, inflammatory papules and pustules, telangectatic vessels and hypertrophy of the sebaceous glands with fibrosis. Ocular changes can range from mild blepharitis and conjunctivitis through to sight threatening keratitis. Typically, rosacea follows a pattern of remission and flares of symptoms. There is often an overlapping of symptoms, however, in the majority of patients a particular clinical picture of rosacea dominates.
This allows rosacea to be classified into four subtypes:
Subtype 1 is termed Erythrematotelangiectatic. Patients in this group have troublesome flushing and persistent central facial erythema. Telangectatic vessels are present. Flushing is exacerbated by spicy foods, alcohol, hot drinks, temperature change, exercise and emotional stress. The differential diagnosis includes lupus erythematosus, chronic actinic damage, and photosensitivity. If flushing is severe carcinoid syndrome, phaeochromocytoma and polycythaemia may need to be considered.
. Papulopustular rosacea (subtype 2) is characterised by erythematous dome-shaped papules and small pustules on the central face with a background erythema. Sometimes oedema can occur. In contrast with acne, patients with rosacea do not have comedones (whiteheads and blackheads) and scarring of the skin does not occur.
Phymatous rosacea is subtype 3. It is rare and most commonly seen in men. It results from hyperplasia of the sebaceous glands and connective tissue and is characterised by distorted thickened skin and surface nodules. It is most commonly seen on the nose (rhinophyma).
Ocular rosacea (subtype 4) is common but is frequently overlooked. It has been estimated to be present in 50 per cent of patients with rosacea. Symptoms range from mild irritation to burning and stinging to blurred vision. Patients can have blepharoconjunctivitis, chalaia, hordeola, and very rarely keratitis, with potential visual loss.
These subtypes are useful in the guidance of therapy. The severity of each subtype can be graded as 1(mild), 2 (moderate) or 3 (severe).
Management of rosacea includes avoidance of exacerbating factors, medications to suppress the inflammatory lesions and the use of surgery or laser therapy for phymatous disease and telangectasias. Treatment is guided by the predominant subtype of rosacea the patient has.
Patients with rosacea have sensitive skin, so mild cleansers and emollients are advised. All patients with rosacea should apply sunscreens daily to prevent the development of facial photodamage that will exacerbate the redness of rosacea. Patients should attempt to identify aggravating factors to flushing and avoid these, and be advised that effective cosmetic coverage can neutralise erythema. Accurate patient information can be accessed via groups such as the National Rosacea Society () and American Academy of Dermatology () that have websites.
Erythematotelangectatic rosacea is difficult to treat. Where telangiectatic vessels are significant pulsed dye laser therapy, which causes selective photothermolysis, can be employed. This results in coagulation of the superficial vessels without associated dermal damage.
Topical and systemic antibiotics are the principal treatments for papulopustular rosacea. Topical metronidazole is both antibacterial and anti-inflammatory, and application twice daily results in less erythema and a reduction in inflammatory lesions. Topical metronidazole should be used with caution in women of child bearing age who are not taking oral contraception as it potentially can be absorbed and has mutagenic side effects.
Sodium sulfacetamide (antibacterial) and sulfur (keratolytic) topically can be used. Azelaic acid (antibacterial, anti-inflammatory) top- ically is comparable in efficacy to topical metronidazole. Topical erythromycin (antibacterial; anti-inflammatory) is another effective therapy.
Systemic agents, with or without concurrent topical treatment, are indicated in moderate to severe (grades 2 and 3) papulopustular rosacea.
Systemic agents such as oxytetracycline, doxycycline, erythromycin and minocycline, are most frequently used. Treatment should be for four to 12 weeks. Once systemic treatments are ceased, topical therapy is then continued to maintain a remission.
Rhinophyma is uncommon. Grades 2 and 3 rhinophyma can be effectively treated with surgical excision, electrosurgery or CO2 – laser therapy.
Ocular rosacea is common and usually mild. It is treated with good eyelid hygiene and warm compresses, artificial tears and topical application of metronidazole gel to the eyelid margins. Grades 2 and 3 may require treatment with systemic antibiotics. Referral to an ophthalmologist should be made if symptoms are persistent or severe.
Summary:
• Rosacea is a common condition with a significant psychosocial impact.
• Rosacea can be classified into subtypes which guide effective therapy.
• All patients should apply sunscreen daily and, where possible, avoid exacerbating factors.
• Erythematotelangiectatic rosacea is best managed with sun protection and possibly carbon dioxide laser treatment for prominent telangectasias.
• Papulopustular rosacea is usually treated with topical agents and/or systemic antibiotics.
• Phymatous rosacea is uncommon. Effective therapies include surgery and laser therapy.
• Ocular rosacea can be managed with eyelid hygiene, artificial tears and topical metronidazole. Persistent or severe symptoms should prompt referral to an ophthalmologist.
• Patient can access accurate information on websites such as the National Rosacea Society or the American Academy of Dermatology .
Dr Maeve McAleer, Dermatology Senior House Officer, Regional Centre of Dermatology, Mater Misericordiae University Hospital, Dublin
posted by Nick Riley at 8:23 AM
<< Home