Acne Rosacea

Basics

Description

  • Rosacea is a chronic condition characterized by recurrent episodes of facial flushing, erythema (due to dilatation of small blood vessels in the face), papules, pustules, and telangiectasia (due to increased reactivity of capillaries) in a symmetrical, facial distribution. Sometimes associated with ocular symptoms (ocular rosacea).
  • System(s) affected: Skin/Exocrine
  • Synonym(s): Rosacea
Geriatric Considerations
  • Uncommon >60 years of age
  • Effects of aging might increase the side effects associated with oral isotretinoin (at present, data are insufficient due to lack of clinical studies in elderly patients ≥65)

Epidemiology


Prevalence
  • Predominant age: 30–50 years
  • Predominant sex: Female > Male. However, males at greater risk for progression to later stages.

Risk Factors

  • Exposure to cold, heat, hot drinks
  • Environmental trigger factors: Sun, wind, cold

Genetics
People of Northern European and Celtic background commonly afflicted

General Prevention

No preventive measures known

Etiology

  • No proven cause
  • Possibilities include:
    • Thyroid and sex hormone disturbance
    • Alcohol, coffee, tea, spiced food overindulgence (unproven)
    • Demodex follicular parasite (suspected)
    • Exposure to cold, heat, hot drinks
    • Emotional stress
    • Dysfunction of the GI tract

Commonly Associated Conditions

  • Seborrheic dermatitis of scalp and eyelids
  • Keratitis with photophobia, lacrimation, visual disturbance
  • Corneal lesions
  • Blepharitis
  • Uveitis

Diagnosis

History

  • Usually have a history of episodic flushing with increases in skin temperature in response to heat stimulus in mouth (hot liquids), spicy foods, alcohol, sun (solar elastosis).
  • Acne may have preceded onset of rosacea by years; nevertheless, rosacea usually arises de novo without preceding history of acne or seborrhea.
  • Excessive facial warmth and redness are the predominant presenting complaints. Itching is generally absent.

Physical Exam

  • Rosacea has typical stages of evolution:
    • The rosacea diathesis: Episodic erythema, “flushing and blushing”
    • Stage I: Persistent erythema with telangiectases
    • Stage II: Persistent erythema, telangiectases, papules, tiny pustules
    • Stage III: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent “solid” edema of the central part of the face (phymatous)
  • Facial erythema, particularly on cheeks, nose, and chin. At times, entire face may be involved.
  • Inflammatory papules are prominent; pustules and telangiectasia may be present.
  • Comedones are absent (unlike acne).
  • Women usually have lesions on the chin and cheeks, whereas nose is commonly involved in men.
  • Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.

Diagnostic Tests and Interpretation

Diagnosis is based on physical exam findings.

Pathological Findings
  • Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
  • Absence of comedones and blocked ducts
  • Vascular dilation and dermal lymphocytic infiltrate

Differential Diagnosis

  • Drug eruptions (iodides and bromides)
  • Granulomas of the skin
  • Cutaneous lupus erythematosus
  • Carcinoid syndrome
  • Deep fungal infection
  • Acne vulgaris
  • Seborrheic dermatitis
  • Steroid rosacea (abuse)
  • Systemic lupus erythematosus

Treatment

Medication (Drugs)


First Line
  • Topical metronidazole preparations once or twice daily for 7–12 weeks was significantly more effective than placebo in patients with moderate to severe rosacea (1)[A]. A rosacea treatment system (cleanser, metronidazole 0.75% gel, hydrating complexion corrector, and sunscreen SPF30) may offer superior efficacy and tolerability to metronidazole (2).
  • Azelaic acid (Finacea) with oral doxycycline is very effective as initial therapy; azelaic acid topical alone is effective for maintenance (3)[A].
  • Doxycycline 40-mg dose is at least as effective as 100-mg dose and has a correspondingly lower risk of adverse effects (1).
  • Precautions: Tetracycline may cause photosensitivity; sunscreen is recommended.
  • Significant possible interactions:
    • Tetracycline: Avoid concurrent administration with antacids, dairy products, or iron.
    • Broad-spectrum antibiotics: May reduce the effectiveness of oral contraceptives; barrier method is recommended.

Pediatric Considerations
Tetracycline: Not for use in children <8 years

Pregnancy Considerations
  • Tetracycline: Not for use during pregnancy
  • Isotretinoin: Teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception
Second Line
  • Topical erythromycin
  • Topical clindamycin lotion preferred
  • Possible utility of calcineurin inhibitors (tacrolimus 0.1%; pimecrolimus 0.1%). Pimecrolimus 1% is effective to treat mild to moderate inflammatory rosacea (4).
  • Permethrin 5% cream (5)[A]; similar efficacy compared to metronidazole
  • Topical steroids should not be used, as they may aggravate rosacea.
  • For severe cases, isotretinoin PO for 4 months

Additional Treatment


General Measures
  • Use of mild, nondrying soap is recommended; local skin irritants should be avoided.
  • Reassurance that rosacea is completely unrelated to poor hygiene
  • Treat psychological stress if present.
  • Avoid oil-based cosmetics:
    • Others are acceptable and may help women tolerate symptoms.
  • Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
  • Cyclosporine 0.05% ophthalmic emulsion may be more effective than artificial tears for rosacea of the eyes (1).
  • Possible evolving laser therapy
  • Support physical fitness

Surgery/Other Procedures

Laser treatment is an option for progressive telangiectasias or rhinophyma.

Ongoing Care

Follow-Up Recommendations

Outpatient treatment

Patient Monitoring
  • Occasional and as needed
  • Close follow-up for women using isotretinoin

Diet

Avoid alcohol, excessive sun exposure, and hot drinks of any type.

Prognosis

  • Slowly progressive
  • Subsides spontaneously (sometimes)

Complications

  • Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
  • Conjunctivitis
  • Blepharitis
  • Keratitis
  • Visual deterioration

Additional Reading

  • Del Rosso JQ, Webster GF, Jackson M, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56:791–802.
  • Liu RH, Smith MK, Basta SA, et al. Azelaic acid in the treatment of papulopustular rosacea: A systematic review of randomized controlled trials. Arch Dermatol. 2006;142:1047–1052.

See Also

Codes

ICD-9

695.3 Rosacea

ICD-10

  • L71.9 Rosacea, unspecified
  • L71.8 Other rosacea

SNOMED

  • 398909004 Rosacea (disorder)

Clinical Pearls

  • Rosacea usually arises de novo without any preceding history of acne or seborrhea.
  • Rosacea may cause chronic eye symptoms, including blepharitis.
  • Avoid alcohol, sun exposure, and hot drinks.
  • Medication treatment resembles that of acne vulgaris with oral and topical antibiotics.

Authors


Adarsh K. Gupta, DO, MS, FACOFP

Figures

Figure 1-14

Rosacea. As seen here, rosacea is characterized by inflammatory papules and pustules and telangiectasias located on the central third of the face.

Bibliography

  1. van Zuuren EJ, Kramer SF, Carter BR, et al. Effective and evidence-based management strategies for rosacea: Summary of a Cochrane systematic review. Br J Dermatol. 2011;165(4):760–781. Epub 2011 Sep 15.
  2. Leyden JJ. Efficacy of a novel rosacea treatment system: An investigator-blind, randomized, parallel-group study. J Drugs Dermatol. 2011;10(10):1179–1185.  [PMID:21968669]
  3. Thiboutot DM, Fleischer AB, Del Rosso JQ, et al. A multicenter study of topical azelaic acid 15% gel in combination with oral doxycycline as initial therapy and azelaic acid 15% gel as maintenance monotherapy. J Drugs Dermatol. 2009;8:639–648.  [PMID:19588640]
  4. Kim MB, Kim GW, Park HJ, et al. Pimecrolimus 1% cream for the treatment of rosacea. J Dermatol. 2011;38(12):1135–1139. Epub 2011 Sep 28.
  5. Koçak M, Yağli S, Vahapooğlu G, et al. Permethrin 5% cream versus metronidazole 0.75% gel for the treatment of papulopustular rosacea. A randomized double-blind placebo-controlled study. Dermatology. 2002;205:265–270.  [PMID:12399675]


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