• 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

ALERT
Geriatric Considerations

• Uncommon >60 years of age
• Effects of aging might increase the side effects associated with oral isotretinoin (at present, data is insufficient due to lack of clinical studies in elderly patients aged 65 and above)

Prevalence

• Predominant age: 30–50 years
• Predominant sex: Female > Male. However, male will often progress to later stages.

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

Genetics People of Northern European and Celtic background commonly afflicted

No preventive measures known

• No proven cause
• Possibilities include:
  • Thyroid and gonadal 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

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

• 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 the onset of rosacea by years; nevertheless, rosacea usually arises de novo without any preceding history of acne or seborrhea.
• Excessive facial warmth and redness are the predominant presenting complaints. Itching is generally absent.

• 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, the entire face may be involved.
• Inflammatory papules are prominent, and there may be pustules and telangiectasia.
• 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.

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

• 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

First Line

• Azelaic acid (Finacea) with oral doxycycline is very effective as initial therapy and then azelaic acid topical alone is effective for maintenance (1)[A]
• 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.

ALERT
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%)
• Permethrin 5% cream (2)[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

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 the symptoms.
• Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
• Possible evolving laser therapy
• Support physical fitness

Laser treatment is an option for progressive telangiectasias or rhinophyma.

Outpatient treatment

Patient Monitoring

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

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

• Slowly progressive
• Subsides spontaneously (sometimes)

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

• 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;142:1047–52.

• Acne Vulgaris; Blepharitis; Dermatitis, Seborrheic; Lupus Erythematosus, Discoid; Uveitis
• Algorithm: Acne

695.3 Rosacea

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

398909004 Rosacea (disorder)

• 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

Adarsh K. Gupta, DO, MS

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.

1. 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;8:639–48.  [PMID:19588640]
2. 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;205:265–70.  [PMID:12399675]

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