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6-28: Rosacea

Kanade Shinkai; Lindy P. Fox

Key Clinical Updates in Rosacea

Most treatments target the papulopustular and cystic components. Only certain topical medications (brimonidine and oxymetazoline) and laser benefit erythema, with laser treatment having longer term benefit.

ESSENTIALS OF DIAGNOSIS

  • A chronic disorder affecting the face.

  • Neurovascular component: erythema and telangiectasis and a tendency to flush easily.

  • Acneiform component: papules and pustules may be present.

  • Glandular component: sebaceous hyperplasia and fibrosis of affected areas (eg, rhinophyma) (eFigure 6–54).

GENERAL CONSIDERATIONS

Rosacea is a common condition that presents in adulthood. The pathogenesis of this chronic disorder is not known. Topical corticosteroids applied to the face can induce rosacea-like conditions (eFigure 6–57).

eFigure 6–57.

This eruption resembling rosacea occurred following topical use of a steroid cream. (Used, with permission, from S Goldstein, MD.)

A photo shows rashes on the cheek and chin of a patient and its enlargement.
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CLINICAL FINDINGS

Patients frequently report flushing or exacerbation of their rosacea due to heat, hot drinks, spicy food, sunlight, exercise, alcohol, emotions, or menopausal flushing. The cheeks, nose, chin, and ears—at times the entire face—may be affected. No comedones are seen. In its mildest form, erythema and telangiectasias are seen on the cheeks (eFigure 6–58). Inflammatory papules may be superimposed on this background and may evolve to pustules (Figure 6–20) (eFigure 6–59). Associated seborrhea may be found. The patient often complains of burning or stinging with episodes of flushing and extremely cosmetic-intolerant skin. Patients may have associated ophthalmic disease, including blepharitis, keratitis, and chalazion, which often requires topical or systemic antibiotic or immunosuppressive therapy.

eFigure 6–58.

Telangiectasias—rosacea. (Used, with permission, from Richard P. Usatine, MD in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 3rd ed. McGraw-Hill, 2018.)

A close-up photo of a cluster of spider veins on the patient's nose. The spider veins appear as thin, thread-like patterns on the skin.
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eFigure 6–59.

Acne rosacea: close-up of papules. Note the absence of comedones. This is not acne. This is papulopustular rosacea. (Used, with permission, from Richard P. Usatine, MD in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 3rd ed. McGraw-Hill, 2018.)

A close-up photo of innumerous red bumps on the nose and cheeks.
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Figure 6–20.

Rosacea in a 34-year-old woman showing erythema, papules, and pustules covering much of the face. (Used, with permission, from Richard P. Usatine, MD, in Usatine RP, Smith MA, Mayeaux EJ Jr, Chumley H. The Color Atlas of Family Medicine, 2nd ed. McGraw-Hill, 2013.)

A photo of a woman’s face covered with red, raised patches of plaques clustered around the nose, and mouth and across the forehead.
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DIFFERENTIAL DIAGNOSIS

Rosacea is distinguished from acne by the presence of the neurovascular component and the absence of comedones (eFigure 6–55). Lupus is often misdiagnosed, but the presence of pustules excludes that diagnosis.

TREATMENT

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