Rosacea

Essentials of Diagnosis

• A chronic facial disorder

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

• Acneiform component: papules and pustules may also be present

• Glandular component: sebaceous hyperplasia and fibrosis of affected areas (eg, rhinophyma)

General Considerations

• Pathogenesis is not known

• Topical corticosteroids applied to the face can induce rosacea-like conditions

• Rosacea is usually a lifelong affliction, so maintenance therapy is required

Symptoms and Signs

• Patients frequently report flushing or exacerbation of the rosacea by heat, hot drinks, spicy food, sunlight, exercise, alcohol, emotions, or menopausal flushing

• The cheeks, nose, chin, and ears—at times the entire face—may have a rosy hue

• No comedones

• In its mildest form, erythema and telangiectasias are seen on the cheeks

• Inflammatory papules are prominent, and there may be pustules

• Associated seborrhea may be found

• Patients may also have associated ophthalmic disease, including blepharitis, keratitis, and chalazion

Differential Diagnosis

• Acne vulgaris

• Seborrheic dermatitis

• Perioral dermatitis

• Systemic lupus erythematosus

• Carcinoid

• Dermatomyositis

• Topical corticosteroids can change trivial dermatoses of the face into perioral dermatitis and steroid rosacea

• Clinical

Medications

• See Table 6–2

• Medications are most effective directed at the inflammatory papules and pustules and the erythema that surrounds them

LOCAL THERAPY

• Metronidazole, 0.75% gel applied twice daily or 1% cream once daily, is the topical treatment of choice

• If metronidazole is not tolerated, topical clindamycin (solution, gel, or lotion) 1% used twice daily is effective; response is noted in 4–8 weeks

• Sulfur-sodium sulfacetamide-containing topicals are helpful in patients only partially responsive to topical antibiotics

• Benzoyl peroxide, as in acne vulgaris, may be helpful in reducing the pustular component

• Topical retinoids can be carefully added for maintenance

• Topical bromonidine tartrate gel 0.5% can temporarily reduce the flush/redness of rosacea patients

SYSTEMIC THERAPY

• Oral tetracyclines should be used when topical therapy is inadequate

• Minocycline or doxycycline, 50–100 mg once or twice daily orally, may also be effective

• Metronidazole or amoxicillin, 250–500 mg twice orally daily

  • May be used in refractory cases

  • Side effects are few, although metronidazole may produce a disulfiram-like effect when the patient ingests alcohol and it may cause neuropathy with long-term use

• Rifaximin, 400 mg orally three times daily (for 10 days), is an alternative for refractory cases

• Isotretinoin may succeed where other measures fail; a dosage of 0.5–1.0 mg/kg/day orally for 12–28 weeks is recommended

Therapeutic Procedures

• Educate patients to avoid exacerbating factors (especially alcohol)

• Drinking ice water may be effective in temporarily reducing facial erythema and flushing

• Patients should wear a broad-spectrum sunscreen with UVA coverage

  • However, exquisite sensitivity to topical preparations may limit patient options

  • Zinc- or titanium-based sunscreens are better tolerated

  • Barrier protective silicones in the sunblock may enhance tolerance

Surgery

• Laser therapy

  • Effective for telangiectases

  • More effective than topical brimonidine tartrate gel for erythema

• Phymatous overgrowth of the nose can be treated by surgical reduction

Prognosis

• Usually a lifelong condition, so maintenance therapy is required

• With the regimens described above, it can usually be controlled adequately

When to Refer

• There is a question about the diagnosis

• Recommended therapy is ineffective

• Specialized treatment is necessary