Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 6-28: Rosacea + Key Features Download Section PDF Listen +++ +++ 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 + Clinical Findings Download Section PDF Listen +++ +++ 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 + Diagnosis Download Section PDF Listen +++ ++ Clinical + Treatment Download Section PDF Listen +++ +++ 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 + Outcome Download Section PDF Listen +++ +++ 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 + References Download Section PDF Listen +++ + +Alexis AF et al. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: review and clinical practice experience. J Am Acad Dermatol. 2019 Jun;80(6):1722–9. [PubMed: 30240779] + +Del Rosso JQ et al. Update on the management of rosacea from the American Acne & Rosacea Society (AARS). J Clin Aesthet Dermatol. 2019 Jun;12(6):17–24. [PubMed: 31360284] + +van Zuuren EJ et al. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. Br J Dermatol. 2019 Jul;181(1):65–79. [PubMed: 30585305]