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A. Characteristics navigator

  1. Common disorder formerly called acne rosacea
  2. Most patients age 30-60 years and have fair hair and skin
  3. Inflammatory process of unclear etiology
    1. Infectious diseases have been implicated
    2. Helicobacter pylori and face mite Demodex folliculorum
  4. Constellation of skin findings
    1. Facial flushing
    2. Telangiectatic vessels
    3. Persistent redness of face
    4. Eruption of inflammatory papules, pustules
    5. Hypertrophy of sebaceous glands of nose
    6. Nasal fibrosis (rhinophyma)
    7. Mild dryness and irritation
    8. Blepharaitis and/or conjunctivitis
  5. Classified into Four Types
    1. Erythematotelangiectatic
    2. Papulopustular
    3. Phymatous
    4. Ocular
  6. Vascular Dysfunction
    1. Vasomotor instability leads to flushing
    2. Vascular endothelial growth factor (VEGF) may be involved in telangiectasias
    3. Migraines also have some link (abnormal vascular dilation)
  7. Many aggrevating factors identified

B. Symptomsnavigator

  1. Erythema (>95%)
  2. Intermittent facial flushing (~40%)
  3. Inflammatory lesions usually on face - papules and pustules
  4. Telangiectasia (~50%) and Lymphedema (<20%)
  5. Social stigma with psychological disturbances
  6. Rhinophyma
    1. Severe rosacea, occurs in ~15% of cases
    2. Hypertrophy of connective tissue of nose
    3. Cosmetic surgery is required to correct rhinophyma

C. Stagesnavigator

  1. Pre-rosacea: flushing and blushing
  2. Vascular: central facial erythema and telangiectasias, ocular symptoms
  3. Inflammatory: papules and pustules
  4. Late: rhinophyma

D. Aggrevating Factorsnavigator

  1. Sun exposure
  2. Emotional stress
  3. Hot weather
  4. Alcohol
  5. Spicy foods
  6. Exercise
  7. Wind
  8. Hot baths
  9. Cold weather
  10. Hot drinks
  11. Skin-care products
  12. Niacin

E. Differential Diagnosis navigator

  1. Acne vulgaris
  2. Systemic Lupus Erythematosus (SLE)
    1. Often spares tip of nose and nasolabial folds
    2. Rosacea may affect both of these areas
    3. Pustules are extremely rare in SLE
  3. Polymorphus light eruption (photodermatitis)
    1. Triggered by sunlight exposure
    2. Skin lesions similar to early acne
    3. Affects ALL sun-exposed areas of skin, unlike rosacea
  4. Seborrheic Dermatitis
  5. Perioral Dermatitis
  6. Steroid induced acne
  7. Cutaneous sarcoidosis - biopsy may be required

F. Treatment [3] navigator

  1. Avoidance of triggers is generally not successful
    1. Substantial alcohol ingestion should be avoided
    2. Sunscreens should be used on sun exposed skin
    3. Topical therapy should be instituted early to avoid permanent damage
    4. Erythema and flushing may respond to clonidine or nonselective ß-adrenergic blockers
    5. Topical glucocorticoids are usually avoided as they can exacerbate disease
  2. Topical Antibiotic
    1. Effective for mild rosacea, particularly early in course
    2. A 2 week trial of specific agent is used
    3. Should reduce papules and pustules >50%, mildly reduce erythema
    4. Topical metronidazole (Metrogel®, Metrocream®, Galderma®) qd or bid is first line
    5. Metronidazole gel 0.75% effective in >50% of patients, generally well tolerated
    6. Erythromycin or clindamycin (Cleocin®) creams are reasonable second lines
    7. In pregnancy or nursing, metronidazole and tetracyclines should be avoided
    8. Continue agent for 1-2 months if effective
    9. Recurrence is common and chronic intermittent use is most common
    10. Does not affect telangiectasia, rhinophyma or ocular disease
  3. Azelaic Acid
    1. Gel 15% (Finacea®) and cream 20% (Azelex®) are available for bid application
    2. Likely has antibacteria, anti-keratinizing, anti-inflammatory activity
    3. Probably slightly more effective than metronidzole gel
    4. Burning, stinging, itching all transient, ~40% of patients
    5. No effect on telangiectasia, rhinophyma, ocular disease
  4. Retinoids
    1. Topical tretinoin (Retin A®) - for antibiotic resistant cases
    2. Oral isotretinoin (Accutane®) - for resistance to topical agents
    3. Activity of these agents has been questioned for true rosacea
    4. Probably some benefit in papular and pustular disease
  5. Oral Antibiotics
    1. Generally for moderate and severe rosacea
    2. Doxycyline 50-100mg po qd or bid or minocycline 100mg po bid is first line
    3. Low dose doxycycline 40mg po qd (Oracea®) is FDA approved for rosacea [4]
    4. All tetracyclines associated with photosensitivity (minocycline is least)
    5. Oral metronidazole (Flagyl®) or clindamycin may be used second line
    6. Trimethoprim/sulfamethoxazole (TMP/SMX, Bactrim®) third line
    7. Effective for ocular disease (topical agents not effective in ocular disease)
  6. Dapsone or hydroxychloroquine may be considered
  7. Anti-bacterial therapy against H. pylori may be effective
  8. Ocular Rosacea
    1. Oral doxycycline first line and very effective
    2. Short course of topical glucocorticoid solution may be effective (caution with use)
    3. Liquid tears for dry eyes
    4. Low dose oral isotretinoin 10mg 3X weekly for 2-3 months can be tried
  9. Plastic surgery for rhinophyma
  10. Laser therapy is effective for telangiectasias

References navigator

  1. Powell FC. 2005. NEJM. 352(8):793 abstract
  2. Blount BW and Pelletier AL. 2002. Am Fam Physician. 66(3):435 abstract
  3. Azelaic Acid. 2003. Med Let. 45(1165):76 abstract
  4. Doxycycline Low Dose. 2007. Med Let. 49(1252):5 abstract