Rosacea

Essentials

• The diagnosis is based on the patient's history and clinical presentation.
• Treatment according to the subtype of the disease.
• Exacerbations may be prevented with maintenance therapy.
• Bear in mind the symptoms caused by ocular rosacea and their treatment.

Aetiology

• Endogeneous and multifactorial
• Hereditary tendency; in the great majority of cases the disease can be encountered in close family members.
• Peak age of onset between 30 and 50 years, more common in women.
• Rapidly developing patchy facial flushing is a common first sign of rosacea. It usually lasts for longer than physiological flushing.
• Facial flushing Episodic Attacks of Flushing may be exacerbated by hot drinks, alcohol, spicy food, sunlight and heat.
• Glucocorticoid and tacrolimus creams may trigger a response on the face resembling rosacea (steroid rosacea).

Clinical picture

• A chronic skin disease associated with periodic exacerbations
• Symptoms occur intermittently principally on the central portion of the face and the convex surfaces of the cheeks.
• Diagnosis is clinical.
• Rosacea is classified into four different subtypes, which often co-exist in the same patient.
  • Erythematotelangiectatic type (couperose skin): facial flushing and redness as well as dilated blood vessels, i.e. telangiectasias, are typical (pictures )
  • Papulopustular: pustules and papules on the face, predominantly on the central portion of the face (picture )
  • Rhinophyma: sebaceous hyperplasia around the nose (picture )
  • Ocular rosacea: chronic blepharitis and other ocular symptoms Blepharitis caused by rosacea (pictures )
    • Minor ocular symptoms, such as eye dryness or stinging, are common.
    • A multitude of ocular manifestations are encountered, and even sight-threatening corneal lesions are possible.
    • Ocular manifestations of rosacea are often not well treated or are not treated at all.

Differential diagnosis

• The differential diagnosis of facial rashes is often challenging. The cornerstones are the patient's history, clinical presentation and the examination of other skin areas.
• Acne Acne: often seen in younger patients and is associated with comedos (blackheads)
• Perioral dermatitis Perioral Dermatitis: around the mouth, no telangiectasias
• Atopic dermatitis Atopic Dermatitis in Children: Clinical Picture, Diagnosis and Treatment: often around the eyelids, atopic diathesis
• Seborrhoeic dermatitis Seborrhoeic Dermatitis in the Adult: scaling, visible also, for example, on the scalp
• Allergic contact dermatitis Allergic Contact Dermatitis: may have papules, often pruritic
• Butterfly rash (picture ) suggestive of systemic lupus erythematosus Systemic Lupus Erythematosus (Sle) may sometimes be difficult to distinguish from rosacea; systemic symptoms and positive test results for serum antinuclear antibodies.

Treatment

• The mainstay of treatment is the avoidance of factors that, based on the patient's observations, aggravate the condition.
• Protection against the sun is always an integral part of treatment.
• Concealing cosmetics can be used provided that the products chosen are suitable for the patient's skin type.
• Erythematotelangiectatic rosacea
  • Response to topical treatment is usually fairly poor and very slow.
  • Brimonidine gel once daily is a symptomatic treatment option for facial flushing. It may also be effective for flushing symptoms induced by other causes.
  • Some patients benefit from low-dose beta-blocker treatment, e.g. propranolol 10-20 mg 3 times daily, propranolol as a depot preparation 160-320 mg once daily or atenolol 12.5-25 mg once daily, to attenuate the flushing reactions.
  • More permanent response is achieved by burning off superficial capillaries with KTP laser, Nd-YAG laser or pulsed dye laser, or broadband pulsed light devices.
• Papulopustular rosacea Interventions for Rosacea
  • Mild cases can be managed with gels or emulsions containing metronidazole or azelaic acid, which are applied once or twice daily in courses of 3-6 months.
  • Ivermectin cream once daily at night in courses of 3-4 months
  • Pimecrolimus cream 1-2 times daily in courses of 1-2 months
  • Clindamycin solution or emulsion 1-2 times daily in courses of 2-3 months.
  • The effect of topical treatment becomes apparent slowly, within 1-3 months.
  • Maintenance therapy, applied for example twice a week, is important in the prevention of exacerbations.
  • In more severe cases, a 6-12 week course of systemic antimicrobials is combined with topical treatment. Thereafter only topical maintenance treatment is continued.
  • Antimicrobials work on rosacea principally through mechanisms other than targeting microbes. They have no effect on flushing or telangiectasias.
    • Doxycycline 100-50 mg once daily, lymecycline 300-150 mg once or twice daily, tetracycline 500-250 mg once or twice daily (for 6-12 weeks)
      • The higher starting dose may be used for e.g. 2 to 4 weeks, whereafter the dose can be tapered off. Depending on the response the patient may as well continue with the starting dose during the whole treatment period and decrease the dose as needed if adverse effects should occur.
    • A treatment alternative is low-dose doxycycline 40 mg once daily (for 6-16 weeks).
    • Alternatives for tetracyclines are erythromycin 250-500 mg once or twice daily (for 6-12 weeks), azithromycin 250-500 mg on 2-3 days of a week (for 6-12 weeks) or metronidazole 200 mg once or twice daily (a shorter course, 4-6 weeks).
• Rhinophyma
  • Treatment is mainly surgical.
  • Only in mild cases might isotretinoin therapy, at the discretion of a dermatologist, be sufficient.
  • Hypertrophied tissue can be paired down using ablative laser therapy, electrosurgery or radiofrequency surgery with a wire loop or shave excision. Long term treatment results are usually achieved.
• Ocular rosacea (e.g. blepharitis)
  • Eyelid margin hygiene may be sufficient to treat mild ocular symptoms.
    • Place a soft towel moistened with warm water on the eyelids for 5 minutes in the evening.
    • Clean the eyelid margin with a cotton-tipped swab moistened with ophthalmic boric acid (or with ketoconazole shampoo diluted to 1:5-1:10). If the above is not tolerated, physiological saline or boiled water can be used.
    • Finally, apply eye ointment containing an antimicrobial drug or a combination of hydrocortisone and an antimicrobial drug to the eyelid margin.
    • Continue treatment for 2 weeks, after which continue with maintenance therapy of local heat and cleansing of the eyelid margin every other evening or a few times a week.
    • No ointment should be applied to the eyelid margin during maintenance therapy.
    • Continue with treatment so that the eyelid cleansing and ointment application is carried out every evening for one week every month for at least 6 months.
  • The condition is often further complicated by chronic conjunctivitis and dry eyes, which can be managed with preservative-free anti-inflammatory non-steroidal eye drops (e.g. cromoglycate eye drops). If necessary, standard artificial tears may also be used.
  • If the condition proves treatment-resistant, a consultation with a dermatologist and systemic antimicrobials are warranted.

Specialist consultation

• Rosacea resistant to appropriate treatment may warrant systemic isotretinoin therapy at the discretion of a dermatologist.
  • Some cases of sebaceous hyperplasia (e.g. rhinophyma) require surgical management.
  • Patients with treatment-resistant ocular rosacea or with severe eye symptoms should be referred to the care of an ophthalmologist.

Pictures