Acne Rosacea Flashcards
Presentation of acne rosacea
Patients usually complain of the skin condition but direct enquiry may often reveal a long history of flushing back to early teens or before.
The symptoms are initially intermittent but progress to a constant flushing with obvious telangiectasia.
A few complain of gritty eyes and facial oedema.
The skin is not greasy as in acne and may be rather dry.
Erythema and telangiectasias over the forehead and cheeks are variable.
Although the usual areas affected are the nose, cheeks and forehead, other areas, such as the neck, chest and ears, can become involved.
Sebaceous glands are prominent.
The nose may be enlarged and distorted by rhinophyma.
There may be peri-orbital oedema.
Classification of acne rosacea
Papulopustular rosacea
Ocular rosacea
Phymatous rosacea
Erythemato-telangiectatic rosacea
What is papulopustular rosacea?
Patients are typically middle-aged women with a red central portion of their face that contains small erythematous papules surmounted by pinpoint pustules.
They may have flushing. Telangiectasias are often present but may be difficult to distinguish from the erythematous background in which they exist.
What is phymatous rosacea?
Shows marked skin thickenings and irregular surface nodularities of the nose, chin, forehead, one or both ears and/or the eyelids.
There are four histological types of rhinophyma that include glandular, fibrous, fibroangiomatous and actinic.
What is ocular rosacea?
May precede the cutaneous form by years but often they develop together. The ocular signs include blepharitis, conjunctivitis, inflammation of the lids and meibomian glands, interpalpebral conjunctival hyperaemia and conjunctival telangiectasia.
There may be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation. This may sometimes be confused with blepharitis.
What is erythemato-telangiectatic rosacea?
Shows central facial flushing, often with burning, stinging or itching. The redness usually spares around the eyes.
They usually have skin with a fine texture that lacks a sebaceous quality typical of other types.
The erythematous areas of the face at times appear rough with scale likely due to chronic, low-grade dermatitis.
The burning or stinging is exacerbated when topical treatments are applied. The flushing often progresses to a permanent erythema and telangiectasias over the affected areas.
What are the triggers of flushing?
Heat or changes in temperature. Alcohol. Caffeine. Spicy foods. Stress or embarrassment. Sun or wind. Medication that causes vasodilatation.
Differentials for acne rosacea
Acne vulgaris
Seborrhoeic dermatitis which is more likely to cause flaking and dryness of the skin.
Perioral dermatitis from use of potent steroids on the face.
SLE or discoid lupus erythematous
Polymyositis and dermatomyositis
Photosensitive eruptions
Menopause because of hot flushes
Investigations for acne rosacea
Clinical diagnosis
Skin biopsy may be helpful.
Management of acne rosacea
General measures include:
Reassure patients of the benign nature of the condition and the relative rarity of any complications (including development of rhinophyma).
Avoid precipitating or aggravating factors for their trigger factors of flushing.
Facial massage may reduce oedema.
Sunscreens should be applied daily.
Avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents to be removed, or products containing sodium lauryl sulfate.
Drugs such as metronidazole topical, azelaic acid and oral tetracyclines
Laser treatment can obliterate telangiectasia
Rhinophyma responds poorly to medical treatment and surgery is usually required such as mechanical dermabrasion.
Drugs used in the treatment of acne rosacea
Mild-to-moderate rosacea should be treated with a topical preparation.
Topical metronidazole 0.75% is a common first-line option.
Azelaic acid 15% gel is an alternative, especially in those with more inflammatory rosacea. It may be more effective but can cause sensitivity reactions in some patients.
Moderate-to-severe papulopustular rosacea usually requires oral antibiotics. These are thought to act by virtue of their anti-inflammatory rather than antimicrobial action.
Commonly used preparations are oxytetracycline 500 mg bd, lymecycline 408 mg od or doxycycline 40 mg od.
Management of ocular rosacea
Regular lid hygiene with diluted baby shampoo and a cotton bud with warm compress.
Artificial tears should be used at frequent intervals.
Systemic tetracyclines are an effective treatment for ocular rosacea.
Referral to secondary care for acne rosacea
Routine dermatology referral:
Persistent symptoms that are causing psychological or social distress.
Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
Uncertain diagnosis.
Routine referral to a plastic surgeon:
Severe phymatous disease.
Prominent rhinophyma.
Routine referral to an ophthalmologist:
Ocular symptoms are severe.
Ocular symptoms fail to respond to maximal treatment in primary care.
Urgent referral to an ophthalmologist:
Suspected keratitis when there is eye pain, blurred vision or sensitivity to light.
What is acne excoriee?
Patient picks at the skin producing disfiguring erosions.
The acne itself is usually mild but tends to be persistent as it is often very difficult to help the patient break this habit.
What is acne conglobata?
A severe form of acne, more common in boys and in tropical climates.
There is extensive, nodulocystic acne, and abscess formation affecting particularly the trunk, face, and limbs.
Acne fulminans is similarly severe but is associated with systemic symptoms of malaise, fever and joint pains.
