Acne Rosacea (PHARM)

Question 1

Acne Rosacea Definition

Answer 1

-Non contagious chronic skin disorder characterized by recurrent flushing, persistent redness on the central face (cheeks, chin, nose and forehead)

-Appearance of spider like blood vessels (telangiectasia)
-Eruption of papule and pustules on the central face convexities

-Occasional hypertrophy of sebaceous glands on the nose resulting in fibroses called rhinopehyma

-Affects mostly fair skin, sensitive skin, women, people who blush easily vascular instability

-Peak 40-50 yrs

Question 2

Pathophysiology of acne rosacea

Answer 2

1. Genetic predisposition and environmental triggers (immune defence, cytokines)
2. Neuro-vascular dysregulation (flush)
3. Vasodilation (erythema, telangiectasia)
4. Microorganisms such as mite
5. Chronic inflammation, sustained innate immune and neurogenic stimulation (fibrosis)

Question 3

4 phases of rosacea

Answer 3

1. Pre-rosacea phase: flushing and blushing, stinging
2. Vascular phase: facial erythema and edema, multiple telangiectasis, vasomotor instability
3. Inflammatory phase: sterile papules and pustules
4. Late phase: in some male patients, coarse tissue hyperplasia and fibrosis of the necks and nose (rhinophyma) -> tissue inflammation, collagen deposition and sebaceous gland hyperplasia

Question 4

Medications that worsen Rosacea

Answer 4

-Calcium channel blockers
-Niacin
-Amyl nitrate
-Opioid analgesics
-Amiodarone
-Topical steroids, nasal steroids
-High dose of Vitamin B 6 and 12

Question 5

4 subtypes of rosacea

Answer 5

1. Vascular (erythematotelangiectatic): flushing, burning or stinging
2. Inflammatory (papulopustular): persistent erythema on central face with small papule and pinpoint pustules with NO comedones, flushing/burning is possible, facial edema
3. Phymatous: skin thickening and irregular modularities on nose, chin, ears, eyelids, rhinophyma
4. Ocular: watery, bloodshot eyes, blepharitis ,conjunctivitis, scleritis, keratitis, eye lid irregularities, inflammation, vision loss is possible

Question 6

Non-pharmacological treatment for Rosacea

Answer 6

-Non pharmacological management: avoid triggers
-Sunscreen daily
-Avoid drying soaps
-Moisturize “occlusive substances”: to retain water of stratum corneum

Question 7

Pharmacological treatment for Rosacea

Answer 7

-Mild to moderate rosacea: topical metronidazole or azelaic acid, topical sulfacetaminde/sulfur, topical erythromycin or clindamycin, topical brimonidine for redness

-Recurrent and severe rosacea: use same acne due to presence of pustules, oral antibiotics such as tetracycline to reduce redness and inflammation in full dosage up to 6 months

-Treatment resistant rosacea: oral isotretinoin

Question 8

Metronidazole cream for rosacea

Answer 8

-Anti-inflammatory and anti-bacterial
-Gold standard for stage 1 and 2
-Avoid in pregnant women, category B
-Side effects: burning, transient erythema, mild pruritus and dryness
-Redness decreased within 2 weeks
-At 8 weeks seen improvements
-Use for 6-8 weeks

Question 9

Azelaic Acid gel

Answer 9

-Anti-inflammatory and anti-bacterial
-Avoid in pregnant women, category B
-Side effects: burning, transient erythema, mild pruritus and dryness, hypopigmentation with dark complexions

Question 9

Sodium Sulfacetamide and sulfur

Answer 9

-Anti-inflammatory and anti-bacterial
-8 weeks efficacy
-Contraindications: sulfonamide hypersensitivity, kidney disease, allergic swollen eyes, facial dryness, pruritis, hives, increase erythema
-Pregnancy category B

Question 10

Benzoyl Peroxide use for rosacea what for?

Answer 10

-To reduce papule and pustules
-Used for subtype 2
-Once a day
-Pregnancy category C

Question 11

Erythromycin and Clindamycin topical for rosacea

Answer 11

-Used for subtype 2
-Pregnancy category B

Question 12

Oral antibiotics for rosacea

Answer 12

-most effective against inflammatory papules and pustules, minimal effect on redness and telangiectasia

-Inhibition of neutrophil chemotaxis and reactive oxygen species

-Tetracyclines as anti-inflammatory effects (decrease in nitric oxide reducing inflammation), pregnancy category D and lactation B,

-Macrolides-erythromycin alternative to allergic and intolerance to tetracycline

-Oral metronidazole

Question 13

What is Brimonidine topical ?

Answer 13

-For facial redness in rosacea
-Alpha-2 adrenergic receptor agoinst
-Potent vasoconstrictor
-Avoid the eyes, eyelids, lips and mouth or inside the nose
-Onset 30 min after application lasts up to 12 hr
-cardiovascular side effects due to systemic absorption if applied to damaged skin or ingested orally