Rosacea

Question 1

What factors cause rosacea?

Answer 1

Genetics = fam hx

compromised or impaired skin barrier = allow micro-orgs to penetrate + cause inflam

Altered immune response, skin and gut microbiome

Vascular hyper-reactivity

Question 2

What are some signs and symptoms of rosacea?

Answer 2

Transient/recurrent flushing of skin

Telangiectasia (broken capillaries under skin)

Pustules and papules

thickening of skin

Persistent facial swelling

Question 3

Summarise Erythematotelangiectatic rosacea (ETR)

Answer 3

freq/recurrent blushing/flushing of face (nose, medial cheeks)

persistent

Question 4

Summarise papulopustular rosacea (PPR)

Answer 4

Inflammatory papules and pustules –> common feature

Comedones are not present

Papules/pustules (sometimes) on nose, forehead, cheeks, chin often follow

Question 5

Summarise phymatous rosacea

Answer 5

Enlarged unshapely nose with prominent pores (Sebaceous hyperplasia) and fibrous thickening

Firm swelling of other facial features (inc eye lids)

Persistent redness and swelling or solid oedema of upper face due to lymphatic obstruction

Question 6

Summarise ocular rosacea

Answer 6

Eye irritation and blepharitis = 20% of rosacea patients

Red, sore, or gritty eyelid margins (inc papules and styes)

Sore or tired eyes (conjunctivitis, keratitis, episcleritis)

Question 7

Explain some differential diagnoses for rosacea

Answer 7

Acne = involves open/closed comedone, not involve eyes

Periorbital dermatitis = involves an eruption of small pap/pustules around mouth

Seborrhoeic dermatitis = may improve upon sun exposure, flaky dry skin, no papules or pustules -> itchy, greasy scales

Question 8

What are some non-pharmacological treatments of rosacea?

Answer 8

Minimise risk factors that cause flushing

avoid emotional, alcohol, spicy food, exercise, extreme temp, hot drinks

sun protection plus sun avoidance

Use emollient soap-free cleanser combined with low irritant sunscreen and/or foundation –> reduce irritation, mask erythrotelangiectatic feature

AVOID topical corticosteroids = can cause severe flare

Question 9

What are some common causes/contributors of flushing?

Answer 9

Menopause

rosacea

Emotional stress

rapid change in temp

alcohol

Hot or spicy foods

Question 10

What are some less common factors associated with flushing?

Answer 10

Food additives (monosodium glutamate, nitrites, nitrates)

Neurological disorders

carcinoid syndrome

Phaechromocytoma

Systemic mastocytosis

Question 11

List the treatments used for rosacea-derived papules and pustules

Answer 11

Metronidazole gel or cream

azelaic acid gel

Topical ivermectin

Oral antibiotic +/- topical therapy

Question 12

Summarise the use of metronidazole in rosacea (length of use, when improvement seen, etc.)

Answer 12

Dose freq = once or twice daily for 6-12 weeks

Improvement seen w/in 2-4 weeks

Long-term maintenance req

Well tolerated, dryness, redness, burning and stinging

Question 13

Summarise the use of azelaic acid in rosacea (length of use, when improvement seen, etc.)

Answer 13

Once or twice daily (morning and night) for 6-12 weeks

Less effective than metronidazole

Question 14

Summarise the use of topical ivermectin in rosacea

Answer 14

For those unresponsive or intolerant to metronidazole or azelaic acid

Benefit seen after 2-4 wks

Question 15

Summarise the use of antibiotics in rosacea

Answer 15

1) Doxycycline, erythromycin
2) minocycline

If not tolerated or no response after 4 wks - change

Question 16

What is used to treat rosacea when nothing else works?

Answer 16

Low dose isotretinoin

Question 17

How is ocular rosacea treated?

Answer 17

Eye lid hygiene

ocular lubricants

Oral abx as per papulopustular rosacea

Refer to ophthalmologist

Question 18

How is erytematotelangiectatic rosacea treated? (facial erythema)

Answer 18

Brimonidine gel (topical vasocon) = once daily in morning

Effect seen in 30 mins, lasts 12 hours for short term improvement

A/E = rebound erythema with long term use, worse than baseline but transient

Vascular laser treatment

Question 19

What medications treat mild-moderate rosacea?

Answer 19

metronidazole gel or cream

Question 20

What medications treat mild and papulopustular rosacea?

Answer 20

azelaic acid gel

Question 21

What medications treat mild/moderate papulopustular rosacea?

Answer 21

Topical ivermectin

Question 22

What medications treat severe rosacea when topical therapy is unsuccessful rosacea?

Answer 22

Oral antibiotics

1) doxycycline, erythromycin

2) minocycline

Question 23

What lifestyle factors can help rosacea?

Answer 23

Try to identify triggers

Be sun safe = sunscreen

Commit to basic skincare regimen and be kind to skin

Avoid overheating = alcohol, spicy food, hot temp, extreme temp

Minimise changes in cosmetics

Apply cool water to face after exercise

No picking or squeezing pustular lesions