Rosacea Flashcards
what is rosacea?
o A Chronic cutaneous disorder1
o Common features2
o 4 subtypes of Rosacea1,4
o Patients can evolve from one subtype to another4,7
o Regardless of subtype, patients may progress from mild to moderate to severe4,7
o No cure for Rosacea6
o Background redness or erythema, ocular rosacea is a type
o Patients can resolve from one kind of rosacea to another
epidemiology of rosacea
o 30+
o 16 million Americans1
o Most frequently seen in Fitzpatrick skin types I & II
o Higher incidence in individuals of Celtic and Northern European descent
o Roughly 10% of fair skinned people have rosacea1,7
o With ETR and PPR, women are more affected than men
o With Phymatous rosacea, vast majority are men1
o Ocular rosacea affects both sexes equally
o Rosacea is extremely rare in people under 30
erythematotelangiectatic rosacea
o Characterized by flushing and persistent facial erythema o Telangiectasia are common o Central facial symptoms o A history of flushing alone is common o Rough, dry, scaly facial skin
panulopustular rosacea
o Persistent facial erythema
o Papules and pustules
o Burning and stinging
o Can be in combination with type 1
phymatous rosacea
o Thickening skin, irregular suface nodule
o Very oily skin
o May also occur in other areas of the face
o Often occurs with type 1 and 2
ocular rosacea
o Watery or bloodshot eyes, foreign body sensation
o Burning and stinging
o Telangiectases of the lid margins
o History of frequent hordeolum and chalazion
o Occurs in 50% of rosacea patients
diagnostic criteria of rosacea - primary features
o Presence of ONE OR MORE of the following primary features:
Flushing (Transient Erythema) – A hx of frequent flushing or blushing is common
Non-transient erythema
Papules and pustules
Telangiectasia
o Non-transient erythema is the most common sign
o Must differentiate between other causes of flushing
diagnostic criteria of rosacea - secondary features
o May include one or more of the following: Burning and stinging Plaque Dry appearance Edema Ocular manifestations Peripheral location Phymatous changes
pathophysiology of rosacea
o Selective receptor activation by rosacea triggers may determine phenotypic outcomes. Rosacea triggers have variable receptor activation patterns, depending on the stimulus. Dysregulated receptors render rosacea skin abnormally sensitive, and activation of neurogenic inflammation and innate immune pathways results in production of distinct mediators that may facilitate clinical manifestation of predominantly erythema, inflammatory lesions or phyma, respectively. Triggers that stimulate multiple receptor types with shared inflammatory axes among the pathways likely result in mixed phenotypic outcomes. Strength of activation: +, present; ++, intermediate; +++ strong
o CHEESE IS A MAJOR TRIGGER
o Proposed innate pathophysiological pathways in rosacea encompass skin, immune cells, nerves, and vessels. Trigger activation of TLR2 on keratinocytes or possibly mast cells yields active LL‐37, whose actions may result in angiogenesis and leucocyte chemotaxis. Activation of NALP3 in the IL‐1β inflammasome complex in macrophages or keratinocytes influences expression or secretion of downstream inflammatory modulators that manifest clinically in the formation of pustules, papules, and sensations of heat and pain, processes that may be further amplified by TLR2 activation or neuropeptides. Neuropeptides, which are produced in response to triggering of TRP ion channels on neuronal and non‐neuronal cells, can directly or indirectly result in vasodilation and mast cell activation. Other vascular effects and fibrotic processes can be perpetuated by inflammatory intermediates synthesized in response to these cellular activities
approach to flushing
o Distinguish between “true flushing” and disorders that cause facial erythema10
Lupus, Photosensitivity reaction, Rosacea
o Non-Rosacea Flushing10
Thermoregulatory Flushing
Menopause
Emotional Flushing
Medications (CCB’s, Nitro, PDE5 inhibitors, Niacin)
Alcohol
initial workup of rosacea
o Clinical Observation6
Look for any primary and secondary features
o A complete medical history is key
o Labs and Biopsy – No answer machine here (CT) (meaning that you cant send a sample out and get a definitive response)
No labs, biopsy is not warranted
o Look for other disease states that mimic rosacea
o Medical reconciliation6
o As Lauri would say, “LOOK AT YOUR PATIENT!”
o What are the unique Rosacea triggers?
difference between rosacea and acne
o The key: look for comedones o No comedones in rosacea o Erythema o Look for acne elsewhere o Centrofacial distribution o Acne and rosacea can coexist
non-pharmacologic treatment
o Lifestyle Management
Identify each patients unique triggers
Keep a diary recording possible triggers
Examples of triggers: heat, sun exposure, hot beverages, spicy foods, ETOH, psychogenic exercise
o “In one survey, 90% of patients who avoided their specific triggers had vast improvement of symptoms.”
o Will present with irritated, sensitive and inflamed skin
o They have self treated with OTC steroids, harsh cleansers and crap like apricot scrubs
o Stop using anything with FRAGRANCES, including:
Laundry detergents, hand soaps, perfumes or the dreaded scented body lotions
o Eliminate dryer sheets
o Proper skin care regimen is critical – must repair the epidermal barrier function8
o Sunscreen – At least spf 30+6
Use only PHYSICAL BLOCKS, no chemical blocks
Looks for products with Dimethicone3
o Facial Cleansing
Non-soap cleansers are preferred
Wash with only the finger tips3
No washcloths or Loofahs
o Basic function of moisturizers: provide SC hydration by reducing TEWL
o Epidermal dryness leads to cutaneous inflammation, and progression from non-inflammed to xerotic skin
o Find a moisturizer that has occlusive properties but greater humectant properties
o Post shower: blot with a towel and wait 30 minutes to apply any topical products
o Prime the skin: When they present with a FLARE14
3-5 days of ONLY mild cleansers and a moisturizer
Skin priming essentially resets the SC permeability barrier
Corrects the SC impairment
o Cosmetics
Green tint3
Flesh colored foundation
No waterproof cosmetics
FDA approved topicals
o Metronidazole is first line tx for papulopustular rosacea o Ivermectin is an antiparasitic topical = number one prescribed med in derm for papulopustular o Sodium Sulfacetamide-Sulfur Creams, lotions, cleansers Antimicrobial and Antidemodectic Concomitant Seborrheic Dermatitis7 65% decrease in inflammatory lesions6 o Metronidazole 50.7% reduction in lesion count11 Reduces ROS à Anti-inflammatory action QD-BID 2-4 weeks Relapse is common when D/C’d o Azelaic Acid Gel or Cream BID Decreases KLK5, ROS, UVB cytokines3 73% decrease in lesion count3 Irritating o Ivermectin 64.9% reduction in lesion count11 Anti-inflammatory, Anti-parasitic3 Less irritating than vehicle
non FDA approved topicals
• Elidel o Essential for ETR and PPR7 o Baseline irritant contact dermatitis o Non-irritating, non-steroidal anti-inflammatory6,7 o Short course o Atopic Dermatitis o Black Box Warning
