Rosacea

Question 1

2 main abnormalities in rosacea?

Answer 1

Neurovascular dysregulation: heightened TRPV activity within skin.

Aberrant innate immune response: vasodilation, plasma extravasation of protein and recruitment of inflammatory cells and regulation of IL-37

Question 2

Morphology of rosascea?

Answer 2

It is normally on the central face

Question 3

Types of rosacea?

Answer 3

erythematotelangiectatic (vascular), papulopustular, phymatous, ocular rosacea

Question 4

Difference between papulopustular rosacea and acne?

Answer 4

deeper red color and no comedones unlike acne.

Question 5

What is the difference between acne and rosacea fulminans (also called pyoderma faciale)?

Answer 5

Usually in women (vs adolescent men), associated with IBD, RAPID onset of intensely inflamed coalescent fluctuant nodules and cysts on the background of dark red erythema.

Question 6

What two things can cause caseating histiocytic granulomas?

Answer 6

Tuberculosis, and lupus miliarias desseminata faciale

Question 7

Epidemiology of rosacea?

Answer 7

Peaks at 30-40 y/o, F>M, 20% have a family hx of rosacea, skin types I and II most commonly affected.

Question 8

What are the two major abnormalities seen in rosacea?

Answer 8

Neurovascular dysregulation: heightened TRPV activity within the skin. Aberrant innate immune response: causes vasodilation, plasma extravasation of protein, and recruitment of inflammatory cells. (upregulation of LL-37)

Question 9

Clinical presentation of erythematotelangietatic rosacea?

Answer 9

Usually is on the central face. With the vascular variant, you get central face w/ recurrent blush that eventually becomes permanent flushing. They also can have a burning, stinging sensation; easily irritated w/ roughness and scaling. Can also have edema and telangiectasias

Question 10

Clinical feature of papulopustular rosacea?

Answer 10

Similar to acne vulgaris, but lesions may have a deeper red color and no comedones.

• Persistent central facial erythema w/ transient papules/ pustules
• Pustules are small <3mm, dome-shaped, erythematous papules with varying stages of evolution

Question 11

What bacteria is associated with demodex and can stimulate inflammation in rosacea?

Answer 11

Bacillus oleronius

Question 12

What is the cause of phymatous rosacea?

Answer 12

Thickening of the skin occurs due to the overgrowth of sebaceous glands.

Question 13

How common is ocular rosacea?

Answer 13

About 50% of rosacea patients are affected

Question 14

Presentation of ocular rosacea?

Answer 14

Dryness foreign body sensation, photosensitivity, burning/stinging, blepharitis, recurrent chalazion, conjunctivitis, keratitis, iritis, scleritis

Question 15

Types of rosacea that can cause facial edema?

Answer 15

Morbihan disease and rosacea lymphedema

Question 16

Presentation of morbihan disease and rosacea lymphedema?

Answer 16

Hard nonpitting swelling of forehead, glabella, nose, cheeks. Can be more pronounced during the morning hours, spontaneous resolution does not occur.

Question 17

Treatment for morbihan’s disease or rosacea lymphedema

Answer 17

Isotretinoin plus/minus ketotifen (antihistamine). You can also try systemic steroids, antibiotics, and lymphatic drainage/compression therapy.

Question 18

What is pyoderma faciale?

Answer 18

Another name for rosacea fulminans. The Key is that there are no comedones which is a big difference between this and acne fulminans.

Question 19

What systemic sx’s can be presetn in rosacea fulminans?

Answer 19

Can have low grade fever, myalgias, increased WBC, increased ESR.

Question 20

What is the treatment for rosacea fulminans?

Answer 20

Prednisone (slow taper) and isotretinoin

Question 21

What is granulomatous rosacea?

Answer 21

Granulomatous rosacea: discrete yellow/brown-red firm monomorphic papules or nodules on background of diffusely reddened thickened skin no butterfly region. Can also be distributed around periphery of face and perioral areas. On histology, non-caseating epithelioid granulomas; resembles sarcoidosis.

Question 22

Treatment for granulomatous rosacea?

Answer 22

Tetracyclines and isotretinoin.

Question 23

What is this? 25 y/o woman, presenting w/ smooth, firm, yellow-brown to red 1-3mm monomophous papules.

Answer 23

Lupus miliaris disseminatus faciei

The involvement of the eyelid is especially characteristic. It heals with scarring.

Tx is difficult and you can consider isotretinoin adn tetracyclines.

Question 24

Histologic findings of rosacea?

Answer 24

• perivascular and perifollicular lymphohistocytic infiltrate, vascular ectsia, mild edema, sebaceous hyperplasia (eyrethematotelangetatic)
• Papulopustular: dense dermal infiltrate of lymphs, predominatly surrounding an involved hair follicle - marked solar elastosis
• granulomatous subtype histocytes, giant cells, admixed lymphs filling upper interfollicular derms

Question 25

What stains/histologic markers are increased in rosacea?

Answer 25

VEGF, CD31 (also vascular), D2-40 (lymphatic endothelial marker, podoplanin)

Question 26

Topical tx options for rosacea?

Answer 26

Metronidazole, sodium sulfacetamide/sulfur, azelaic acid, benzoyl peroxide, clindamycin, green-tinted makeup

Question 27

What genodermatosis is associated w/ a rosacea-like eruption and verrucous lesions?

Answer 27

Cutaneous disorder of hyperpigmentation characterized by reticulated pigmentation of the person's skin. - Key features: rosacea-like facial eruption reticulated hyperpigmentation of major flexures, comedones on the back and neck, and pitted facial scars

Question 28

What is rosaceiform dermatitis?

Answer 28

- Cutaneous reaction to a drug that resembles rosacea - Usually topical or systemic corticosteroids and topical calcineurin inhibitors - Facial erythema plus small papules and pustules - Widespread distribution on face

Question 29

Clinical presentation of steroid-induced rosacea?

Answer 29

Facial eruption erythema, papules and pustules 2/2 repeated application of mod-high potency steroids.

Question 30

What is idiopathic facial aseptic granuloma?

Answer 30

Single erythematous nodule on the cheek of a child (several months, then resolves)

Question 31

What is the clinical presentation of pityriasis folliculorum?

Answer 31

Women 20-40 y/o who rarely allow water on their face and instead use moisturizing and cleansing creams Roughened whitish scaling skin surface (frosty) and some scattered fine papules and pustules Tx: topical sulfur or permethrin 5% cream

Question 32

What skin types are most commonly affected by rosacea?

Answer 32

Types I and II

Question 33

What part of the face is most commonly affected by rosacea?

Answer 33

Central face distribtuion

Question 34

What is the histology seen in rosacea?

Answer 34

Perivascular and perifollicular lymphohistiocytic infiltrate, vascular ectasia, mild edema, and sebaceous hyperplasia

Question 35

What are the general treamtent principles of rosacea?

Answer 35

- Avoid triggers: sunlight, heat/cold, stress, strong emotions, EtOH, hot beverages, spicy foods, and chemical irritation - Topicals: **metronidazole**, sodium sulfacetamide/sulfur, azelaic acid, BP, clindamycin, and green-tinted makeup - Systemic: Doxy/minocycline, isotretinoin if severe - Can use laser for vascular changes/redness: IPL and PDL

Question 36

What is Haber's syndrome?

Answer 36

Genodermatosis w/ rosacea-like eruption and verrucous lesions

Question 37

What is the treatment for ocular rosacea?

Answer 37

Doxycycline/minocycline

Question 38

What times of the day is Morbihan's disease and rosacea lymphedema worse?

Answer 38

Tends to be worse in the early morning

Question 39

Does solid facial edema in rosacea spontaneously resolve?

Answer 39

NO! Needs to be treated

Question 40

What is the clinical presentation of lupus miliaris disseminatus faciei?

Answer 40

Smooth, firm, yellow-brown to red 1-3 mm monomorphous papules - Occurs in the typical distribution of rosacea (central butterfly of the face) - **Eyelid skin involvement is characteristic**

Question 41

What is the most common attributed cause of perioral/periorificial dermatitis?

Answer 41

Topical fluorinated corticosteroids

Question 42

What are the topical fluorinated corticosteroids?

Answer 42

Triamcinolone acetonide, betamethasone and beclomethasone

Question 43

The clinical description of perioral/periorificial dermatitis?

Answer 43

Clusters of small, pink, discrete scaly papules/pustules in personal region - **Has clear zone around the vermillion border** - Can also involve nasolabial folds and cheeks

Question 44

What are the typical sx's of perioral/periorificial dermatitis?

Answer 44

Burning sensation - Not much itching

Question 45

Treatment of perioral/periorificial dermatitis?

Answer 45

Self-limited usually (months-years) - Doxy/minocycline, or erythromycin if in the pediatric population for 6-8 weeks then taper - Can also try topical calcineurin inhibitors, topical antibiotics, topical metronidazole