Rosacea

Question 1

What is rosacea?

Answer 1

A chronic rash - relapsing and remitting disorder of blood vessels and pilosebaceous units in central facial areas

Question 2

What age range does it typically affect?

Answer 2

30-60

Question 3

Who is it common in?

Answer 3

Typically fair skinned people
Blue eyes
Celtic origin

Question 4

Is it related to acne?

Answer 4

No

Question 5

What pre-rosacea features can occur?

Answer 5

Flushing triggered by stress/ blushing, alcohol and spices

Question 6

What features occur?

Answer 6

A central facial rash - cheeks, forehead, nose, chin with erythema
Telangiectasia
Papules and pustules (without comedones)
Inflammatory nodules
Facial oedema
Sensitive skin

Question 7

What ocular involvement can occur?

Answer 7

Blepharitis / conjunctivitis
Episcleritis
Chalazion

Question 8

What can occur in men?

Answer 8

Rhinophyma

Question 9

What is rhinophyma?

Answer 9

Swelling and soft tissue overgrowth of nose
Skin thickened and sebaceous oil glands enlarged
Often prominent vessels - thin and red or large and purple
May be bulbous, pitted (due to prominent pores) and scarred

Question 10

What is often the first symptom?

Answer 10

Flushing

Then later develops into persistent erythema with papules and pustules

Question 11

What can exacerbate symptoms?

Answer 11

Sunlight

Question 12

Do blackheads, whiteheads or nodules occur?

Answer 12

No

Question 13

Scaling can occur. What is this called?

Answer 13

Rosacea dermatitis

Question 14

What is telangiectasia?

Answer 14

Prominent cutaneous blood vessels - red or purple in colour

Broken capillaries

Question 15

How is rosacea diagnosed?

Answer 15

Mostly clinically

Occasionally a skin biopsy performed - chronic inflammation and vascular changes

Question 16

What is the cause?

Answer 16

Several theories - genetic, environmental, vascular and inflammatory factors. Skin damage due to chronic UV exposure plays a part

High conc of antimicrobial peptides e.g cathelicidines have been observed - promote infiltration of neutrophils in dermis and dilation of vessels - fluid leaks out causing swelling and pro inflammatory cytokines leak into dermis increasing inflammation

MMPs play a role - contribute to thickened skin

Question 17

What self care advice can be given?

Answer 17

Reassure person about its benign nature, progression to severe disease e.g rhinophyma especially in women is uncommon
Not related to poor hygiene
Chronic condition - can be improved but flare ups may occur

Frequent application of high factor SPF to face
If skin is dry - hypoallergenic emollients
Avoid oil based creams
If flushing an issue, avoid triggers - stress, spicy food, caffeine, cheese, alcohol

Question 18

Why should you review a patient’s medication?

Answer 18

Some drugs can aggravate flushing e.g calcium channel blockers
Topical steroids can cause flare ups

Question 19

How should mild or moderate papulopustular rosacea (limited papules and pustules with no plaques) be managed?

Answer 19

Topical metronidazole - BD for 6-9 weeks
- generally well tolerated
OR
Azelaic acid 15% BD - may be more effective if do not have sensitive skin

Question 20

What side effects can azelaic acid cause?

Answer 20

Transient stinging, dryness, burning, itching

Question 21

How should moderate to severe rosacea be managed?

E.g extensive papules, pustules or plaques

Answer 21

An oral tetracycline or erythromycin
E.g tetracycline 500mg BD for 6-12 weeks

Erythromycin 500mg BD if pregnant or breastfeeding

Question 22

What should be considered if predominant flushing but limited telangiectasia?

Answer 22

Brimonidine 0.5% gel

Does not have any effect on papules, pustules or phymatous changes

Question 23

Prominent rhinophyma should be…

Answer 23

Referred to plastic surgeon

Question 24

What differentials are there?

Answer 24

Acne vulgaris
Seborrhoeic dermatitis
SLE

Question 25

How can telangiectasia be treated?

Answer 25

Laser treatment

Question 26

How can ocular rosacea be managed?

Answer 26

Eyelid hygiene
Ocular lubricants
Oral tetracycline if moderate to severe

Question 27

What areas of the face are sparred?

Answer 27

Perioral and periorbital skin

Question 28

What percentage have ocular involvement ?

Answer 28

50%