Acne Rosacea

Acne Rosacea

Basics

Description

• Rosacea is a chronic condition characterized by recurrent episodes of facial flushing, erythema (due to dilatation of small blood vessels in the face), papules, pustules, and telangiectasia (due to increased reactivity of capillaries) in a symmetrical, facial distribution. Sometimes associated with ocular symptoms (ocular rosacea).
• System(s) affected: Skin/Exocrine
• Synonym(s): Rosacea

Geriatric Considerations

• Uncommon >60 years of age
• Effects of aging might increase the side effects associated with oral isotretinoin (at present, data is insufficient due to lack of clinical studies in elderly patients aged 65 and above).

Epidemiology

Prevalence

• Predominant age: 30–50 years
• Predominant sex: Female > Male. However, male will often progress to later stages.

Risk Factors

• Exposure to cold, heat, hot drinks
• Environmental trigger factors: Sun, wind, cold

Genetics

People of Northern European and Celtic background commonly afflicted

General Prevention

No preventive measures known

Etiology

• No proven cause
• Possibilities include:
  • Thyroid and gonadal disturbance
  • Alcohol, coffee, tea, spiced food overindulgence (unproven)
  • Demodex follicular parasite (suspected)
  • Exposure to cold, heat, hot drinks
  • Emotional stress
  • Dysfunction of the gastrointestinal tract

Commonly Associated Conditions

• Seborrheic dermatitis of scalp and eyelids
• Keratitis with photophobia, lacrimation, visual disturbance
• Corneal lesions
• Blepharitis
• Uveitis

Diagnosis

History

• Usually have a history of episodic flushing with increases in skin temperature in response to heat stimulus in mouth (hot liquids), spicy foods, alcohol, sun (solar elastosis). Acne may have preceded the onset of rosacea by years; nevertheless, rosacea usually arises de novo without any preceding history of acne or seborrhea.
• Excessive facial warmth and redness is the predominant presenting complaint. Itching is generally absent.

Physical Exam

• Rosacea has typical stages of evolution:
  • The rosacea diathesis: Episodic erythema, “flushing and blushing”
  • Stage I: Persistent erythema with telangiectases
  • Stage II: Persistent erythema, telangiectases, papules, tiny pustules
  • Stage III: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent “solid” edema of the central part of the face (phymatous)
• Facial erythema, particularly on cheeks, nose, and chin. At times, entire face may be involved.
• Inflammatory papules are prominent, and there may be pustules and telangiectasia.
• Comedones are absent (unlike acne).
• Women usually have lesions on the chin and cheeks, whereas nose is commonly involved in men.
• Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.

Diagnostic Tests & Interpretation

Diagnosis is based on physical exam findings.

Pathological Findings

• Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
• Absence of comedones and blocked ducts
• Vascular dilation and dermal lymphocytic infiltrate

Differential Diagnosis

• Drug eruptions (iodides and bromides)
• Granulomas of the skin
• Cutaneous lupus erythematosus
• Carcinoid syndrome
• Deep fungal infection
• Acne vulgaris
• Seborrheic dermatitis
• Steroid rosacea (abuse)
• Systemic lupus erythematosus

Treatment

Medication

First Line

• Azelaic acid (Finacea) with oral doxycycline is very effective as initial therapy and then Azelaic acid topical alone is effective for maintenance (3,3)[A].

Precautions: Tetracycline may cause photosensitivity; sunscreen is recommended.

Significant possible interactions:

• Tetracycline: Avoid concurrent administration with antacids, dairy products, or iron.
• Broad-spectrum antibiotics: May reduce the effectiveness of oral contraceptives; barrier method is recommended.

Pediatric Considerations

• Tetracycline: Not for use in children <8 years

Pregnancy Considerations

• Tetracycline: Not for use during pregnancy
  • Isotretinoin: Teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception

Second Line

• Topical erythromycin
• Topical clindamycin lotion preferred
• Possible utility of calcineurin inhibitors (tacrolimus 0.1%; pimecrolimus 0.1%)
• Permethrin 5% cream (5)[A] similar efficacy compared to metronidazole
• Topical steroids should not be used, as they may aggravate rosacea.
• For severe cases, isotretinoin p.o. for 4 months

Additional Treatment

General Measures

• Use of mild, nondrying soap is recommended; local skin irritants should be avoided.
• Reassurance that rosacea is completely unrelated to poor hygiene
• Treat psychological stress if present
• Avoid oil-based cosmetics:
  • Others are acceptable and may help women tolerate the symptoms.
• Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
• Possible evolving laser therapy
• Support physical fitness

Surgery/Other Procedures

Laser treatment is an option for progressive telangiectasias or rhinophyma.

Ongoing Care

Follow-Up Recommendations

Outpatient treatment

Patient Monitoring

• Occasional and as needed
• Close follow-up for women using isotretinoin

Diet

Avoid alcohol, excessive sun exposure, and hot drinks of any type.

Prognosis

• Slowly progressive
• Subsides spontaneously (sometimes)

Complications

• Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
• Conjunctivitis
• Blepharitis
• Keratitis
• Visual deterioration