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Integumentary system

Rosacea

Chronic facial inflammatory dermatosis affecting blood vessels and pilosebaceous units presenting with recurrent flushing, erythema, telangiectasia, papules, or pustules on nose, chin, cheeks, and forehead.

Chronic facial inflammatory dermatosis affecting blood vessels and pilosebaceous units presenting with recurrent flushing, erythema, telangiectasia, papules, or pustules on nose, chin, cheeks, and forehead.

  • > 5% worldwide prevalence

Aetiology


Clinical features

Rosacea is primarily manifested as erythematous flushing, blushing, telangiectasias, papules, and pustules affecting the central third of the face. Combination of symptoms and signs focused around the central face can be divided in primary and secondary features.

Primary features
One or more present
Secondary features
May/may not be present
Flushing (transient erythema)Burning or stinging
Nontransient erythemaPlaque
Papules and pustulesDry appearance
TelangiectasiaOedema
 Ocular manifestations
 Peripheral location
 Phymatous changes

Clinical subtypes:

Subtypes of rosacea are based on the predominant signs and symptoms. The subtypes are not mutually exclusive. Patients can present with features of multiple subtypes, and the predominant features and areas of involvement can change over time.
  1. Erythemato-telangiectatic rosacea (ETR) (M/C): Persistent erythema with intermittent flushing of nose and cheeks
  2. Papulopustular rosacea (PPR) “adult acne”: Eruptions of papules and pustules on the affected area on the face.
  3. Phymatous rosacea: Fibrosis and hypertrophy of sebaceous glands, typically on the nose of male patients (rhinophyma). Other sites of manifestation:
    • Mentophyma (chin)
    • Metophyma (forehead)
    • Gnatophyma (chin)
    • Otophyma (ears)
    • Blepharophyma (eyelids)
  4. Ocular rosacea: Tearing, dry eye, gritty sensation, pruritus, hordeola, and blepharitis.
dr-2016-1-6387-g001
The 4 different types of rosacea examined: A) erythematotelangiectatic rosacea; B) papulopustular rosacea; C) rhinophyma (phymatous rosacea) and D) ocular rosacea. | Mikkelsen, C. S., Holmgren, H. R., Kjellman, P., Heidenheim, M., Kappinnen, A., Bjerring, P., & Huldt-Nystrøm, T. (2016). Rosacea: a Clinical Review. Dermatology Reports, 8(1), 6387. https://doi.org/10.4081/dr.2016.6387

Diagnosis

GRADE (Grading of Recommendations, Assessment, Development and Evaluation) scale:

Helps in making judgments about quality of evidence and strength of recommendations
GRADE Score Clinical description
Clear 0 No inflammatory lesions present, no erythema
Almost clear 1 Very few small papules/pustules, very mild erythema present
Mild 2 Few small papules/pustules, mild erythema
Moderate 3 Several small or large papules/pustules, moderate erythema
Severe 4 Numerous small and/or large papules/pustules, severe erythema

Differential diagnosis:

rd
Differential Diagnosis of Rosacea | Culp, B., & Scheinfeld, N. (2009). Rosacea: a review. P & T : A Peer-Reviewed Journal for Formulary Management, 34(1), 38–45. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/19562004

Management

“The perfect cure of [acne] rosacea is, in fact, never accomplished” –

Thomas Bateman, Delineations of cutaneous diseases, 1812

The choice of therapy is guided by the signs and symptoms present for the individual patient. The majority of the therapies aim to reduce inflammation. Though they provide anti-inflammatory properties, topical steroids should be avoided in rosacea as they are associated with rebound flaring or induction of rosacea-like perioral dermatitis.

Lifestyle changes:

Identify and avoid triggers
  • UV light
  • Spices
  • Weather changes
  • Alcoholic beverages

Universal skin care:

Rosacea often causes the skin to become sensitive and irritable, and products that cause irritation should be avoided. Cosmetics containing green pigment are best for masking persistent erythema.
  • pH-balanced skin cleansers (as opposed to soaps)
  • Broad-spectrum sunscreen with SPF 30 or higher
  • Regular use of moisturizers
dr-2016-1-6387-g002
Stepwise treatment of rosacea | Mikkelsen, C. S., Holmgren, H. R., Kjellman, P., Heidenheim, M., Kappinnen, A., Bjerring, P., & Huldt-Nystrøm, T. (2016). Rosacea: a Clinical Review. Dermatology Reports, 8(1), 6387. https://doi.org/10.4081/dr.2016.6387

Topical management:

Persistent erythema and telangiectasias are not completely secondary to inflammation and often require treatment targeting the skin vasculature
  • Brimonidine
  • Oxymetazoline
  • Vascular laser
640px-steroid_rosacea
Topical Steroid induced rosacea (left); after steroid withdrawal and photobiomodulation therapy (right). | Corinna Kennedy – CC BY-SA 4.0, https://commons.wikimedia.org/w/index.php?curid=55294750

Surgical management:

Phymatous changes of rosacea result in irreversible changes to the skin that require surgical intervention when indicated.
  • Laser excision and skin grafting

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