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rosacea

Chronic episodic skin disorder of unknown etiology. Etiology: 1) idiopathic 2) postulated causes a) genetic predisposition b) hypertension c) Demodex folliculorum mites d) gastrointestinal disease 3) risk factors a) predisposition to flushing 1] dietary & environmental precipitation - hot liquids, spicy foods, alcohol, chemical irritants 2] menopause 3] vasodilator drug therapy b) exposure to sunlight & heat c) stress & strong emotions Epidemiology: 1) onset between ages 30 & 50 2) fair-skinned individuals [5] 3) women affected 3 fold more than men 4) 5% of US population, > 13 million cases in US Pathology: - overexpression of kallikrein-5 cleaves cathelicidin thus producing clinical manifestations of rosacea [7] - increased gene expression relative to dermatoheliosis & controls of: [11] - matrix metalloproteinase-1 - matrix metalloproteinase-3 - matrix metalloproteinase-9 - calcitonin gene-related peptide - substance P - collagen type I - collagen type III - decorin - erythema of rosacea consists of inflammation & vasodilation rather than vasodilation alone [11] - hyperreactivity of the innate immune system [25] - histopathology - variable - a combination of findings may support diagnosis of rosacea * histopathology images [17] Clinical manifestations: 1) intermittent, but progressively more severe episodes 2) mild episodes may include erythema & scattered telangiectasias lasting hours to days 3) more severe episodes may include all features of the disease & last for weeks 4) erythema, telangiectasias, papules & pustules occur on the forehead, cheeks, chin nose & glabella after an episode of flushing (central facial) 5) flushing is often induced by ingestion of hot liquids, spicy foods, alcohol, 6) exacerbated by - exposure to sunlight & heat - stress & strong emotions 7) comedones are generally absent 8) chronic inflammation, connective tissue hypertrophy & diffuse sebaceous gland hypertrophy is characteristic of severe rosacea 9) phymas, rhinophyma 10) ocular involvement (50%) [25] - blepharitis - conjunctivitis [19] (images) - iritis & keratitis considered complications * images [12,17,18,25] Laboratory: 1) no definitive laboratory tests 2) biopsy not routinely indicated Differential diagnosis: 1) acne vulgaris 2) perioral dermatitis 3) seborrheic dermatitis - rosacea may accompany seborrhea [8] 4) contact dermatitis 5) lupus erythematosus a) cutaneous lupus erythematosus b) systemic lupus erythematosus c) lupus spares the nasolabial folds d) papules, pustules & flushing supports diagnosis of rosacea [2] 6) carcinoid flush 7) cutaneous tuberculosis 8) amyotrophic dermatomyositis - heliotrope rash, Gottron papules, photosensitive facial poikiloderma 9) dermatoheliosis (photoaging) [11] - centrofacial location of redness, flushing, sensory change, & involvement of the nose suggest rosacea [11] - no finding definitively distinguishes the two [11] Complications: 1) iritis 2) keratitis 3) increased risk of Parkinson's disease (RR=1.71) - RR=2.03 if ocular rosacea - risk normalized by treatment with tetracycline [20] Management: 1) general a) may respond to treatment, but generally not curable b) treatment is symptomatic; response may take 6-12 weeks c) avoidance of triggers (precipitating factors) 2) pharmacologic agents a) topical agents - topical antibiotics have little effect on erythema & telangiectasias - topical metronidazole* (0.75%) MetroGel) BID - topical tetracycline 0.5-2% BID - topical erythromycin 0.5-2% BID (Erycette) - topical clindamycin 0.5-2% BID (Cleocin-T) - drying agents applied BID - benzoyl peroxide - sulfacetamide plus sulfur-containing lotions - Rosula Gel, Clenia cream or wash - azelaic acid 15-20% (Finacea Gel, Finevin) [4,6] - hydrocortisone 1% - may be useful in reducing erythema & edema - fluorinated steroid should not be used - prolonged use causes rebound worsening of rosacea symptoms - MKSAP19 advises to avoid glucocorticoids [2] - topical calcineurin inhibitors [2] - topical tacrolimus - topical pimecrolimus - topical permethrin [2] - topical ivermectin [2] b) systemic agents - systemic antibiotics - indications - effective for pustular rosacea - eye manifestations [2] - tetracycline - 250 mg PO QID until symptoms diminish - then taper to 250-500 mg/day - continue therapy for at least 6 months - indefinite therapy may be required - doxycycline 40 mg QD only FDA-approved oral therapy [4,25] - minocycline (Emrosi) [4] - macrolide if tetracycline is ineffective - erythromycin 500-1000 mg QD - azithromycin [2] - clarithromycin [2] - metronidazole 250 mg BID, as a 1st line agent or if tetracycline is ineffective - isotretinoin (13-cis-retinoic acid) (Accutane) - 0.5-1.0 mg/kg/day for 15-20 weeks - low-dose 0.1-0.2 mg/kg/day may take longer than standard dose, but fewer adverse effects - minidose 2.5-5 mg QD - up to 6 months therapy may be necessary - adverse effects are minimal - indicated for rosacea refractory to therapy with antibiotics & topical steroids 3) physical modalities a) telangiectatic vessels may be treated with superficial electrodesiccation or laser surgery [25] b) rhinophyma may be treated with CO2 laser surgery, dermabrasion, or electrosurgery 4) ophthalmology consultation for eye involvement - doxycycline - dexamethasone ophthalmic - artificial tears - eyelid hygiene [19] 5) diet a) avoid foods that may cause vasodilation & thus facial flushing b) i.e. hot liquids, alcohol, coffee, tea, spicy foods 6) environmental control a) avoid extremes of weather - wind - heat - cold b) avoid prolonged sun exposure 7) patient education a) avoid tobacco b) use mild, non-drying soap c) use sunscreen d) stress management may be helpful * treatment of choice [2,3] Notes: - spironolactone mitigates risk of rosacea [9] (it is not FDA-approved to treat rosacea)

Related

Demodex folliculorum phyma rhinophyma sebaceous gland

Specific

lupus miliaris disseminatus faciei; facial idiopathic granulomas with regressive evolution (LMDF, FIGURE)

General

sebaceous gland disease chronic skin disease (chronic dermatologic disorder, chronic dermatopathy, chronic dermatosis)

References

  1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1003-1004
  2. Medical Knowledge Self Assessment Program (MKSAP) 11, 15, 16, 17, 19. American College of Physicians, Philadelphia 1998, 2009, 2012, 2015, 2022 - Medical Knowledge Self Assessment Program (MKSAP) 19 Board Basics. An Enhancement to MKSAP19. American College of Physicians, Philadelphia 2022
  3. Geriatrics Review Syllabus, American Geriatrics Society, 5th edition, 2002-2004; 7th edition 2011 - Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  4. Ingram I FDA Approves New Option for Rosacea. Antibiotic Emrosi topped doxycycline, placebo in phase III trials MedPage Today November 4, 2024 https://www.medpagetoday.com/dermatology/generaldermatology/112743
  5. Takahashi S, In: UCLA Intensive Course in Geriatric Medicine & Board Review, Marina Del Ray, CA, Sept 29-Oct 2, 2004
  6. Prescriber's Letter 14(2): 2007 Drug treatment for rosacea Detail-Document#: 230210 (subscription needed) http://www.prescribersletter.com
  7. Yamasaki K, Di Nardo A, Bardan A, Murakami M, Ohtake T, Coda A, Dorschner RA, Bonnart C, Descargues P, Hovnanian A, Morhenn VB, Gallo RL. Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea. Nat Med. 2007 Aug;13(8):975-80. Epub 2007 Aug 5. PMID: 17676051
  8. Geriatrics at your Fingertips, 13th edition, 2011 Reuben DB et al (eds) American Geriatric Society
  9. Spoendlin J, Voegel JJ, Jick SS, Meier CR. Spironolactone may reduce the risk of incident rosacea. J Invest Dermatol. 2013 Oct;133(10):2480-3. PMID: 23594595
  10. Aksoy B, Altaykan-Hapa A, Egemen D, Karagoz F, Atakan N. The impact of rosacea on quality of life: effects of demographic and clinical characteristics and various treatment modalities. Br J Dermatol. 2010 Oct;163(4):719-25 PMID: 20545683
  11. Helfrich YR et al. Clinical, histologic, and molecular analysis of differences between erythematotelangiectatic rosacea and telangiectatic photoaging. JAMA Dermatol 2015 Mar 23; [e-pub]. PMID: 25798811 - Wilkin JK. Erythematotelangiectatic rosacea and telangiectatic photoaging: Same, separate, and/or sequential? JAMA Dermatol 2015 Mar 23 PMID: 25798736
  12. Rosacea (image) American Academy of Dermatology https://www.aad.org/public/diseases/acne-and-rosacea/rosacea
  13. Powell FC Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24;352(8):793-803 PMID: 15728812
  14. Kennedy Carney C, Cantrell W, Elewski BE. Rosacea: a review of current topical, systemic and light- based therapies. G Ital Dermatol Venereol. 2009 Dec;144(6):673-88. PMID: 19907406
  15. Stone DU, Chodosh J. Ocular rosacea: an update on pathogenesis and therapy. Curr Opin Ophthalmol. 2004 Dec;15(6):499-502 PMID: 15523195
  16. van Zuuren EJ, Kramer SF, Carter BR, Graber MA, Fedorowicz Z. Effective and evidence-based management strategies for rosacea: summary of a Cochrane systematic review. Br J Dermatol. 2011 Oct;165(4):760-81 PMID: 21692773 - van Zuuren EJ, Kramer S, Carter B et al Interventions for rosacea. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD003262. Review. Update in: Cochrane Database Syst Rev. 2015;4:CD003262. PMID: 21412882 - van Zuuren EJ, Fedorowicz Z, Carter B et al Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 28;(4):CD003262. Review. PMID: 25919144
  17. Banasikowska AK, James WD (images) Medscape: Rosacea http://emedicine.medscape.com/article/1071429-overview
  18. DermNet NZ. Rosacea (images) http://dermnetnz.org/acne/rosacea.html
  19. Asoklis R, Malysko K IMAGES IN CLINICAL MEDICINE. Ocular Rosacea N Engl J Med 2016; 374:771. February 25, 2016 PMID: 26933851 http://www.nejm.org/doi/full/10.1056/NEJMicm1504309
  20. Egeberg A et al. Exploring the association between rosacea and Parkinson disease: A Danish nationwide cohort study. JAMA Neurol 2016 Mar 21 PMID: 26999031
  21. Jackson JM, Pelle M. Topical rosacea therapy: the importance of vehicles for efficacy, tolerability and compliance. J Drugs Dermatol. 2011 Jun;10(6):627-33. Review. PMID: 21637903
  22. Keshtcar-Jafari A, Akhyani M, Ehsani AH et al Correlation of the severity of cutaneous rosacea with ocular rosacea. Indian J Dermatol Venereol Leprol. 2009 Jul-Aug;75(4):405-6. PMID: 19584472 Free Article
  23. van Zuuren EJ Rosacea. N Engl J Med 2017; 377:1754-1764. November 2, 2017 PMID: 29091565 http://www.nejm.org/doi/full/10.1056/NEJMcp1506630 - Rothaus C Rosacea NEJM Resident 360. Nov 2, 2017 https://resident360.nejm.org/content_items/rosacea-3
  24. Webster G, Schaller M. Ocular rosacea: a dermatologic perspective. J Am Acad Dermatol. 2013 Dec;69(6 Suppl 1):S42-3. Review. PMID: 24229636
  25. Lipper GM Rosacea: 5 Things to Know. Medscape. September 19, 2018September 19, 2018 https://www.medscape.com/viewarticle/902020
  26. http://www.rosacea.org