Rosacea

For other meanings, see Rosacea (disambiguation).

Rosacea
An Old Man and His Grandson, by Domenico Ghirlandaio, shows skin damage from rhinophyma.
Classification and external resources
Pronunciation	/roʊˈzeɪʃiə/
Specialty	Dermatology
ICD-10	L71
ICD-9-CM	695.3
DiseasesDB	96
MedlinePlus	000879
eMedicine	derm/377
Patient UK	Rosacea
MeSH	D012393

Rosacea is a chronic skin condition characterized by facial redness, small and superficial dilated blood vessels on facial skin, papules, pustules, and swelling. Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting the eyes (ocular type). Left untreated, it worsens over time. Treatment in the form of topical steroids can aggravate the condition.

It primarily affects people of northwestern European descent and has been nicknamed the "curse of the Celts" by some in Britain and Ireland, although such a connection has been questioned. Rosacea affects both sexes, but is almost three times more common in women. It is commonly found in people between the ages of 30 and 50, and is more common in Caucasians.

Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp. In some cases, additional signs, such as semipermanent redness, dilation of superficial blood vessels on the face, red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.

Cause

The exact cause of rosacea is unknown. Triggers that cause episodes of flushing and blushing play a part in its development. Exposure to temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one, such as heated shops and offices during the winter, can each cause the face to become flushed. Certain foods and drinks can also trigger flushing, such as alcohol, foods and beverages containing caffeine (especially hot tea and coffee), foods high in histamines, and spicy foods.

Medications and topical irritants have also been known to trigger rosacea flares. Some acne and wrinkle treatments reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin. Steroid-induced rosacea is caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare-up.

Cathelicidins

Richard Gallo and colleagues recently noticed that patients with rosacea had high levels of the antimicrobial peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea, but they may only work because they inhibit some SCTEs.

Demodex mites

Studies of rosacea and Demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid-induced rosacea. When large numbers are present, they may play a role along with other triggers. On other occasions, demodicidosis (mange) is a separate condition that may have "rosacea-like" appearances. Demodex mites have also been implicated in rosacea in that it may be caused by a reaction to bacteria in the mite's feces.

Intestinal bacteria

Small intestinal bacterial overgrowth (SIBO) was demonstrated to have greater prevalence in rosacea patients and its eradication led to skin lesion improvement in two studies, and in rosacea patients who were SIBO negative, the antibiotic therapy had no effect on the skin lesions. The effectiveness of SIBO eradication in rosacea may suggest that these bacteria play a role in the pathogenesis of rosacea lesions.

Diagnosis

Most people with rosacea have only mild redness and are never formally diagnosed or treated. No single, specific test for rosacea is known.

In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.

The disorder can be confused with, and co-exist with, acne vulgaris and/or seborrheic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.

Classification

Zones

Four rosacea subtypes are identified, and patients may have more than one subtype present:

1. Erythematotelangiectatic rosacea exhibits permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small, widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and/or itching sensations. People with this type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp.
2. Papulopustular rosacea presents with some permanent redness with red bumps (papules); some pus-filled pustules can last 1–4 days or longer. This subtype can be easily confused with acne.
3. Phymatous rosacea is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Telangiectasias may be present.
4. In ocular rosacea, eyes and eyelids affected by it may appear red (due to telangiectasias) and inflammation and may feel dry, irritated, or gritty. Other symptoms include foreign body sensations, itching, burning, stinging, and sensitivity to light. Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and vision loss can occur if the cornea is affected.

The variants of rosacea include:

• Pyoderma faciale (also known as rosacea fulminans) is a conglobate, nodular disease springing up abruptly on the face.
• Rosacea conglobata is a severe rosacea that shows a reaction that mimics acne conglobata with hemorrhagic nodular abscesses and indurated plaques.
• Phymatous rosacea is a cutaneous condition characterized by overgrowth of sebaceous glands. "Phyma" is the Greek word for swelling, mass, or bulb, and these can occur in various areas of the face and ears in associated with rosacea.

Treatments

Acne rosacea on face.

Treating rosacea varies depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists. Mild cases are often not treated at all, or are simply covered up with normal cosmetics.

Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions, decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents. Laser therapy has also been classified as a form of treatment. While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually one to two years, may result in permanent control of the condition for some patients. Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.

Behavior

Avoiding triggers that worsen the condition can help reduce the onset of rosacea, but alone will not normally lead to remission except in mild cases. Keeping a journal is sometimes recommended to help identify and reduce food and beverage triggers.

Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims. Like sunlight, emotional stress can also trigger rosacea. People who develop infections of the eyelids must practice frequent eyelid hygiene.

Managing pretrigger events such as prolonged exposure to cool environments can directly influence warm room flushing.

Medications

Medications for which evidence of good results exists include ivermectin and azelaic acid creams and brimonidine, doxycycline, and isotretinoin by mouth. Lesser evidence supports metronidazole cream and tetracycline by mouth.

Metronidazole is thought to act through anti-inflammatory mechanisms, while azelaic acid is thought to decrease cathelicidin production. Oral antibiotics of the tetracycline class such as doxycycline and oxytetracycline are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.

Using alpha-hydroxy acid peels may help relieve redness caused by irritation, and reduce papules and pustules associated with rosacea. Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.

The flushing and blushing that typically accompanies rosacea is typically treated with the topical application of alpha agonists such as brimonidine and less commonly oxymetazoline or xylometazoline.

Laser

Laser treatment for rosacea using a V-Beam laser

Dermatological vascular laser (single wavelength) or intense pulsed light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin. They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxyhemoglobin, which heats up, causing the capillary walls to heat up to 70°C (158°F), damaging them, and causing them to be absorbed by the body's natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly formed capillaries.

CO₂ lasers can be used to remove excess tissue caused by phymatous rosacea. CO₂ lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporize tissue. Low-level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it.

See also

• Keratosis pilaris

References

Rosacea Uncovered - Symptoms, Causes and Treatments Interview with Michelle Osbourne

External links

• Rosacea photo library at Dermnet
• National Rosacea Society
• Helpful Rosacea Information
• Questions and Answers about Rosacea - US National Institute of Arthritis and Musculoskeletal and Skin Diseases