rosacea

Rosacea is an inflammatory condition that causes facial redness, spots, blotchy skin and in severe cases, rhinophyma (enlargement of the nose). It can be seen affecting the nose, cheeks, forehead, chin, neck and chest. Triggers range in nature from food to the environment to emotional stress.

Epidemiology

In fair-skinned populations, the prevalence of rosacea ranges from 2-22% [1]
A study carried out in Germany and Russia both found that 75% of people affected were women and the mean age was 40 years [2]
A study carried out on the UK found that the incidence rate for diagnosed rosacea was 1.65 per 1000 person-years (measure the number of people in the study and the amount of time spent by each person on the study)
Rosacea was diagnosed in approximately 80% of cases after the age of 30 years [3]

Source: DermNetNZ.org

Rosacea
Papular (spots) rosacea found on the cheeks

Source: DermNetNZ.org

Rosacea
Severe rosacea with pustules and papules as well as rhinophyma (nose affected by rosacea)

Causes [4]
- Inheritance from family
- Could potentially be due to bacteria growth which causes the immune system to overreact
- H pylori is common in people with rosacea
- Abnormal processing of the protein, cathelicidin, that is responsible for protecting your skin from infection

Pathophysiology [5]
- Medical students
  - Neurovascular dysregulation
    - Rosacea is characterised by dilation of lymphatic and blood vessels due to exposure to extreme temperatures, spices, and alcohol.
    - Nonspecific cation channels on sensory neurons and keratinocytes play a role in erythema and flushing after exposure to triggers.
  - Activation of the immune system
    - Over-expression of effector cells and receptors leads to activation of the adaptive and innate immune system in rosacea.
    - Activation of mast cells via increased protein production is observed due to receptor activation.
    - Expression of matrix metalloproteinases and vascular endothelial growth factor is increased in rosacea.
  - Infestation with Demodex mites
    - The presence of microbes, such as Demodex folliculorum on the skin and helicobacter pylori infection in the gut, may trigger the immune response in rosacea.
- Patients
  - Blood vessel and nerve response disfunction
    - Rosacea is characterised by dilation of lymphatic and blood vessels due to exposure to extreme temperatures, spices, and alcohol.
    - Nonspecific cation channels on sensory neurons and keratinocytes (cells on the skin responsible for repairing the skin barrier) play a role in erythema (redness) and flushing after exposure to triggers.
  - Activation of the immune system
    - Over-expression of effector cells (defend the body in immune reactions) and receptors leads to activation of the adaptive and innate immune system in rosacea.
    - Activation of mast cells via increased protein production is observed due to receptor activation.
    - Expression of matrix metalloproteinases (responsible for tissue remodelling and processes within the skin) and vascular endothelial growth factor (a factor which determines the growth of the cells lining the inner layers of blood vessels such as arteries and veins) is increased in rosacea.
  - Infestation with Demodex mites
    - The presence of microbes, such as Demodex folliculorum on the skin and helicobacter pylori infection in the gut, may trigger the immune response in rosacea.

Source: DermNetNZ.org

Rosacea
Rosacea with papules and pustules on the cheeks

Source: Waikato District Health Board; DermNetNZ

Rosacea
Cluster on the cheek with pustules and redness

Risk factors
- Genetics and immune system damage can cause an abnormal response to inflammation
- Increased age
- UV exposure
- Smoking
- Spicy food and hot drinks
- Alcohol excess
- Stress
- Environment change (hot, cold)
- Medications such as calcium channel blockers and steroids [6,7]
Presentation [8]
- Flushing/blushing of the face in early stages
- Uncomfortable stinging
- Redness and swelling
- Hyperpigmentation (dark red/brown) on darker skin
- Dilation of blood vessels (capillaries)- telangiectases
- Inflammation
- Spots
- Late stages include increased tissue size (hyperplasia) affecting the cheek and nose
- Thickened skins with spots on the nose, known as rhinophyma
Investigations [9]
- Clinical assessment of appearance of the skin, history of symptoms, family history and possible triggers of rosacea

Source: Waikato District Health Board; DermNetNZ

Rosacea
Papular (spots) rosacea on the cheeks

Differential diagnosis [9]
- Acne vulgaris
- Seborrheic dermatitis- also known as dandruff
- Contact dermatitis inflammation of the skin caused by contact with substances (irritants and allergens)
- Photodermatitis- skin damage caused by sunlight exposure
- Peri-oral or peri-ocular dermatitis- inflammation near the eyes, mouth and nose
- Drug induced dermatitis (eg. steroids)
- Systemic lupus erythematosus- butterfly rash on the face
- Erysipelas- bacterial infection of skin that causes a butterfly rash
- Keratosis pilaris- spots with follicle inflammation
- Mastocytosis- excess of mast cells in the body tissue
- Sarcoidosis- yellow-red spots found on the skin caused by a rare condition creating granuloma (white blood cell buildup)

Source: DermNetNZ.org

Rosacea
Telangiectatic (blood vessels present) with rosacea on the nose, cheeks and chin

Management [8]
- Medical students
  - Primary initial treatment for rosacea involves:
    - Avoidance of triggers (including sunscreen use)
    - Antibiotics and/or azelaic acid for inflammatory disease
    - Objective of treatment is symptom control, not cure.
  - Topical treatments include:
    - Metronidazole cream, lotion, or gel
    - Azelaic acid cream
    - Benzoyl peroxide can be added for improved control
    - Topical ivermectin cream for inflammatory lesions
  - Oral antibiotics may be indicated for multiple papules/pustules and ocular rosacea:
    - Doxycycline, tetracycline, minocycline, erythromycin, azithromycin
    - Subantimicrobial doses of doxycycline are effective for acne and rosacea.
  - Persistent erythema or flushing can be treated with topical brimonidine gel or oxymetazoline hydrochloride cream.
  - Recalcitrant cases may respond to oral isotretinoin.
  - Techniques for treating rhinophyma include dermabrasion, laser ablation, and tissue excision.
  - Techniques for treating telangiectasia include laser and electrocautery.
- Patients
  - Primary initial treatment for rosacea involves:
    - Avoidance of triggers (including sunscreen use)
    - Antibiotics and/or azelaic acid for inflammatory disease
    - Objective of treatment is symptom control, not cure.
  - Topical (applied to skin) treatments include:
    - Metronidazole cream, lotion, or gel
    - Azelaic acid cream
    - Benzoyl peroxide can be added for improved control
    - Topical ivermectin cream for inflammatory lesions
  - Oral antibiotics may be indicated for multiple papules/pustules and ocular (affecting the eye) rosacea:
    - Doxycycline, tetracycline, minocycline, erythromycin, azithromycin
    - Subantimicrobial (below anti-microbial action) doses of doxycycline are effective for acne and rosacea.
  - Persistent erythema (redness) or flushing can be treated with topical brimonidine gel or oxymetazoline hydrochloride cream.
  - Unresponsive cases may respond to oral isotretinoin.
  - Techniques for treating rhinophyma (affecting the nose) include dermabrasion (skin-resurfacing procedure that uses a rapidly rotating device to sand the outer layers of skin), laser ablation (surgery treated to remove damage tissue), and tissue excision (cutting of affected tissue)
  - Techniques for treating telangiectasia (dilated or broken blood vessels located near the skin) include laser and electrocautery (removal of damaged tissue using electricity)

Rosacea

Red papules seen on darker skin with sparse distribution, some yellow discolouration

Complications [10]
- Rhinophyma- rosacea affecting the nose
- Inflammation of the eyes such as sclera, conjunctiva
- Self esteem- self worth complications from appearance
- Limitations to activities sue to fear of triggering rosacea (eg. going to sunny places)

Myths
- Rosacea presents with the same symptoms on all patients
- Rosacea doesn’t flare up, it is constant
- There is a cure for rosacea
- Rosacea is contagious
- Rosacea is the same as acne [11,12]
Questions to ask your doctor
- What can trigger my rosacea?
- What caused my rosacea?
- How long does treatment take to be effective?
- What lifestyle measures can be taken to manage symptoms of rosacea?
- Who do I contact if I suspect the beginning of complications?
Support
- National Rosacea Society
- Schweiger Dermatology Group
- American Academy of Dermatology