rosacea

23 Jul

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.

- 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]
- 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 [4]
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
  - This may trigger the immune response in rosacea.
Patients
- Sensitive Blood Vessels (Neurovascular Changes)
  - In rosacea, the immune system becomes more active
  - Rosacea causes your skin’s blood vessels to widen more easily, leading to redness and flushing.
- This can happen after exposure to:
  - Hot or cold temperatures
  - Spicy foods
  - Alcohol
- Some natural skin and nerve cells overreact to these triggers, causing the skin to turn red.
- Immune System Activation
  - In rosacea, the immune system becomes more active than usual.
  - Overproduction of certain proteins and chemicals, which keep the skin red and irritated
- Demodex Mites and Gut Bacteria
  - Demodex mites (tiny organisms that live on most people’s skin) are found in higher numbers in people with rosacea.
  - These may trigger the immune system and make rosacea worse.
  - A gut bacteria called Helicobacter pylori may also be linked to rosacea in some people. [5]
- 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]
- 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 [8]
- Clinical assessment of appearance of the skin, history of symptoms, family history and possible triggers of rosacea [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) [9]
Medical Students
- Initial Management
  - Avoid known triggers (e.g., heat, alcohol, spicy foods)
  - Daily sunscreen use is recommended
  - Treatment aims to control symptoms, not cure
- Topical Therapies
  - Metronidazole (cream, lotion, or gel)
  - Azelaic acid cream
  - Benzoyl peroxide can be added for enhanced effect
  - Topical ivermectin effective for inflammatory lesions
- Systemic Therapies
  - Indicated for multiple papules/pustules or ocular involvement
  - Oral antibiotics: doxycycline, tetracycline, minocycline, erythromycin, azithromycin
  - Subantimicrobial doxycycline (e.g., 40 mg daily) effective in inflammatory rosacea
- Persistent Erythema/Flushing
  - Topical brimonidine gel or oxymetazoline hydrochloride cream
- Refractory/Severe Disease
  - Oral isotretinoin for recalcitrant rosacea
- Procedural Interventions
  - Rhinophyma: dermabrasion, laser ablation, tissue excision
  - Telangiectasia: laser therapy or electrocautery
Patients
- First Steps
  - Avoid triggers like spicy food, alcohol, and heat
  - Use sunscreen daily
  - Treatment helps manage symptoms but does not cure rosacea
- Skin (Topical) Treatments
  - Creams or gels with:
  - Metronidazole
  - Azelaic acid
  - Ivermectin (for red bumps and pimples)
  - Benzoyl peroxide may be added to improve results
- Tablets (Oral Antibiotics)
  - Used if you have many spots or if your eyes are affected
  - Options include: doxycycline, tetracycline, minocycline, erythromycin, azithromycin
  - A low-dose doxycycline can be used long-term safely
- Redness and Flushing
  - Can be treated with:
  - Brimonidine gel
  - Oxymetazoline cream
- If Other Treatments Don't Work
  - Isotretinoin tablets may be tried in stubborn cases
- Procedures for Severe Forms
  - Rhinophyma (swollen nose): laser, sanding, or cutting away extra tissue
  - Visible blood vessels: treated with laser or heat-based tools
- 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) [10]
- 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]
- 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?
- National Rosacea Society
- Schweiger Dermatology Group
- American Academy of Dermatology
[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#:~:text=Estimates%20of%20the%20prevalence%20of,from%202%20to%2022%20percent.&text=A%20recent%20prospective%20study%20from,9%20and%203%20percent%2C%20respectively.
[2] https://pubmed.ncbi.nlm.nih.gov/26915718/
[3] https://pubmed.ncbi.nlm.nih.gov/22564022/
[4] https://www.aad.org/public/diseases/rosacea/what-is/causes
[5]https://www.ncbi.nlm.nih.gov/books/NBK557574/#:~:text=Neurovascular%20dysregulation%2C%20activation%20of%20the,pathophysiological%20mechanisms%20postulated%20for%20rosacea
[6] https://pubmed.ncbi.nlm.nih.gov/2572109/
[7] https://www.nejm.org/doi/10.1056/NEJMcp1506630?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed
[8] https://www.msdmanuals.com/en-gb/professional/dermatologic-disorders/acne-and-related-disorders/rosacea?query=rosacea
[9] https://cks.nice.org.uk/topics/rosacea/diagnosis/assessment/
[10] https://dermnetnz.org/topics/rosacea
[11] https://www.rosacea.org/blog/2014/january/debunking-the-top-rosacea-myths
[12] https://www.skinwellnesscenter.net/4-myths-about-rosacea/