Acne rosacea is a chronic acneiform disorder affecting the nose, chin, forehead, or eyelids.
Affects approximately 1 in 20 Americans.
• Age (usually occurs between the ages of 30–60 years)
• Equal sex distribution
• Suggestion that there is increased prevalence in fair-skinned persons of European or Celtic descent, although not well-substantiated
• Dark pigmentation in black populations may mask presentation.
No gene identified as causing rosacea, but tends to run in families.
Rosacea cannot be prevented, although several factors may trigger flare-ups including sun, wind, hot, cold, exercise, stress, and certain foods.
Anomalous vascular response.
• Poorly understood, although infectious, climactic, neurologic, and immunologic factors have been implicated.
• Vasodilation may cause extravasation of plasma, which can induce an inflammatory response.
• Demodex folliculorum has also been implicated, but this is largely circumstantial.
• Family history
• Symptoms including flushing, persistent erythema, papules, pustules, burning or stinging of the skin, and dryness
• Skin involvement (nose, cheeks, chin, central forehead, neck, and chest)
– Diffuse erythema
– Hypertrophy of sebaceous glands
– Rhinophyma (thickening and purplish discoloration of nose skin)
Inspissation of meibomian glands
Telangiectasias of lid margin
Recurrent hordeolum and chalazion
Conjunctival hyperemia and congestion
• Corneal (usually involves inferior cornea)
– Punctuate epithelial keratitis
– Corneal vascularization
– Corneal infiltration
– Corneal ulceration
– Corneal perforation
• Reports of involvement of episclera, sclera, and iritis, although not widely reported
DIAGNOSTIC TESTS & INTERPRETATION
No lab testing required
Diagnosis is clinical
• Vascular dilatation of small vessels
• Perivascular infiltration of histiocytes, plasma cells, and lymphocytes
• Infiltration of conjunctiva and cornea by lymphocytes, epithelioid cells, giant, and plasma cells
• Loss of superficial dermal connective tissues
– Collagen disruption
• Rhinophyma shows increase in sebaceous glands and connective tissue
• Skin biopsies show deposition of complement and immunoglobulin at dermal–epidermal junction
• Acne vulgaris
• Lupus erythematosus
• Seborrheic dermatitis
• Carcinoid syndrome
• Oral tetracycline (250 mg every 6 hours for 3–4 weeks, with tapering)
• Doxycycline or minocycline (50–100 mg every 12 hours)
• Oral erythromycin
• Oral isotretinoin
• Topical metronidazole (0.75% gel twice daily)
• Azelaic Acid
• Sodium sulfacetamide lotion
• Intensive lid hygiene
• Bacteriostatic ointment at bedtime
• Topical corticosteroids (short-term)
• Electrocautery for telangiectasias
• Tetracycline not for use in children <8 years old
• Tetracycline should not be used during pregnancy
• Isotretinoin is teratogenic and contraindicated during pregnancy – women of childbearing age should be placed on oral contraceptives when warranted
• Avoidance of sun exposure
• Daily sunscreen use
• Use of mild soaps
• Avoidance of oil-based cosmetics
Issues for Referral
• Severe ocular involvement (corneal infiltration/ulceration, recurrent chalazia)
• Rhinophyma refractory to standard treatments
COMPLEMENTARY & ALTERNATIVE THERAPIES
• Topical niacinamide
• B vitamins
• Elimination and challenge diet
• Conjunctival flaps, tectonic lamellar keratoplasty, penetrating keratoplasty
• Laser, intense pulse light, photodynamic therapy
• Electrosurgery, surgical steel resculpturing, dermabrasion, or carbon dioxide laser treatment for rhinophyma
Close ophthalmologic monitoring for corneal thinning, ulceration, infiltration, or perforation
Limit spicy foods, alcohol, and hot beverages.
The National Rosacea Society (www.rosacea.org)
Good prognosis for controlling symptoms, although rosacea is a chronic condition.
• van Zuuren EJ, Gupta AK, Gover MD, et al. Systematic review of rosacea treatments. J Am Acad Dermatol 2007;56:107.
• Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol 2004;51:327.
• Webster GF. Rosacea. Med Clin N Am 2009;93:1183–1194.
• 372.20 Blepharoconjunctivitis, unspecified
• 374.89 Other disorders of eyelid
• 695.3 Rosacea
• Rosacea may cause chronic ocular symptoms
• History of recurrent hordeolum or chalazion may represent ocular rosacea
• Mainstay of treatment remains topical and oral antibiotics