BASICS

DESCRIPTION

Acne rosacea is a chronic acneiform disorder affecting the nose, chin, forehead, or eyelids.

EPIDEMIOLOGY

Prevalence

Affects approximately 1 in 20 Americans.

RISK FACTORS

• 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.

Genetics

No gene identified as causing rosacea, but tends to run in families.

GENERAL PREVENTION

Rosacea cannot be prevented, although several factors may trigger flare-ups including sun, wind, hot, cold, exercise, stress, and certain foods.

PATHOPHYSIOLOGY

Anomalous vascular response.

ETIOLOGY

• 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.

DIAGNOSIS

HISTORY

• Family history

• Symptoms including flushing, persistent erythema, papules, pustules, burning or stinging of the skin, and dryness

PHYSICAL EXAM

• Skin involvement (nose, cheeks, chin, central forehead, neck, and chest)

– Diffuse erythema

– Telangiectasias

– Papules

– Pustules

– Hypertrophy of sebaceous glands

– Rhinophyma (thickening and purplish discoloration of nose skin)

• Ophthalmologic

– Blepharoconjunctivitis

Inspissation of meibomian glands

Telangiectasias of lid margin

Recurrent hordeolum and chalazion

Conjunctival hyperemia and congestion

Follicular reaction

Papillary hypertrophy

• 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

Lab

No lab testing required

Diagnostic Procedures/Other

Diagnosis is clinical

Pathological Findings

• 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

– Edema

– Collagen disruption

– Elastosis

• Rhinophyma shows increase in sebaceous glands and connective tissue

• Skin biopsies show deposition of complement and immunoglobulin at dermal–epidermal junction

DIFFERENTIAL DIAGNOSIS

• Acne vulgaris

• Lupus erythematosus

• Dermatitis

• Erysipelas

• Seborrheic dermatitis

• Carcinoid syndrome

• Tuberculosis

• Syphilis

TREATMENT

MEDICATION

First Line

• Oral tetracycline (250 mg every 6 hours for 3–4 weeks, with tapering)

• Doxycycline or minocycline (50–100 mg every 12 hours)

Second Line

• Oral erythromycin

• Oral isotretinoin

• Ampicillin

• Metronidazole

• 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

Pediatric Considerations

• Tetracycline not for use in children <8 years old

Pregnancy Considerations

• 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

ADDITIONAL TREATMENT

General Measures

• 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

SURGERY/OTHER PROCEDURES

• 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

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

• Ophthalmology

• Dermatology

Patient Monitoring

Close ophthalmologic monitoring for corneal thinning, ulceration, infiltration, or perforation

DIET

Limit spicy foods, alcohol, and hot beverages.

PATIENT EDUCATION

The National Rosacea Society (http://www.rosacea.org)

PROGNOSIS

Good prognosis for controlling symptoms, although rosacea is a chronic condition.

ADDITIONAL READING

• 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.

CODES

ICD9

• 372.20 Blepharoconjunctivitis, unspecified

• 374.89 Other disorders of eyelid

• 695.3 Rosacea

CLINICAL PEARLS

• Rosacea may cause chronic ocular symptoms

• History of recurrent hordeolum or chalazion may represent ocular rosacea

• Mainstay of treatment remains topical and oral antibiotics

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