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Uncommon >60 years of age
Effects of aging might increase the side effects associated with oral isotretinoin used for treatment (at present, data are insufficient due to lack of clinical studies in elderly patients ≥65 years).
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EPIDEMIOLOGY
Prevalence
- Predominant age: 30 to 50 years
- Predominant sex: female > male. However, males are at greater risk for progression to later stages.
ETIOLOGY AND PATHOPHYSIOLOGY
- No proven cause
- Possibilities include the following:
- Thyroid and sex hormone disturbance
- Alcohol, coffee, tea, spiced food overindulgence (unproven)
- Demodex follicular parasite (suspected)
- Exposure to cold, heat
- Emotional stress
- Dysfunction of the GI tract
Genetics
People of Northern European and Celtic background commonly afflicted á
RISK FACTORS
- Exposure to spicy foods, hot drinks
- Environmental factors: sun, wind, cold, heat
GENERAL PREVENTION
No preventive measures known á
COMMONLY ASSOCIATED CONDITIONS
- Seborrheic dermatitis of scalp and eyelids
- Keratitis with photophobia, lacrimation, visual disturbance
- Corneal lesions
- Blepharitis
- Uveitis
DIAGNOSIS
HISTORY
- Usually have a history of episodic flushing with increases in skin temperature in response to heat stimulus in mouth (hot liquids), spicy foods, alcohol, sun exposure (solar elastosis)
- Acne may have preceded onset of rosacea by years; nevertheless, rosacea usually arises de novo without preceding history of acne or seborrhea.
- Excessive facial warmth and redness are the predominant presenting complaints. Itching is generally absent.
PHYSICAL EXAM
- Rosacea has typical stages of evolution:
- The rosacea diathesis: episodic erythema, "flushing and blushing"Ł
- Stage I: persistent erythema with telangiectases
- Stage II: persistent erythema, telangiectases, papules, tiny pustules
- Stage III: persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent "solid"Ł edema of the central part of the face (phymatous)
- Facial erythema, particularly on cheeks, nose, and chin. At times, entire face may be involved.
- Inflammatory papules are prominent; pustules and telangiectasia may be present.
- Comedones are absent (unlike acne vulgaris).
- Women usually have lesions on the chin and cheeks, whereas the nose is commonly involved in men.
- Ocular findings (mild dryness and irritation with blepharitis, conjunctival injection, burning, stinging, tearing, eyelid inflammation, swelling, and redness) are present in 50% of patients.
DIFFERENTIAL DIAGNOSIS
- Drug eruptions (iodides and bromides)
- Granulomas of the skin
- Cutaneous lupus erythematosus
- Carcinoid syndrome
- Deep fungal infection
- Acne vulgaris
- Seborrheic dermatitis
- Steroid rosacea (abuse)
- Systemic lupus erythematosus
- Lupus pernio (sarcoidosis)
DIAGNOSTIC TESTS & INTERPRETATION
Diagnosis is based on physical exam findings. á
Test Interpretation
- Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
- Absence of comedones and blocked ducts
- Vascular dilatation and dermal lymphocytic infiltrate
TREATMENT
GENERAL MEASURES
- Proper skin care and photoprotection are important components of management plan (1)[B]. Use of mild, nondrying soap is recommended; local skin irritants should be avoided.
- Avoidance of triggers
- Reassurance that rosacea is completely unrelated to poor hygiene
- Treat psychological stress if present.
- Topical steroids should not be used, as they may aggravate rosacea.
- Avoid oil-based cosmetics:
- Others are acceptable and may help women tolerate symptoms
- Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
- Possible evolving laser therapy
- Support physical fitness.
MEDICATION
First Line
- Topical metronidazole preparations once (1% formulation) or twice (0.75% formulations) daily for 7 to 12 weeks was significantly more effective than placebo in patients with moderate to severe rosacea. A rosacea treatment system (cleanser, metronidazole 0.75% gel, hydrating complexion corrector, and sunscreen SPF 30) may offer superior efficacy and tolerability to metronidazole (2)[A].
- Azelaic acid (Finacea) is very effective as initial therapy; azelaic acid topical alone is effective for maintenance (3)[A].
- Topical ivermectin 1% cream (2)[A]
- Recently found to be more effective than metronidazole for treatment of PPR
- Topical brimonidine tartrate 0.5% gel is effective in reducing erythema associated with ETR (4)[A].
- ╬▒2-Adrenergic receptor agonist; potent vasoconstrictor
- Doxycycline 40-mg dose is at least as effective as 100-mg dose and has a correspondingly lower risk of adverse effects but is much more expensive (5)[A].
- Precautions: Tetracyclines may cause photosensitivity; sunscreen is recommended.
- Significant possible interactions:
- Tetracyclines: Avoid concurrent administration with antacids, dairy products, or iron.
- Broad-spectrum antibiotics: may reduce the effectiveness of oral contraceptives; barrier method is recommended.
Second Line
- Topical erythromycin
- Topical clindamycin (lotion preferred)
- Can be used in combination with benzoyl peroxide; commercial topical combinations are available
- Possible use of calcineurin inhibitors (tacrolimus 0.1%; pimecrolimus 1%). Pimecrolimus 1% is effective to treat mild to moderate inflammatory rosacea (6)[A].
- Permethrin 5% cream; similar efficacy compared to metronidazole (7)[B]. For severe cases, oral isotretinoin at 0.3 mg/kg for a minimum of 3 months.
Pediatric Considerations
Tetracyclines: not for use in children <8 years
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Pregnancy Considerations
Tetracyclines: not for use during pregnancy
Isotretinoin: teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception; requires registration with iPLEDGE program
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ADDITIONAL THERAPIES
Cyclosporine 0.05% ophthalmic emulsion may be more effective than artificial tears for ocular rosacea. á
SURGERY/OTHER PROCEDURES
Laser treatment is an option for progressive telangiectasias or rhinophyma. á
ONGOING CARE
FOLLOW-UP RECOMMENDATIONS
Outpatient treatment á
Patient Monitoring
- Occasional and as needed
- Close follow-up and laboratory assessment for women using isotretinoin per prescribing instructions and iPLEDGE program guidance.
DIET
Avoid alcohol, excessive sun exposure, and hot drinks of any type. á
PROGNOSIS
- Slowly progressive
- Subsides spontaneously (sometimes)
COMPLICATIONS
- Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
- Conjunctivitis
- Blepharitis
- Keratitis
- Visual deterioration
REFERENCES
11 Del Rosso áJQ, Thiboutot áD, Gallo áR, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 3: a status report on systemic therapies. Cutis. 2014;93(1):18-28.22 van Zuuren áEJ, Fedorowicz áZ, Carter áBR, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015;(4):CD003262. doi:10.1002/14651858.CD003262.pub5.33 Thiboutot áDM, Fleischer áAB, Del Rosso áJQ, et al. A multicenter study of topical azelaic acid 15% gel in combination with oral doxycycline as initial therapy and azelaic acid 15% gel as maintenance monotherapy. J Drugs Dermatol. 2009;8(7):639-648.44 Fowler áJJr, Jackson áJM, Moore áA, et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013;12(6):650-656.55 Del Rosso áJQ, Webster áGF, Jackson áM, et al. Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea. J Am Acad Dermatol. 2007;56(5):791-802.66 Kim áMB, Kim áGW, Park áHJ, et al. Pimecrolimus 1% cream for the treatment of rosacea. J Dermatol. 2011;38(12):1135-1139. doi:10.1111/j.1346-8138.2011.01223.x.77 Ko žak áM, Ya─čli áS, Vahapo─člu áG, et al. Permethrin 5% cream versus metronidazole 0.75% gel for the treatment of papulopustular rosacea. A randomized double-blind placebo-controlled study. Dermatology. 2002;205(3):265-270.
ADDITIONAL READING
- Leyden áJJ. Efficacy of a novel rosacea treatment system: an investigator-blind, randomized, parallel-group study. J Drugs Dermatol. 2011;10(10):1179-1185.
- Liu áRH, Smith áMK, Basta áSA, et al. Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Arch Dermatol. 2006;142(8):1047-1052.
SEE ALSO
- Acne Vulgaris; Blepharitis; Dermatitis, Seborrheic; Lupus Erythematosus, Discoid; Uveitis
- Algorithm: Acne
CODES
ICD10
- L71.9 Rosacea, unspecified
- L71.8 Other rosacea
ICD9
- 695.3 Rosacea
- 370.49 Other keratoconjunctivitis
SNOMED
- 398909004 Rosacea (disorder)
- 200933006 Ocular rosacea (disorder)
- 257006 Acne rosacea, erythematous telangiectatic type (disorder)
- 75867005 Acne rosacea, papular type (disorder)
- 371097007 Rosacea blepharoconjunctivitis
CLINICAL PEARLS
- Rosacea usually arises de novo without any preceding history of acne or seborrhea.
- Rosacea may cause chronic eye symptoms, including blepharitis.
- Avoid alcohol, sun exposure, and hot drinks.
- Medication treatment resembles that of acne vulgaris, with oral and topical antibiotics.