Acne Rosacea
Acne Rosacea is a chronic inflammatory facial eruption characterized by papules and pustules on a background of erythema and telangiectasia.
Epidemiology
Acne Rosacea is common. peak age at presentation is the third or fourth decade and the condition has been more frequently observed in patients with fair skin. It has an equal sex incidence but men often have more severe disease.
Pathology
The pathogenesis of Acne Rosacea is unknown. Histologically there is a non-specific perifollicular and perivascular inflammatory infiltrate with dilated capillaries in the superficial dermis.
Clinical features
Acne Rosacea is a persistent disease with episodic inflammatory flares. Patients usually have a long history of episodic facial flushing, which may be exacerbated by heat, emotional upset, hot drinks, spicy foods and alcohol. During these episodes, there is intense erythema symmetrically over the cheeks, nose, forehead and chin. There are three stages in the evolution of this disease.
Chronic Acne Rosacea can be associated with marked sebaceous hyperplasia, most commonly on the nose giving a bulbous craggy appearance. This is known as rhinophyma. There may also be lymphoedema resulting in swelling of the central part of the face. Approximately 50% of patients have minor degrees of ocular involvement, most commonly conjunctivitis, blepharitis and keratitis leading to corneal scarring.
Investigations
Acne Rosacea can be diagnosed clinically; investigations are not usually required.
Skin biopsy
If the diagnosis is in doubt a skin biopsy may be required for histopathology.
Stages in the evolution of Acne Rosacea
Stage Clinical features
I Persistent erythema with telangiectasia
II Persistent erythema, telangiectasia, papules and tiny pustules
III Persistent deep erythema, dense telangiectasia, papules, pustules and nodules
Management
Identify and address precipitating factors
Patients are advised to avoid factors that provoke facial flushing. Reduction of alcoholic and hot beverages is helpful in some cases.
Concealing agents
Camouflages can be used for the erythema, and laser treatment is helpful in the treatment of telangiectasia.
Antibiotic therapy
Papules and pustules of Acne Rosacea respond well to topical metronidazole or to oral oxytetracycline or tetracycline 500 mg twice daily. Courses usually last 6-12 weeks and are repeated intermittently. Alternatively doxycycline or minocycline 100 mg daily can be given.
Oral retinoids
Isotretinoin is occasionally given in refractory or severe cases. Despite topical and systemic treatment the redness and telangiectasia may not improve.
Surgery
Rhinophyma is treated by surgery or laser surgery, shaving the hypertrophic tissue from the nose. Unfortunately regrowth of this tissue frequently occurs.
Prognosis
Despite optimal treatment, recurrences are common.
what is Rosacea
Rosacea is a common chronic inflammatory disorder of the hair follicles, sebaceous glands and vasculature of the face. The role of Demodex mite in the pathogenesis of Rosacea is controversial.
Rosacea sufferers have recurrent flushing, exacerbated by heat (shower, hot drinks), spicy foods, sunlight, cold, alcohol, and stress. They have sensitive skin, and may complain of dry and gritty eyes.
The peak incidence of Rosacea is 30—50 yr; Females being more affected than Males.
Rosacea sufferers may develop erythema, telangiectases, papules, and pustules of central face; there are no comedones in contrast to acne. Sebaceous hyperplasia, seborrheic dermatitis and facial lymphedema are also more common.
There are 4 Major Subtypes of Rosacea:
Erythematotelangiectatic, papulopustular, ocular, and phymatous.
Chronic inflammation may progress to rhinophyma (enlarged nose; in males). Ocular involvement is also common (e.g., gritty, conjunctival injection, styes, photophobia).
Investigations include clinical diagnosis; uncommonly, skin biopsy is indicated to rule out lupus or sarcoidosis.
Similar conditions that needs to be differentiated from Rosacea are: Acne, lupus erythematosus, perioral dermatitis, sarcoidosis, seborrheic dermatitis.
Treatment of Rosacea is based on severity and subtype.
Lifestyle modification:
Avoid triggers; sun protection and avoidance; facial massage for lymphedema.
Topical antibiotics:
Metronidazole 0.75% gel or 1% cream bid.
Sodium sulfacetamide lotion 10% bid.
Oral antibiotics (moderate to severe cases with inflammatory papulopustular component):
Tetracycline 500 mg po bid
Minocycline 100 mg po od—bid.
Doxycycline 20 mg po bid (subantimicrobial dose therapy) or 100 mg po qd–bid.
Isotretinoin (low dose); less commonly, topical retinoids may be used.
Laser therapy (e.g., PDL, IPL) for telangiectases and ablative laser (e.g., CO2) for rhinophyma.
Camouflage makeup (e.g., Dermablend, Covermark) for erythema.
Ophthalmologist to assess for ocular Rosacea (blepharitis, conjunctivitis, episcleritis).
