The diagnosis of Acne rosacea is made by fulfilling one of several primary and one of many secondary criteria. Primary criteria for Acne rosacea include transient erythema/flushing, persistent facial redness, papules and pustules, and increased facial telangiectasias. Secondary criteria include burning/stinging, elevated red facial plaques with or without scale, dry/scaly skin, persistent facial edema (subtypes of solid facial or soft facial type), phymatous changes, and ocular manifestations such as burning/itching, conjunctival hyperemia, lid inflammation, styes, chalazia, and corneal damage.
There are four subtypes and one variant of Acne rosacea that have been defined by the National rosacea Society committee on the classification and staging of Acne rosacea: (i) erythematotelangiectatic, (ii) papulopustular, (iii) phymatous, and (iv) ocular. Erythematotelangiectatic rosacea is characterized by flushing and persistent central facial erythema with or without telangiectasia. The papulopustular type has persistent central facial edema and transient papules, pustules, or both. Phymatous rosacea occurs most often on the nose (rhinophyma) and is characterized by thick skin with an irregular surface, nodularities, and bulbous enlargement. Careful evaluation of a nose with the changes of rhinophyma should be undertaken because basal cell carcinomas may be present, as well as less common tumors. Lastly, the ocular type of rosacea has many symptoms, of eye affection. Granulomatous rosacea is a variant characterized by noninflammatory, hard, brown, yellow, or red papules/nodules of the central face. It is of note that rosacea fulminans (pyoderma faciale), steroid-induced acneiform eruption, and perioral dermatitis are not considered Acne rosacea variants but separate entities.
Ocular changes (blepharitis, conjunctivitis, and keratitis) and sebaceous hyperplasia of the nose (rhinophyma) may be associated with ocular rosacea. Differential diagnostic considerations include (i) acne vulgaris, which is characterized by a wider distribution of lesions and the presence of comedones, (ii) periorificial dermatitis, (iii) seborrheic dermatitis, (iv) malignant carcinoid syndrome, (v) lupus erythematosus, and (vi) photodermatoses. Ocular rosacea has been theorized to be secondary to increased local levels of interferon-1 that is pro-inflammatory and leads to lid irritation and erythema. Lipid breakdown in the tears releases fatty acids that are also irritating. Some studies have also shown a more alkaline pH of tears in patients with Acne rosacea.
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).
Wednesday, December 17, 2008
Acne rosacea causes
Acne rosacea is a chronic disorder of unknown cause that affects the central face. At least 13 million people are affected by this noncurable disorder. It is characterized by two clinical components: a vascular change consisting of intermittent or persistent erythema and flushing and an acneiform eruption with papules, pustules, cysts, and sebaceous hyperplasia. There is no correlation between the sebum excretion rate and the severity of Acne rosacea. Lesional blood flow as measured by laser Doppler is three to four times that of controls. Onset is most often between the ages of 30 and 50; pediatric cases have also been reported. Although women are affected three times as frequently as men, the disease may become more severe in men. Acne rosacea is much more common in light-skinned, fair-complexioned individuals but may also occur in darker skin types. It is estimated that 10% of individuals in Sweden have Acne rosacea.
There is speculation that a defect in the trigeminal afferent nerve pathway contributes to a predisposition to facial flushing. Over time, after repeated bouts of flushing, the vessels become ectatic and there is permanent vasodilatation. Hot liquids are thought to promote erythema and flushing when they heat up the tissues of the oral mucosa, leading to a countercurrent heat exchange with the carotid artery. A further signal from the carotid body is then relayed to the hypothalamus (the body's thermostat), which signals the body to dissipate heat through flushing and vasodilatation because of the perceived increase in core body temperature.
Helicobacter pylori, a microaerophilic gram-negative bacteria implicated in gastric ulcer disease, has been theorized to be the inciting organism in Acne rosacea on the basis of an increased incidence of dyspepsia in this population and the responsiveness of Acne rosacea to metronidazole. Fifty percent of the world's population and 25% of the US population may have antibodies to this organism. Colonization is associated with increased levels of serum gastrin, which can cause flushing. Also, H. pylori infection can increase levels of histamine, prostaglandins, leukotrienes, and various other cytokines. Therapy to eradicate this organism usually consists of a combination of oral metronidazole, amoxicillin, and omeprazole. Conflicting studies regarding this association with Acne rosacea have recently been in the literature. In general, it is felt that strong support for a link between H. pylori infection and Acne rosacea is lacking. Large case control studies would be needed to prove this association because of the high baseline incidence of this exposure.
Infection with Demodex mites is common, with infection approaching 100% in sensitive tests of healthy adults. Some have hypothesized that infection with Demodex is a cause of Acne rosacea. There is controversy within the literature whether this is the case. In one study, there was a link between higher mite counts and papulopustular but not erythematotelangiectatic Acne rosacea. It is unclear whether Demodex is pathologic or just normal skin flora.
There is speculation that a defect in the trigeminal afferent nerve pathway contributes to a predisposition to facial flushing. Over time, after repeated bouts of flushing, the vessels become ectatic and there is permanent vasodilatation. Hot liquids are thought to promote erythema and flushing when they heat up the tissues of the oral mucosa, leading to a countercurrent heat exchange with the carotid artery. A further signal from the carotid body is then relayed to the hypothalamus (the body's thermostat), which signals the body to dissipate heat through flushing and vasodilatation because of the perceived increase in core body temperature.
Helicobacter pylori, a microaerophilic gram-negative bacteria implicated in gastric ulcer disease, has been theorized to be the inciting organism in Acne rosacea on the basis of an increased incidence of dyspepsia in this population and the responsiveness of Acne rosacea to metronidazole. Fifty percent of the world's population and 25% of the US population may have antibodies to this organism. Colonization is associated with increased levels of serum gastrin, which can cause flushing. Also, H. pylori infection can increase levels of histamine, prostaglandins, leukotrienes, and various other cytokines. Therapy to eradicate this organism usually consists of a combination of oral metronidazole, amoxicillin, and omeprazole. Conflicting studies regarding this association with Acne rosacea have recently been in the literature. In general, it is felt that strong support for a link between H. pylori infection and Acne rosacea is lacking. Large case control studies would be needed to prove this association because of the high baseline incidence of this exposure.
Infection with Demodex mites is common, with infection approaching 100% in sensitive tests of healthy adults. Some have hypothesized that infection with Demodex is a cause of Acne rosacea. There is controversy within the literature whether this is the case. In one study, there was a link between higher mite counts and papulopustular but not erythematotelangiectatic Acne rosacea. It is unclear whether Demodex is pathologic or just normal skin flora.
Monday, December 1, 2008
Acne Rosacea FAQ
What is Acne Rosacea?
Acne Rosacea is a common pustular eruption with flushing and telangiectasias of the butterfly area of the face may occur in adults especially in the 40- to 60-year-old age group.
What are the primary Acne Rosacea lesions?
Diffuse redness, papules, pustules, and, later, dilated venules, mainly of the nose, cheeks, and forehead, are seen.
What are the secondary Acne Rosacea lesions?
Severe, longstanding cases eventuate in the bulbous, greasy, hypertrophic nose characteristic of rhinophyma.
What about the course of Acne Rosacea?
The pustules are recurrent and difficult to heal. Rosacea keratitis of the eye may occur.
What are the causes of Acne Rosacea?
Several factors influence the disease:
heredity (oily skin);
excess ingestion of alcoholic beverages, hot drinks, and spicy foods;
Demodex mites (may be causative);
increased exercise;
increased exposure to hot or cold environment; and
topical or systemic corticosteroids.
Excess sun exposure and emotional stress can aggravate some cases of Acne Rosacea.
What are the conditions that have some similarities to Acne Rosacea?
Systemic lupus erythematosus: No papules or pustules; positive ANA blood test.
Boils: Usually only one large lesion; can be recurrent but may occur sporadically; an early case of Acne Rosacea may look like small boils. Bacterial culture shows Staphylococcus aureus or group A hemolytic streptococci. Responds to anti-Staphylococcus antibiotics.
Iodide or bromide drug eruption: Clinically similar, but drug eruption usually is more widespread; history positive for drug.
Seborrheic dermatitis: Pustules uncommon; red and scaly; also in scalp.
Acne Rosacea-like tuberculid of Lewandowsky: Mimics small papular Acne Rosacea clinically and tuberculids histologically, rare; biopsy helpful.
Outline Acne Rosacea treatment?
* Prescribe avoidance of these foods: chocolate, nuts, cheese, cola drinks, iodized salt, seafood, alcohol, spices, and very hot drinks.
* Metronidazole gel (MetroGel, Metrocream, Metrolotion or Noritate cream)
Apply thin coat b.i.d. Response to therapy is slow, taking 4 to 6 weeks to benefit.
* Sulfur, ppt. 6%
Resorcinol 4%
Colored alcoholic shake lotion q.s. 60.0
Apply to face h.s.
Similar proprietary lotions are Sulfacet-R lotion Rosac Cream (contains a sunscreen), Rosula (contains urea to decrease irritation), sodium sulfacetamide topical preparations, Plexion topical preparations, Novacet lotion, Avar Green (contains green tint to hide redness).
* Tetracycline, 250-mg capsules
Take 1 capsule q.i.d. for 3 days, then 1 capsule b.i.d. for weeks, as necessary for benefit. Other antibiotics that can be used, as for acne, include doxycycline, minocycline, and erythromycin.
* Therapy for Helicobacter pylori in the same treatment regimens as for peptic ulcer disease has been tried with some benefit in severe cases.
* Azeleic acid (Azelex, Finacea) in thin coat b.i.d.
* Crotamiton (Eurax) lotion in thin coat b.i.d.
Acne Rosacea is a common pustular eruption with flushing and telangiectasias of the butterfly area of the face may occur in adults especially in the 40- to 60-year-old age group.
What are the primary Acne Rosacea lesions?
Diffuse redness, papules, pustules, and, later, dilated venules, mainly of the nose, cheeks, and forehead, are seen.
What are the secondary Acne Rosacea lesions?
Severe, longstanding cases eventuate in the bulbous, greasy, hypertrophic nose characteristic of rhinophyma.
What about the course of Acne Rosacea?
The pustules are recurrent and difficult to heal. Rosacea keratitis of the eye may occur.
What are the causes of Acne Rosacea?
Several factors influence the disease:
heredity (oily skin);
excess ingestion of alcoholic beverages, hot drinks, and spicy foods;
Demodex mites (may be causative);
increased exercise;
increased exposure to hot or cold environment; and
topical or systemic corticosteroids.
Excess sun exposure and emotional stress can aggravate some cases of Acne Rosacea.
What are the conditions that have some similarities to Acne Rosacea?
Systemic lupus erythematosus: No papules or pustules; positive ANA blood test.
Boils: Usually only one large lesion; can be recurrent but may occur sporadically; an early case of Acne Rosacea may look like small boils. Bacterial culture shows Staphylococcus aureus or group A hemolytic streptococci. Responds to anti-Staphylococcus antibiotics.
Iodide or bromide drug eruption: Clinically similar, but drug eruption usually is more widespread; history positive for drug.
Seborrheic dermatitis: Pustules uncommon; red and scaly; also in scalp.
Acne Rosacea-like tuberculid of Lewandowsky: Mimics small papular Acne Rosacea clinically and tuberculids histologically, rare; biopsy helpful.
Outline Acne Rosacea treatment?
* Prescribe avoidance of these foods: chocolate, nuts, cheese, cola drinks, iodized salt, seafood, alcohol, spices, and very hot drinks.
* Metronidazole gel (MetroGel, Metrocream, Metrolotion or Noritate cream)
Apply thin coat b.i.d. Response to therapy is slow, taking 4 to 6 weeks to benefit.
* Sulfur, ppt. 6%
Resorcinol 4%
Colored alcoholic shake lotion q.s. 60.0
Apply to face h.s.
Similar proprietary lotions are Sulfacet-R lotion Rosac Cream (contains a sunscreen), Rosula (contains urea to decrease irritation), sodium sulfacetamide topical preparations, Plexion topical preparations, Novacet lotion, Avar Green (contains green tint to hide redness).
* Tetracycline, 250-mg capsules
Take 1 capsule q.i.d. for 3 days, then 1 capsule b.i.d. for weeks, as necessary for benefit. Other antibiotics that can be used, as for acne, include doxycycline, minocycline, and erythromycin.
* Therapy for Helicobacter pylori in the same treatment regimens as for peptic ulcer disease has been tried with some benefit in severe cases.
* Azeleic acid (Azelex, Finacea) in thin coat b.i.d.
* Crotamiton (Eurax) lotion in thin coat b.i.d.
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