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).
