Diagnosis

Rosacea

Etiology

Cause [szn]

• Unknown

• Genetics (family history, HLA association)

• Immune reaction

• Microorganisms (Demodex folliculorum mites, Helicobacter pylori)

• UV exposure

• Triggering factors [znn]

  • Hot or cold temperatures

  • Wind

  • Hot drinks

  • Caffeine

  • Exercise

  • Spicy food

  • Alcohol

  • Emotions

  • Topical products

  • Medications: potent corticosteroids, flushing drugs

Pathophysiology [r3a][szn]

1. Neurovascular dysregulation:

   • Dilation of lymphatic and blood vessels --> erythema and flushing

2. Inflammatory activation:

   • Chronic low-grade dermatitis --> neoangiogenesis

   • Dermal matrix degeneration

   • Pilosebaceous unit abnormalities

   • Reactive oxygen species

3. Subtypes: [znn][szn]

   • Erythematotelangiectatic: Persistent erythema with intermittent flushing

   • Papulopustular: Papules and pustules ("adult acne" without comedones)

   • Phymatous: Fibrosis and hypertrophy of sebaceous glands (male nose)

   • Ocular affection (50-75%): Redness, tearing, dry eye, tingling/burning, foreign-body sensation, light sensitivity, blurred vision, gritty sensation, pruritus, hordeola, and blepharitis

Epidemiology

Prevalence per 100.000 [mgd][qzu][edf][f3p]

Approach

• Clinical diagnosis

• Skin biopsy to exclude differential diagnosis

Diagnostic criteria [znn]

• Diagnostic phenotypes (≥1 required):

  • Fixed centrofacial erythema that may periodically intensify

  • Phymatous changes

• Major phenotypes (≥2 required)

  • Papules and pustules

  • Flushing

  • Telangiectasia

  • Ocular manifestations

• Secondary signs and symptoms that may appear

  • Burning and stinging

  • Edema (facial edema)

  • Dry-appearing skin

• Ocular rosacea:

  • Lid margin telangiectasia

  • Interpalpebral conjunctival injection

  • Spade-shaped infiltrates in the cornea

  • Scleritis and sclerokeratitis

  • "Honey crust" and collarette accumulation at the base of the lashes

  • Irregularity of the lid margin

  • Evaporative tear dysfunction

Treatment

Rosacea is treatable but not curable [s2t][edf][szn]

1. Topical rosacea:

   • Avoid local irritation (UV light, hot/cold temperatures, wind, hot drinks, caffeine, exercise, spicy food, alcohol, soaps, alcoholic cleansers, tinctures, astrigents, abrasives and peeling agents. Only very mild soaps and diluted detergents are advised.

   • Color-correcting powders (make-up)

   • Sunscreen with SPF>30

   • Anti-inflammatory antibiotics: Tetracyclines, clindamycin, erythromycin, metronidazole gel

   • Imidazole

   • Ketoconazole cream (anti-inflammatory and immonusuppressive)

   • Drying lotions (sulphur lotion)

   • Topical retinoids (Isotretinoin)

   • Azelaic acid

   • Ivermectin cream

   • Brimonidine tartrate gel (alpha-2 agonist)

   • Oxymetazoline (topical alpha agonist)

   • Dapsone (severe, refractory rosacea)

   • Corticosteroids only used in rosacea fulminans

2. Systemic rosacea:

   • Antibiotics: Tetracyclin 1-1.5g/day (alternative: Doxycycline/Erythromycin)

   • Isotretinoin 0.1-1.0mg/kg/day (side effects: dry eyes/blepharitis)

3. Rosacea fulminans:

   • Oral corticosteroids: Prednisolon 1mg/kg/day for one week

   • Then Isotretinoin 0.2-0.5mg/kg/day with slow tapering of Prednisolon

4. Ocular rosacea:

   • Lid hygiene

   • Lubricating eye drops: Fusidic acid gel (daily 1 to 2 times application on eyelids)

   • Topical antibiotics: Metronidazole 0.75% gel

   • Cyclosporine 0.05% eyedrops

5. Remove telangiectasia:

   • Laser treatment

   • Surgical resection

   • Electrosurgery

Differential diagnoses

Acne, Carcinoid syndrome, Dermatomyositis, Drug side effects, Eczema, Mastocytosis, Mixed connective tissue disease, Perioral dermatitis, Photosensitivity, Polycythemia vera, Polymorphic light eruption, Sarcoidosis, Seborrheic dermatitis, Systemic lupus erythematosus