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Rosacea

Updated : January 31, 2024





Background

Recurrent erythema, telangiectasia, pustules, papules, or flushing on the forehead, nose, chin, and cheeks are symptoms of the prevalent severe inflammatory condition rosacea. Based on the most common symptoms and signs, rosacea can be classified into four different clinical types: phymatous, erythematotelangiectatic, ocular, and papulopustular.

The subtypes do not compete with one another. Patients may exhibit traits from several distinct subtypes, and throughout time, the defining traits and regions of involvement may vary. Between 50 and 75 percent of rosacea patients experience ocular symptoms, such as redness, dryness, tears, tingling or burning, a feeling of a foreign body, sensitivity to light, & blurred sight.

In addition to its effects on the skin and eyes, rosacea can lead to anxiety, shame, and sadness, as well as negatively affect one’s life quality. Despite typically only affecting the skin, rosacea has been linked to systemic morbidities such as cardiovascular disease, irritable bowel syndrome, and neurologic disorders.

 

Epidemiology

Since the majority of rosacea diagnoses are made purely on clinical judgment, many patients, particularly those with moderate illness, may go untreated. The prevalence of rosacea is thought to be greater than 5 percent of the global population.

It affects more than 10 percent of White people, is more prevalent in adults between the ages of 30 & 50, affects women more than men, and is frequently diagnosed in people with light skin (phototypes I & II).

 

Anatomy

 

 

Pathophysiology

Among the pathophysiological pathways proposed for rosacea are immune response activation, Demodex insect infestation, & neurovascular dysfunction. It has been discovered that rosacea patients’ lymphatic & blood capillaries enlarge when exposed to hot temperatures, spicy foods, & alcohol.

The theorized mechanism for the erythema & flushing involves overexpression of unspecified ion channels such as TRPV-1 (transient receptor protentional vanilloid 1) & ankyrin 1 on sensory receptors & keratinocytes as well as the release of vasoactive mediators after reaction to triggers. Another known pathomechanism for rosacea is the activation of the immune system’s innate and adaptive by upregulation of toll-like protein 2 (TLR-2) and Th1/Th17, respectively.

Mast cell activity is boosted by TLR-2 activation due to an increase in LL-37 synthesis. Additionally, rosacea patients have higher expression levels of endothelial vascular growth factor and metalloproteases. Microbes may cause the immune system to get activated in people with rosacea. An increasing number of organisms, including Demodex folliculorum on the surface & helicobacter illness in the gut of rosacea patients, lend support to this hypothesis.

 

Etiology

It is unclear how exactly rosacea is caused. Known etiological causes for the onset of rosacea include genetics, immunological response, microbes, environmental variables, & neurovascular dysfunction. In addition, ultraviolet exposure may contribute to the genesis of the condition in addition to its known action as a rosacea trigger. A higher disease incidence in individuals with a family background of rosacea provides evidence of genetic susceptibility.

Additionally, distinct HLA (human leukocyte antigen) loci have been found in rosacea patients. Demodex insects are among the microorganisms that appear to be involved in rosacea since they are more prevalent on skin that has the condition, while it is unclear whether this is a cause or effect of rosacea. The bacteria H. pylori is also another one that has been linked to rosacea in several studies.

 

Genetics

 

 

Prognostic Factors

Rosacea does not pose a life-threatening concern, and the prognosis is favorable in general. However, it could result in anxiety and sadness. Patients may experience chronic erythema and irreversible scarring if their condition is not managed. Additionally, unmanaged ocular rosacea may result in ocular sequelae.

Recent research extended the potential relationship between rosacea and concomitant gastrointestinal, endocrine, cardiovascular, and neurologic conditions. Taking these comorbidities into account in rosacea patients may be necessary, even if there aren’t any established evidence-based screening guidelines at the moment.

 

Clinical History

Clinical History

Patients frequently have a history of face flushing those dates back to their childhood or adolescence. Flushing may become more frequently caused in adulthood by hot beverages, heat, emotion, and other factors that generate fast fluctuations in body temperature. Unspecific reports of flushing with alcohol come from certain patients.

Although the symptoms are frequently transient, they can eventually result in skin that is permanently flushed. The latter is characterized as having a high hue and is linked to the emergence of persistent telangiectasia. A few people also mention the eyes having a gritty look and facial edema.

Physical Examination

Physical Examination

The disease has a range of symptoms and indications, with most individuals not progressing through all stages. Over the cheeks and forehead, there is variable erythema & telangiectasia. The nose, forehead, and cheeks are the most common areas to see inflamed papules & pustules. Rarely does extra facial involvement extend to the upper chest and neck? Sebaceous gland prominence may be seen, and in severe cases, thickened and deformed noses (rhinophyma) may emerge.

Patients typically do not describe greasiness of the surface, unlike breakouts, but rather dryness & peeling. Another beneficial distinguishing characteristic is the absence of comedones. Although rare, ocular lymphedema can be noticeable. Scarring is not typically a result of the disorder. Rhinophyma can develop on its own without any additional rosacea symptoms or indicators. Rhinophyma can be stressful for sufferers since it is disfiguring. Phymatous rosacea is one of the four subtypes of rosacea, but other authorities believe rhinophyma to represent a separate disease process.

Lymphedema can be seen around the eyes, and occasionally it’s the presenting symptom. Conjunctival injection and, less frequently, chalazion and episcleritis may accompany the symptoms of ocular rosacea. Fortunately, Rosacea fulminans (pyoderma faciale) is a rather uncommon condition that manifests as nodules, abscesses, sinus tract formation, and systemic symptoms. Low-grade fever, an elevated ESR, and potentially an elevated white blood cell count are common in patients.

Seborrhea and seborrheic dermatitis/blepharitis are frequently seen in rosacea patients. These associations’ causes are partially clear. Acne agminata/lupus miliaris disseminatus faciei, a rare granulomatous type of rosacea, can present with inflammatory erythematous or flesh-colored papules dispersed symmetrically across the top region of the face, especially around the eyes and nose. The lesions are often distinct, and there may or may not be accompanying erythema. These patients frequently have yet to gain experience with flushing. This type of rosacea may be resistant to conventional therapy and is occasionally accompanied by scarring.

Age group

Associated comorbidity

Associated activity

Acuity of presentation

Differential Diagnoses

Differential Diagnoses

Seborrheic Dermatitis

Perioral Dermatitis

Acute Cutaneous Lupus Erythematosus

Acute Complications of Sarcoidosis

Laboratory Studies

 

 

Imaging Studies

 

 

Procedures

 

 

Histologic Findings

 

 

Staging

 

 

Treatment Paradigm

Management

The first step in treating rosacea is to provide the patient advice on how to recognize and afterward stay away from triggers, including alcohol, Ultraviolet light, certain foods, and seasonal changes. All rosacea patients should use pH-balanced face cleansers rather than soaps, wide-ranging sunblock with SPF 30 or greater, and moisturizers on a regular basis. Products that irritate the skin should be avoided because rosacea frequently makes it sensitive and unpleasant.

The finest cosmetics for concealing recurrent erythema are those with green pigment. The signs and symptoms that the specific patient is experiencing inform the therapeutic selection. Most treatments are intended to lessen inflammation. Chronic erythema & telangiectasias are frequently treated using medications that target the skin’s vasculature, such as vascular laser, brimonidine, or oxymetazoline, because they are not entirely related to inflammation.

Topical therapy:

Erythema

Oxymetazoline hydrochloride 1% cream (regular application)

Brimonidine tartrate 0.33% gel (regular application)

Inflammatory pustules and papules

Ivermectin 1% cream (regular application)

1% and 0.75% gel or cream metronidazole (regular 1 – 2 times application)

Ocular Involvement:

Artificial tears

0.75% metronidazole gel (daily application to the eyelids once to twice) minimal effectiveness data are available

Acid fusidic gel (daily application to the eyelids once to twice) minimal effectiveness data are available.

0.05% cyclosporine eyedrops (one drop every 12 hours) minimal effectiveness data are available

Systemic Treatment:

Flushing

Carvedilol (6.25 mg twice daily) and propranolol (20 – 40 mg twice daily)

Clonidine (50 mcg twice daily)

Inflammatory pustules and papules

Modified-release subantimicrobial-dose doxycycline (For 8 – 12 weeks, take 40 mg daily with 30 mg rapid-release beads and 10 mg slow-release beads)

Tetracycline (8 – 12 weeks of twice-daily intake of 250 – 500 mg)

Minocycline (for 8 – 12 weeks, twice-daily intake of taking 50 – 100 mg)

Azithromycin (for 4 – 8 weeks, thrice-daily intake of taking 250 – 500 mg)

Isotretinoin (for 12 – 16 weeks, 0.25 – 0.3 mg/kg/day)

Ocular Involvement

Modified-release subantimicrobial-dose doxycycline (40 – 100 mg daily)

Phyma (inflamed)

Tetracycline (8 – 12 weeks of twice-daily intake of 250 – 500 mg)

Isotretinoin (for 3 – 4 months, 0.25 – 0.3 mg/kg/day)

Doxycycline (100 mg once or twice a day for 8 – 12 weeks)

Interventions/Procedures

The use of an intense pulsed laser

Telangiectasia/erythema

NdYAG laser

PDL 585–595 nm pulsed dye laser

Phyma (non-inflamed)

Surgical excision

CO2 laser 10,600 nm

Electrosurgery

If the patient exhibits any eye involvement, particularly severe signs and visual disruption, consultation with an ophthalmologist is advised. Pregnant women should consider topical therapy. Pregnant women with severe to moderate inflamed rosacea are thought to be safe to use clarithromycin, erythromycin, and azithromycin. When topical medication alone is ineffective for treating flares, systemic treatments are frequently employed. After containing the flare-up, it is advised to continue topical therapy to preserve remission.

 

by Stage

 

 

by Modality

 

 

Chemotherapy

 

 

Radiation Therapy

 

 

Surgical Interventions

 

 

Hormone Therapy

 

 

Immunotherapy

 

 

Hyperthermia

 

 

Photodynamic Therapy

 

 

Stem Cell Transplant

 

 

Targeted Therapy

 

 

Palliative Care

 

 

Medication

 

 

 

benzyl peroxide 

Apply a small amount of cream onto the affected skin



ondansetron 

(Off-label)
4-8 mg orally every 12 hours for 3 weeks
Secondly, 12 mg intravenously for 4 days



azelaic acid 

Apply a thin minimum layer on the affected facial area twice daily
Apply the product gently and thoroughly on washed and dried skin



brimonidine topical 

Apply a small sized amount each day on the central forehead, nose, chin, and cheek
Apply the product smoothly across the face avoiding the nose & mouth



oxymetazoline topical 

Topically apply every day; take a pea-sized quantity of cream in thin layer on the entire face (nose, forehead, chin and each cheek), avoiding the lips and eyes
after application, immediately Wash hands



metronidazole topical  

1%: use topically daily to impacted areas of skin
0.75%: use topically two times daily to impacted areas of skin
Administration
Clear the treated regions before use
Put a thin layer and massage into the skin
Beauty products can be used after at least 5 minutes of application



 

oxymetazoline topical 

Topically apply every day; take a pea-sized quantity of cream in thin layer on the entire face (nose, forehead, chin and each cheek), avoiding the lips and eyes
after application, immediately Wash hands



 

Media Gallary

References

https://www.ncbi.nlm.nih.gov/books/NBK557574/

 

ADVERTISEMENT 

Rosacea

Updated : January 31, 2024




Recurrent erythema, telangiectasia, pustules, papules, or flushing on the forehead, nose, chin, and cheeks are symptoms of the prevalent severe inflammatory condition rosacea. Based on the most common symptoms and signs, rosacea can be classified into four different clinical types: phymatous, erythematotelangiectatic, ocular, and papulopustular.

The subtypes do not compete with one another. Patients may exhibit traits from several distinct subtypes, and throughout time, the defining traits and regions of involvement may vary. Between 50 and 75 percent of rosacea patients experience ocular symptoms, such as redness, dryness, tears, tingling or burning, a feeling of a foreign body, sensitivity to light, & blurred sight.

In addition to its effects on the skin and eyes, rosacea can lead to anxiety, shame, and sadness, as well as negatively affect one’s life quality. Despite typically only affecting the skin, rosacea has been linked to systemic morbidities such as cardiovascular disease, irritable bowel syndrome, and neurologic disorders.

 

Since the majority of rosacea diagnoses are made purely on clinical judgment, many patients, particularly those with moderate illness, may go untreated. The prevalence of rosacea is thought to be greater than 5 percent of the global population.

It affects more than 10 percent of White people, is more prevalent in adults between the ages of 30 & 50, affects women more than men, and is frequently diagnosed in people with light skin (phototypes I & II).

 

 

 

Among the pathophysiological pathways proposed for rosacea are immune response activation, Demodex insect infestation, & neurovascular dysfunction. It has been discovered that rosacea patients’ lymphatic & blood capillaries enlarge when exposed to hot temperatures, spicy foods, & alcohol.

The theorized mechanism for the erythema & flushing involves overexpression of unspecified ion channels such as TRPV-1 (transient receptor protentional vanilloid 1) & ankyrin 1 on sensory receptors & keratinocytes as well as the release of vasoactive mediators after reaction to triggers. Another known pathomechanism for rosacea is the activation of the immune system’s innate and adaptive by upregulation of toll-like protein 2 (TLR-2) and Th1/Th17, respectively.

Mast cell activity is boosted by TLR-2 activation due to an increase in LL-37 synthesis. Additionally, rosacea patients have higher expression levels of endothelial vascular growth factor and metalloproteases. Microbes may cause the immune system to get activated in people with rosacea. An increasing number of organisms, including Demodex folliculorum on the surface & helicobacter illness in the gut of rosacea patients, lend support to this hypothesis.

 

It is unclear how exactly rosacea is caused. Known etiological causes for the onset of rosacea include genetics, immunological response, microbes, environmental variables, & neurovascular dysfunction. In addition, ultraviolet exposure may contribute to the genesis of the condition in addition to its known action as a rosacea trigger. A higher disease incidence in individuals with a family background of rosacea provides evidence of genetic susceptibility.

Additionally, distinct HLA (human leukocyte antigen) loci have been found in rosacea patients. Demodex insects are among the microorganisms that appear to be involved in rosacea since they are more prevalent on skin that has the condition, while it is unclear whether this is a cause or effect of rosacea. The bacteria H. pylori is also another one that has been linked to rosacea in several studies.

 

 

 

Rosacea does not pose a life-threatening concern, and the prognosis is favorable in general. However, it could result in anxiety and sadness. Patients may experience chronic erythema and irreversible scarring if their condition is not managed. Additionally, unmanaged ocular rosacea may result in ocular sequelae.

Recent research extended the potential relationship between rosacea and concomitant gastrointestinal, endocrine, cardiovascular, and neurologic conditions. Taking these comorbidities into account in rosacea patients may be necessary, even if there aren’t any established evidence-based screening guidelines at the moment.

 

Clinical History

Patients frequently have a history of face flushing those dates back to their childhood or adolescence. Flushing may become more frequently caused in adulthood by hot beverages, heat, emotion, and other factors that generate fast fluctuations in body temperature. Unspecific reports of flushing with alcohol come from certain patients.

Although the symptoms are frequently transient, they can eventually result in skin that is permanently flushed. The latter is characterized as having a high hue and is linked to the emergence of persistent telangiectasia. A few people also mention the eyes having a gritty look and facial edema.

Physical Examination

The disease has a range of symptoms and indications, with most individuals not progressing through all stages. Over the cheeks and forehead, there is variable erythema & telangiectasia. The nose, forehead, and cheeks are the most common areas to see inflamed papules & pustules. Rarely does extra facial involvement extend to the upper chest and neck? Sebaceous gland prominence may be seen, and in severe cases, thickened and deformed noses (rhinophyma) may emerge.

Patients typically do not describe greasiness of the surface, unlike breakouts, but rather dryness & peeling. Another beneficial distinguishing characteristic is the absence of comedones. Although rare, ocular lymphedema can be noticeable. Scarring is not typically a result of the disorder. Rhinophyma can develop on its own without any additional rosacea symptoms or indicators. Rhinophyma can be stressful for sufferers since it is disfiguring. Phymatous rosacea is one of the four subtypes of rosacea, but other authorities believe rhinophyma to represent a separate disease process.

Lymphedema can be seen around the eyes, and occasionally it’s the presenting symptom. Conjunctival injection and, less frequently, chalazion and episcleritis may accompany the symptoms of ocular rosacea. Fortunately, Rosacea fulminans (pyoderma faciale) is a rather uncommon condition that manifests as nodules, abscesses, sinus tract formation, and systemic symptoms. Low-grade fever, an elevated ESR, and potentially an elevated white blood cell count are common in patients.

Seborrhea and seborrheic dermatitis/blepharitis are frequently seen in rosacea patients. These associations’ causes are partially clear. Acne agminata/lupus miliaris disseminatus faciei, a rare granulomatous type of rosacea, can present with inflammatory erythematous or flesh-colored papules dispersed symmetrically across the top region of the face, especially around the eyes and nose. The lesions are often distinct, and there may or may not be accompanying erythema. These patients frequently have yet to gain experience with flushing. This type of rosacea may be resistant to conventional therapy and is occasionally accompanied by scarring.

Differential Diagnoses

Seborrheic Dermatitis

Perioral Dermatitis

Acute Cutaneous Lupus Erythematosus

Acute Complications of Sarcoidosis

 

 

 

 

 

 

 

 

 

 

Management

The first step in treating rosacea is to provide the patient advice on how to recognize and afterward stay away from triggers, including alcohol, Ultraviolet light, certain foods, and seasonal changes. All rosacea patients should use pH-balanced face cleansers rather than soaps, wide-ranging sunblock with SPF 30 or greater, and moisturizers on a regular basis. Products that irritate the skin should be avoided because rosacea frequently makes it sensitive and unpleasant.

The finest cosmetics for concealing recurrent erythema are those with green pigment. The signs and symptoms that the specific patient is experiencing inform the therapeutic selection. Most treatments are intended to lessen inflammation. Chronic erythema & telangiectasias are frequently treated using medications that target the skin’s vasculature, such as vascular laser, brimonidine, or oxymetazoline, because they are not entirely related to inflammation.

Topical therapy:

Erythema

Oxymetazoline hydrochloride 1% cream (regular application)

Brimonidine tartrate 0.33% gel (regular application)

Inflammatory pustules and papules

Ivermectin 1% cream (regular application)

1% and 0.75% gel or cream metronidazole (regular 1 – 2 times application)

Ocular Involvement:

Artificial tears

0.75% metronidazole gel (daily application to the eyelids once to twice) minimal effectiveness data are available

Acid fusidic gel (daily application to the eyelids once to twice) minimal effectiveness data are available.

0.05% cyclosporine eyedrops (one drop every 12 hours) minimal effectiveness data are available

Systemic Treatment:

Flushing

Carvedilol (6.25 mg twice daily) and propranolol (20 – 40 mg twice daily)

Clonidine (50 mcg twice daily)

Inflammatory pustules and papules

Modified-release subantimicrobial-dose doxycycline (For 8 – 12 weeks, take 40 mg daily with 30 mg rapid-release beads and 10 mg slow-release beads)

Tetracycline (8 – 12 weeks of twice-daily intake of 250 – 500 mg)

Minocycline (for 8 – 12 weeks, twice-daily intake of taking 50 – 100 mg)

Azithromycin (for 4 – 8 weeks, thrice-daily intake of taking 250 – 500 mg)

Isotretinoin (for 12 – 16 weeks, 0.25 – 0.3 mg/kg/day)

Ocular Involvement

Modified-release subantimicrobial-dose doxycycline (40 – 100 mg daily)

Phyma (inflamed)

Tetracycline (8 – 12 weeks of twice-daily intake of 250 – 500 mg)

Isotretinoin (for 3 – 4 months, 0.25 – 0.3 mg/kg/day)

Doxycycline (100 mg once or twice a day for 8 – 12 weeks)

Interventions/Procedures

The use of an intense pulsed laser

Telangiectasia/erythema

NdYAG laser

PDL 585–595 nm pulsed dye laser

Phyma (non-inflamed)

Surgical excision

CO2 laser 10,600 nm

Electrosurgery

If the patient exhibits any eye involvement, particularly severe signs and visual disruption, consultation with an ophthalmologist is advised. Pregnant women should consider topical therapy. Pregnant women with severe to moderate inflamed rosacea are thought to be safe to use clarithromycin, erythromycin, and azithromycin. When topical medication alone is ineffective for treating flares, systemic treatments are frequently employed. After containing the flare-up, it is advised to continue topical therapy to preserve remission.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

benzyl peroxide 

Apply a small amount of cream onto the affected skin



ondansetron 

(Off-label)
4-8 mg orally every 12 hours for 3 weeks
Secondly, 12 mg intravenously for 4 days



azelaic acid 

Apply a thin minimum layer on the affected facial area twice daily
Apply the product gently and thoroughly on washed and dried skin



brimonidine topical 

Apply a small sized amount each day on the central forehead, nose, chin, and cheek
Apply the product smoothly across the face avoiding the nose & mouth



oxymetazoline topical 

Topically apply every day; take a pea-sized quantity of cream in thin layer on the entire face (nose, forehead, chin and each cheek), avoiding the lips and eyes
after application, immediately Wash hands



metronidazole topical  

1%: use topically daily to impacted areas of skin
0.75%: use topically two times daily to impacted areas of skin
Administration
Clear the treated regions before use
Put a thin layer and massage into the skin
Beauty products can be used after at least 5 minutes of application



oxymetazoline topical 

Topically apply every day; take a pea-sized quantity of cream in thin layer on the entire face (nose, forehead, chin and each cheek), avoiding the lips and eyes
after application, immediately Wash hands



 

 

https://www.ncbi.nlm.nih.gov/books/NBK557574/

 

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