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Chapter 81. Rosacea

Definition

A papular and pustular inflammatory process that is centered in follicles and is distributed mostly in the middle third of the face in both vertical and horizontal directions. Among the varied manifestations of rosacea are innumerable telangiectases, perioral and periocular dermatitis, and rhinophyma. Complications of rosacea include keratitis and conjunctivitis.

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Course

The sequence chronologic of lesions of rosacea varies greatly because the lesions themselves vary so greatly. The mostly telangiectatic expression of rosacea simply worsens in time with more telangiectases appearing on the middle third of the face. Papules of rosacea may come and go for years or they may enlarge to become permanent nodules. The rhinophymatous manifestation of rosacea tends to worsen progressively and may be deforming.

In sum, only papular lesions of rosacea regress, and inconsistently; the telangiectatic and rhinophymatous expressions of rosacea tend to progress and worsen.

Integration: Unifying Concept

It is extremely difficult to integrate the various features of rosacea because they are so disparate from one another. How are telangiectases, i.e., dilated end venules, related to papules that consist largely of perifollicular granulomas in company with telangiectases? And how is rhinophyma that represents infundibular cysts that have ruptured and induced suppurative, granulomatous, and fibrosing inflammation combined with prominent sebaceous gland hyperplasia related to keratitis? The answers are not known. Yet another conundrum is posed by the many clinical presentations of the papular expression of rosacea, among them, perioral and periocular dermatitis, rosacea-like tuberculid of Lewandowski, and lupus miliaris disseminatus faciei. In short, rosacea remains an enigma. One issue is clear, namely, that the mite Demodex folliculorum, long claimed to be the etiologic agent of rosacea, is irrelevant to the condition.

A diagnosis can be made of all variants of rosacea clinically, and of papular and rhinophymatous presentations of rosacea histopathologically if attributes of the process pictured in this chapter are identified.

Therapy

Click here for an up-to-date discussion of therapeutic management presented in Therapeutic Strategies in Dermatology.

Distribution

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Fig. 81-1

Telangiectases, papules, and zones of erythema on the scalp, forehead, nose, malar regions, and cheeks.


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Fig. 81-2

Telangiectases, papules, and zones of erythema on the forehead, malar regions, and nose especially.


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Fig. 81-3

Telangiectases and papules on the nose, malar eminences, and cheeks.


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Fig. 81-4

Erythema and swollen tip of the nose.


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Fig. 81-5

Papules and pustules of  “perioral dermatitis” and of “periocular dermatitis,” rosacea both.


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Fig. 81-6

Papules on the forehead, glabellar region, cheeks, and paranasal and nasolabial regions.


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Fig. 81-7

Papules in the periorbital region (periocular dermatitis).


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Fig. 81-8

Papules in the malar region, paranasal region, and chin (perioral dermatitis).


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Fig. 81-9

Papules in periocular and perioral distribution (periocularand perioral dermatitis).


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Fig. 81-10

Papules in the perioral region (perioral dermatitis) and scattered on the malar region, eyelids, and forehead.


Individual Lesions

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Fig. 81-11 A

Telangiectases, papules, and diffuse erythema.


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Fig. 81-11 B

Telangiectases, papules, and diffuse erythema.


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Fig. 81-12 A

Telangiectases, papules, and diffuse erythema.


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Fig. 81-12 B

Telangiectases, papules, and diffuse erythema.


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Fig. 81-13

Papules and papulopustules on an erythematous base.


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Fig. 81-14

Papules, some of them in clusters.


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Fig. 81-15

Papules and papulopustules on an erythematous base.


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Fig. 81-16

Numerous papules and papulopustules.


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Fig. 81-17

Cluster of papules.


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Fig. 81-18

Papules, papulopustules, scales, and crusts on an erythematous base.


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Fig. 81-19

Papules, papulopustules, pustules, and crusts on a swollen erythematous base (pyoderma faciale, rosacea fulminans).


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Fig. 81-20

Varicosities on the nose and telangiectases on the cheeks.


Rhinophyma

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Fig. 81-21 A

Papules, papulopustules, and nodules on an erythematous base. Periorbital edema is striking (persistent edema of rosacea). In addition to rhinophyma, there are analogous changes on the forehead (metophyma).


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Fig. 81-21 B

Papules, papulopustules, and nodules on an erythematous base. Periorbital edema is striking (persistent edema of rosacea). In addition to rhinophyma, there are analogous changes on the forehead (metophyma).


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Fig. 81-22

Rhinophyma and telangiectases, and papules and nodules on the malar region and cheeks.


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Fig. 81-23

Rhinophyma and telangiectases, papules, and erythema on the cheeks and chin.


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Fig. 81-24

Rhinophyma.


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Fig. 81-25

Cyrano de Bergerac-like nose of rhinophyma. Changes of rosacea are present also on the cheeks and chin.


Degrees of Severity

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Fig. 81-26

Telangiectases and papules on an erythematous base.


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Fig. 81-27

Papules and papulopustules.


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Fig. 81-28

Pustules on an erythematous base.


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Fig. 81-29

Papules, papulopustules, and diffuse erythema.


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Fig. 81-30

Telangiectasias, papules, papulopustules, diffuse erythema, and incipient rhinophyma.


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Fig. 81-31

Nodules and tumors of rhinophyma.


Variations

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Fig. 81-32

Extrafacial as well as facial rosacea.


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Fig. 81-33

Facial and extrafacial rosacea with innumerable papules, erosions, ulcers, and crusts (rosacea fulminans).


New! Additional Images

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Fig. 81-34

Rosacea: Papules on malar eminences especially.


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Fig. 81-35 A

Rosacea: Few lesions are present on the face, the vast majority of them being situated on the neck and the chest, an exceptional circumstance.


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Fig. 81-35 B

Rosacea: Few lesions are present on the face, the vast majority of them being situated on the neck and the chest, an exceptional circumstance.


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Fig. 81-36

Rosacea: The entire face is involved, including the nose (rhinophyma) and the forehead (metaphyma).


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Fig. 81-37

Rosacea: Papules on the face. In the vicinity of the mouth, the condition is termed “perioral dermatitis,” an example of unnecessary superfluous synonymy; the diagnosis is rosacea, papular expression.


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Fig. 81-38 A

Rosacea: Papules and pustules, not only in the center of the face, but at the periphery of it, too.


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Fig. 81-38 B

Rosacea: Papules and pustules, not only in the center of the face, but at the periphery of it, too.


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Fig. 81-39

Rosacea: Papules on the forehead, some of them eroded secondary to excoriation.


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Fig. 81-40 A

Rosacea: Rhinophyma in company with papules of rosacea on the cheeks.


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Fig. 81-40 B

Rosacea: Rhinophyma in company with papules of rosacea on the cheeks.


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Fig. 81-41

Rosacea: Perioral dermatitis, like periocular dermatitis, is merely a manifestation of rosacea.


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Fig. 81-42

Rosacea: Lesions may involve the nasolabial fold, sometimes in conjunction with seborrheic dermatitis, and the perioral region, the latter being unusual in a man.


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Fig. 81-43

Rosacea: Unilateral involvement.