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Rosacea

Key Points

  • Rosacea has 4 different clinical presentations: erythemato-telangiectatic, papulo-pustular, phymatous, and ocular. It is essential to correctly identify the subtype of rosacea in order to select the appropriate medical or surgical therapy.
  • Rosacea treatment should be tailored to the clinical subtype and disease severity to optimize therapy.
  • Facial erythema is the primary feature of rosacea and presents ubiquitously in all subtypes.  Persistent facial erythema has significant impact on quality of life.
  • A new topical treatment option, the alpha adrenergic agonist brimonidine (Mirvaso), is now available to effectively reduce erythema in erythemato-telangiectactic rosacea.
  • Papulo-pustular rosacea must be distinguished from acne vulgaris, seborrheic dermatitis, perioral dermatitis, and Demodex folliculitis (demodicidosis).
  • Rosacea treatment should be tailored to the clinical subtype to optimize therapy.  Erythemato-telangiectatic rosacea must be differentiated from chronic sun damage.
  • Rosacea patients often have sensitive skin and suffer from intolerance to skin products and cosmetics.
  • Patients with rosacea flush, have facial erythema, telangectasia, papules and pustules, sebaceous hyperplasia of the nose (rhinophyma), and/or ocular symptoms. Triggers for flushing include alcohol, sun exposure, hot weather, exercise, ingestion of hot or spicy foods/ drink or a medication, and emotional stress.  Eliminating the triggers of flushing can alleviate rosacea symptoms.
  • Ocular rosacea requires systemic antibiotics.
  • Phymatous rosacea may require laser treatment or other surgical intervention.

Erythemato-telangiectatic (E-T) subtype: Characterized by diffuse erythema and telangiectasias on the cheeks, forehead, dorsal nose, or entire face.

  • Patients often complain of intolerance or sensitivity to topical products and cosmetics.
  • This subtype is best treated with avoidance of flushing, photoprotection, and surgical or laser therapies (see table, Subtype Directed Therapy).
  • Though considered the mildest form of rosacea, the E-T subtype is marked by significant impact on quality of life stemming from persistent facial erythema.
  • A significant advancement in treatment of rosacea erythema is now commercially available; once-daily application of brimonidine gel 0.33% (Mirvaso) has been approved  as an effective topical treatment for facial redness in rosacea.

Papulo-pustular subtype: Characterized by papules and pustules often on a blush of erythema primarily affecting the nose, cheeks, and forehead. Predilection of lesions on the central aspect of the face, sometimes with central facial edema. Associated with flushing.

  • This subtype is best treated with topical or systemic antibiotics and/or topical 5% sulfur/ 10% sulfacetamide wash or lotion (such as Plexion, Rosac, Rosanil, Rosula, or Sulfacet-R).
  • Start with topical metronidazole gel, lotion, or cream 0.75% – 1% (such as MetroCream, MetroGel, MetroLotion, or Noritate) b.i.d. The only drug validated for the maintenance treatment of papulo-pustular rosacea by randomized controlled trial is topical metronidazole.
  • Another effective topical option is azelaic acid (15 or 20% cream), such as Azelex or Finacea, applied b.i.d.
  • If papules/pustules persist or do not respond to topicals, consider low-dose doxycycline 40 mg once daily (Oracea) or oral tetracycline 250-500 mg daily to b.i.d., minocycline (such as Minocin or Solodyn) 40-100 mg or doxycycline (such as Adoxa, Doryx) 100 mg daily to b.i.d. After initial clearance, the dosing may be reduced or stopped.
  • Systemic tetracycline antibiotics should not be used in children under the age of 8 because of potential permanent discoloration of teeth. Macrolide antibiotics are an alternative treatment for children under the age of 8.
  • Severe cases may require isotretinoin (such as Accutane, Amnesteem, Claravis, or Sotret). It is important to note that isotretinoin will not necessarily eradicate all of the features of rosacea, with the notable exception being facial erythema.

Phymatous subtype: Marked by thickening of the skin, irregular skin texture, edema, hypertrophy and hyperplasia of sebaceous glands, connective tissue, and vascular bed of the nose (rhinophyma). These changes can also be seen on the chin (gnathophyma), ears (otophyma), forehead (metophyma), and eyelids (blepharophyma). Almost exclusively in males.

This severe form of rosacea requires maximizing medical therapy with systemic antibiotics, and sometimes use of isotretinoin. Once the medical regimen has been maximized, the patient is a candidate for surgical/laser resurfacing of the affected area by a dermatologist (see table).

Ocular subtype: Can be seen in the presence or absence of skin manifestations of rosacea. Characterized by conjunctival erythema and injection, sometimes accompanied by eyelid edema (blepharitis), foreign body sensation, and/or glandular inflammation (chalazion) along the eyelid margin. Patients report subjective symptoms: foreign body sensations, dry eyes, itching and burning, photosensitivity. The vision is rarely affected.

  • Ocular rosacea requires systemic antibiotics, and oral tetracycline 250-500 mg b.i.d. is an excellent first-line therapy for this form of rosacea. Minocycline 40-100 mg or doxycycline 100 mg daily to b.i.d may also be used.
  • Topical corticosteroid eyedrops may be beneficial.

Differential diagnosis

Acne vulgaris: Open (blackheads) and closed (whiteheads) 1-2mm follicular-based papules. Some of the lesions are excoriated. Comedones are not a feature of rosacea.

Nodular acne: Nodules are present on the upper right forehead and bilateral medial cheeks, in addition to inflammatory papules, pustules, and scars. Nodules and scars are not typical features of rosacea.

Seborrheic dermatitis: Scaly, flaky, itchy, red skin on the scalp, face (nasolabial folds), and trunk.

Peri-orificial dermatitis (i.e., peri-oral dermatitis): Papules and pustules are small in size, monomorphous, and occur around the mouth (rarely around eyes).

This subtype is also treated with topical or systemic antibiotics (tetracyclines), as well as topical 5% sulfur/10% sulfacetamide wash or lotion.

 

Systemic lupus erythematosus: Malar erythema in a clearly photodistributed pattern on the face.

Management of the patient with rosacea

  1. Establish the clinical diagnosis of rosacea (subtype, severity, ocular involvement).
  2. Prescribe treatment (topical, systemic, physical).
  3. Refer patient to an ophthalmologist when needed.
  4. Advise patient to avoid trigger factors, use photoprotection (broad spectrum, both UVA and UVB), select gentle daily skin care. Skin care becomes an important part of their therapy (see handout Skin care for rosacea patients).
  5. Avoid drugs that worsen rosacea. Stop or taper all topical corticosteroids stronger than hydrocortisone 1%. Anticipate a flare when they are discontinued.
  6. Use maintenance therapy.

Subtype Directed Therapy

Topical

Systemic

Physical

Sun protection, specific skin care

Other

Erythemato-telangiectatic

Brimonidine 0.33% gel

-

Pulse-dye laser/KTP laser/ Nd :YAG/ intense pulsed light therapy

+

Avoidance of triggers
Papulo-pustular Metronidazole
Azelaic acid
Sulfacetamide/ sulfur
Low-dose doxycycline
Tetracyclines
Macrolides
Metronidazole
Isotretinoin
Pulse-dye laser/KTP laser/ Nd :YAG/ intense pulsed light therapy

+

Avoidance of triggers
Phymatous

-

Antibiotics
Isotretinoin
Surgery (conventional, laser)

+

Avoidance of triggers
Ocular Corticosteroid eyedrops Tetracyclines Eyelid warm compress

+

Lid hygiene
Artificial tears

Pitfalls

  • Isotretinoin is contraindicated in pregnancy, and tetracycline-class antibiotics are contraindicated after week 14 gestation. Adequately documented contraception, a negative pregnancy test, and extensive counseling are required.
  • Topical corticosteroids can induce rosacea (steroid-induced rosacea).
  • Patients with rosacea have sensitive skin and tolerate topical irritants poorly. Topical retinoids (i.e., tretinoin cream) or high concentrations of benzoyl peroxide are not always recommended (see handout Skin care for rosacea patients).
  • It is recommended that patients are referred to an experienced dermatologist to supervise systemic isotretinoin treatment.
  • Rosacea fulminans (sudden onset of coalescent papules, pustules, nodules) may occur during pregnancy, thyroid diseases, depression, emotional stress, induced by medications. This exacerbation may require use of systemic corticosteroids (prednisone 0.5 to 1 mg/kg/day) and/or isotretinoin.

Need for dermatologic and/or ophthalmologic care

  • As the differential diagnosis and treatment of rosacea is challenging, it is always beneficial to refer the patient to a dermatologist.
  • Severe rosacea cases that require systemic isotretinoin.
  • If a diagnosis of cutaneous rosacea is suspected, an ophthalmologic examination is always beneficial to detect ocular involvement and to prevent complications such as keratitis and corneal ulcers.

Clinical Cases

Case 1. Erythemato-telangiectatic rosacea

  • 55-year-old woman
  • Chronic flushing, erythema and telangiectasias on cheeks, nose
  • Not responding to topical antibiotics

Treatment

  • Discontinue topical antibiotics
  • Topical brimonidine 0.33% gel (Mirvaso)
  • Photoprotection, sunscreen use advised, appropriate skin care (gentle facial cleanser and moisturizer)
  • Identify and avoid triggers of flushing
  • Consider referral to laser treatment for vascular features

Case 2. Papulo-pustular rosacea

  • 40-year-old woman
  • Long-standing erythematous papules, plaques on the cheeks, nose, chin, forehead
  • Skin lesions are exacerbated by sun exposure and alcohol consumption
  • No response to topical antibiotics alone

Treatment

  • Low-dose doxycycline 40 mg p.o. daily
  • 5% sulfur/10% sulfacetamide wash daily
  • Topical metronidazole (1% cream or gel)
  • Photoprotection, sunscreens advised; appropriate skin care (gentle facial cleanser and moisturizer)
  • Avoid alcohol consumption, sun exposure

Follow-up visit at 6 weeks

  • Lesions improved
  • Discontinue doxycycline
  • Continue topical metronidazole
  • Continue photoprotection and skin care
  • Continue to avoid alcohol consumption and other triggers

Case 3. Rosacea with ocular symptoms

  • 25-year-old woman
  • Recurrent erythematous papules on cheeks, nose, forehead with associated blepharitis, conjunctival erythema and edema, foreign body sensation
  • Topical antibiotic lotion alleviates skin but not ocular symptoms
  • No clear triggers for symptoms

Treatment

  • Tetracycline 500 mg p.o. b.i.d. (oral tetracyclines are first-line treatment for ocular rosacea)
  • Metronidazole 1% cream or gel applied b.i.d. to skin lesions
  • Photoprotection, sunscreens advised; appropriate skin care with gentle facial cleanser and moisturizer
  • Refer to an opthalmologist if needed

Follow-up visit at 6 weeks

  • Lesions improved, no ocular signs present
  • Continue metronidazole 1% cream or gel applied b.i.d. to skin lesions
  • Continue photoprotection, skin care

Suggested Reading

Fowler J et al (2012). Once-daily topical brimonidine tartrate gel 0.5% is a novel treatment for moderate to severe facial erythema of rosacea: results of two multicenter, randomized and vehicle-controlled studies, BJD, 166:633-641.

Fowler J et al (2013) Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized double-blind, vehicle-controlled pivotal studies, JDD, 12(6): 650-656.

Del Rosso JQ (2012) Advances in understanding and managing rosacea: Part 1 & 2, J Clin Aesth Derm, 5(3):16-25, 26-36.

Webster GF (2009) Rosacea. Med Clin North Am. 2009 93(6):1183-94.

van Zuuren EJ, Gupta AK, Gover MD, Graber M, Hollis S (2007) Systematic review of rosacea treatments. J Am Acad Dermatol. 56(1):107-15.

Chamaillard M, Mortemousque B, Boralevi F, et al (2008) Cutaneous and ocular signs of childhood rosacea, Arch Dermatol, 144:167-171

Powell FC (2005) Clinical practice: Rosacea, NEJM 352: 793-803.

Odom R, Dahl M, Dover J, et al (2009) Standard management options for rosacea, part 2: options according to subtype, Cutis 84: 97-104.

Odom R, Dahl M, Dover J, et al (2009) Standard management options for rosacea, part 1: overwiev and broad spectrum of care, Cutis 84: 43-47.

Del Rosso JQ, Baldwin H, Webster G et al (2008) American Acne & Rosacea Society medical management guidelines, J Drugs Dermatol 7(6): 531-533.