Clinical REVIEW - An overview on the diagnosis and assessment

Paula Oliver

Abstract This article provides an overview of the assessment, diagnosis and treatment options for rosacea

Citation: Oliver P (2017) Rosacea – An overview on the diagnosis and assessment. Dermatological Nursing 17(2):10-14

Introduction The word rosacea is derived from pathophysiology is still unclear to Rosacea is a common chronic the Latin adjective meaning like roses.3 date.4 A link has also been established inflammatory disorder of the skin The term rosacea and adult acne between high levels of the Demodex predominantly affecting the central are misleading and obsolete, acne and mite (such as D.follicularum and face. It is characterised by frequent rosacea are separate disease processes, D.brevis) and rosacea, with signs and flushing, persistent erythema, even though they may co-exist at times. symptoms of rosacea potentially telangiectasia and interspersed with It is therefore important to establish resulting from heightened pro- episodes of during which the correct disease diagnosis to ensure inflammatory skin response.5 The patients experience tissue swelling that an appropriate treatment plan may demodex mites are small worm-like with papules and pustules. Patients be implemented. inhabitants of the sebaceous follicles may also experience ocular lesions on normal adult skin. They have eight and rhinophymas (excess growth of The psychosocial impact of living short stubby legs with claw-like ends, tissue of the nose) and cutaneous with rosacea can adversely impact an which they use to move about the sensations often include stinging and individual’s well-being, and that level of facial skin surface from one follicle burning. It typically appears between psychological burden should influence to another. This apparently occurs at the ages of 30-60.1 Phymatous rosacea treatment decisions. In addition, there night as it has been shown that the can also affect other areas on the face is also a psychosocial impact associated mites react negatively to light. These such as the chin (gnathophymas), ears with rosacea treatments. Patients can organisms seem to live in a harmonious (), forehead (mentophyma) become disheartened as they are relationship with their hosts and in or the eyelids (blepharophyma). advised there is no cure for rosacea normal circumstances do not excite Characteristically, rosacea is a and there may be a need for on- an inflammatory reaction in the skin. condition of the white population and going treatment and medication costs. In patients with rosacea, these mites it is three times more common in Furthermore, trigger factor exposure are greatly increased in number and women than men.2 can lead to lifestyle limitations. are found mainly in the centrofacial Education is essential to ensure that area, the area typically affected by patients are able to manage their inflammatory pustules and papules.6 condition and minimise flare-ups of the disease where possible by avoiding triggers such as alcohol, heat, spicy foods and sunlight (list not exhaustive). Alcohol can causing flushing, but is often linked to rosacea by the misconception that excessive alcohol consumption is the cause.

Paula Oliver RGN BSc(Hons) MSc INP holds Recent research suggests that an honorary clinical role at Sussex Community deregulation of innate immune om c Dermatology Service and Brighton and Sussex pathways, as well as vascular changes . e

University Hospitals NHS Trust. are present, with different degrees of Q

Figure 1 e Nurse Consultant/Team Leader for Galderma importance in the various subtypes. D u RM ST (UK) Ltd The aetiology, genetics and the Image of a demodex mite close up

10 Dermatological Nursing, 2017, Vol 16, No 2 www.bdng.org.uk Clinical REVIEW

Consensus recommendations in 2002 suggested that rosacea was classified into four subtypes based on the clinical presentation, as follows: 8 Erythematotelangiectatic rosacea (ETTR); 8 Papulopustular (PPR); 8 Phymatous rosacea (PYR); and 8 Ocular rosacea (OR).

However patients often present with a varied range of symptoms that overlap these sub-types.7 As an example, patients may present with papulopustular rosacea and also persistent erythema, and even if the PPR is treated successfully the erythema either transient or fixed may Figure 2 still remain. Erythematotelangiectatic rosacea (ETTR) Rosacea features can span multiple subtypes and progress between subtypes. Therefore, their clinical presentation may be more accurately defined by the term phenotype (individual features), which describes an individual’s observable characteristics that can be influence by genetic or environmental factors. Subtype classification may not fully cover the range of clinical presentations and is likely to confuse severity assessment, whereas a phenotype-based approach could improve patient outcomes by addressing an individual patient’s clinical presentation and their concerns. Tan et al suggests that adopting a phenotype led approach will Figure 3 address rosacea and its treatments in Papulopustular (PPR)I a way that is more consistent with the individual’s experience.8

The disease is unpredictable and can vary from week to week for patients. This can affect the patient’s quality of life. In addition to the physical impact, it is well documented that patients report significant psychological distress owing to the sometimes dramatic changeable nature of the signs and symptoms. The National Rosacea Society (NRS) conducted a survey of 1,675 patients, of which 90% of respondents said the effects of the disease on their personal appearance had lowered their self-esteem and self-confidence; 88% reported embarrassment; and om c others noted feelings of frustration . e

(76%), anxiety and helplessness (54%), Q

Figure 4 e depressions (43%), anger (34%), and D u RM ST isolation (32%) Phymatous rosacea (PYR) www.bdng.org.uk Dermatological Nursing, 2017, Vol 16, No 2 11 Clinical REVIEW

Primary features The presence of one or more of the following signs with central face distribution is suggestive of rosacea, although patients may have more than one of these features: 8 Flushing 8 Persistent erythema of the facial skin 8 Dome-shaped papules with or without pustules and nodule may also be present 8 Telangiectasia.

Secondary features om c Theses often appear with one or more . e

of the primary features but also may Q

Figure 5 e appear independently: D u RM ST 8 Burning or stinging Ocular rosacea (OR) 8 Raised plaques 8 Dry appearance rough and scaling commonly seen in teenage years, while triggered by environmental factors, 8 Oedema rosacea occurs most often between including sun exposure, temperature 8 Ocular signs that may include 30-60 years of age. Also, in acne, unlike changes, stress and spicy foods burning , itching, hyperemia, rosacea, open comedones (blackheads) to name a few. However, affected inflammation, styes, chalazia are generally present, and papules rosacea skin exhibits increased 8 Peripheral location and pustules on extra facial locations sensitivity to these triggers and 8 Phymatous changes. such as trunk and upper arms are patients need to try and identify common. While SLE and rosacea share their own individual triggers that some manifestations, including facial exacerbates their condition. Besides Rosacea can resemble erythema, sensitivity to ultra violet trigger avoidance, the most common other dermatological light and tends to affect more females treatment approaches to rosacea are disorders, including than males, clinicians have often used pharmacological in nature. acne and systemic lupus serology screening or histopathology erythematosus to confirm the diagnosis of SLE. Emollients and sunscreen are recommended for all rosacea Triggers patients to stabilise the skin’s barrier Differential diagnosis Sign and symptoms of rosacea can be dysfunction and to help prevent ETTR is characterised by centrofacial erythema, a tendency to flush frequently and typically prominent Sun 81% facial telangiectasias. PPR is usually Emotional stress 79% diagnosed on the clinical appearance Hot weather 75% of erythema, papules and pustules in Wind 57% a centrofacial distribution. In PYR, a Heavy exercise 56% range of phymatous changes may be Alcohol 52% seen in patients with rosacea, however Hot baths 51% is the most common and Cold weather 46% mainly occurs in males. Finally OR Spicy foods 45% is common and is often overlooked Humidity 44% by the patients and the healthcare professional, symptoms are usually Certain skin care products 41% mild and serious consequences of OR Indoor heat 41% are rare. Heated beverages 36% Certain cosmetics 27% Rosacea can resemble other dermatological disorders, Figure 6 including acne and systemic lupus Known triggers: National Rosacea Society Results based on a survey of 1,066 rosacea patients trigger for rosacea erythematosus (SLE). Acne is more http://www.rosacea.org/patients/materials/triggersgraph.php Website last accessed: March 2017

12 Dermatological Nursing, 2017, Vol 16, No 2 www.bdng.org.uk Clinical REVIEW photo-aggravation. Patients may need Patients need to be instructed how to anti-inflammatory and anti-parasitic, to explore a range of products to apply the gel evenly to achieve a good thereby reducing inflammation find one that will suit their skin as outcome. and inhibiting the demodex mite. moisturisers, make-up and sunscreen Metronidazole 0.75% gel or cream can potentially irritant sensitive Laser therapy using a pulsed dye historically has been used for PPR skin. Identifying trigger factors is an laser is also an option for patient and also azealic acid 15% cream these individual process and what may cause that can self-fund. Pulsed dye laser need applying twice daily both have an a skin reaction in one patient may treatment targets redness of rosacea anti-microbial mode of action. not in another. A rosacea diary could by delivering a long pulse of energy include a daily checklist of the most to the affected areas. It will often In more severe cases, or if topical common factors that trigger rosacea entail several treatment sessions over treatments fail, an antibiotic may be flare- ups in patients. Patients can a period of weeks. This can be very necessary using a tetracycline e.g. complete a daily log and look for items effective and improve the cosmetic oxytetracycline 500mg BD, that seem to coincide with any appearance for patients but rarely lymecycline 408mg OD or a low rosacea flare. will be funded on the NHS. Cosmetic dose doxycycline 40mg. The low camouflage is also an option and dose doxycyline 40mg delivers an Management of symptoms and treatment patients can explore more about this anti-inflammatory dose rather than options via the Changing Faces website.10 an anti-microbial dose to the patient. Patients should be provided with an Erythromycin 500mg BD is also an information leaflet to inform them alternative. As rosacea is a chronic on how to minimise their triggers, Identifying trigger factors inflammatory condition it is not ideal which may aggravate their condition, is an individual process to continue on systemic antibiotics in and also how to care for their skin and what may cause a skin the long term so treatment is usually with a simple skin cleansing and reaction in one patient may recommended for a minimum of moisturising regime. The Primary not in another three months then to reduce the Care Dermatology Society (PCDS)9 dose. For severe disease that responds has recently reviewed and published poorly to treatment, referral to a rosacea management guidelines that Cosmetic camouflage can be used to dermatologist should be considered are available at www.pcds.org cover the skin, and over the years has for assessment and a low dose helped numerous patients with a wide of isotretinoin may be potentially Flushing/erythema and telangiectasia variety of skin conditions. Trained skin recommended. Flushing of the face is caused by facial camouflage practitioners will find the vasodilation leading to increased best colour match for each person Rhinophymas cutaneous blood flow.6 Causes of skin tone and then teach them how to Patients with rhinophymas respond flushing include rosacea, alcohol, spices, self-apply the specialist cover products. very well to CO2 laser or surgical some drugs including calcium channel The products are fully waterproof shave excision. Both of these blockers, and neurological disorders. and are available on prescription from treatments are designed to remove general practitioners; the products are the excess of affected tissue. For many patients this can be a listed in the British National Formulary prominent cutaneous symptom and (BNF) in the borderline substance’s Ocular symptoms has a profound impact on a patient’s section. Patients presenting with ocular quality of life. Transient flushing symptoms can experience ‘gritty’ eyes, on the central aspects of the face Papules, pustules and nodules conjunctivitis, blepharitis and chalazion, (which can last for minutes) may be In inflammatory PPR patients should which are on the eyelids. It is helped in the short term by a non- be advised that while a chronic thought that 50% of patients with selective cardiovascular beta-blocker condition that cannot be cured it diagnosed rosacea have ocular such as propranolol 40mg BD or can be very well controlled by using involvement. Educating patients on clonidine 50mcg BD. If the erythema anti-inflammatory treatments and eyelid hygiene is important. Eyelids can is persistent and causing psychological if required in the long term non- be cleaned using cotton wool soaked distress, Brimonidine Tartrate topical antibiotic therapies are preferable to in boiled cooled water. Artificial gel 0.33%, an alpha adrenergic agonist, reduce increasing antibiotic resistance. tears can help the ‘gritty’ sensation is indicated for the topical treatment experienced by some patients. of persistent facial erythema in adults If patients symptoms are mild to Systemic tetracyclines are the most aged 18 years or over. This needs moderate topical therapies such as effective treatment for ocular rosacea. to be applied thinly once a day and ivermectin 10mg/g cream provides a Systemic retinoids such as isotretinion its mode of action is to constrict newer antibiotic-free treatment option, are generally avoided in patients with the facial blood vessels causing a is applied once a day to facial skin and severe ocular problems as they can temporary reduction in the erythema. is tolerated well. Its mode of action is worsen symptoms. If severe symptoms www.bdng.org.uk Dermatological Nursing, 2017, Vol 16, No 2 13 Clinical REVIEW persist a referral to an ophthalmologist both the conditions were concern References for further management may be over the appearance with feelings of 1. Wolf JE. Rosacea: Diagnosis and necessary. embarrassment.13 management of a complex and significant disorder. Consultant 2016, Reducing antibiotic therapies 56(10) 901-905 Roughly 8% of all The World Health Organization 2. Stollery N. Managing patients with (WHO) has spoken about the evolving antibiotics prescribed rosacea. MIMS Dermatology 2017, threat of antimicrobial resistance and in the United Kingdom 13(1) 36-37 has called for action globally. This year, are thought to be for a 3. Plegwin G. Kligman A. Acne and World Antibiotic Awareness Week will dermatological indication Rosacea. 3rd Completely revised and be held from 13-19th November 2017 enlarged edition. Springer New York and all healthcare professionals are 2000 p456 urged to join the campaign. Patients also described their 4. Holmes A D. Steinhoff M. Integrative concerns by physical symptoms including concepts of rosacea pathophysiology, Roughly 8% of all antibiotics erythema, papules and pustules and the clinical presentation and new prescribed in the United Kingdom are facial redness for rosacea. Although in therapeutics. Experimental Dermatology thought to be for a dermatological the author’s experience, controversially 2016, 1-9 indication.11 Considering that rosacea on occasions HCPs have suggested 5. Steinhoff M, Vocanson M, Voegel J, is a chronic inflammatory condition, that these symptoms are of cosmetic Hacini-Rachinel F, Schafer G. Topical clinicians need to consider the concern and don’t require interventions. Ivermectin 10mg/g and oral Doxycycline 40mg Modified-release: appropriateness of the long term use The survey provided further evidence Current evidence on the complementary of both topical and systemic antibiotics that the psychological needs of these use of anti-inflammatory Rosacea and explore alternative non-antibiotics patients are not being met and the treatments. Adv Ther 2016, 33 treatment when possible. important role for dermatology nurses 1481-1501 acting as the patients advocate and 6. Powell FC. Rosacea Diagnosis and The Psychological impact of Rosacea performing psychological assessment management. Informa Healthcare. 2009 and also ensuring that other HCPs are Chapter 5 p69 “…….there was a summoner with us at adhering to best practice. 7. Baldwin HE. Diagnosis and that inn, treatment of Rosacea: state of the art. J Conclusion Drugs and Dermatol 2012, 11(6) his face on fire like a cherubin, for he Rosacea is a chronic inflammatory 725-30 had carbuncles….no that is clearly visible, 8. Tan J, Almeida LMC, Bewley, A et al. quicksilver, lead ointment, tartar creams, but its cause is often unknown and Updating the diagnosis, classification no brimstone, no boric, it is misunderstood by the general and assessment of roscea: public. The visible appearance is recommendations from the global so it seems, could make a salve that had often distressing and the relapsing ROSacea COsensus (ROSCO) panel. the power to bite, clean up and remitting nature of the condition British Journal of Dermatology 2017, 176 431-438 or cure his whelks or knobberly white or may have a negative impact on a 9. Primary Care Dermatology Society purge the pimples patient’s quality of life. Nurses can play an important role in educating (PCDS) www.pcds.org.uk [last accessed April 2017] sitting on his cheeks……. Chaucer, and supporting patients about the skin diagnosis and its management. 10. Changing Faces Charity www. (Canterbury Tales) As well as the psychological support, changingfaces.org.uk [last accessed nurses can discuss lifestyle changes and April 2017] The psychological impact of triggers that may reduce the flare-up 11. Walsh TR, Dreno B. Antibiotic living with a skin condition is well frequency. In the future, healthcare resistance in acne, an increasing topical documented.12 professionals may be treating patients and oral threat: a systemic review. on the individual clinical presentation The Lancet Infectious Diseases 2016, 16(3) Psychological difficulties for skin and target the treatments accordingly, patients include increased levels of rather than attempting to treat each 12. Moustafa et al. The psychological anxiety and depression, concerns subtype as discussed in this article. DN impact of Rosacea and the influence of with body image, low self-esteem current management options. J Am Acad 2014, 71(5)973-80 and concerns with social interactions. Conflict of interest A survey was conducted to explore Paula is also a Nurse Consultant/ 13. Krasuska M, Millings A, Lavda A, GP’s provision of psychological Team Leader for Galderma (UK) Thompson A. Psychological needs and care to patients with rosacea and availability of support for people with Ltd. This article is not endorsed by Rosacea and Psoriasis findings from a psoriasis and they found that the most Galderma (UK) Ltd. GP survey. Dermatological Nursing 2016 commonly reported symptoms for 15(2) 48-49

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