MedicineToday 2015; 16(1): 34-40

PEER REVIEWED FEATURE 2 CPD POINTS

Triggers and treatment of SHIEN-NING CHEE MB BS, MMed PATRICIA LOWE MB BS, MMed, FACD Key points Rosacea is a common chronic inflammatory that can • Rosacea is a common lead to significant facial changes, ocular involvement and decreased condition characterised by quality of life. Its cause is multifactorial and not completely understood. flushing, erythema, inflammatory lesions and Treatment aims to control, but not cure, the disease. telangiectasia. • The cause is multifactorial osacea is a common chronic inflam­ PATHOPHYSIOLOGY and not completely matory skin disease primarily affecting The pathophysiology of rosacea is multifactorial understood: genetics, the facial convexities. It is characterised and not completely understood. At present, neurovascular dysregulation Rby vascular lability, leading to flushing, rosacea is thought of as a complex inflammatory and infections may be telangiectasia and fixed erythema, and cuta­ disorder arising in genetically predisposed involved. neous , manifesting as papules, individuals. • Diagnosis of rosacea is pustules and lymphoedema. Although not based on clinical findings, life -threatening, rosacea may have a significant Genetics although investigations may impact on a patient’s self-esteem and quality of Rosacea often affects multiple family members. be required to exclude life. Early diagnosis and treatment will reduce Recent analyses have found distinct genetic differential diagnoses. morbidity. profiles for each rosacea subtype, with expres­ • Treatment is tailored to the sion of more than 500 different genes compared individual and aims to EPIDEMIOLOGY with healthy skin.3 The skin of patients with control symptoms and signs, Estimated prevalence rates of rosacea range from rosacea has been found to be dry and acidic, but not cure the disease. 0.9 to 22%. The largest studies estimate preva­ with altered sebum fatty acid composition.4 • Referral of the patient to a lence at 2 to 3% of the general population.1 general dermatologist is Rosacea tends to occur in adults over the Neurovascular dysregulation and recommended when rosacea age of 30 years. In groups aged younger than augmented immune detection and does not respond to 35 years or older than 50 years, men and women response conventional therapy. are affected equally; however, there is a pre­ Precipitating and exacerbating factors associated • Referral of the patient to an dominance in women in the 36- to 50-year age with rosacea include alcohol intake, heat, cold, ophthalmologist is group.1 Incidence is highest in people with skin exercise, smoking, eating spicy food, drinking hot recommended if eye types I and II, although it does also occur in beverages and stress. Patients with rosacea have involvement is suspected. people with Asian and pigmented skin types.2 a greater immunological response to these triggers,

Dr Chee is Dermatology Research Registrar in the Department of Dermatology, Royal Prince Alfred Hospital, Sydney. Copyright _LayoutDr 1 Lowe 17/01/12 is a Senior 1:43 Staff PM Specialist Page 4 in the Department of Dermatology, Royal Prince Alfred Hospital, Sydney; and

Clinical Senior Lecturer in the Discipline of Dermatology, University of Sydney, Sydney, NSW. © CORBIS/MICHAEL PRINCE/DIOMEDIA.COM. MODEL USED FOR ILLUSTRATIVE PURPOSES ONLY.

34 MedicineToday x JANUARY 2015, VOLUME 16, NUMBER 1 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. resulting in cellular infiltration, increased vasculature and an influx of proteolytic enzymes into the stratum corneum. Some of the factors implicated in caus­ ing rosacea include cathelicidin, vascular endothelial growth factor and substance P. The understanding of the innate immune response and host defence peptides, known as antimicrobial peptides (AMPs), is an exciting area of research in general medi­ cine. The concentration of an AMP known as cathelicidin LL-37, is increased in patients with rosacea-prone skin. Such Figure 1. Erythematotelangiectatic discoveries may have ramifications for rosacea. future targeted therapies.3,5,6 –– flushing (transient or reversible Infection erythema): a history of frequent Certain infections have been implicated as blushing or flushing spontane­ causes of rosacea. The face mite Demodex ously or in response to various folliculorum, an obligatory parasite of stimuli is common human pilosebaceous follicles, has been –– erythema (fixed or persistent) of Figure 2. Papulopustular rosacea. identified in elevated numbers in patients the facial skin: this is common with rosacea. It is hypothesised that an –– inflammatory lesions: these immune defect allows the mite to penetrate ­typically appear as dome-shaped Erythematotelangiectatic rosacea the dermis and stimulate an exaggerated red papules with or without Erythematotelangiectatic rosacea is char­ immune response, giving rise to the papules ­pustules; comedones are absent acterised by flushing and persistent ­central and pustules of rosacea.7 In other studies, –– telangiectasia: these are usually facial erythema ­(Figure 1). Telangiectases abundant numbers of the commensal linear, dilated capillaries of may be present, and patients may report Gram -positive bacterium Staphylococcus varying diameter, fine, medium central facial oedema, stinging, burning, epidermidis have been detected in patients or coarse. roughness or scaling.12 with pustular rosacea. Significantly, strains • Possible presence of one or more of were the beta-haemolytic variant, differing the ­following secondary features: Papulopustular rosacea from the nonhaemolytic form isolated from –– burning or stinging sensations Papulopustular rosacea is characterised normal controls.8,9 Although Helicobacter –– erythematous plaques by persistent central facial erythema with pylori has also been implicated in the devel­ –– rough or scaly central facial skin transient papules and/or pustules in the opment of rosacea, studies have yielded –– oedema accompanying or following central facial distribution (Figure 2). contradictory results.10 facial erythema Comedones are absent, in contrast to , –– ocular manifestations, including and burning and stinging may be present. CLINICAL FEATURES burning sensation, dry gritty eyes, This subtype of rosacea is often seen in The clinical presentation of patients with conjunctival hyperaemia combination with or develops after rosacea is variable. Areas of the body –– involvement of peripheral locations, erythematotelangiectatic­ rosacea.12 typically affected are the central convex e.g. limbs areas of the face (cheeks, nose, chin and –– phymatous changes due to Phymatous rosacea forehead). Occasionally the scalp, upper ­sebaceous tissue hypertrophy: the Phymatous rosacea refers to hypertrophy chest, back and even limbs may be most common form, ­, of sebaceous glands and fibrous thicken­ involved.11 affects the nasal skin. ing of the skin due to chronic inflamma­ Diagnosis of rosacea is based on the tion (Figure 3). It clinically manifests as presence of the clinical features listed Subtypes of rosacea tissue enlargement, prominent pores and below.12 There are four primary subtypes of rosacea. nodularity of the skin surface. • Presence of one Copyrightor more of_Layout the 1 17/01/12One 1:43 subtype PM Page may 4 progress to another or The most common presentation is ­following primary features: they can occur in isolation. rhino ­phyma, characterised by coarse thick

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Steroid-induced DIFFERENTIAL DIAGNOSES OF ROSACEA Steroid -induced acneiform eruption is an inflammatory response that can occur • Acne vulgaris during or after chronic topical and systemic • Seborrhoeic dermatitis corticosteroid use.12 • Perioral dermatitis • Steroid-induced acneiform eruption Perioral dermatitis is characterised by ery­ (steroid rosacea) thema, microvesicles and scaling around • Lupus erythematosus – discoid, 12 the mouth, nose or eyes. It is commonly systemic or subacute cutaneous induced by topical corticosteroids or occlu­ • Cutaneous sarcoidosis of the nose sive skincare products such as emollients, (lupus pernio) sunscreens and cosmetics. • Tinea faciei Figure 3. Phymatous rosacea – demonstrating rhinophyma. Lupus erythematosus • Essential telangiectasia The presence of pustules, papules or • Carcinoid syndrome blepharitis favours a diagnosis of rosacea, • Drug reaction nasal skin particularly involving the nasal whereas scaling, follicular plugging, pig­ tip; it is commonly referred to as ‘alcoholic’ mentary disturbance and scarring favour • Polymorphous light eruption or ‘potato’ nose. Interestingly, other loca­ discoid lupus erythematosus (DLE) as the • Atypical infections tions may be involved, including the ears diagnosis. Histological examination may • Contact dermatitis – irritant or (), forehead (), be necessary to make a distinction between allergic eyelids () and chin the two. Both eruptions can be photo-­ • Lupus vulgaris (cutaneous tuberculosis) ­(gnatophyma). This subtype is often seen aggravated. Systemic lupus erythematosus in combination with, or develops after, (SLE) and subacute cutaneous lupus • Acne agminata erythematotelangiectatic or papulopus­ ­erythematosus (SCLE) are less common.2 • Dermatomyositis tular rosacea subtypes.12 • Polycythaemia rubra vera Cutaneous sarcoidosis of the • Superior vena cava obstruction Ocular rosacea nose (lupus pernio) Ocular rosacea occurs in up to 70% of This condition may resemble rhinophy­ patients with rosacea. One-third of these matous rosacea; however, there is minimal symptoms may be present. patients may develop corneal involvement, skin surface change in patients with cuta­ A list of differential diagnoses is which is potentially sight-threatening.13,14 neous sarcoidosis of the nose.11 ­provided in the box. Further details are given below in the ­section ‘Associations and complications’ Tinea faciei INVESTIGATIONS on page 39. Tinea faciei is an infection of the facial Minimal investigations are required as the skin by dermatophyte fungi. Diagnosis is diagnosis of rosacea is usually based on DIFFERENTIAL DIAGNOSES confirmed by microscopy and culture of history and clinical findings. Baseline blood Seborrhoeic dermatitis skin scrapings. test results including full blood count and Seborrhoeic dermatitis may coexist with kidney and liver function tests are necessary rosacea. It is best differentiated by the Essential telangiectasia if the use of systemic therapy is being con­ presence of greasy scale in the nasolabial Patients with essential telangiectasia will sidered. A skin scraping is useful to exclude folds, external ear canals and central only have this condition and no other fungal infection. Autoimmune serology ­eyebrow region.2 features of rosacea. (antinuclear antibodies [ANA] and extract­ able nuclear antigens [ENA]) should be Acne vulgaris Carcinoid syndrome performed if a connective tissue disease Acne vulgaris tends to occur in a younger In patients who present with severe or such as lupus is suspected. Creatine kinase age group and is characterised by the sudden -onset facial flushing, it is worth (CK) levels should be checked for dermat­ ­presence of open andCopyright closed _Layoutcomedones. 1 17/01/12 investigating 1:43 PM Page for 4carcinoid syndrome. omyositis. Skin biopsy (for haematoxylin It can also coexist with rosacea.2 Gastrointestinal, cardiac and pulmonary and eosin staining, immunofluorescence

36 MedicineToday x JANUARY 2015, VOLUME 16, NUMBER 1 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. with or without culture) is worthwhile if symptoms are atypical, the diagnosis TABLE. THERAPIES DIRECTED AT THE ROSACEA SUBTYPE remains unclear or the condition is unre­ Subtype of rosacea Therapies sponsive to conventional therapy.15 Erythematotelangiectatic Topical brimonidine Histological findings Vascular laser and intense pulsed light Erythematotelangiectatic rosacea Papulopustular Topical metronidazole Erythematotelangiectatic rosacea is char­ Topical azelaic acid acterised by the presence of enlarged Oral doxycycline or minocycline dilated capillaries and venules in the upper Isotretinoin dermis. These vessels may be unusually shaped (e.g. tortuous or geometric). Demo- Phymatous Isotretinoin dex mites are commonly present in Ablative laser affected patients. Other features include Surgery oedema in the upper dermis, lymphocytic inflammation and spongiosis. the skin. Improvement may be gradual, creams are usually all that are needed. The dermoepidermal junction appears so patients need to persevere with treat­ Patients should use their fingers to apply normal in patients with rosacea, unlike ment. Therapy should be trialled for at the products (not foam pads or brushes) to in those with lupus erythematosus in least three months to assess efficacy, and minimise mechanical disruption of the skin which there are lichenoid changes at this may be needed intermittently or contin­ barrier. Application of potential irritants, junction.15 uously for years.11 such as soap bars, toners and alcohol-based Of course, if the patient is asympto­ cleansers, should be avoided, as should Papulopustular rosacea matic, no treatment is an option. products containing menthol, camphor and Papulopustular rosacea is characterised by sodium lauryl sulphate.16 a mixed inflammatory cell infiltrate, with Avoid precipitants As sunlight is a common trigger for numerous plasma cells, neutrophils and In patients with mild rosacea, avoidance rosacea flare-ups, patients should wear a sometimes eosinophils. Demodex mites of triggers may be enough to improve the broad -spectrum low irritant SPF 50+ sun­ are often present in affected patients, as are condition. Triggers to consider avoiding screen daily, and limit sun exposure by spongiosis and solar elastosis. Retentional include extremes of temperature (hot or wearing protective clothing and hats. elements, such as comedones and dermal cold), ultraviolet (UV) radiation exposure, Shade should be sought when outdoors, infundibular , are absent, helping to intake of spicy foods, hot or alcoholic bev­ and patients should be encouraged to stay differentiate papulopustular rosacea from erages, wind, exercise and stress.2,11 indoors during periods of high UV radi­ papulopustular acne.15 Affected patients should avoid using ation. Sunscreens containing the physical topical corticosteroid agents. Although blockers titanium dioxide and zinc oxide Phymatous rosacea immediate improvement may be observed are well tolerated by most patients, and Phymatous rosacea commonly presents after application of a corticosteroid due to newer chemical agents are proving to be with rhinophyma, which is characterised their vasoconstrictive and anti-inflamma­ less irritant.16 by an increased volume of sebaceous glands tory effects, in the long term topical corti­ Makeup may be used to conceal the and fibrosis. The sebaceous lobules are of costeroids worsen rosacea and may trigger signs of rosacea. Waterproof cosmetics and normal structure but extremely large. The acneiform eruptions. heavy foundations should be avoided, infundibula are also enlarged and filled Encourage patients to apply a cool, because these are difficult to remove with­ with keratin, eosinophilic debris and damp (tap water) soft cotton compress out the use of irritating solvents and abra­ organisms, commonly Demodex mites.15 regularly to the facial skin for 10 minutes sive cloths. Green-tinted concealer helps to reduce symptoms such as burning and camouflage erythema.16 MANAGEMENT stinging. Education Topical therapies It is important from the outset to explain General skin care measures Fortunately a wide range of topical agents to patients that rosacea is a chronic skin Patients with rosacea should minimise their are effective as first-line therapy for patients condition that can be controlled but not use of skin care products and cosmetics with rosacea and a limited number of pap­ cured. Reassure themCopyright that it _Layout is generally 1 17/01/12 (‘less 1:43 is more’).PM Page Fragrance 4 - and preserva­ ules and pustules. Careful consideration responsive to treatment and rarely scars tive -free cleansers and light emollient must be given to the vehicle used to deliver

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baseline 12 hours after application. Phase 3 trials showed no major adverse reactions besides occasional mild and transient skin irritation. Specifically, no significant tachyphylaxis or rebound erythema was noted.5

Azelaic acid Topical azelaic acid (available as a 20% Figures 4a and b. Telangiectases. Before lotion or 15% gel) applied once or twice (a, left) and after (b, right) treatment with daily is an alternative to topical metroni­ pulsed dye laser (and after). dazole in the treatment of patients with papulopustular rosacea. Although studies show it to be more efficacious than met­ Figure 5. Erythema and spot purpura the active agent because this will affect ronidazole, it can be more irritating, so immediately after pulsed dye laser tolerability (in view of altered skin barrier patients should be advised to apply the therapy. function), patient compliance and efficacy.17 preparation every second or third day Formulations available include gels, lotions, initially.14 creams, foams and ointments. have been used traditionally but recent Other topical agents studies show subantimicrobial doses of Metronidazole Other topical agents such as compounded 40 mg/day are as effective (see novel ther­ Topical metronidazole 0.5 to 0.75% (avail­ tacrolimus 0.03%, pimecrolimus 1%, apies below).18 Minocycline (off-label use; able as a cream or gel) applied once or ­compounded sodium sulfacetamide 10% 50 to 100 mg/day) is also used to treat twice daily is effective in treating patients with sulphur 5%, and clindamycin 1% patients with papulopustular rosacea and with papulopustular rosacea and has been (off -label use) may be ­useful in certain is more lipophilic. used since the 1980s. It may also reduce cases of rosacea.16 Chronic use of oral tetracyclines has blanchable erythema (but not telangiec­ been associated with the development of tasia) in patients with erythematotelan­ Oral therapies irreversible blue-grey pigmentation and giectatic rosacea. Anecdotally, patients Oral therapy is preferable when the skin drug -induced systemic lupus in a small with sensitive skin tolerate the cream lesions of rosacea are more extensive or percentage of patients. Response can be formulation best, whereas men tend to when patients have not responded to topical seen within four weeks. Intermittent use prefer the gel base. Several weeks of appli­ therapy. Topical therapy may be added to is preferable. cation are required to see obvious the treatment regimen once the inflam­ improvement and it may be used on a mation has begun to settle with the sys­ Metronidazole long -term basis to maintain remission. temic agent; this minimises potential Oral metronidazole (off-label use) 200 mg Patients should be advised that topical irritation. Once the rosacea improves, the twice daily may be trialled in patients agents work best when applied to an entire systemic therapy may be discontinued with rosacea in whom tetracyclines are affected area rather than as spot and improvement maintained with topical contraindicated or ineffective. However, treatment.2,14,16 treatment alone.2,14 patients must abstain from alcohol intake during metronidazole therapy to avoid Alpha-adrenoreceptor agonists Tetracyclines alcohol­ -induced headaches via disulfiram Topical brimonidine 0.33% gel is a prom­ Oral tetracyclines have anti-inflammatory reactions.16 ising new therapy approved in Australia properties and have been the mainstay of in 2014 for intermittent topical treatment treatment for patients with rosacea for Other antibiotics of patients with the persistent facial decades. They are particularly effective in Studies have shown oral clarithromycin ­eryt ­hema of rosacea. It targets the alpha- treating patients with papulopustular and azithromycin to be useful in the treat­ adrenoreceptors in the smooth muscle of rosacea.­ ment of patients with rosacea (off-label superficial cutaneous blood vessel walls. With the loss of tetracycline hydro­ uses).16 Trimethoprim-­sulfamethoxazole Application reduces erythema within chloride from the Australian market, and ciprofloxacin are not generally used 30 minutes, with theCopyright peak effect_Layout lasting 1 17/01/12 ­doxycycline 1:43 PM (offPage-label 4 use) has become the due to concerns of resistant bacterial pop­ three to six hours, and gradual return to drug of choice. Doses of 50 to 100 mg/day ulations. Penicillins and cephalosporins

38 MedicineToday x JANUARY 2015, VOLUME 16, NUMBER 1 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. are generally ineffective in the treatment little blood loss compared with scalpel The course of rosacea fluctuates, char­ of patients with rosacea.2 excision. acteristically waxing and waning in response to the various stimuli discussed Isotretinoin Surgery above. When persistent, rosacea results in Low -dose isotretinoin (off-label use) may Scalpel excision has been used to debulk fixed facial erythema. Only a portion of be effective in patients with severe papu­ and sculpt the nose but is less precise than patients, usually men, develop cutaneous lopustular or phymatous rosacea. Referral laser therapy. hypertrophy, and this manifests most of these patients to a dermatologist is ­commonly as rhinophyma.11 advised. Patients with refractory disease Novel therapies typically respond well to doses of 10 to Subantimicrobial-dose tetracyclines ASSOCIATIONS AND COMPLICATIONS 20 mg/day; long-term maintenance At higher doses the oral tetracyclines are Psychosocial impact ­therapy may be required as the lasting antimicrobial; at lower doses they have Although rosacea is not a life-threatening response seen in acne does not often occur anti -inflammatory actions without anti­ disease, the impact on a patient’s quality in rosacea.2 biotic activity. Doxycycline 40 mg once of life can be significant. Rosacea may daily (delayed release) or 20 mg twice daily cause embarrassment, anxiety, decreased Other oral therapies is effective in the treatment of patients with self­ -esteem and social isolation. Patients Other oral therapies reported to be effec­ rosacea, without any development of anti­ may feel self-conscious of their ‘alcoholic tive in patients with rosacea include biotic resistance or impact on skin flora. nose’ or report disappointment that their clonidine, spironolactone, naloxone Efficacy is comparable with traditional disease cannot be cured.19 These feelings and ondansetron (all off-label use).16 dosing of doxycycline but there are fewer should be taken into account when devis­ Single -dose oral ivermectin (off-label use) adverse effects.18 A slow-release doxycycline ing a treatment plan. Online support has been used in immunocompromised preparation is not currently available in groups such as the Rosacea Support Group patients with rosacea-like demodicidosis Australia. (http://rosacea-support.org/australia) can with good effect.18 be useful. NSAIDs, such as diclofenac, may offer Beta-blockers symptomatic relief in patients with Nonselective beta-blockers decrease sym­ Ocular rosacea rosacea. pathetic activity and produce vasocon­ At least 70% of patients with rosacea expe­ striction, which suppresses flushing. Oral rience ocular symptoms, with men and Physical therapies propranolol 30 to 120 mg/day and carve­ women being affected equally. Symptoms Laser and light dilol 15 to 25 mg/day have been shown to are often mild, so it is worth specifically Vascular laser therapy, such as with the 595 reduce the frequency and severity of flush­ asking about ocular involvement at the first nm pulsed dye laser, and intense pulsed ing episodes (both off-label use). They may consultation. Severe eye involvement may light therapy can be used to remove refrac­ be used in normotensive patients as long lead to ocular keratitis with subsequent scar­ tory background erythema and clinically as doses are gradually escalated and blood ring, corneal perforation and vision loss.13 significant telangiectases (Figures 4a and pressure monitored.18 Symptoms include tearing, conjunctival b). The light in these devices is absorbed hyperaemia, foreign body sensation, burn­ by oxyhaemoglobin and haemoglobin, Other antimicrobials ing, stinging, dryness, itching, light sensi­ leading to vessel destruction with minimal Topical 5% permethrin, 10% crotamiton tivity and blurred vision. When the cornea collateral tissue damage (Figure 5).16 Abla­ and 1% ivermectin (all off-label use) have is involved, patients may report decreased tive lasers can be used for the contouring been reported to be useful in patients with visual acuity. Other signs include telangi­ of hypertrophied tissue in patients with rosacea. However, they should be used ectases of the conjunctiva and lid margin, phymatous rosacea.2,14 Patients may be with caution as they may irritate sensitive lid and periocular erythema, blepharitis, referred to a dermatologist for laser skin.18 conjunctivitis and styes.13 therapy. Early consultation with an ophthalmol­ Rhinophyma can be debulked by an PROGNOSIS ogist is recommended as slit lamp exami­ ablative resurfacing laser (e.g. carbon The duration of rosacea is highly variable, nation of the ocular surface is needed.13,14 It ­dioxide) or radiofrequency electro­surgery ranging from months to decades. Treat­ is worth noting that ocular rosacea may devices. Treatment is aimed at debulking ment of affected patients aims to suppress occur in the absence of cutaneous mani­ the excess tissue and then sculpting the symptoms and prevent disease progression festations, and the severity of ocular symp­ disfigured nose. TheseCopyright devices _Layout are 1pre 17/01/12­ and 1:43 complications; PM Page 4 it does not appear to toms is not necessarily related to the severity ferred for recontouring because there is alter disease duration. of cutaneous findings.13

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12. Wilkin J, Dahl M, Detmar M, et al. Standard General measures to relieve ocular symp­ ­management of the condition. classification of rosacea: Report of the National toms include application of warm com­ With the renewed interest in the patho­ Rosacea Society Expert Committee on the presses and lubricating eye drops. Mild genesis of rosacea, particularly at both the Classification and Staging of Rosacea. J Am Acad 20 6 rosacea can be treated with topical cyclo­ microbiota and immunological levels, Dermatol 2002; 46: 584-587. sporin 0.05% (off-label use), which increases novel topical and systemic agents are 13. Vieira AC, Mannis MJ. Ocular rosacea: common tear production and has mild anti-inflam­ under development. An exciting area of and commonly missed. J Am Acad Dermatol 2013; matory effects, and antibiotic ointments to translational research is the inactivation of 69(6 Suppl 1): S36-S41. decrease eye flora. Metronidazole gel is enzymes of the kallikrein family, which 14. van Zuuren EJ, Kramer SF, Carter BR, Graber MA, useful in cases of rosacea-associated blephar­ should reduce cathelicidin levels in patients Fedorowicz Z. Effective and evidence-based manage- itis. Topical corticosteroids may be used to with rosacea-prone skin and thus prevent ment strategies for rosacea: summary of a Cochrane systematic review. Br J Dermatol 2011; 165: 760-781. settle inflammation; however, long-term use aberrant activation of the innate immune 15. Cribier B. Rosacea under the microscope: 21 MT should be avoided because of increased risk response. ­characteristic histological findings. J Eur Acad of ocular infections and potential side effects Dermatol Venereol 2013; 27: 1336-1343. such as glaucoma and cataracts. Moderate REFERENCES 16. Pelle M, Crawford G, James W. Rosacea: II. to severe ocular rosacea may require sys­ 1. Tan J, Berg M. Rosacea: current state of epide- Therapy. J Am Acad Dermatol 2004; 41: 499-512. temic therapies such as oral doxycycline or, miology. J Am Acad Dermatol 2013; 69(6 Suppl 1): 17. Jackson JM, Pelle M. Topical rosacea therapy: as second-line, azithro­mycin.13,14 Regular S27-S35. the importance of vehicles for efficacy, tolerability and lubrication of eyes is essential when using 2. Powell FC, Raghallaigh SN. Rosacea and related compliance. J Drugs Dermatol 2011; 10: 627-633. oral isotretinoin for c­ utaneous rosacea. disorders. In: Bolognia KL, Jorrizzo JL, Rapini RP, 18. Layton A, Thiboutot D. Emerging therapies in eds. Dermatology. 3rd ed. New York: Mosby Elsevier rosacea. J Am Acad Dermatol 2013; 6(6 Suppl 1): Lymphoedema publishing; 2012. pp. 561-569. S57-S65. 3. Steinhoff M, Schauber J, Leyden JJ. New 19. Aksoy B, Altaykan-Haa A, Egemen D, Karagoz Chronic inflammation in patients with insights into rosacea pathophysiology: a review of F, Atakan N. The impact of rosacea on quality of life: long-standing rosacea damages local recent findings. J Am Acad Dermatol 2013; 69(6 effects of demographic and clinical characteristics ­lymphatic vessels, resulting in a build-up Suppl 1): S15-S26. and various treatment modalities. Br J Dermatol of protein-rich lymphatic fluid in the skin 4. Ní Raghallaigh, Bender K, Lacey N, Brennan L, 2010; 163: 719-725. (lymphoedema). Although an uncommon Powell FC. The fatty acid profile of the skin surface 20. Murillo N, Raoult D. Skin microbiota: overview and complication of rosacea, lymphoedema lipid layer in papulopustular rosacea. Br J Dermatol role in the skin diseases acne vulgaris and rosacea. preferentially affects periorbital skin, result­ 2012; 166: 279-287. Future Microbiol 2013; 8: 209-222. ing in eyelid swelling and even ectropion.11 5. Del Rosso J. Management of facial erythema of 21. Salzer S, Suzika T, Schauber J. Face-to-face It can be acute or subacute in onset, and rosacea: what is the role of topical alpha-adrenergic with anti-inflammatory therapy for rosacea. Exp unilateral or bilateral in distribution. receptor agonist therapy? J Am Acad Dermatol 2013; Dermatol 2014; 23: 379-381. 69(6 Suppl 1): S44-S56. 6. Gerber PA, Buhren BA, Steinhoff M, Homey B. Salivary gland involvement COMPETING INTERESTS: None. Rosacea: the cytokine and chemokine network. Although rare, inflammation of the sali­ J Investig Dermatol Symp Proc 2011; 15: 40-47. Online CPD Journal Program vary glands as a consequence of rosacea 7. Forton FM. Papulopustular rosacea, skin immuni- can result in reduced salivary secretions ty and Demodex: pityriasis folliculorum as a missing 11 and dry mouth. link. J Eur Acad Dermatol Venereol 2012; 26: 19-28. 8. Dahl MV, Ross AJ, Schlievert PM. Temperature CONCLUSION regulates bacterial protein production: possible role Rosacea is a common chronic inflamma­ in rosacea. J Am Acad Dermatol 2004; 50: 266-272. tory skin disease that often impacts signif­ 9. Whitfield M, Gunasingam N, Leow LJ, Shirato K, icantly on the patient’s quality of life. Preda V. Staphylococcus epidermidis: a possible Referral to a dermatologist is recommended role in the pustules of rosacea. J Am Acad Dermatol 2011; 64: 49-52. when the disease is not responding to con­ Is telangiectasia a primary feature 10. Holmes AD. Potential role of microorganisms in ventional therapy or for consideration of the pathogenesis of rosacea. J Am Acad Dermatol of rosacea? laser or light therapies. Ophthalmology 2013; 69: 1025-1032. Review your knowledge of this topic and review is recommended if eye involvement 11. Berth-Jones J. Rosacea, perioral dermatitis and earn CPD/PDP points by taking part in MedicineToday’s Online CPD Journal Program. is suspected. General measures such as similar dermatoses, flushing and flushing syndromes. avoidance of known precipitants and use In: Burns DA, ed. Rook’s textbook of dermatology. Log in to Copyright _Layout 1 17/01/12 1:43 PM Page 4 of fragrance- and preservative-free skin 8th ed. Oxford: Blackwell Publishing Ltd; 2010. pp. www.medicinetoday.com.au/cpd care products are paramount to the 43.1-43.2.

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