Rosacea in the Pediatric Population
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CONTINUING MEDICAL EDUCATION Rosacea in the Pediatric Population Nicole L. Lacz, MD; Robert A. Schwartz, MD, MPH GOAL To gain a thorough understanding of rosacea in the pediatric population OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Discuss the etiology of rosacea. 2. Explain the possible clinical presentation of rosacea in children. 3. Outline the treatment options for rosacea in the pediatric population. CME Test on page 112. This article has been peer reviewed and is accredited by the ACCME to provide continuing approved by Michael Fisher, MD, Professor of medical education for physicians. Medicine, Albert Einstein College of Medicine. Albert Einstein College of Medicine designates Review date: July 2004. this educational activity for a maximum of 1 This activity has been planned and implemented category 1 credit toward the AMA Physician’s in accordance with the Essential Areas and Policies Recognition Award. Each physician should claim of the Accreditation Council for Continuing Medical only that hour of credit that he/she actually spent Education through the joint sponsorship of Albert in the activity. Einstein College of Medicine and Quadrant This activity has been planned and produced in HealthCom, Inc. Albert Einstein College of Medicine accordance with ACCME Essentials. Drs. Lacz and Schwartz report no conflict of interest. The authors report discussion of off-label use for numerous acne vulgaris medications, including oral tetracycline and doxycycline, as well as topical erythromycin, clindamycin, azelaic acid, and isotretinoin. Dr. Fisher reports no conflict of interest. Rosacea is a condition of vasomotor instability an eye examination should be performed to rule characterized by facial erythema most notable in out ocular manifestations. It may be beneficial to the central convex areas of the face, including recognize children in the early stage of rosacea; the forehead, cheek, nose, and perioral and peri- however, it is uncertain if prophylactic treatment ocular skin. Rosacea tends to begin in childhood is necessary. as common facial flushing, often in response to Cutis. 2004;74:99-103. stress. A diagnosis beyond this initial stage of rosacea is unusual in the pediatric population. If a child is identified with the intermediate stage Epidemiology of rosacea, consisting of papules and pustules, Rosacea in childhood is most likely underreported because of its clinical similarity to other erythema- 1 Accepted for publication March 29, 2004. tous facial disorders. Rosacea is generally thought Dr. Lacz is a staff physician at Memorial Sloan-Kettering Cancer of as a disease of fair-skinned, young to middle- Center, New York, New York. Dr. Schwartz is Professor and aged adults, though it has been noted to affect peo- Head of Dermatology, University of Medicine and Dentistry of ple of other complexions and ages.2 Most New Jersey-New Jersey Medical School, Newark. Reprints: Nicole L. Lacz, MD, Dermatology, UMDNJ-New Jersey full-blown cases in the pediatric population have Medical School, 185 S Orange Ave, Newark, NJ 07103-2714 been in light-skinned children ranging from infants (e-mail: [email protected]). to adolescents. VOLUME 74, AUGUST 2004 99 Rosacea in the Pediatric Population Etiology Clinical Description The etiology of rosacea is unknown, though cer- The first stage of rosacea consists of blushing, in tain exacerbating factors undoubtedly have a role which the face becomes bright red in response to in predisposed individuals.3,4 Emotions such as certain stimuli (Figure). Episodes of erythema are anger, anxiety, and embarrassment can lead to recurrent and last longer than normal physiologic flushing. Environmental conditions such as wind, flushing, which typically subsides within minutes.11 cold, humidity, or heat from any source (eg, sun, Telangiectasias can become apparent over time. sauna, whirlpool, vigorous exercise) can do the Children in this early stage of the condition may same. Vasodilators such as alcohol or vasodilatory complain of burning or irritation. medications can lead to flushing, though these are In the second, or intermediate, stage of rosacea, not likely causes in children. Spicy foods such as the rash consists of papules and pustules on a back- chili, curry, and peppers, as well as hot foods and ground of erythema with telangiectasias confined beverages including coffee, tea, and hot chocolate, to the child’s face. Although peripheral involve- may contribute to symptoms. Irritants such as ment of the back, upper chest, and scalp may be alcohol-based cleansers, astringents, perfume, seen in adults, these areas seem to be spared in the shaving lotion, certain soaps, sunscreen, and face- pediatric population.12 cloths may aggravate rosacea.3,4 Saprophytic mites The third, or late, stage of rosacea involves (Demodex folliculorum and Demodex brevis) may coarse skin, inflammatory nodules, or gross cause an inflammatory or allergic reaction by enlargement of facial features.11 Such chronic either blocking hair follicles or acting as vectors changes do not occur in children as they do in for microorganisms that some believe may be adults, presumably because the disease process responsible for or may trigger rosacea.5 Immuno- takes more time to evolve.13 deficiency, as in patients with human immuno- Eye involvement can occur in children.14 It may deficiency virus, also may contribute to the include manifestations such as blepharoconjunc- development of rosacea.6 tivitis, episcleritis, keratitis, meibomianitis, cha- Genetics plays an uncertain role in the develop- lazia, hordeola, and hyperemic conjunctivae.15,16 ment of blushing and ultimately rosacea. If Although any of these eye conditions can poten- vasodilator substances or mediators are implicated tially occur in children, meibomian gland inflam- in the development of rosacea as postulated, the mation and keratitis are the common findings disease may have a genetic basis because such noted.17 Peripheral vascularization followed by mediators are often under the control of single subepithelial infiltrates can lead to scarring or per- genes.7 In one study, 20% of children with rosacea foration in the lower two thirds of the cornea. The were found to have a history of rosacea in their disease may be unilateral, but most commonly it immediate families, though this number may be an affects both eyes.17 underestimate because only one parent of each Steroid-induced rosacea also has been termed patient was examined and half of the parents clin- iatrosacea because of its mode of acquisition.18 Top- ically diagnosed with rosacea reported no familial ical fluorinated and low-dose corticosteroids can involvement.8 A family history of perioral dermati- cause a rosacealike dermatitis of the face consisting tis also may be important, as this condition may be of persistent erythema with papules, pustules, related to rosacea.9 telangiectasias, and sometimes atrophy.19-22 Corti- costeroids may be an exacerbating factor leading to Pathophysiology classic rosacea rather than the cause of an inde- Chronic transient vasodilation, as occurs with pendent disease.2 The distribution of steroid blushing, is the earliest representation of rosacea. rosacea to the eyelids and lateral face may help dis- The warmth and redness associated with flushing is tinguish it from the centrally located typical caused by vasodilation, allowing excess blood flow, rosacea.23 A case of pediatric rosacea associated and by engorgement of the subpapillary venous with the use of topical fluorinated glucocortico- plexus.2 Flushing without sweating is typically seen steroids was identified in a 9-month-old boy and in children and is likely due to circulating vaso- 16-year-old girl, both with erythematous patches dilator substances or mediators such as bradykinin, and papules on the cheeks, paranasal areas, and catecholamines, cytokines, endorphins, gastrin, chin.18,23 Forty-six boys and 60 girls, ranging in histamine, neuropeptides, serotonin, substance P, age of onset from 6 months to 13 years (average, and vascular endothelial growth factor.10 A flaw in 7 years), were diagnosed with steroid rosacea. the autonomic innervation of the cutaneous vascu- Nearly all of the children had perinasal and peri- lature also is a likely mechanism.10 oral involvement of erythematous skin interspersed 100 CUTIS® Rosacea in the Pediatric Population A B A rosy tint on the cheeks of a boy at age 2 years (A) and 4 years (B). The child’s mother has rosacea. with papules and/or pustules. The lower eyelids Thus, sweating may be helpful in reaching a diag- were affected in roughly half of the patients.8 nosis; however, exceptions exist.2 Frey syndrome (auriculotemporal syndrome), which is character- Diagnosis ized by warmth and sweating in the malar region Consistent flushing in children may be a sign of caused by aberrant autonomic fiber connections vasomotor instability and early rosacea. These after damage in the parotid region, may mimic the children may blush more frequently and with early stage of rosacea. greater intensity for longer periods than their peers The intermediate stage of pediatric rosacea may exposed to the same stimuli.24 Thus, blushing in be confused with other papulopustular disorders the early stage of rosacea may be an accentuation such as acne vulgaris, perioral dermatitis, and lupus of the body’s normal physiologic response system. erythematosus (Table). Careful attention to symp- A diagnosis of pediatric rosacea beyond