Triggers and Treatment of Rosacea

MedicineToday 2015; 16(1): 34-40 PEER REVIEWED FEATURE 2 CPD POINTS Triggers and treatment of rosacea SHIEN-NING CHEE MB BS, MMed PATRICIA LOWE MB BS, MMed, FACD Key points Rosacea is a common chronic inflammatory skin condition 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 inflammation, 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 selfesteem 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 50year 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 LL37, is increased in patients with rosaceaprone 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 domeshaped 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 betahaemolytic 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 acne, – 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, rhinophyma, 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 MedicineToday x JANUARY 2015, VOLUME 16, NUMBER 1 35 Downloaded for personal use only. No other uses permitted without permission. © MedicineToday 2015. ROSACEA CONTINUED Steroid-induced acneiform eruption 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 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 (otophyma), forehead (metophyma), be necessary to make a distinction between allergic eyelids (blepharophyma) 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

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