Rosacea: Diagnosis and Treatment LINDA K. OGE’, MD, Louisiana State University Department of Family Medicine, University Hospital and Clinics, Lafayette, Louisiana HERBERT L. MUNCIE, MD, Louisiana State University Department of Family Medicine, New Orleans, Louisiana AMANDA R. PHILLIPS-SAVOY, MD, MPH, Louisiana State University Department of Family Medicine, University Hospital and Clinics, Lafayette, Louisiana Rosacea is a chronic facial skin condition of unknown cause. It is characterized by marked involvement of the central face with transient or persistent erythema, telangiectasia, inflammatory papules and pustules, or hyperplasia of the con- nective tissue. Transient erythema, or flushing, is often accompanied by a feeling of warmth. It usually lasts for less than five minutes and may spread to the neck and chest. Less common findings include erythematous plaques, scaling, edema, phymatous changes (thickening of skin due to hyperplasia of sebaceous glands), and ocular symptoms. The National Rosacea Society Expert Committee defines four subtypes of rosacea (erythematotelangiectatic, papulopustular, phy- matous, and ocular) and one variant (granulomatous). Treatment starts with avoidance of triggers and use of mild cleansing agents and moisturizing regimens, as well as photoprotection with wide-brimmed hats and broad-spectrum sunscreens (minimum sun protection factor of 30). For inflammatory lesions and erythema, the recommended ini- tial treatments are topical metronidazole or azelaic acid. Once-daily brimonidine, a topical alpha-adrenergic receptor agonist, is effective in reducing erythema. Papulopustular rosacea can be treated with systemic therapy including tet- racyclines, most commonly subantimicrobial-dose doxycycline. Phymatous rosacea is treated primarily with laser or light-based therapies. Ocular rosacea is managed with lid hygiene, topical cyclosporine, and topical or systemic antibiot- ics. (Am Fam Physician. 2015;92(3):187-196. Copyright © 2015 American Academy of Family Physicians.) More online osacea is a chronic facial skin con- Subtypes at http://www. dition characterized by marked The National Rosacea Society Expert Com- aafp.org/afp. involvement of the central face mittee defined four subtypes (Table 1) and CME This clinical content with transient or persistent ery- one variant.8 Granulomatous rosacea is the conforms to AAFP criteria Rthema, inflammatory papules or pustules, sole variant with firm, indurated papules for continuing medical education (CME). See telangiectasia, or hyperplasia of the con- or nodules. Many dermatologists consider CME Quiz Questions on nective tissue.1,2 Transient erythema, or rosacea fulminans and perioral dermatitis page 180. flushing, usually lasts less than five minutes as rosacea variants. Patients may experience Author disclosure: No rel- and may spread to the neck and chest, often fluctuation in symptoms and overlapping of evant financial affiliations. 9 ▲ accompanied by a feeling of warmth. Less symptoms between subtypes. Patient information: common findings include erythematous A handout on this topic is Pathophysiology available at http://www. plaques, scaling, edema, phymatous changes aafp.org/afp/2015/0801/ (thickening of skin due to hyperplasia of The etiology of rosacea is unknown but is p187-s1.html. sebaceous glands), and ocular symptoms. likely multifactorial. Factors involved in the Rosacea can be associated with low self- pathophysiology include the dense presence esteem, embarrassment, and diminished of sebaceous glands on the face, the physiol- quality of life. In a national survey, 65% of ogy of the nerve innervation, and the vas- patients with rosacea reported symptoms of cular composition of the skin.10 Numerous depression.3 triggers initiate or aggravate the clinical The exact prevalence of rosacea in the manifestations of rosacea, including ultra- United States is unknown4,5; however, it violet light, heat, spicy foods, and alcohol is probably between 1.3% and 2.1%, and (Table 2).4,11 may be as high as 5%.6 Women are affected A predilection for fair-skinned individu- more often than men, but men are more als of Celtic or northern European descent likely to have phymatous changes, especially suggests a genetic component to rosa- rhinophyma.7 cea.10 However, no specific gene has been AugustDownloaded 1, 2015 from ◆ the Volume American 92, Family Number Physician 3 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2015 American Academy of FamilyAmerican Physicians. Family For the Physician private, noncom 187- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Rosacea Table 1. Subtypes and Variants of Rosacea and Table 2. Triggers Associated with Worsening Their Characteristics Rosacea Symptoms Classification Characteristics Patients with rosacea Trigger who report trigger (%) Subtype Erythemato­ Flushing and persistent central facial Sun exposure 81 telangiectatic erythema with or without telangiectasia Emotional stress 79 Papulopustular Persistent central facial erythema with Hot weather 75 transient, central facial papules or pustules Wind 57 or both Strenuous exercise 56 Phymatous Thickening skin, irregular surface nodularities Alcohol consumption 52 and enlargement; may occur on the nose, chin, forehead, cheeks, or ears Cold weather 46 Ocular Foreign body sensation in the eye, Spicy foods 45 burning or stinging, dryness, itching, Certain skin care products 41 ocular photosensitivity, blurred vision, Heated beverages 36 telangiectasia of the sclera or other parts Certain cosmetics (comedogenic) 27 of the eye, or periorbital edema Medications (topical steroids, niacin, 15 Variant beta blockers) Granulomatous Noninflammatory; hard; brown, yellow, Dairy products 8 or red cutaneous papules; or nodules of Other factors 24 uniform size Information from references 4 and 11. NOTE: Photos of these subtypes of acne rosacea are available at http:// www.aafp.org/afp/2009/0901/p461.html. Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosa- Table 3. Guidelines for the Diagnosis of Rosacea cea. J Am Acad Dermatol. 2002;46(4):586. http://www.sciencedirect. com/science/journal/01909622/. Presence of one or May include one or more of more of the following the following secondary primary features: features: identified.4 Patients with the genetic predisposition have Flushing (transient Burning or stinging a receptor that mediates neovascular regulation. When erythema) Plaque Nontransient erythema exposed to triggers, neuropeptide release (flushing, Dry appearance Papules and pustules edema) occurs, resulting in recruitment of proinflam- Edema Telangiectasia matory cells to the skin.10 Ocular manifestations Peripheral location Diagnosis Phymatous changes Rosacea is diagnosed based on a compatible history and Reprinted with permission from Wilkin J, Dahl M, Detmar M, et al. physical examination12 (Table 3 8). One of the following Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosa- centrofacial features is required: flushing, nontransient cea. J Am Acad Dermatol. 2002;46(4):585. http://www.sciencedirect. erythema (Figures 1A and 1B), telangiectasia (Figure 1C), com/science/journal/01909622/. or papules/pustules8 (Figures 2A and 2B). Laboratory testing is not useful. Patients may receive a misdiagnosis of skin condi- Treatment tions that share similar features. Rosacea is commonly GENERAL MEASURES misdiagnosed as adult acne vulgaris, photodermatitis, Although rosacea findings may change over time, no seborrheic dermatitis, or contact dermatitis. Table 4 lists proven natural progression exists.13 Treatment decisions features that distinguish these conditions from rosacea. are based on the patient’s current clinical manifestations Less common mimicking conditions include systemic (Table 5). lupus erythematosus, atopic dermatitis, folliculitis, bro- Because rosacea can be triggered by a variety of stim- moderma, and mastocytosis. uli, avoidance of known triggers is recommended. To 188 American Family Physician www.aafp.org/afp Volume 92, Number 3 ◆ August 1, 2015 Rosacea A B C Figure 1. Facial erythema with telangiectasia. (A) Frontal view of centrofacial erythema. (B) Close-up view of centrofa- cial erythema with scaling. (C) Close-up view of telangiectasias on lateral chin. Dimethicone- and simethicone-based products containing titanium dioxide and zinc oxide may be better tolerated.2 Cos- metics with green or yellow tint applied to the central facial erythema may conceal redness.14 FDA-APPROVED TOPICAL THERAPIES Topical agents are first-line therapy in the treatment of mild to moderate rosacea (Table 6).17,18 Medication therapy is based A B on the presence or absence of persistent Figure 2. Inflammatory lesions (papules and pustules). (A) Papulopustu- central facial erythema or inflamma- lar lesions and scaling on the lateral nose. (B) Close-up view of papulo- tion (e.g., papules, pustules, lesional and pustular rosacea. perilesional erythema), the severity of symptoms, and the patient’s response to identify potential triggers, patients should be encour- previous therapeutic interventions. aged to keep a journal documenting exposures, diet, and Five topical agents are approved by the U.S. Food and activities that cause flare-ups.14