Last Updated: 02/18/2010
Rosacea is a chronic, common, inflammatory condition of the face that causes facial flushing and localized erythema; telangiectasia; papules; and pustules on the nose, cheeks, brow, and chin. In men, severe cases often result in hypertrophy and lymphedema of the subcutaneous tissue, which in turn results in swellings known as phymas. Rhinophyma is the most common of these and refers to characteristic deformity of the nose. Ocular symptoms, such as a gritty eye sensation, are common. Patients may report a burning or stinging sensation. The etiology and pathogenesis are poorly understood, but cutaneous vascular changes and environmental exposures such as sunlight and certain foods or drugs may play a role. Four subtypes have been identified: papulopustular, ocular, erythematotelangiectatic, and phymatous.
It frequently develops in individuals aged 30–50 and is more common in women. Fair-skinned individuals are primarily affected, though the disease is seen in Mediterranean skin types as well. Rosacea fulminans (pyoderma faciale) refers to the sudden onset of severe facial pustulation with abscess and sinus tract formation. Systemic signs and symptoms are present.
In contrast to cellulitis, rosacea is often bilateral (ie, affecting both cheeks) and slowly progressive. Papules and pustules are more prevalent than with cellulitis.
Erythematous papules and pustules located at the nose and cheeks. There are often varying amounts of background erythema and telangiectasias. Some individuals present with erythema alone and/or telangiectasias. Facial edema may be present. Rhinophyma (hypertrophy of the distal nose) is more common in men.
Extrafascial involvement is rare, but the disease may involve the neck and superior chest. In cases with ocular involvement, conjunctival injection and chalazia may be seen.
Rosacea fulminans presents with pustules, nodules, and abscesses with sinus tract formation.
Ask the patient about ocular symptoms; many patients experience a gritty sensation in their eyes and have evidence of conjunctivitis, episcleritis, iritis, and keratitis.
Rosacea patients do not have comedones, which are frequently seen in acne.
Seborrheic dermatitis is observed commonly in patients that also have rosacea.
Papulopustular rosacea: Acne vulgarisPerioral dermatitis (periorificial dermatitis)
BromodermaFolliculitisSarcoidosisPyoderma facialeErythematotelangiectatic rosacea:Menopause, "hot flashes"
Cellulitis (usually unilateral)
Erysipelas (usually unilateral)
Carcinoid syndromePheochromocytomaMedullary thyroid carcinoma
Lupus erythematosusSeborrheic dermatitisPhotosensitive or
photoallergic drug eruptionMastocytosis
This is a clinical diagnosis. If the situation warrants, testing for urinary 5-HIAA may be performed to rule out carcinoid syndrome and serology to rule out lupus erythematosus.
There is not substantial evidence that testing for
Helicobacter pylori in the stomach (and treating it specifically) has any value in testing for rosacea.
In severe cases, use both an oral therapy with tetracycline and topical metronidazole.
Advise patients to avoid agents that cause vasodilation (eg, coffee, tea, hot drinks in general, spicy foods, chocolate, and alcohol). Encourage the use of sunscreens and sun-protective clothing.
Patients with long-standing or severe rosacea should be seen by an ophthalmologist.
Topical therapies:
Currently, topical metronidazole is the treatment of choice: metronidazole gel 0.75% twice daily (for patients with oily skin types); metronidazole 0.75% cream or lotion twice daily (for patients with dry skin types). Alternatively, topical 20% azelaic acid cream has been shown to be equally as effective as topical metronidazole.
Second-line topical therapies include 2% erythromycin solution twice daily, clindamycin 1% lotion twice daily, and benzoyl peroxide (5% or 10% as tolerated).
Systemic therapies:
Tetracyclines are first line: tetracycline 500–1,000 mg twice daily OR doxycycline 100–200 mg daily OR minocycline 50 mg twice daily for at least 2–3 months, then taper to 1 pill daily. Oral erythromycin is also a good choice: 250–500 mg twice daily.
Alternative regimens: Oral metronidazole 200 mg twice daily, azithromycin 250–500 mg daily 3 days per week.
Therapies aimed at specific disease manifestations include the following:
- Telangiectasias: vascular lasers (pulsed dye, KTP, etc), intense pulsed light therapy, camouflage cosmetics.
- Flushing: clonidine 0.05 mg twice daily, intense pulsed light, pulsed dye laser, and beta blockers (nadolol 40 mg daily).
- Rhinophyma: surgical paring/sculpting, electrosurgery, and laser (argon, carbon dioxide, Nd:YAG).
- Rosacea fulminans: conventional treatment plus prednisolone 1 mg/kg daily for 1–2 weeks, then add isotretinoin 0.2–0.5 mg/kg. Taper prednisolone over 2–3 weeks; continue isotretinoin for 3–4 months.
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PubMed Id: 9006372
AppearanceNo Acute Distress
Body LocationCheek
Eyelids
Face
Inferior Eyelid
Nose
Superior Eyelid
ConfigurationConfluent
DistributionBilateral
ExposuresCosmetics
Heat Exposure - Prolonged, Heating Pad, Stoves, Etc
Sun Exposure - History of Severe Sunburns
Sunscreens
LesionBlanching Macule
Blanching Patch
Conjunctival Adhesions (Symblepharon)
Conjunctival Injection (Redness, Bloodshot Eyes)
Corneal Peripheral Lesion
Corneal Ulcer (Defect)
Papule
Pustule
Telangiectasia
OccupationsMilitary
Signs and SymptomsEye Burning
Flushing
Gritty Eyes
No Fever (Afebrile, Apyrexial)
TemporalDeveloped Chronically Lasting Months to Years
Developed Steadily Over Weeks to Months
Medical HistoryBlepharitis
Hordeolum (Stye) and Chalazion
Meibomitis
Authors
Tara Mahar MD, Art Papier MD
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