Rosacea

General Information

Classification: Integumentary
Figure 1 Rosacea patients most commonly present with central facial erythema (Source: OpenI, NLM)

What is it?

Chronic autoimmune inflammatory disease that is differentiable from true acne or acne vulgaris; is also colloquially known as “adult acne”

Most commonly affects forehead, nose/mid cheeks, chin and often manifests symmetrically/bilaterally

Risk Factors: genetic predisposition, demodex mites, Heliobacter pylori, UV rays, medication, celtic heritage

Evaluation:

Signs & Symptoms (see below regarding specific subtypes)

  • Central facial erythema and redness (Figure 1)
  • Pustules/papules
  • Telangiectasias: visible veins and vasculature (seen more often in older individuals)
  • Rhinophyma
  • Eye/ocular involvement

Pathophysiology

Autoimmune activation of immune system

  • Overexpression of Th1/Th17 and TLR-2 (associated with increased activity of mast cells)

Increased expression of matrix metalloproteinases and VEGF

Lymphatic vasodilation, increasing release of vasoactive peptides

Demodex mite infestation or H.pylori infection

Clinical Subtypes

Note that patients may present with multiple subtypes, and have evolving symptomatology.

Erythemato-telangiectactic

Persistent erythema and flushing (central facial region)

The most common subtype and clinical manifestation

Papulopustuler, “Adult Acne”

Presents similarly to acne vulgaris due to eruption of papules and pustules (but unlike acne, individuals with rosacea do not have comedones

Figure 2 Rhinophyma (nose enlargement) commonly seen with phymatous rosacea

Phymatous

Presents with nose enlargement (rhinophyma)

  • Can also affect the chin (mentophyma), forehead (metophyma), ears (otophyma), eyelids (bleherophyma)
  • Pathophysiology
    • Hypertrophic sebaceous glands, sebum plugging
    • Fluid leakage into dermis leading to inflammation and fibrosis

Typically in older males

Is due to more developed, untreated, chronic rosacea

Ocular

Presents with dryness, redness, blurred vision, light sensitivity

Also blepharitis (eyelid inflammation), conjunctivitis (pink eye), keratitis (corneal inflammation), iritis (iris inflammation), lid margin telangiectasia

Treatment

Lifestyle modifications

Avoid triggering factors, minimize UV exposure (SPF), gentle moisturizers and skincare products

By subtype symptomatology

Erythema: brimonidine tartrate gel, oxymetazoline HCL gel

Inflammation: topical cyclines, metronidazole (avoid retinal)

Demodex mites: ivermectin

Rhinophyma: doxyxycline, isotretinoin, tetracycline

  • If surgical removal (if permanently enlarged): must be off isotretinoin
    • Reduce hypertrophy of sebaceous glands, recontour nasal region
    • Excisional treatment
      • Graft reconstruction
      • Cryosurgery
      • Laser surgery

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