Rosacea - A fitzpatric review

Rosacea (40-50)

Females predominantly, but rhinophyma occurs mostly in males.

The rosacea diathesis: episodic erythema, "flushing and blushing"

Stage I: Persistent erythema with telangiectases.

Stage II: Persistent erythema, telangiectases, papules, tiny pustules.

Stage III: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent "solid" edema of the central part of the face

Acne may have preceded the onset of rosacea by years; nevertheless, rosacea may and usually does arise de novo without any preceding history of acne or seborrhea.

Early

Pathognomonic flushing; tiny papules and papulopustules (2 to 3 mm), pustule often small (<1>No comedones

Late

Red facies and dusky-red papules and nodules (Figs. 1-5, 1-6, and 1-7) Scattered, discrete lesions. Telangiectases. Marked sebaceous hyperplasia and lymphedema in chronic rosacea, causing disfigurement of the nose, forehead, eyelids, ears, and chin

Distribution

Characteristic is the symmetric localization on the face (Fig. 1-7). Rarely, neck, chest (V-shaped area), back, and scalp

Rhinophyma (enlarged nose, Fig. 1-8), metophyma (enlarged cushion-like swelling of the forehead), blepharophyma (swelling of the eyelids), otophyma (cauliflower-like swelling of the earlobes), and gnathophyma (swelling of the chin) result from marked sebaceous gland hyperplasia and fibrosis. Upon palpation: soft, rubber-like.

Dermatopathology

Nonspecific perifollicular and pericapillary inflammation with occasional foci of "tuberculoid" granulomatous areas; dilated capillaries. Foci of neutrophils high and within the follicle. Later stages: diffuse hypertrophy of the connective tissue, sebaceous gland hyperplasia, epithelioid granuloma without caseation, and foreign-body giant cells.

DIferential Dx: Facial Papules/Pustules

Acne (in rosacea there are no comedones), perioral dermatitis, S. aureus folliculitis, gram-negative folliculitis, D. folliculorum infestation.

Facial Flushing/Erythema

Seborrheic dermatitis, prolonged use of topical glucocorticoids, systemic lupus erythematosus; dermatomyositis

Topical

Metronidazole gel or cream, 0.75%, twice daily—very effective

Metronidazole cream, 1%, once daily

Sodium sulfacetamide , sulfur lotions 10% and 5%

Topical antibiotics (e.g., erythromycin gel) are less effective.

Systemic

Oral antibiotics are more effective than topical treatment.

Minocycline or doxycycline , 50 to 100 mg twice daily, first-line antibiotics; very effective (doxycycline is a phototoxic drug and its use limits exposure to sunlight in summer).

Tetracycline , 1 to 1.5 g/d in divided doses until clear; then gradually reduce to once-daily doses of 250 to 500 mg.

A dose of 50 mg minocycline or doxycycline or 250 to 500 g tetracycline is given as maintenance.

Oral Isotretinoin

For individuals with severe disease (especially stage III) not responding to antibiotics and topical treatments. A low-dose regimen of 0.1 to 0.5 mg/kg body weight per day is effective in most patients, but occasionally 1 mg/kg may be required. (For side effects and precautions see Severe Acne

RINOPHYMA