Rosacea

Rosacea is a common facial eruption, which is characterized by redness, blushing, flushing and abnormal blood vessel growths called telangiectasia’s. Acne Rosacea is a disorder of skin pigmentation which presents during the ages of middle age, around 30-50. Acne rosacea is found more commonly in females, however, the involved and extent of disease is much more severe in males. This may be do to the more common finding of rhinophyma in males, while females mainly have the erythromatotelangiectatic form, which consists of flushing and persistent facial redness (please see below).

ACNE ROSACEA: Signs and Symptoms

Facial flushing, the presence of telangiectatic vessels, persistent redness of the face, inflammatory papules and pustules, hypertrophy of the sebaceous glands of the nose. Fibrosis of the sebaceous glands may also occur, which is referred to as rhinophyma. Ocular changes may also be present, and include dryness and irritation of the eyes, with blepharitis and conjunctivitis to rare, but life-threatening keratitis. The disease is chronic and progressive. Some patients clear in their later years, such as in their 60′s.

Acne Rosacea Skin

The skin of paitents with acne rosacea can have numerous different components. These include vascular, acneiform, ocular and phymatous changes.

Vascular

These include intermittent, with progression to persistent erythema (redness) and facial flushing. Telangiectasias may also be present which are small dilated blood vessels that have become prominently visible.

Acneiform

Similar to common acne, acne rosacea may also have lesions found in acne which point to an inflammation component of the diseases. These include papules, pustules and nodules. There are never comedones present. If comedones are present, the patient may have associated acne or the skin changes may be due to common acne and not acne rosacea if other rosacea skin changes are not found.

Ocular Involvement

In acne rosacea, the skin around the eye, as well as the eye may be involved. These include conjunctivitis and keratitis (inflammation) of the eye, and blepharitis, inflammation of the skin and tissue around the eye.

Phymatous Changes

Phymatous changes include rhinoyphyma (involvement of the nose), which are uncommon, but severe, late stage complication of progressive enlargement of nose disfiguration and enlargement resulting from sebaceous hyperplasia and skin damage through chronic inflammation. Involvement of other portions of the face can also occur, and the disease is not limited to the nose.

Onset of Acne Rosacea

Occurs between the ages of 30 and 50, and is more common in women by about 3 times. However, the distorting phymatous skin changes are more common in men. Overall, men also have more severe disease.

Exacerbating and triggers of flushing factors

These include sunlight, hot weather, alcohol, spicy foods, exercise, hot beverages such as tea, hot baths, cold weather, stress, menstruation, certain foods such as soya and medications.

Acne rosacea is associated with :

With migraine headaches in women, seborrheic dermatitis, and with Helicobacter pylori infection. Family history is also evident in about 1/3 of all patients.
The severity of the acne rosacea is graded as 1 (mild), 2 (moderate), and 3 (severe).

Acne Rosacea is subdivided into four subtypes:

Erythematotelangiectatic Acne Rosacea

This type of acne rosacea has intermittent and then persistent erythema (redness) of the central face, accompanied with flushing, telangiectasia, irritated skin, burning of the face, and often rhinophyma. Treated mainly with surgical or laser therapy to ablate prominent dilated vessels in severe types. There is often an acneiform component such as the presence of papules, pustules and nodules, but never comedones. If comedones are present, think acne, not acne rosacea. Mild types of erythematotelangiectatic acne rosacea are usually treated with topical ointments and creams, such as Metronidazole antibacterial creams.

Papulopustular Acne Rosacea

This type of acne has persistent erythema of the central face, but with prominent acne features without comedones, such as papules and pustules.

Phymatous Acne Rosacea

Phymatous, also commonly known as rhinophyma when involving the nose, is an uncommon late stage complication of progressive enlargement of the skin and tissue, mainly of the nose. The enlargement of the skin and tissue is believe to be due to sebaceous gland hyperplasia (overgrowth) and chronic abnormal inflammation.

Ocular Acne Rosacea

Ocular changes such as blepharitis (inflammation of skin around the eye), conjunctivitis (inflammation of white of the eye) and keratitis (inflammation of the keratin, coloured, layer of the eye). Usually presents with redness and itchiness in the eye.

Steroid-induced Rosacea

Acne rosacea, that presents similar to the erythematotelangiectatic form, secondary to steroid use, mainly prolonged topical steroid use on the face. Stoppage of steroids is the mainstay of treatment.

Acne Rosacea Course and Prognosis

Acne rosacea unfortunately is a chronic and slowly progressive skin disorder which rarely clears. Treatments help slow this progression, and commonly stop it. Many senior have also been reported to clear their acne rosacea in their 70′s.

Acne Rosacea can be mistaken for:

Seborrheic Dermatitis is known to coexist with acne rosacea.
Systemic Lupus Erythematosus
Acne Vulgaris
Basal Cell Carcinoma

Acne Rosacea Treatments and Medicines

Rosacea is very difficult to treat because it is caused by vasodilated vessels largely unresponsive to treatment. Corticosteroids are effective in reversing this vasodilation, but are contraindicated due to numerous adverse effects (e.g. atrophy of skin, such as thinning).
The main treatment is avoidance of substances and circumstances that cause vasodilation of these vessels. The mainstay of treatment is to begin with topical therapy, which includes metronidazole.

Topical Treatments and Medicines

Topical medications are not as good for vascular aspects of the disease, but moreso for prevention of disease progression. Treatment is long-term.

Metronidazole for Rosacea

Metronidazole is an antibiotic that has anti-inflammatory properties, and thereby decreasing the inflammation (redness) in the area fairly effectively, and mildly removes the redness due to vasodilated vessels. Metronidazole decreases papules and pustules, skin changes, around 70% over a 3 month period.
It is given as:
Metronidazole 0.75% Metrogel or Metrocream and 1% cream Noritate or Rosasol.
Metronidazole acts as an anti-inflammatory, thereby decreasing the formation of papules and pustules. This is believed to occur at a total decrease of 70% over a 2 months of consistent use.

Benzoyl Peroxide

Mainly used in common acne. Removes a small layer of skin and thereby removes the stimulus of inflammation. For mild acne rosacea.

Azelaic acid

20 % cream, applied twice daily is also effective

Sulfur

Precipitated sulfur at 1-3% concentration can be added to creams or 1% hydrocortisone preparations. This may potentiate steroid-induced acne rosacea however.

Cosmetic Cover-up

Rosacure and Diroseal, agents that are used to cover and mask the redness associated with acne rosacea.

Systemic Antibiotics

The use of systemic antibiotics is not well supported in acne rosacea, in contrast to common acne.

Tetracycline

Overall, poorly effective for erythematotelangiectatic rosacea and accompanied redness, but effective for clearing acne papules and pustules, as well as ocular rosacea. Given as 250 mg to 1000 mg daily based on severity of disease. Minocin may also be used at 100 mg.

Erythromycin

Similar to tetracycline, taken as 250 mg to 1000 mg a daily.

Clonidine

Clonidine, also known as Dixarit, may help relieve flushing. Started at 0.05 mg twice a day dose initially.

Accutane

Isotretinoin

Its effectiveness in acne rosacea is not well-documented, but seems less than with common acne. Overall, a very good medications to decrease acne lesions and redness, as well as some rhinophyma. The dosage used in acne rosacea is much less than that used to treat common acne.

Telangiectasia Treatments

Laser or Electrodesiccation.

Surgery

Surgical shave reduction, dermabrasion and electrosurgery for rhinophyma. CO2 laser can also be used.