Clinical Pearls & Morning Reports
Published November 1, 2017
Rosacea usually starts in affected persons when they are between 30 and 50 years of age and is characterized by episodes of exacerbation and remission. Women are more commonly affected than men, and rosacea has been shown to be particularly common among fair-skinned people of Celtic origin. The pathophysiology of rosacea remains uncertain. Genetic factors, dysregulation of the innate and adaptive immune system, vascular and neuronal dysfunction, and microorganisms such as Demodex folliculorum appear to be involved. Read the latest Clinical Practice Article.
Q: What are the clinical features of rosacea?
A: Rosacea is a chronic, inflammatory skin disease that affects primarily the cheeks, nose, chin, and forehead. Manifestations include persistent facial erythema, papules, pustules, telangiectasia, and recurrent flushing. Phymatous changes (hypertrophy of the sebaceous glands and fibrosis) can also occur, the most common of which is rhinophyma (bulbous nose). Involvement of the eyes (ocular rosacea) is estimated to occur in up to three quarters of patients with rosacea and frequently includes foreign-body sensation, dryness, burning, itching, redness, photophobia, tearing, and blurred vision. Sight-threatening keratitis is rare.
Figure 1. Erythematotelangiectatic and Papulopustular Rosacea.
Figure 2. Phymatous and Ocular Rosacea.
Q: Is a skin biopsy required to diagnose rosacea?
A: The diagnosis of rosacea is based on clinical features and careful history taking. A skin-biopsy specimen is obtained only to rule out other diagnoses, since the histopathological features of rosacea are typically not specific. The differential diagnosis includes seborrheic dermatitis, flushing disorders, acne vulgaris, perioral dermatitis, lupus erythematosus, and chronic actinic damage.
A: Randomized trial data on interventions for transient erythema and flushing are lacking. However, on the basis of empirical evidence, when flushing is bothersome, beta-blockers (e.g., nadolol, propanolol, and carvedilol) or α2-adrenergic agonists (e.g., clonidine) are often prescribed. Treatment with 0.5% brimonidine tartrate gel, a highly selective α2-adrenergic agonist with vasoconstrictive activity, was shown to reduce persistent erythema in two randomized, controlled trials involving a total of 553 patients. Treatment with 1% oxymetazoline hydrochloride cream, an α1-adrenergic agonist and a partial α2-adrenergic agonist, has recently been approved by the Food and Drug Administration (FDA) for the treatment of persistent erythema associated with rosacea on the basis of two randomized, controlled trials involving a total of 885 participants. Although laser therapy and other light-based therapy are widely used in the treatment of erythema and telangiectasia, these methods of treatment have been investigated primarily in observational studies.
A: Treatments for inflammatory papules and pustular lesions depend on the severity of the inflammation. Topical azelaic acid, topical metronidazole, and topical ivermectin are all first-line treatment options. When first-line treatments are inadequate in mild cases or when rosacea is more severe at presentation, combining topical treatments with oral antibiotic agents is generally recommended, although supporting data are limited. The only oral treatment approved by both the FDA and the European Medicines Agency for inflammatory lesions associated with rosacea is modified-release doxycycline at a dose of 40 mg once daily. This dose is considered to have antiinflammatory effects but not an antimicrobial effect. For severe cases of inflammatory papules and pustules or for inflammatory papules and pustules that do not respond to oral antibiotics or that recur after the discontinuation of oral antibiotics, treatment with low-dose oral isotretinoin (0.25 to 0.30 mg per kilogram of body weight per day) for 12 to 16 weeks has been shown to be effective in two randomized, controlled trials.