Rosacea

(Acne Rosacea)

A chronic, multiphasic inflammatory disorder, usually beginning in middle age or later, characterized by telangiectasia, erythema, papules, and pustules primarily in the central areas of the face.

Rosacea is most common in persons of Celtic descent. Onset typically occurs between the 4th and 6th decades. The etiology and pathogenesis are unknown, although genetic predisposition, hormonal influences, psychologic factors, GI infections, or Demodex folliculorum mites may play a role. A rosacea-like eruption may occur with abuse of topical corticosteroids on the face. Variants include lupoid or granulomatous rosacea, gram-negative rosacea, rosacea conglobata (rosacea fulminans), and persistent edema of rosacea.

Symptoms and Signs

Rosacea is a multiphasic disease characterized by persistent telangiectasia (which may be the principal or only manifestation) and papulopustules of the central face. Comedones and scarring, as observed in acne vulgaris, are notably absent. Episodes of erythema may be triggered by heat, sunlight, alcohol, or hot beverages; the skin may also be sensitive to cosmetic products. Photodamage frequently coexists with rosacea.

Eye involvement of varying severity is common. Eye symptoms include soreness, grittiness, burning, and lacrimation. Blepharitis and conjunctival hyperemia are the most common manifestations, but iritis, episcleritis, superficial punctate keratitis, corneal neovascularization, scarring, thinning, and corneal perforation may also occur.

Rhinophyma, a bulbous hypertrophy of the nose that usually affects men, occasionally manifests at the end-stage of the disease.

Not all patients progress through the multiple phases or experience the many manifestations of rosacea.

Treatment

Patients should avoid situations that trigger flushing and vasodilation and should use sun protection.

Mild to moderate disease may be treated with topical antibiotics. Metronidazole gel or cream decreases papules but does not significantly alter telangiectasia or erythema. Ketoconazole cream can also be used. Topical erythromycin, clindamycin, and sulfacetamide/sulfur are also effective. Some authorities recommend eliminating D. folliculorum mites with crotamiton or lindane cream, especially in resistant cases.

More severe inflammatory disease, including eye involvement, is treated with an oral antibiotic, initially at doses similar to those for acne vulgaris. First-line oral antibiotics include tetracycline 500 mg po bid, doxycycline 100 mg po bid, and minocycline 100 mg po bid, which are continued for >= 1 month. Response is usually dramatic. Lower antibiotic doses may also be effective. Second-line oral antibiotics include erythromycin and metronidazole. After control is achieved, the dose is tapered to the smallest effective dose. Many patients require oral maintenance treatment or intermittent courses, each lasting weeks to months. Topical treatment may be given concurrently. Recalcitrant disease can be treated with isotretinoin: the dose ranges from that used to treat acne vulgaris (0.5 to 1 mg/kg/day po in 2 divided doses for 4 to 5 months) to a low dose (0.1 to 0.2 mg/kg/day) to a mini-dose (2.5 to 5.0 mg/day).

Telangiectasia usually responds to pulsed dye laser therapy, a simple outpatient procedure that is widely available. Alternatively, electrocautery may be used.