ACNE ROSACEA

ACNE ROSACEA - LarryMillikan, MD
BASICS
DESCRIPTION
Chronic skin eruption with flushing and dilatation of small blood vessels in the face, especially nose and cheeks. Sometimes associated with ocular symptoms (ocular rosacea)
• System(s) Affected: Skin/Exocrine
• Synonym(s): Rosacea
ALERT
Geriatric Considerations
• Uncommon after age 60
• Unlikely in this age group
• Use of oral isotretinoin contraindicated
GENERAL PREVENTION
No preventive measure known
EPIDEMIOLOGY
• Predominant age: 30-50 years
• Predominant sex: Female > Male
Prevalence
Common
RISK FACTORS
Genetics
People of Northern European and Celtic background commonly afflicted
ETIOLOGY
• No proven cause
• Possibilities include
- Thyroid and gonadal disturbance
- Alcohol, coffee, tea, spiced food overindulgence (unproven)
- Demodex follicular parasite (suspected)
- Exposure to cold, heat, hot drinks
- Emotional stress
- Dysfunction of the gastrointestinal tract
- Environmental trigger factors: Sun, wind, cold
ASSOCIATED CONDITIONS
• Seborrheic dermatitis of scalp and eyelids
• Keratitis with photophobia, lacrimation, visual disturbance
• Corneal lesions
• Blepharitis
• Uveitis


DIAGNOSIS
SIGNS AND SYMPTOMS
History
• Skin flush: Prominent at onset
• Redness: Lower half of nose, sometimes whole nose, forehead, cheeks, chin
Physical Exam
• Conjunctivae red: Sometimes
• Erythema, dusky: In advanced cases
• Blood vessels in involved area collapse under pressure
• Acne lesions form papules, pustules, and nodules
- Comedones are rare.
• Telangiectasia
• Rhinophyma: Sometimes (more common in males)
TESTS
Diagnosis based on physical exam findings
Pathological Findings
• Inflammation around hypertrophied sebaceous glands, producing papules, pustules, and cysts
• Absence of comedones and blocked ducts
• Vascular dilation and dermal lymphocytic infiltrate
DIFFERENTIAL DIAGNOSIS
• Drug eruptions (iodides and bromides)
• Granulomas of the skin
• Cutaneous lupus erythematosus
• Carcinoid syndrome
• Deep fungal infection
• Acne vulgaris
• Seborrheic dermatitis
• Steroid rosacea (abuse)
TREATMENT
GENERAL MEASURES
• Reassurance
• Treat psychological stress if present
• Avoid oil-based cosmetics
- Others are acceptable and may help women tolerate the symptoms.
• Electrodesiccation or chemical sclerosis of permanently dilated blood vessels
• Possible evolving laser therapy
Diet
No restrictions
Activity
• No restrictions
• Support physical fitness
MEDICATION (DRUGS)
First Line
• Low-dose oral tetracycline, 500-1,000 mg/d, or doxycycline, 50-150 mg/d, or minocycline, 75-200 mg/d; doxycycline, 20 mg PO b.i.d., 40 mg b.i.d. (oracea) if persistent
• Sulfur-containing local applications:
- Alcohol-sulfur (Liquimat)
- Sulfur (Fostril)
- Resorcinol-sulfur (Rezamid)
- Sulfacetamide-sulfur (Sulfacet-R, Nicosyn, Avar Gel, Avar Cleanser, Avar Green, Rosanil Cleanser, Plexion Cleanser, Ovace Wash, Clenia Emollient Cream, Clenia Foam Wash)
- Urea-sulfacetamide-sulfur (Rosula)
• Azelaic acid (Finacea) topically
• Topical metronidazole (MetroGel) 0.75% gel: 1% gel. Apply each morning and at bedtime after cleansing skin; also available as a cream and lotion, which may be better tolerated by some patients; or 1% cream formulation of metronidazole (Noritate), used once daily
• Topical erythromycin
• Topical clindamycin lotion preferred
• Possible utility of calcineurin inhibitors (tacrolimus, 0.1%; pimecrolimus, 0.1%)
• Topical steroids should not be used, as they may aggravate rosacea.
• Contraindications
- Tetracycline: Not for use during pregnancy or in children 8 years
- Isotretinoin: Teratogenic; not for use during pregnancy or in women of reproductive age who are not using reliable contraception
• Precautions: Tetracycline may cause photosensitivity; sunscreen recommended
• Significant possible interactions
- Tetracycline: Avoid concurrent administration with antacids, dairy products, or iron
- Broad-spectrum antibiotics: May reduce the effectiveness of oral contraceptives; barrier method recommended
Second Line
For severe cases, isotretinoin PO for 4 months
SURGERY
Surgical treatment of rhinophyma
FOLLOW-UP
DISPOSITION
Outpatient treatment
PROGNOSIS
• Slowly progressive
• Subsides spontaneously (sometimes)
COMPLICATIONS
• Rhinophyma (dilated follicles and thickened bulbous skin on nose), especially in men
• Conjunctivitis
• Blepharitis
• Keratitis
• Visual deterioration
PATIENT MONITORING
• Occasional and as needed
• Close follow-up for women using isotretinoin
REFERENCES
1. Fitzpatrick TB, et al., eds. Dermatology in General Medicine, 5th ed. New York: McGraw-Hill, 1999.
2. Habif T. Clinical Dermatology, 4th ed. St. Louis MO: Mosby, 2004.
3. Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005;352:793-803.