Definition
A.A multivariate skin disease with phenotype manifest, acne rosacea is characterized by chronic and relapsing inflammatory processes in which flushing and dilation of the blood vessels occur on the face.
Incidence
A.Acne rosacea affects approximately 13 million people in the United States.
Pathogenesis
A.The origination and development of rosacea is poorly understood. Abnormalities in the innate immune system, inflammatory reactions to cutaneous organisms, ultraviolet (UV) exposure, and vascular hyperreactivity have all been identified as possible causative factors.
Predisposing Factors
A.Tendency to flush frequently.
B.Exposure to heat, cold, or sunlight.
C.Consumption of hot or spicy foods and alcoholic beverages.
D.Some topical medications, astringents, or toners.
E.Acute psychological stressors.
F.Menopausal hot flashes.
Common Complaints
A.Diagnostic phenotypes:
1.Persistent centrofacial redness that may repeatedly accentuate, phymatous changes.
B.Major phenotypes:
1.Papules.
2.Pustules.
3.Flushing.
4.Telangiectasia.
5.Ocular manifestations.
C.Secondary phenotypes:
1.Burning.
2.Stinging.
Subjective Data
A.Ask the patient to describe the location and the onset. Was the onset sudden or gradual? How have the symptoms continued to develop?
B.Assess if the skin is itchy or painful.
C.Assess for any associated discharge (blood or pus).
D.Complete a drug history. Has the patient recently taken any antibiotics or other medications?
E.Determine whether the patient has used any topical medications, astringents, toners, or new skin care products.
F.Rule out any possible exposure to industrial or domestic toxins, insect bites, and possible contact with venereal disease or HIV.
G.Ask the patient about close contact with others with skin disorders.
H.Identify whether exposure to heat, cold, or sunlight provokes the symptoms.
I.Ask whether eating or drinking hot or spicy foods or consumption of alcoholic beverages provokes the symptoms.
Physical Examination
A.Check temperature, pulse, and blood pressure.
B.Inspect:
1.Inspect skin, focusing on face and scalp.
2.Inspect nose and paranasal structures.
3.Inspect eyes, eyelids, conjunctiva, and cornea. An ocular manifestation, rosacea keratitis, may cause corneal ulcers to develop.
Diagnostic Tests
A.None.
B.Consider skin biopsy to rule out granulomatous rosacea, if suspected.
Differential Diagnoses
A.Clinical findings shared with centrofacial erythema:
1.Acne rosacea.
2.Sun-damaged skin.
3.Seborrheic dermatitis.
4.Acute cutaneous lupus erythematous.
5.Dermatomyositis.
B.Clinical findings shared with papules and pustules:
1.Acne rosacea.
2.Acne vulgaris.
3.Steroid-induced acne.
4.Perioral dermatitis.
5.Keratosis pilaris rubra faceii.
6.Demodicosis.
C.Granulomatous rosacea.
D.Pyoderma faciale.
Plan
A.General interventions: Identify any causative or provocative factors: heat, cold, hot or spicy foods, alcoholic beverages, sunlight:
1.Advise washing face with mild soap such as Cetaphil soap daily.
2.Avoid direct sunlight exposure, wear protective clothing/hats when outdoors. Suggest using a sunscreen of sun protection factor (SPF) 30 when exposed to sunlight.
B.See Section III: Patient Teaching Guide Acne Rosacea.
C.Pharmaceutical therapy:
1.Rosacea with persistent facial erythema, no papules or pustules:
a.Topical brimonidine 0.33%.
2.Rosacea with persistent facial erythema and papules or pustules:
a.Mild to moderate disease:
i.Topical metronidazole gel 0.75% apply BID 1.0% apply daily.
ii.Azelaic acid 15% cream apply BID.
iii.Ivermectin 1% cream apply daily.
b.Moderate to severe disease:
i.Initial treatment options:
•Tetracycline 250 to 500 mg twice daily for 4 to 12 weeks.
•Doxycycline 50 to 100 mg twice daily for 4 to 12 weeks.
•Minocycline 50 to 100 mg twice daily for 4 to 12 weeks.
ii.Maintenance treatment:
•Topical metronidazole gel 0.75% BID.
•Azelaic acid cream 15% apply BID.
3.Other:
a.Do not use topical steroids. Topical steroids may worsen irritation.
b.Refractory cases may respond to isotretinoin (Accutane).
Follow-Up
A.Follow up in 2 weeks to evaluate therapy.
B.See patients monthly for evaluation until maintenance is reached.
C.Relapses are common following discontinuance of antibiotics; repeat treatment.
Consultation/Referral
A.Consult or refer the patient to a dermatologist if there is no improvement, or if the patient is unable to reach maintenance.
B.Provide an immediate referral to an ophthalmologist for treatment and follow up if the eye is involved.
Individual Considerations
A.Pregnancy:
1.Precautions should be used when prescribing medications for treatment during pregnancy.
B.Geriatrics:
1.Recent studies indicated rosacea is a systemic disorder associated with dyslipidemia, hypertension (HTN), metabolic disorders, cardiovascular disease, and alcohol/tobacco use, which are all prevalent in chronic renal disease (CRD). Geriatric populations with a high rosacea severity have an increased risk of CRD and need ongoing evaluation renal function labs: creatinine, blood urea nitrogen (BUN) and glomerular filtration rate (GFR).
2.Research suggested that rosacea is an independent risk factor for Parkinson’s disease through association to pathogenic mechanisms of elevated metalloproteinase activity. There was a two-fold risk of Parkinson’s disease for patients with ocular rosacea, and treatment of tetracycline appeared to reduce the risk of developing Parkinson’s disease. Practitioners must keep consistent skin assessments with patients who suffer from Parkinson’s disease and discuss treatment options with families and caregivers.
3.Monitor geriatrics for trigger medications that can worsen rosacea: vasodilators, niacin, or topical steroids.
4.Encourage elder patients to use sunblock with titanium and/or zinc oxide on areas of the scalp with alopecia. Remind them that stress, hot/humid environments, alcohol, spicy foods, and hot drinks can trigger a rosacea outbreak.