Rosacea

Introduction | Aetiology and Risk Factors | Clinical Presentation | Diagnosis | Management and Treatment | Prevention | When to Refer | References

Introduction

Rosacea is a chronic inflammatory skin condition that primarily affects the face, characterised by facial redness, visible blood vessels, and often papules and pustules. It typically occurs in adults between the ages of 30 and 50, and while it can affect anyone, it is more common in individuals with fair skin. Rosacea is a relapsing condition with periods of exacerbation and remission, and it can significantly impact quality of life due to its visible symptoms.

Aetiology and Risk Factors

The exact cause of rosacea is not fully understood, but several factors are believed to contribute to its development:

• Genetic Predisposition: A family history of rosacea may increase the likelihood of developing the condition, suggesting a genetic component.
• Vascular Dysfunction: Abnormalities in the blood vessels of the face may contribute to the flushing and persistent redness associated with rosacea.
• Immune System Factors: An overactive immune response, particularly involving certain antimicrobial peptides like cathelicidins, is thought to play a role.
• Microorganisms: The presence of the skin mite Demodex folliculorum and the bacterium Helicobacter pylori have been implicated in some cases of rosacea, though their exact role remains unclear.
• Environmental Triggers: Sun exposure, heat, cold, wind, alcohol, spicy foods, and stress are known to trigger or exacerbate rosacea symptoms.
• Skin Type: Rosacea is more common in individuals with fair skin, particularly those of Celtic or Northern European descent.
• Age and Gender: Rosacea typically affects adults between the ages of 30 and 50, with women more commonly affected, although men often present with more severe symptoms.

Clinical Presentation

Rosacea presents with a variety of symptoms, which can vary in severity and form. The condition is generally classified into four main subtypes:

1. Erythematotelangiectatic Rosacea (ETR)

• Facial Redness: Persistent redness (erythema) primarily affecting the central face, including the cheeks, nose, chin, and forehead.
• Flushing: Episodes of flushing or blushing, often triggered by environmental factors or emotional stress.
• Visible Blood Vessels: Telangiectasias (visible blood vessels) may be present on the affected areas of the face.

2. Papulopustular Rosacea

• Papules and Pustules: Red, inflammatory bumps (papules) and pus-filled lesions (pustules) often resembling acne but without comedones (blackheads or whiteheads).
• Background Erythema: Persistent redness is usually present along with the inflammatory lesions.

3. Phymatous Rosacea

• Skin Thickening: Thickening of the skin, particularly on the nose (rhinophyma), chin, forehead, ears, or eyelids, due to sebaceous gland hyperplasia and fibrosis.
• Irregular Surface Texture: The skin may develop a bumpy or nodular appearance.

4. Ocular Rosacea

• Eye Irritation: Red, dry, itchy, or gritty sensation in the eyes, which may be accompanied by tearing, burning, or light sensitivity.
• Inflammation: Inflammation of the eyelids (blepharitis), conjunctiva (conjunctivitis), or, in severe cases, the cornea (keratitis).

Diagnosis

Rosacea is diagnosed clinically based on the patient’s history and physical examination:

• History: Take a detailed history of symptoms, including the pattern of facial redness, triggers, and any associated eye symptoms. Ask about a family history of rosacea or other skin conditions.
• Physical Examination: Examine the skin for the characteristic signs of rosacea, such as erythema, telangiectasias, papules, pustules, and phymatous changes. Check the eyes for signs of ocular rosacea.
• Differential Diagnosis: Consider other conditions that may mimic rosacea, such as acne vulgaris, seborrhoeic dermatitis, lupus erythematosus, and perioral dermatitis.
• Skin Biopsy: A biopsy is rarely needed but may be performed if the diagnosis is unclear or if other conditions are suspected.

Management and Treatment

Management of rosacea focuses on controlling symptoms, reducing triggers, and improving the patient’s quality of life. Treatment varies depending on the subtype and severity of the condition:

1. General Measures

• Trigger Avoidance: Identify and avoid known triggers, such as sun exposure, hot drinks, spicy foods, alcohol, and stress. Keeping a symptom diary can help patients identify specific triggers.
• Sun Protection: Advise patients to use broad-spectrum sunscreen with SPF 30 or higher daily, wear protective clothing, and avoid peak UV exposure times.
• Gentle Skin Care: Recommend the use of gentle, fragrance-free cleansers and moisturisers. Patients should avoid abrasive scrubs, alcohol-based products, and other skin irritants.

2. Topical Treatments

• Metronidazole Cream or Gel: A first-line treatment for papulopustular rosacea, metronidazole has anti-inflammatory and antimicrobial properties. It is applied once or twice daily.
• Ivermectin Cream: An effective treatment for papulopustular rosacea, ivermectin targets both the inflammatory and parasitic (Demodex) components of the condition. It is applied once daily.
• Azelaic Acid Gel or Cream: Azelaic acid has anti-inflammatory and keratolytic properties, making it useful for treating both erythema and papulopustular lesions. It is applied once or twice daily.

3. Oral Treatments

• Tetracycline Antibiotics: Oral antibiotics such as doxycycline or lymecycline are commonly used for moderate to severe papulopustular rosacea. They have anti-inflammatory properties and are typically used in low doses for extended periods.
• Isotretinoin: In severe, refractory cases, low-dose isotretinoin may be considered, particularly for patients with phymatous changes. It requires careful monitoring due to potential side effects.

4. Procedural Treatments

• Laser and Intense Pulsed Light (IPL) Therapy: Vascular lasers and IPL can effectively reduce persistent erythema and telangiectasias by targeting blood vessels in the skin.
• Electrosurgery and Laser Therapy for Phymatous Rosacea: These procedures can be used to reshape and reduce the thickened, nodular areas associated with phymatous rosacea.

5. Management of Ocular Rosacea

• Eye Hygiene: Advise patients to perform regular eyelid hygiene, including gentle cleaning of the eyelid margins with diluted baby shampoo or commercial eyelid cleansers.
• Artificial Tears: Lubricating eye drops can help relieve dryness and irritation associated with ocular rosacea.
• Oral Antibiotics: Tetracyclines such as doxycycline are often used to manage more severe ocular symptoms, particularly blepharitis and keratitis.
• Referral to Ophthalmology: Severe or persistent ocular rosacea may require referral to an ophthalmologist for further evaluation and management.

Prevention

Preventive strategies are essential to manage rosacea and reduce the frequency and severity of flare-ups:

• Consistent Skin Care Routine: Encourage patients to maintain a gentle, consistent skincare routine with appropriate sun protection and avoidance of known triggers.
• Regular Follow-Up: Patients should have regular follow-up appointments to monitor their condition and adjust treatment as necessary.
• Stress Management: Techniques such as mindfulness, relaxation exercises, and counselling may help patients manage stress, a common trigger for rosacea flare-ups.

When to Refer

Referral to a dermatologist or ophthalmologist may be necessary in the following situations:

• Severe or Refractory Rosacea: If rosacea does not respond to standard treatments or if the condition is severe, referral to a specialist is advised.
• Phymatous Rosacea: Patients with significant skin thickening or disfigurement may benefit from specialist procedures such as laser therapy or electrosurgery.
• Ocular Rosacea: Patients with persistent or severe eye symptoms should be referred to an ophthalmologist for further evaluation and management.
• Uncertain Diagnosis: If the diagnosis is unclear or if other conditions are suspected, a dermatologist's input may be necessary.

References

1. British Association of Dermatologists (2024) Guidelines for the Management of Rosacea. Available at: https://www.bad.org.uk (Accessed: 26 August 2024).
2. National Institute for Health and Care Excellence (2024) Rosacea: Diagnosis and Management. Available at: https://www.nice.org.uk/guidance/ng105 (Accessed: 26 August 2024).
3. British National Formulary (2024) Topical and Oral Treatments for Dermatological Conditions. Available at: https://bnf.nice.org.uk/ (Accessed: 26 August 2024).