Rosacea

Rosacea is a chronic skin disorder in which the nose and cheeks are abnormally red. The cause is usually unknown. Rosacea is aggravated by the use of corticosteroid creams. The disorder is most common among middle-aged women. Rosacea usually begins with temporary flushes, but may develop into permanent redness of the skin, sometimes accompanied by acne-like pustules. In elderly men, it may lead to rhinophyma (bulbous swelling of the nose). Treatment includes oral tetracycline or topical (applied to the skin) metronidazole. Rosacea tends to recur for five to ten years before disappearing.

Rosacea - technical article

Rosacea diagnosis and management - technical article

Definition

Rosacea is a skin disease typically appearing in people during their 30s and 40s. It is marked by redness (erythema) of the face, flushing of the skin, and the presence of hard pimples (papules) or pus-filled pimples (pustules), and small visible spider-like veins called telangiectasias. In later stages of the disease, the face may swell and the nose may take on a bulb-like appearance called rhinophyma.

Description

Rosacea produces redness and flushing of the skin, as well as pustules and papules. Areas of the face, including the nose, cheeks, forehead, and chin, are the primary sites, but some people experience symptoms on their necks, backs, scalp, arms, and legs.

The similarity in appearance of rosacea to acne led people in the past to erroneously call the disease acne rosacea or adult acne.

Like acne, the skin can have pimples and papules. Unlike acne, however, people with rosacea do not have blackheads.

In early stages of rosacea, people typically experience repeated episodes of flushing. Later, areas of the face are persistently red, telangiectasia appear on the nose and cheeks, as well as inflamed papules and pustules. Over time, the skin may take on a roughened, orange peel texture. Very late in the disorder, a small group of patients with rosacea will develop rhinophyma, which can give the nose a bulb-like look.

Up to one half of patients with rosacea may experience symptoms related to their eyes. Ocular rosacea, as it is called, frequently precedes the other manifestations on the skin.Most of these eye symptoms do not threaten sight, however. Telangiectasia may appear around the borders of the eyelid, the eyelids may be chronically inflamed, and small lumps called chalazions may develop. The cornea of the eye, the transparent covering over the lens, can also be affected, and in some cases vision will be affected.

Causes and symptoms

There is no known specific cause of rosacea. A history of redness and flushing precedes the disease in most patients. The consensus among many experts is that multiple factors may lead to an overreaction of the facial blood vessels, which triggers flushing. Over time, persistent episodes of redness and flushing leave the face continually inflamed. Pimples and blood vessel changes follow.

Certain genetic factors may also come into play, although these have not been fully described. The disease is more common in women and light-skinned, fair-haired people. It may be more common in people of Celtic background, although this is an area of disagreement among experts.

Certain antibiotics are useful in the treatment of rosacea, leading some researchers to suspect a bacterium or other infectious agent may be the cause. One of the newest suspects is a bacterium called Helicobacter pylori, which has been implicated in causing many cases of stomach ulcers but the evidence here is mixed.

Other investigators have observed that a particular parasite, the mite Demodex folliculorum, can be found in areas of the skin affected by rosacea. The mite can also be detected, however, in the skin of people who do not have the disease. It is likely that the mite does not cause rosacea, but merely aggravates it.

Diagnosis

Diagnosis of rosacea is made by the presence of clinical symptoms. There is no specific test for the disease. Episodes of persistent flushing, redness (erythema) of the nose, cheeks, chin, and forehead, accompanied by pustules and papules are hallmarks of the disease. A dermatologist will attempt to rule out a number of other diseases that have similar symptoms. Acne vulgaris is perhaps the disordermost commonly mistaken for rosacea, but redness and spider-like veins are not observed in patients with acne. Blackheads and cysts, however, are seen in acne patients, but not in those with rosacea.

Other diseases that produce some of the same symptoms as rosacea include perioral dermatitis and systemic lupus erythematosus.

Treatment

The mainstay of treatment for rosacea is oral antibiotics. These appear to work by reducing inflammation in the small blood vessels and structure of the skin, not by destroying bacteria that are present. Among the more widely used oral antibiotics is tetracycline. In many patients, antibiotics are effective against the papules and pustules that can appear on the face, but they appear less effective against the background redness, and they have no effect on telangiectasia. Patients frequently take a relatively high dose of antibiotics until their symptoms are controlled, and then they slowly reduce their daily dose to a level that just keeps their symptoms in check. Other oral antibiotics used include erythromycin and minocycline.

Some patients are concerned about long-term use of oral antibiotics. For them, a topical agent applied directly to the face may be tried in addition to an oral antibiotic, or in its place. Topical antibiotics are also useful for controlling the papules and pustules of rosacea, but do not control the redness, flushing, and telangiectasias. The newest of these topical agents is metronidazole gel, which can be applied twice daily. Like the oral antibiotics, topical preparations appear to work by reducing inflammation, not by killing bacteria.

Vitamin A derivatives, called retinoids, also appear useful in the treatment of rosacea. An oral retinoid, called isotretinoin, which is used in severe cases of acne also reduces the pustules and papules in severe cases of rosacea that do not respond to antibiotics. Isotretinoin must be taken with care, however, particularly in women of childbearing age. They must agree to a reliable form of contraception, because the drug is known to cause birth defects.

Topical vitamin A derivatives that are used in the treatment of acne also may have a role in the treatment of rosacea. Accumulating evidence suggests that topical isotretinoin and topical azelaic acid can reduce the redness and pimples. Some patients who use these medications experience skin irritation that tends to resolve with time.

For later stages of the disorder, a surgical procedure may be needed to improve the appearance of the skin. To remove the telangiectasias, a dermatologist may use an electrocautery device to apply a current to the blood vessel in order to destroy it. Special lasers, called tunable dye lasers, can also be adjusted to selectively destroy these tiny blood vessels.

A variety of surgical techniques can be used to improve the shape and appearance of a bulbous nose in the later stages of the disease. Surgeons may use a scalpel or laser to remove excess tissue from the nose and restore a more natural appearance.

Alternative treatment

Alternative treatments have not been extensively studied in rosacea. Some reports advocate gentle circular massage for several minutes daily to the nose, cheeks, and forehead. Scientifically controlled studies are lacking, however.

Many people are able to avoid outbreaks by reducing things that trigger flushing. Alcoholic beverages, hot beverages, and spicy foods are among the more common factors in the diet that can provoke flushing. Reducing or eliminating these items in the diet can help limit rosacea outbreaks in many people.

Exposure to heat, cold, and sunlight are also known triggers of flushing. The specific things that provoke flushing vary considerably from person to person, however. It usually takes some trial and error to figure these out.

A deficiency in hydrochloric acid (HCl) in the stomach may be a cause of rosacea, and supplementation with HCl capsules may bring relief in some cases.

Prognosis

The prognosis for controlling symptoms of rosacea and improving the appearance of the face is good. Many people require life-long treatment and achieve good results. There is no known cure for the disorder.

Prevention

Rosacea cannot be prevented but once correctly diagnosed, outbreaks can be treated and repeated episodes can be limited.

Use mild soaps

Avoiding anything that irritates the skin is a good preventive measure for people with rosacea. Mild soaps and cleansers are recommended. Astringents and alcohol should be avoided.

Learn what triggers flushing

Reducing factors in the diet and environment that cause flushing of the face is another good preventive strategy. Alcoholic and hot beverages, and spicy foods are among the more common triggers.

Use sunscreen

Limiting exposure of the face to excesses of heat and cold can also help. A sunscreen with a skin protection factor (SPF) of 15 or greater used daily can limit the damage to the skin and small blood vessels caused by the sun, and reduce outbreaks.

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Rosacea - technical article