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Rosacea

Rosacea is a chronic skin condition primarily affecting the face, leading to redness, pimples, swelling, and superficial dilated blood vessels. The most commonly involved areas are the nose, cheeks, forehead, and chin. Severe cases can lead to a red, enlarged nose, a condition known as rhinophyma.

Rosacea over the cheeks and nose
Rosacea over the cheeks and nose

Signs and Symptoms

Rosacea typically starts with reddening (flushing) of the skin in symmetrical patches near the centre of the face. Common signs vary by age and sex: younger individuals often experience flushing and swollen patches, older individuals may have small visible dilated blood vessels, and men frequently develop swelling of the nose. Other signs include papules, pustules, and facial swelling. Many people report stinging, burning pain, and occasionally itching.

Commonly affected zones
Commonly affected zones

Types of Rosacea

  1. Erythematotelangiectatic Rosacea: Characterised by prolonged flushing reactions to stimuli like emotional stress, hot drinks, alcohol, spicy foods, exercise, and temperature changes.
  2. Glandular Rosacea: Predominantly affects men with thick sebaceous skin, presenting with edematous papules, pustules (0.5 to 1.0 cm), and nodulocystic lesions.

Causes

The exact cause of rosacea is unknown. Factors that may trigger episodes include temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and certain foods and drinks. Medications and topical irritants, like high dosages of isotretinoin, benzoyl peroxide, and tretinoin, can also trigger rosacea. Steroid-induced rosacea results from the use of topical steroids, often prescribed for seborrheic dermatitis.

Topical steroid-induced rosacea (left); after steroid withdrawal and photobiomodulation therapy (right)
Topical steroid-induced rosacea (left); after steroid withdrawal and photobiomodulation therapy (right)

Biological Factors

  • Cathelicidins: Elevated levels in rosacea patients might contribute to symptoms.
  • Demodex Mites: Increased numbers of these mites, particularly in steroid-induced rosacea, may play a role.
  • Intestinal Bacteria: Small intestinal bacterial overgrowth (SIBO) has been linked to rosacea, with antibiotics providing symptom improvement.

Diagnosis

Rosacea is primarily diagnosed through visual inspection by a healthcare professional. No specific test exists, but trial treatments can confirm suspected diagnoses. The condition can be confused with acne vulgaris or seborrheic dermatitis. A rash on the scalp or ears suggests a different diagnosis as rosacea mainly affects the face.

Classification

Rosacea on the face
Rosacea on the face
Micrograph showing rosacea
Micrograph showing rosacea as enlarged, dilated capillaries and venules in the upper dermis
  1. Erythematotelangiectatic Rosacea: Permanent redness with a tendency to flush easily, visible blood vessels, and possibly intense burning and itching.
  2. Papulopustular Rosacea: Permanent redness with red bumps (papules) and pus-filled pustules.
  3. Phymatous Rosacea: Characterised by thickening skin, irregular surface nodules, and enlargement, commonly associated with rhinophyma.
  4. Ocular Rosacea: Red eyes and eyelids, dry, irritated, or gritty feeling, and sensitivity to light.

Variants

  • Pyoderma Faciale: A conglobate, nodular disease that arises abruptly on the face.
  • Rosacea Conglobata: Severe form mimicking acne conglobata with hemorrhagic nodular abscesses.

Treatment

Rosacea treatment is tailored to the subtype and severity. Mild cases may not require treatment or can be managed with cosmetics.

Behavioural Changes

Avoiding known triggers like ultraviolet light and irritant cosmetics is recommended. Wearing sunscreen (SPF 30 or greater) and using oil-free foundations and concealers can help manage symptoms.

Medications

  • Topical: Metronidazole, ivermectin, and azelaic acid are commonly used.
  • Oral: Doxycycline, isotretinoin, and tetracycline antibiotics are used for more severe cases. Beta-blockers and alpha agonists can be used for flushing symptoms.

Laser Therapy

Evidence for laser and intense pulsed-light therapy is limited.

Outcomes

Rosacea symptoms can be psychologically challenging, affecting self-esteem and social interactions. It affects around 5% of people worldwide, with a higher prevalence in those of Celtic heritage, and affects men and women equally.


Self-assessment MCQs (single best answer)

What is Rosacea primarily characterised by?



Which area is most commonly affected by Rosacea?



Which subtype of rosacea involves prolonged flushing reactions to stimuli like emotional stress and heat?



What is a characteristic feature of Phymatous Rosacea?



Which biological factor is NOT associated with Rosacea?



What medication is commonly used topically for rosacea treatment?



Which is NOT a recommended behavioural change for managing Rosacea?



What is the term for a red, enlarged nose due to severe Rosacea?



Which symptom is most likely to suggest a diagnosis other than Rosacea?



What percentage of the global population is affected by Rosacea?



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