Rosacea

Rosacea is a chronic inflammatory skin disease that typically affects the face. The cause is unclear, but various triggers (e.g., heat, alcohol) can exacerbate symptoms. Rosacea most commonly affects women 30–60 years of age. Typical clinical features include central facial erythema, telangiectasias, papules, pustules, and facial flushing. Untreated chronic inflammation may result in phymatous changes. Ocular rosacea can occur with or without cutaneous features. Management includes the avoidance of triggers, topical therapy (e.g., ivermectin, metronidazole, azelaic acid, brimonidine), and, for severe or refractory disease, a combination of topical therapy with systemic pharmacological treatment and/or procedures.

• Sex: : ♀ > ♂ ^[1]
• Age range: : 30–60 years ^[1][2]

Epidemiological data refers to the US, unless otherwise specified.

• The cause of rosacea is not fully understood. ^[3]
• Involves chronic inflammation
• Proposed factors include dysregulated inflammatory, immune, and neurovascular responses ^[3]

Rosacea triggers ^[3][4]

• Environmental factors: sun exposure, cold or hot weather, wind
• Dietary factors: spicy food, hot drinks, alcohol use, nicotine use
• Other: stress, intense exercise, hot baths, and, possibly, the Demodex mite

Increased body temperature commonly triggers rosacea flares. ^[3]

• Cutaneous features are distributed across the chin, forehead, cheeks, and nose, sparing the skin folds. ^[3]
  • Fixed erythema on the central region of the face (may periodically worsen)
  • Phymatous changes ^[5]
    • Rhinophyma: enlarged, bulbous nose (usually in men)
    • Thickening of skin and sebaceous glands
    • Widespread nodules that may be inflammatory
  • Papules and pustules
  • Telangiectasias
  • Facial flushing
• Ocular manifestations: See “Ocular rosacea.”
• Associated symptoms
  • Burning or stinging sensation
  • Swelling
  • Dryness

In contrast to acne, rosacea does not manifest with comedones. ^[3]

Erythema and facial flushing can be difficult to visualize in individuals with dark skin. ^[6]

Historically, rosacea has been classified into subtypes: erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea. However, the 2017 National Rosacea Society Expert Committee update no longer uses these subtypes, as manifestations overlap. The following are considered variants. ^[7]

Ocular rosacea ^[3][7][8]

Epidemiology ^[7][8]

• May occur with or without cutaneous involvement
• Affects ≥ 50% of patients with typical cutaneous manifestations of rosacea ^[8][9]

One-fifth of individuals with rosacea develop ocular features before cutaneous manifestations. ^[8]

Clinical features ^[7]

• Features highly suggestive of ocular rosacea
  • Conjunctival hyperemia
  • Telangiectasias at lid margins
  • Corneal spade-shaped infiltrates (on slit-lamp examination)
  • Scleritis or sclerokeratitis (on slit-lamp examination)
• Nonspecific features
  • Sensations of burning, stinging, light sensitivity, foreign body, or dry eyes
  • Blepharitis , possibly with a stye and/or chalazion
  • Honey-colored crusting at lash bases
  • Irregular lid margin
  • Conjunctivitis

Management ^[3][7][8]

• Diagnosis is based on clinical features.
• Refer all patients to ophthalmology.
• In addition to treatments for cutaneous rosacea, treatment options include:
  • Artificial tears and eyelid hygiene ^[8]
  • Topical ocular antiinflammatory agents (e.g., azithromycin, steroids, calcineurin inhibitors) ^[9]
  • Omega-3 supplements

Ocular rosacea can be vision-threatening. Refer patients with impaired vision for immediate ophthalmological evaluation. ^[3][8]

Granulomatous rosacea ^[10]

• Small brown papules, especially around the mouth and eyes
• Granulomatous lesions may occur on their own, without other symptoms of rosacea
• Histology: tuberculoid granulomas

Diagnostic criteria for rosacea ^[7]

Make a clinical diagnosis if either of the diagnostic criteria for rosacea are met.

• ≥ 1 diagnostic phenotypes:
  • Fixed erythema on the central region of the face
  • Phymatous changes
• Or ≥ 2 major phenotypes:
  • Papules and pustules
  • Telangiectasias
  • Flushing
  • Any features highly suggestive of ocular rosacea

Diagnostic studies ^[4][6][11]

For diagnostic uncertainty, consider

• Digital photography, often taken with a blue background, to identify erythema or facial flushing
• Dermoscopy to assess for telangiectasias
• Biopsy to exclude alternative diagnoses

Diagnostics (e.g., blanching, photography, dermoscopy) may help visualize erythema, facial flushing, and telangiectasias, especially in individuals with dark skin. ^[6]

• Acne vulgaris
• Atopic dermatitis
• Seborrheic dermatitis
• Perioral dermatitis
• Systemic lupus erythematosus
• Other causes of facial flushing (e.g., pheochromocytoma, carcinoid syndrome)
• Gram negative folliculitis
• Demodicosis ^[12]
  • A rare disease that may manifest with lesions similar to those in rosacea
    • Unilateral or asymmetrical distribution of facial papules and/or pustules ^[13]
    • Ocular involvement (e.g., blepharitis)
  • Caused by infection of the sebaceous glands by Demodex mites (Demodex folliculorum and Demodex brevis)

The differential diagnoses listed here are not exhaustive.

Approach ^[3][8][14]

• Educate on lifestyle modifications and screen for psychosocial effects.
• Initiate therapy based on severity assessment. ^[15][16][17]
  • Mild to moderate disease: topical pharmacotherapy
  • Severe disease or refractory to topical treatments
    • Consider dermatology referral.
    • Combine topical therapies with systemic pharmacological treatment.
  • For ocular rosacea: Urgently refer to ophthalmology.
• Reassess periodically.
  • Persistent or worsening disease: Refer to dermatology.
  • Following remission : Start maintenance therapy. ^[3][3][5]
    • Monotherapy: Wean to the lowest effective dose; long-term use may be needed.
    • Combination therapy: Transition to long-term monotherapy (typically topical). ^[3][4][8]

Depending on disease severity, a combination of topical and oral pharmacotherapies may be required to achieve remission. ^[4][8]

Lifestyle modifications ^[3][8]

• Avoid rosacea triggers.
• Utilize photoprotective measures (mineral-based sunscreen may cause less irritation).
• Recommend a hypoallergenic, fragrance-free skincare routine.
  • Cleanse twice daily.
  • Moisturize daily.
  • To minimize irritation, dry the face before applying topical therapies.

Topical therapies ^[3][8][14]

• Persistent erythema and/or facial flushing: vasoconstrictors
  • Brimonidine 0.33% ^[3]
  • Oxymetazoline 1% ^[3]
• Papules and pustules: antiinflammatory medications
  • Ivermectin 1% cream ^[3][8]
  • Metronidazole 0.75% or 1% ^[3][8]
  • Azelaic acid 15% ^[3][8]
  • Sulfacetamide sodium/sulfur 10% ^[3][8]
  • Other FDA-approved therapies (no guideline recommendations)
    • Minocycline 1.5% foam ^[3]
    • Encapsulated benzoyl peroxide 5% cream
• Telangiectasias: Consider topical retinoids (off-label).

Counsel patients with skin of color about the risk of changes to skin pigmentation with azelaic acid. ^[3]

Systemic pharmacological treatment ^[3][8][14]

• Papules, pustules, and/or persistent erythema: antiinflammatory medications
  • First line: doxycycline ^[3][8]
  • Alternative: isotretinoin (off-label) ^[3][5]
• Facial flushing: nonselective beta-blockers (for peripheral vasoconstriction)
  • Carvedilol (off-label) ^[3][8]
  • Propranolol (off-label) ^[3][8]

Procedures ^[5][8][14]

• Laser or light therapy: for persistent erythema and telangiectasias ^[5]
• Other procedures: for noninflammatory phymatous changes
  • Electrosurgery
  • Radiofrequency ablation
  • Surgical excision