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New Classification of Rosacea and Present Therapy for Family Practitioners

B. Wang, MDCM, FRCPC
Department of Dermatology, McGill University, Montréal, Québec, Canada

Rosacea is a common condition that is prevalent worldwide. Its incidence is higher in fairer skin types, however it is also seen in Asians, and African-Americans. Rosacea occurs in males and females, often after the age of 30 years.

There are currently no laboratory tests to diagnose rosacea; it remains a clinical diagnosis. The actual pathophysiology and etiology of rosacea also remain unclear; however, quite recently the spectrum of rosacea has been classified and standardized.[Wilkin JK, et al. J Am Acad Dermatol 46:584-7 (2002).] The defining clinical finding is persistent erythema of the central face for at least 3 months. Other primary findings include flushing (transient erythema), papules and pustules, and telangectasias (dilated blood vessels). Secondary findings include stinging, burning, dryness, edema, plaques, ocular manifestations, and phymatous changes.

There are four recognized subtypes of rosacea, and it's important to distinguish among them, as they require different modes of therapy.

Subtypes of Rosacea

  • Erythematotelangectatic rosacea: Flushing and persistent central facial erythema is seen, as well as telangectasias. Often, central facial edema, stinging and burning of the skin, and dryness occurs.
  • Papulopustular rosacea: Papules and pustules are seen, often along with persistent facial erythema.
  • Phymatous rosacea: Thickening of the skin, often presenting as rhinophyma. Irregular surface nodules, enlarged follicles, sebaceous appearance seen. The chin, forehead, cheeks, and ears may be involved.
  • Ocular rosacea: Sensation of burning, grittiness, dryness, burning, “foreign body sensation”, and telangectasia of the sclera. Often, blepharitis, conjunctivitis, chalazions, and styes present. Rarely corneal manifestations (keratitis, infiltrates, and ulcers) may occur.

These subtypes are then graded into mild, moderate, and severe. They may overlap; however, it is currently believed that patients do not progress from one subtype to the next.

Postulated Pathophysiology

  • Vasomotor lability
  • Exposure to UV radiation, heat
  • Degeneration of dermal matrix
  • Perifollicular inflammatory process.

The role of Demodex and Helicobacter pylori are not at present considered to be pathogenic in the development of rosacea.

Aggravating Factors

  • UV exposure
  • Extremes of temperature
  • Consumption of hot beverages, spicy foods, alcohol
  • Topical irritating products containing glycolic acid, alcohol, acetone, exfoliants, astringents, perfumes
  • Medications that can cause flushing such as vasodilatation agents, nicotinic acid, amyl nitrate, calcium channel blockers, and opiates.

Differential Diagnosis

These diseases must be excluded before making the diagnosis of rosacea:

  • Systemic lupus erythematosus, dermatomyositis, mixed connective tissue disease, and other connective tissue diseases
  • Polycythemia vera
  • Carcinoid
  • Mastocytosis

Other situations to be considered include photosensitivity and allergic contact dermatitis. Perioral dermatitis is no longer considered to be a variant of rosacea; it presents with erythematous papules around the mouth or periorbitally. Seborrheic dermatitis can co-exist with rosacea; it presents with orange-red scaling in the T-zone of the face, scalp, and chest.

Treatment Options for Rosacea

  • Erythematotelangiectatic rosacea: Topical metronidazole, sodium sulfacetamide with sulfur, and azeleic acid help decrease erythema. Telangiectasias are best treated with laser and light therapies.
  • Papulopustular rosacea: Topical metronidazole, sodium sulfacetamide with sulfur, azeleic acid, benzoyl peroxide, erythromycin, clindamycin, and tretinoin decrease inflammatory papules and pustules. For a more rapid response, oral antibiotics are used. Low dose oral isotretinoin (to avoid excessive dryness) can also be used.
  • Phymatous rosacea: In early stages, topical therapies can decrease the papules and pustules often present centrally. Isotretinoin can also be used to control the nodules and cysts, as well as temporarily decreasing excessive sebum production. However, rhinophyma itself is treated surgically, including dermabrasion, electrosurgery, cryosurgery and laser surgery.
  • Ocular rosacea: General lid care, tear supplements are essential. Often, oral tetracycline is used to treat the inflammatory lesions. If corneal involvement is suspected, consultation with ophthalmology is advised.

Basic Nonprescription Guidelines to Give Patients Include

  • Daily use of broad spectrum sunscreens that include titanium dioxide and zinc oxide as UV blockers.
  • Use of non-fragranced moisturizers that contain silicone (as dimethicone or cyclomethicone) to protect the skin barrier.
  • Soap-free cleansing of the skin.
  • Green-tinted foundations in powder, liquid, or cream form to help camouflage erythema.
  • Avoidance of aggravating factors (listed above).

Patient Communication

It is important to inform patients that rosacea is a chronic disease, that there is no cure for rosacea, but there exist effective therapies to maintain control. Remission of the disease can be obtained using maintenance treatment to which the patient may have to adhere for life and avoiding aggravating factors. Patients should be counseled that progression of disease can occur when therapy and avoidance behaviors are not maintained.

Dosage and Course of Prescription Treatment for Rosacea

Topical

Systemic

  • Metronidazole 0.75% cream, gel, lotion; also a 1% cream q.d.
  • Sodium sulfacetamide 10% with 5% sulfur cream or lotion b.i.d.
  • Erythromycin 2% lotion, solution b.i.d.
  • Azeleic acid 15% gel b.i.d.
  • Tretinoin 0.025% cream q.h.s.
  • Tetracycline 250-500mg, PO, q.d. or b.i.d. for 6-12 weeks
  • Minocycline 50-100mg, PO, q.d. or b.i.d. for 6-12 weeks
  • Doxycycline 50-100mg, PO, q.d. or b.i.d. for 6-12 weeks
  • Erythromycin 250mg, PO, q.d. or b.i.d. for 6-12 weeks.