Rosacea

Clinical rosacea is not a single disease but rather a combination of cutaneous stigmata which include flushing, erythema, telangiectasia, facial edema, papules, pustules, ocular lesions, and rhinophyma. Mostpatients, of course, have less thanthefull set of these stigmata.¹ The stigmata of rosacea are treatable. It is unpredictably, but potentially, progressive and relapsing.¹

Incidence

There are no accurate figures for the overall prevalence and incidence, which vary with the racial mix of the population. Clinical variants including ocular rosacea or rosacea fulminans should not be forgotten.² The highest prevalence is in countries with a predominantly fair skinned Caucasian population, many with ancestry,^3,4 but rosacea does occur in other groups including blacks⁵ and east asians.⁶

Rosacea is frequently missed or misdiagnosed

The most common wrong diagnosis is acne,⁷ and often patients who actually have rosacea, have already seen many doctors and dermatologists with their so-called acne.⁷ Ocular rosacea generally goes unrecognized (see later section).²

Trigger factors for rosacea

The most frequent trigger factors identified by patients are sunlight, heat, spicy foods and alcohol.⁸ The sun and other climatic influences are important pathogenetically, but less important as precipitants of attacks.³ Dietary factors are only important with regard to flushing,³ but these factors play no other role in causing or maintaining rosacea lesions. Everything else is folklore.⁷ Keep in mind that undue intake of pro-inflammatory substances (e.g. halogens, including iodides and bromides) from fad diets or medications (e.g. cold remedies, sedatives, radio-opaque contrast media) can sometimes precipitate a devastating outbreak of rosacea.⁷

Treatment of rosacea

General

The regular use of an effective, cosmetically acceptable sunscreen with good substantivity is very important.⁷ Sunscreens should be used throughout the day.^7,8

Topical

The topical therapy of choice for rosacea is metronida- zole. Sodium sulfacetamide, with or without sulfur, is also used,⁹ and more recently azelaic acid 20% has been found to be of some benefit.^3,10 In general, it is not necessary to complicate topical application of metronidazole, by adding other so-called active agents such as sulphur, corticosteroids or tretinoin.^{3, 7}

The use of topical tretinoin may provoke and worsen the inflammatory process.¹ In most patients the inflammatory process can be controlled with systemic and topical antibiotics without exacerbating the under- lying vascular process. Since rosacea appears to be in its most fundamental elements a vascular disorder, it would be wise to first do no harm.¹

Systemic

Antibiotics Tetracycline (or erythromycin) in full dosage for up to six months.³ Tetracycline one g/day initially and then reduce the dose (500mg–250 mg/day) for a total period of 3–6 months. Alternatively, minocycline 100 mg/day (reducing to 50 mg/day) can be given. Erythromycin can also be used and clarithromycin compared well with doxycycline in a recent study.¹¹

Isotretinoin With recalcitrant rosacea, isotretinoin has proved to be a worthwhile option.⁸ In some instances low doses of isotretinoin, say 5–10 mg per day, often provide excellent results inmild to moderate rosacea when given once a day initially, later reducing to 3–5 days a week.⁷ Higher doses of 0.5 mg/kg bodyweight, usually combined with systemic steroids, are given to patients with rosacea conglobata or rosacea fulminans.⁷ In recalcitrant rosacea , particularly in some cases resistant to systemic tetracycline and in patients with rhinophyma, isotretinoin 0.5–1 mg/kg/day for 20 weeks can be administered orally.⁸ Treatment may have to be continued for several months. Isotretinoin used to treat rosacea is often less effective than when used to treat acne.¹²

Laser treatment of rosacea

Be careful not to promise too much.⁷ The background diffuse erythema responds poorly to laser treatment, however discrete fine telangiectasia respond well. Large ropey vessels often require more than one treatment.¹⁴

Argon, copper vapor, krypton and KTP lasers can improve the larger telangiectasia.^9,13

CO2 Laser (often used with the CO2 resurfacing laser and the Shaw scalpel) Has proven very helpful for treating rhinophyma.^8,9,13

Pulsed Dye Laser (PDL) Can produce pleasing results for telangiectasia and sometimes erythema.⁹ The PDL is probably the best laser for small vessels,¹⁴ but patients don’t like the resulting purpura which can last 10 days.^13,14 In some cases, after treatment patients may also notice a reduction in inflammatory rosacea lesions.¹³ Repeat treat- ment is sometimes necessary due to recurrence caused by ongoing disease.¹³

Ocular Rosacea

Most patients with cutaneous rosacea have some degree of ocular involvement.¹⁵ Ocular rosacea generally goes unrec- ognized, undiagnosed, undertreated, and under-reported.¹⁶

“The most common tip-off of ocular rosacea is dry eye, a history of styes or an inability to tolerate contact lenses. Another common complaint is discharge, especially in the morning.”
Guy Webster²

The easily overlooked subjective symptoms include nonspecific rather common complaints such as stinging, burning, tearing, photophobia, scratchiness, and feelings of foreign material in the eye. The objective signs are also non-specific and include blepharitis, conjunctivitis, chala- zia, styes, punctate corneal erosions, corneal vasculariza- tion, and chronic keratitis, which in rare cases may even lead to blindness.^{16, 17} Tear break-up time is abnormal in patients with rosacea. Ocular erythema and telangiectasia, meibomian gland dysfunction, and short tear break-up time in patients with cutaneous rosacea are indicators of ocular rosacea.¹⁷ Often patients don’t seem to be aware that they have had eye problems but most studies have found that about 50% of rosacea patients develop eye problems.²

Doxycline is the recommended treatment and will increase the tear break-up time.¹⁷ The initial dose is 200 mg per day but often after several months patients can reduce the dose and remain controlled.² Low-dose isotretinoin can be prescribed for persistent, severe, antibiotic resistant ocular rosacea.

Helicobacter pylori and rosacea

Recent reports suggest a role for Helicobacter pylori in the etiology of rosacea. The disease does respond well to tetracycline, erythromycin, metronidazole and other antibacterials used in the eradication of this organism but “it is difficult to decide whether Helicobacter pylori is a passenger or driver of rosacea.”⁸ However, if a rosacea patient has a history of dyspepsia / peptic ulcer disease, consider referral to a gastroenterologist for a 13 C urea breath test.⁹

Summary

• Sun protection is very important.⁸
• For female patients, recommend the use of agreen tinted foundation which works well atcamouflaging the erythema of rosacea.⁹
• The single best topical treatment is the one worksthat works best for your patient.9Start with topicalmetronidazole and switch to sodium sulfacetamideif a desired response is not obtained.9For severeand persistent rosacea, stress avoidance ofprovocative factors, and use oral antibiotics suchas tetracycline, doxycycline, minocycline orerythromycin⁹ in full dosage for up to six months.³
• The pulsed dye laser can be very effective fortelangiectasia and as it becomes more available isbeing recommended more often.⁹
• Avoid topical corticosteroids as they make rosaceaworse by adding to the dermal dystrophy thatcharacterizes the disorder.³
• Counsel patients with particularly intense erythema,that with successful treatment, posterythema-revealed telangiectasia (PERT) may becomeapparent. This preempts subsequent worries that theantibiotic therapy “produced” the telangiectasia.¹
• When evaluating patients with cutaneous rosacea,inquire about ocular symptoms and examine theeyelids. This is especially important in patientswith mild disease who are more likely to be treatedwith topical treatment alone.¹⁷

References

1. Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol 1994; 130: 359-362.
2. Webster GF. Personal communication May, 1997.
3. Marks R. Personal communication May, 1996.
4. Plewig G, Kligman AM. Rosacea. In: Plewig G, Kligman AM, eds. Acne and Rosacea. New York, NY: Springer-Verlag; 1993: 433-443.
5. Rosen T, Stone MS. Acne rosacea in blacks.J Am Acad Dermatol 1987; 17:70-73.
6. Kim BS, Park SM, Park JN et al. Rosacea in Korea [poster]. 1996 Annual Meeting of the American Academy of Dermatology.
7. Plewig G. personal communication June, 1997.
8. Orfanos CE. Personal communication June, 1997.
9. Thiboutot D. Personal communication June, 1997.
10. Maddin S. Clinical study report in preparation.
11. Torresani C, Pavesi A, Manara GC. Clarithromycin versus doxycycline in the treatment of rosacea. Int J Dermatol 1097; 36: 938-946.
12. Maddin S. Editorial comment.
13. Lui H. Personal communication December, 1997
14. David McLean. Personal communication January, 1997
15. Quarterman MJ, Johnson DW, Abele DC et al. Ocular rosacea. Signs symptoms and tear studies before and after treatment with doxycycline. ArchDermatol 1997; 133: 49-54.
16. Kligman AM. Ocular rosacea. Current concepts and therapy. J Am Acad Dermatol 1997: 133: 89-90.
17. Quarterman MJ, Johnson DW, Abele DC et al. Ocular rosacea. Signs, Symptoms, and tear studies before and after treatment with doxycycline. ArchDermatol 1997; 133: 49-54.