Rosacea

Created 2009.

Learning objectives

• Recognise and manage rosacea

Introduction

Rosacea is a common transient, recurrent or persistent facial rash of unknown cause. It affects the cheeks, nose, chin and forehead of those in their 30s or older, especially those with fair-skin, blue eyes and of Celtic origin.

Clinical features

Rosacea is characterized by mid-facial erythema, asymptomatic dome-shaped inflammatory papules and superficial pustules. The fleshy part of the nose may slowly enlarge with prominent pores and fibrous thickening (rhinophyma). Persistent swelling may also affect cheeks, earlobes, forehead and eyelids.

Erythema and papules

Erythema and telangiectasia

Papules and pustules

Inflammatory rosacea

Rhinophyma

Telangiectasia

Unlike acne vulgaris, there are no comedones, cysts, or nodules.

Rosacea is often accompanied by:

• Flushing
• Telangiectasia
• Blepharitis or meibomianitis (erythematous papules on eyelid margins)
• Facial oedema
• “Sensitive” skin i.e. face creams sting and burn
• Seborrhoeic dermatitis
• Irritant dermatitis

Symptoms are often aggravated by:

• Sun exposure
• Hot and spicy food or drink
• Rapid change in environmental temperature
• Topical steroids

Treatment

• Reduce facial flushing: avoid extremes of temperature, minimize exposure to hot or spicy foods and alcohol, protect from sun exposure;
• Avoid oil-based facial creams -use water-based make-up and sunscreen;
• Oral anti-inflammatory antibiotics such as tetracycline 250-500 mg, doxycycline 100mg or minocycline 100mg daily for 4-8 weeks. Repeat as necessary;
• Topical metronidazole cream or gel or azelaic acid cream or lotion can be used intermittently or long term alone for mild cases and in combination with oral antibiotics for more severe cases;
• Vascular laser treatment of telangiectasia;
• Surgical correction of rhinophyma (using laser, electrosurgery or conventional scalpel).

Rhinophyma that should be treated surgically

Inflamed rosacea resulting in sensitive skin

Telangiectasia prior to vascular laser treatment

Six weeks after single treatment with vascular laser

Activity

What medications may be used to control flushing?