Rosacea

What is rosacea?

Rosacea is a chronic inflammatory skin condition predominantly affecting the central face and most often starts between the age of 30–60 years.

Rosacea is common and is characterised by persistent facial redness. It typically has a relapsing and remitting course, with symptoms controlled by lifestyle measures, general skin care, medications, and procedural interventions.

Papulopustular rosacea on the cheeks 

Erythematotelangiectatic and papulopustular rosacea on the cheeks 

Papular rosacea on the cheeks 

Telangiectatic vessels in a rinophyma shown on dermoscopy (RO-patient4)

Rhinophyma and papular rosacea on the chin (RO-patient2)

Papulopustular and ocular rosacea 

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Who gets rosacea?

Rosacea is estimated to affect around 5% of adults worldwide. Although rosacea is often thought to affect women more than men, studies have revealed an approximately equal gender distribution.

Rosacea typically presents after the age of 30 and becomes more prevalent with age. However, it can occur at any age and occasionally presents in children. Although rosacea can affect anyone, it is more common in those with fair skin, blue eyes, and those of Celtic or North European descent. It may be more difficult and under-recognised in patients with skin of colour.

Rosacea has been associated with depression, hypertension, cardiovascular diseases, anxiety disorder, dyslipidemia, diabetes mellitus, migraine, rheumatoid arthritis, Helicobacter pylori infection, ulcerative colitis, and dementia.

What causes rosacea?

The pathogenesis of rosacea is thought to be multifactorial and includes:

• Genetic susceptibility
  • Association with single nucleotide polymorphisms related to the class II major histocompatibility complex.
• Altered microbiome of the skin and gut
  • Bacterial overgrowth of the small intestine, Helicobacter pylori infection, and increased density of Demodex folliculorum and Staphylococcus epidermidis on the skin may play a role in skin inflammation.
  • Dysregulation of the immune response may lead to excessive inflammation, vasodilation, lymphatic dilatation, and angiogenesis.
• Neurocutaneous mechanisms
  • Triggers include ultraviolet (UV) radiation, temperature change, exercise, spicy foods, alcohol, psychological stress, air pollution, and tobacco smoking. Calcitonin gene-related peptide (CGRP) may play a role in flushing and erythema.
• Impaired skin barrier
  • Affected skin displays features indicating skin barrier impairment, allowing bacterial colonisation and inflammation.

Innate immunity

• In the skin of patients with rosacea, there is increased expression and activity of toll-like receptor 2, cathelicidins, kallikrein 5, and mast cells.
• Furthermore, cathelicidin LL-37 increases sensitivity of the skin to the sun.
• The result is an exaggerated innate immune reaction to the initial trigger.

Adaptive immunity

• Dominant T-helper (Th)1/Th17 gene expression in all features of rosacea.
• Increased Th17 expression can increase levels of cathelicidin LL-37 in keratinocytes and drive further inflammation.

The most significant environmental trigger is UV radiation; affected skin is more sensitive to exposure. UV radiation can damage the dermis and increase skin inflammation.

What are the clinical features of rosacea?

Cutaneous features include:

• Transient recurrent erythema, ie, flushing

• Persistent facial erythema

• Telangiectasia

  • Facial skin other than in the nasal alar region
  • Eyelid margin telangiectasia
  • Together often termed erythematotelangiectatic rosacea

• Inflammatory papules and pustules (papulopustular)

• Phymatous changes

  • Thickening of the skin due to hyperplasia/fibrosis of the sebaceous glands of the face
  • Most common area affected is the nose (termed rhinophyma)
  • More commonly present in men.

Rhinophyma 

Rhinophyma showing swelling and sebeceous gland openings (RO-patient1)

Steroid induced papulopustular rosacea 

Steroid induced rosacea on the forehead 

Steroid induced facial rosacea 

Steroid induced papular rosacea 

Swelling and papulopustules in steroid induced rosacea (SR-patient4)

Occasionally rosacea induces facial lymphoedema (Morbihan disease), producing redness, and swelling of the face and lids.

Facial tenderness and burning pain accompanied by redness and flushing (neurogenic rosacea) is a rare variant of rosacea.

Lid lymphoedema and glabellar swelling in Morbihan disease 

Violaceous swelling of the lower lids in Morbihan disease 

Non-cutaneous ocular features (affects over 50% of patients with rosacea):

• Dryness
• Foreign-body sensation
• Photophobia
• Conjunctivitis
• Blepharitis
• Keratitis — can lead to long-term eyesight impairment.

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How do clinical features vary in differing types of skin?

Rosacea is diagnosed more frequently in fair-skinned patients of Celtic and Northern European descent.

It may be harder to identify key features of rosacea in patients with skin of colour. These features are likely under-recognised and rosacea may be underdiagnosed in these patients.

What are the complications of rosacea?

Complications of rosacea include:

• Phymatous rosacea
• Inflammatory eye complications, eg, blepharokeratoconjunctivitis, sclerokeratitis
• Physical discomfort, eg, from ocular symptoms
• Negative psychosocial effects such as increased anxiety, depression, low self-esteem, and social isolation
• Trigger avoidance leading to lifestyle limitations.

How is rosacea diagnosed?

Rosacea is diagnosed clinically in the majority of cases. Diagnosis is made according to diagnostic and major criteria recommended by the 2017 global ROSacea COnsensus (ROSCO) panel. This requires one diagnostic criterion or two major criteria to be fulfilled.

In patients with darker phototypes where erythema and telangiectasia (visible blood vessels) is more difficult to visualise, greater emphasis may be placed on other major and minor features.

Diagnostic criteria

• Persistent centrofacial erythema associated with periodic intensification by potential trigger factors
• Phymatous changes.

Major criteria (must occur in centrofacial distribution)

• Flushing/transient centrofacial erythema
• Inflammatory papules and pustules
• Telangiectasia — visible blood vessels (excluding nasal alar telangiectases, which are common in adults)
• Ocular rosacea (lid margin telangiectasia, blepharitis, keratitis/conjunctivitis/sclerokeratitis/anterior uveitis).

Minor features

• Burning sensation of the skin
• Stinging sensation of the skin
• Oedema
• Dry sensation of the skin.

In cases where there is diagnostic uncertainty, skin biopsy may be considered.

What is the differential diagnosis for rosacea?

Other conditions that could present with similar cutaneous features include:

• Acne vulgaris
• Carcinoid
• Demodicosis (demodex folliculitis)
• Dermatomyositis
• Drug reaction
• Eczema
• Idiopathic facial aseptic granuloma
• Periorificial dermatitis or periocular dermatitis
• Photo-damaged skin
• Pyoderma faciale
• Seborrhoeic dermatitis
• Steroid-induced acne
• Steroid-induced rosacea
• Systemic lupus erythematosus.

What is the treatment for rosacea?

Although there is no cure for rosacea, symptoms can be managed with the following lifestyle measures, medical, and procedural interventions.

General measures

All patients with rosacea should receive education on general skincare and lifestyle measures.

Lifestyle advice

• Encourage patients to record a symptom diary to aid the identification of triggers:
  • Common triggers include spicy food, hot/cold temperatures (hot baths), exercise, sun exposure, cosmetic products, medications (those that cause vasodilation), alcohol, fruits and vegetables, dairy, marinated meat products
• Avoid the triggers identified.

General skincare advice

• Moisturise frequently
• Use gentle over-the-counter cleansers
  • Mild, synthetic detergent-based cleansers rather than traditional soaps due to risk of irritation
• Use physical sunscreens (ie, zinc oxide/titanium oxide) with SPF ≥ 30
  • Provides broad-spectrum UV radiation and visible light protection
  • May be better tolerated than chemical sunscreens
• Avoid exfoliants
• Avoid alcohol-based topical products
• Avoid use of topical steroids as they may aggravate the condition
• Cosmetics with a green tint are useful to minimise the appearance of redness.

Psychosocial considerations

• Assess the patient’s psychosocial burden of disease and consider referral for psychological support where necessary.

Specific measures

Existing treatments for rosacea can be very effective — however, they often target only one feature. This means that a combination of therapies are required where patients present with multiple features and in severe rosacea.

Many of the following treatments are first-line therapies recommended by the 2019 ROSCO panel:

Transient erythema (flushing)

• Alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline) — they are often used infrequently for special occasions only, as persistent use may result in rebound flushing on discontinuation
• Oral beta-blockers (carvedilol)
• Oral clonidine may reduce flushing
• CGRP antagonists (erenumab)

Persistent erythema

• Alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline, as above)
• Intense pulsed light therapy
• Vascular laser

Inflammatory papules/pustules

• Topical azelaic acid (for mild/moderate only)
• Topical ivermectin
• Topical metronidazole (for mild/moderate only)
• Topical erythromycin
• Oral tetracyclines (oxytetracycline, lymecycline, doxycycline)
• Oral macrolides (erythromycin, azithromycin)
• Oral metronidazole
• Oral isotretinoin often at low dose (for refractory disease only)

Telangiectasia

• Electrodesiccation
• Intense pulsed light therapy
• Vascular laser

Neurogenic rosacea

• Gabapentin
• Amitriptyline
• Oral beta-adrenergic blockers
• Consideration of endoscopic sympathectomy

Phyma

• If clinically inflamed: doxycycline, isotretinoin
• If clinically non-inflamed: physical modalities to remove excess tissue and reshape the structures (eg, ablative CO2 laser, erbium laser, radiofrequency, surgical debulking).

Ocular rosacea

• General management
  • Increase dietary intake of omega-3 fatty acids
  • Warm compresses
  • Gentle eyelash/eyelid cleansing to express sebum trapped in the meibomian glands
• First-line medical management
  • If mild-moderate: topical azithromycin/topical calcineurin inhibitors
  • If severe: azithromycin, doxycycline.

For more information, see Ocular rosacea.

What is the outcome for rosacea?

Although rosacea is not a life-threatening condition, it is a chronic disease that requires long-term management of relapsing and remitting symptoms. Complete resolution of clinical features has been shown to prolong time to symptom relapse and have greater positive impact on quality of life compared with incomplete resolution.

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