Figure 7.1
Edema and fibrosis as a severe manifestation of phymatous rosacea
Acne Vulgaris: Acne can often be confused with the papulopustular form of rosacea. However, acne differs from rosacea in that patients with rosacea do not develop comedones, and the pathogenesis of rosacea is primarily inflammatory without much involvement of Propionibacterium acnes.
Seborrheic dermatitis: Seborrheic dermatitis can present as facial erythema, and often accompanies rosacea as a co-morbid condition; however, patients with pure seborrheic dermatitis usually present with a greasy, yellowish scale and frequently have involvement of the nasolabial folds and eyebrows.
Chronic Actinic damage: Patients with skin changes related to chronic sun exposure usually show evidence of damage on extrafacial skin including the ears, chest and neck helping to distinguish the condition from rosacea.
Further Work Up
There is no histological or laboratory marker of rosacea. The diagnosis requires the presence of one or more of the following characteristics concentrated on the central portion of face: flushing (transient erythema), nontransient erythema, papules and pustules, and telangiectasias. Persistent erythema is the most common finding in rosacea and some dermatologists believe the diagnosis of rosacea can be made simply by the presence of persistent erythema of the central face lasting for at least 3 months. It is also essential to rule out other causes of facial flushing and erythema including polycythemia vera, connective tissue disorders, carcinoid syndrome and mastocytosis.
Diagnosis
Rosacea (Erythematotelangietactic Rosacea)
Discussion
The treatment of rosacea is long-term as the condition is a chronic one with frequent recurrences and flaring. Additionally, treatment varies with each subtype of rosacea. The patient discussed above has erythematotelangiectatic (EMT) rosacea. The treatment of EMT rosacea includes gentle skin care and regular application of sunscreen with ultraviolet A and ultraviolet B protection. In 2013, the FDA approved brimonidine topical gel 0.33 % (Mirvaso™, Galderma Laboratories) for facial erythema in rosacea patients 18 years or older. Brimonidine is an alpha-adrenergic agonist that constricts dilated blood vessels and reduces the erythema and facial flushing of rosacea. Laser therapy is often effective for the treatment of telangiectasias. Many topical treatments used to treat papulopustular rosacea such as metronidazole or azelaic acid may be ineffective or even exacerbate EMT rosacea.
Several topical products have been FDA-approved for the treatment of rosacea and seem to be particularly effective in the papulopustular form. These topical products include the gel, cream and lotion formulations of 0.75 % metronidazole applied twice daily and 1 % metronidazole cream or gel applied once daily. Azelaic acid 15 % gel applied twice daily as well as multiple formulations of the sulfacetamide 10 %-sulfur 5 % are also FDA-approved for the treatment of rosacea. Systemic treatments for rosacea include oral antibiotics as well as isotretinoin [1]. Doxycycline 40 mg (controlled release) daily is FDA-approved for rosacea and is thought to be effective due to its anti-inflammatory properties. The treatment of phymatous rosacea is difficult and often requires surgical excision or laser therapy. Ocular rosacea should be treated with eyelid hygiene and artificial tears. Topical or systemic antibiotics may be necessary and patients should be referred to an ophthalmologist.
In an otherwise healthy, young patient it is unnecessary to perform any further diagnostic work up. Rosacea is a clinical diagnosis made by history and physical examination.
Conventional treatment options for EMT rosacea would include the following:
Facial cleansing with lukewarm water and gentle cleansers
Daily Sunscreen with SPF of 30 or higher
Gentle moisturizers and emollients to improve barrier function
Avoidance of exfoliating agents, physical scrubbing, astringents and toners
Refraining from products containing alcohol, eucalyptus oil, menthols, and fragrances
Cosmetic coverage with water-soluble powder containing light green or yellow pigment to neutralize redness
Avoidance of triggers including hot environments and sun exposure
Topical oxymetazoline
Topical brimonidine gel 0.33 %
Pulse dye laser and intense pulse light device for treatment of erythema and telangiectasias
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