This article presents an overview of the pathophysiology, epidemiology, and clinical presentations of rosacea. It also presents the therapeutic spectrum for effective management of this challenging and often confusing clinical entity.
Key points
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Rosacea is a chronic cutaneous condition characterized by symptoms of facial flushing and a broad spectrum of clinical signs, including erythema, telangiectasias, edema, papules, pustules, ocular lesions, and rhinophyma.
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Medical management includes lifestyle modification; sunscreen products; medical-grade skin care; oral/topical antibiotics; and topical prescription medications, such as benzoyl peroxide and azelaic acid.
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Laser- and light-based therapies are effective for erythema reduction and also targeted treatment of telangiectasias and other prominent vasculature.
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Severe disease may result in rhinophyma, with irregular thickening of the nasal skin and nodular deformation, often necessitating surgical management.
Definition of rosacea
Rosacea is a chronic cutaneous condition characterized by symptoms of facial flushing and a broad spectrum of clinical signs. It is considered a syndrome encompassing various combinations of such cutaneous signs as
- •
Flushing
- •
Erythema
- •
Telangiectasias
- •
Edema
- •
Papules
- •
Pustules
- •
Ocular lesions
- •
Rhinophyma
Typical patients usually present with some of these symptoms as opposed to the spectrum of possible manifestations. Its pathophysiology has been the subject of significant discussion because of its complexity and our relatively poor understanding of disease progression. Understanding the disease is of importance to facial plastic surgeons and clinicians in general because of its prevalence as well as significant lifestyle and treatment implications associated with the diagnosis.
Rosacea is defined by persistent erythema of the central portion of the face lasting for at least 3 months. Supporting criteria include flushing, papules, pustules, and telangiectasias on the convex facial surfaces. Secondary features may include burning and stinging, edema, plaques, skin dryness, ocular manifestations, and phymatous changes. The prevalence of these findings warrants disease subclassification, which, in turn, helps to rationalize the therapeutic options.
Definition of rosacea
Rosacea is a chronic cutaneous condition characterized by symptoms of facial flushing and a broad spectrum of clinical signs. It is considered a syndrome encompassing various combinations of such cutaneous signs as
- •
Flushing
- •
Erythema
- •
Telangiectasias
- •
Edema
- •
Papules
- •
Pustules
- •
Ocular lesions
- •
Rhinophyma
Typical patients usually present with some of these symptoms as opposed to the spectrum of possible manifestations. Its pathophysiology has been the subject of significant discussion because of its complexity and our relatively poor understanding of disease progression. Understanding the disease is of importance to facial plastic surgeons and clinicians in general because of its prevalence as well as significant lifestyle and treatment implications associated with the diagnosis.
Rosacea is defined by persistent erythema of the central portion of the face lasting for at least 3 months. Supporting criteria include flushing, papules, pustules, and telangiectasias on the convex facial surfaces. Secondary features may include burning and stinging, edema, plaques, skin dryness, ocular manifestations, and phymatous changes. The prevalence of these findings warrants disease subclassification, which, in turn, helps to rationalize the therapeutic options.
Classification of rosacea
In 2002, an expert committee assembled by the National Rosacea Society explicitly defined and classified rosacea into 4 subtypes :
- 1.
Erythematotelangiectatic rosacea
- 2.
- 3.
- 4.
General guidelines for diagnosis are based on the presence of primary features and the possible existence of secondary features ( Box 1 ). Often, primary and secondary features occur together. The National Rosacea Society designated specific subtypes based on the most common patterns or groupings of clinical signs ( Table 1 ). Certainly, patients may have characteristics of more than one rosacea subtype at the same time.
Presence of one or more of the following primary features
Flushing (transient erythema)
Nontransient erythema
Papules and pustules
Telangiectasia
May include one or more of the following secondary features
Burning or stinging discomfort
Plaque
Dry appearance and texture
Edema
Ocular manifestations
Peripheral location
Phymatous changes
| Subtype | Characteristics |
|---|---|
| Erythematotelangiectatic | Flushing, persistent central facial erythema with or without telangiectasias |
| Papulopustular | Persistent central facial erythema with transient, central facial papules/pustules |
| Phymatous | Thickened skin, irregular surface nodularities; may occur on the nose (rhinophyma), chin forehead, cheeks, or ears |
| Ocular | Eye foreign body sensation, burning/stinging, dryness, itching, ocular photosensitivity, telangiectasias of sclera, periorbital edema |
Subtype 1: Erythematotelangiectatic Rosacea
Erythematotelangiectatic rosacea is predominantly characterized by central facial flushing, often with burning or stinging. There is usually periocular sparing by the erythema. Red areas of the face are often rough with scaling, likely caused by chronic, low-grade dermatitis. Frequent triggers to flushing include emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, and hot baths and showers. This flushing is characteristically progressive, leading to gradual development of permanent telangiectatic red vessels on the affected areas, initially over cheeks primarily. In early stages, these vessels are red but can also become bluish as they persist and mature, especially around the nose and on the cheeks.
Subtype 2: Papulopustular Rosacea
Papulopustular rosacea is often described as classic rosacea. Patients are typically middle-aged women predominantly presenting with an erythematous central face and small erythematous papules or pinpoint pustules (or both) in a central facial distribution. These patients often have telangiectasias; however, they may be obscured by persistent erythema, papules, or pustules.
Subtype 3: Phymatous Rosacea
Phymatous rosacea is characterized by skin thickening, irregular surface nodularities, and enlargement. The nose is affected most commonly, referred to as rhinophyma; however, this phymatous presentation can also affect the chin, forehead, cheeks, and ears. Significant telangiectasias are also often present over the affected regions. Four distinct histologic variants can occur with rhinophyma: glandular, fibrous, fibroangiomatous, and actinic.
Subtype 4: Ocular Rosacea
Ocular manifestations often precede the development of cutaneous signs but can also occur concurrently. These manifestations may include blepharitis, conjunctivitis, inflammation of the lids and meibomian glands, interpalpebral conjunctival hyperemia, and conjunctival telangiectasias. Patients may often experience eye stinging or burning sensation, excess dryness, irritation with light, or foreign body sensation. Meibomian gland dysfunction presenting as a chalazion or chronic staphylococcal infection as manifested by hordeolum are common signs of rosacea-related ocular disease. Worrisome complications include decreased visual acuity caused by corneal complications (keratitis or corneal ulcers); to lessen the risk of vision loss, the involvement of an ophthalmologic specialist may be warranted in addition to treating the cutaneous disease.
Epidemiology of rosacea
Rosacea is commonly misdiagnosed in many patients who experience facial erythema or even transient rashes of the face. It should be kept in mind that the diagnostic criteria are relatively strict. The epidemiologic data on rosacea remain fragmentary and the methodological quality debatable. The prevalence statistics published in the United States and Europe are highly variable, ranging from less than 1% to greater than 20% of the adult population. Unfortunately, the methods used and populations studied are greatly variable between studies, consequently barring any meaningful comparisons. Individuals with rosacea are disproportionately of fair-skinned European and Celtic origin. Interestingly, the caseating granulomatous variant may more commonly occur in people of Asian or African origin. New studies examining the epidemiology are undoubtedly necessary; it would be prudent for researchers to use the diagnostic and severity criteria established in 2002 and 2004, respectively.
Pathophysiology of rosacea
Despite being one of the most common skin disorders, its pathogenesis remains unclear and controversial and has also been the subject of prolonged study. Several factors are known to be key components in its development, including
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Vasculature
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Climatic exposures
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Dermal matrix degeneration and endothelial damage
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Chemicals and ingested agents
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Pilosebaceous unit abnormalities
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Microorganisms
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Reactive oxygen species (ROS)
The erythema and flushing associated with rosacea result from increased blood flow to the facial vasculature and increased blood vessel density near the skin surface. Patients with rosacea can have an exaggerated vasodilatation response to various triggers, such as hyperthermia.
There is evidence to suggest that harsh climatic exposures and extremes of temperature cause mechanical damage to cutaneous vasculature and dermal connective tissue. This risk also includes exposure to solar irradiation, providing some explanation as to why facial convexities are primarily affected and why symptoms may flare in the spring.
Certain ingested agents, such as spicy foods, alcohol, and hot beverages, may trigger a flushed face in patients with rosacea ( Table 2 ); however, a clear link demonstrating dietary factors playing a central role in pathogenesis does not exist. In addition to various foods, certain medications, such as amiodarone, topical steroids, nasal steroids, and high doses of vitamins B6 and B12, may result in exacerbations of symptoms for patients with rosacea.
| Rosacea Trigger Factors | Patients Affected (%) |
|---|---|
| Sun exposure | 81 |
| Emotional stress | 79 |
| Hot weather | 75 |
| Wind | 57 |
| Strenuous exercise | 56 |
| Alcohol consumption | 52 |
| Cold weather | 46 |
| Spicy foods | 45 |
| Certain skin care products | 41 |
| Heated beverages | 36 |
| Certain cosmetics | 27 |
| Medications | 15 |
| Dairy products | 8 |
| Other factors | 24 |
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