Rosacea

Rosacea is a very common, chronic disease of the skin where facial veins become highly reactive. It is often characterised by frequent or persistent flushing in the central area of the face, swelling and/or acne like appearance. Erythema can also occur in peripheral areas such as the neck and chest. Telangiectasias, or the development of small punctual bleeding areas of the skin, can also contribute to the redness due to dilated or broken capillaries. Swelling, papules and pustules can also be associated with the various forms of rosacea and can often lead to edema or mimic acne. It is a common misconception that rosacea can be a form of acne due to the disease previously being named Acne Rosacea.

The disease is commonly overlooked and is not detrimental to one’s health; however it may have an impact on the patients’ psychosocial and emotional well being, similar to acne.

Incidence

Studies of mild cases have shown that the prevalence of rosacea is roughly around 10% of the population, developing between the ages of 30 – 50. Women are more likely to develop it than men with a ratio of 1:3 but the odds could be different due to the disease being undiagnosed or under-reported. The exact prevalence isn’t known but it is considered most common within Caucasian populations in light/fair-skinned individuals. Although people of any race can be affected by rosacea, rarely do those of Asian or African descent develop rosacea.

Rosacea is most likely to first present between the ages of 30 – 50, however children and adolescents can also develop the disease.

Currently it is estimated that 14 million Americans have rosacea but this figure is likely to be substantially higher due to it frequently being undiagnosed by doctors and/or the disease being under-reported by patients. It is often mistaken for adult acne or sunburn.

Causes

The exact cause of rosacea is unknown and little is known about the inflammatory process that causes it. Since there are many subtypes, it is plausible that there are pathophysiological and etiological differences between them. It is suspected that facial vasculature is more superficial in roscea patients than others, suggesting possible abnormalities in the vasculature or vasculature homeostasis.

Rosacea has a variety of suspected causes; the most common being sun exposure. Other substances that are known to provoke rosacea include:

• Hot and Spicy foods/drinks;
• Alcohol;
• Some facial creams and topical steroids;
• Stress;
• Exercise;
• Other environmental factors (ie. wind, extreme hot or cold).

Suspected causes of rosacea

Epidemiological studies done have confirmed that patients with Papulopustular Rosacea (Stage 2) have a higher Demodex (common hair follicle mite) densities then those without rosacea and it appears that having the disease also seems to promote the proliferation of Demodex mites. The limit of this study is that causation can not be proven, only that changes in skin morphology and possibly lack of washing may lead to larger densities of mites on the skin. Sebaceous glands are also known to be involved, as with acne.

Other proposed causes include:

• Matrix degeneration – degradation of the dermal matrix has be shown histologically in samples from rosacea patients. Rosacea may alter the vascular and lymphatic structure within the dermis.
• Ingested agents – since many foods trigger rosacea, gastro intestinal tract diseases might influence exacerbations.

These mechanisms, along with trigger agents, all potentially have a link in causing rosacea but further studies are still required to determine them.

Symptoms

The main features rosacea patients present are:

• Frequent or prolonged flushing/blushing particularly over the nose, cheeks, forehead and chin, but occasionally can be found to digress to the neck, back and chest;
• Spider veins (talangiectasias; usually on the nose);
• Papules and pustules (acne like appearance, but lacking comedones);
• Facial burning and stinging;
• Swelling of facial areas;
• Enlargement of sebaceous glands giving the nose a bulbous appearance;
• Dry and flaky facial skin;
• Occasional burning/itching of the eye or conjunctivitis may arise.

Primarily for therapeutic reasons, rosacea has been categorized into sub-types pending on which symptoms present and what stage of the disease they are at. The disease is most likely to continue until it reaches its course but progression is very preventable.

Erythematotelangiectatic Rosacea (ETR) or Stage 1

ETR is characterised by persistent flushing, usually for hours or days, along with the presence of telangiectasias and/or facial swelling and edema. Flushing that only lasts for a few minutes is not considered to be an early stage of rosacea. Quite often the erythema is brought on by various stimuli including: spicy foods, hot drinks, stress and sun exposure, causing the patient to experience stinging and burning sensations but exacerbations occur just as often in absence of any stimuli.

As the disease develops, the telangiectasias progressively become more prominent, especially on the nose and cheeks, forming a spray like pattern as well as increased roughness and irritation of the skin.

Papulopustular Rosacea (PPR) or Stage 2

PPR consists of persistent erythema along with inflammatory papules and pustules. These lesions all originate from either sebaceous or hair follicles which can sometimes heal and scar. Burning and stinging may also occur in PPR but is less common when compared to ETR. The inflammation associated with the papulopustules can result in chronic edema which can manifest into solid facial edemas or lead to phymatous (Stage 3) changes.

Phymatous Rosacea or Stage 3

Not many patients proceed to this stage of the disease. It is characterized by inflammatory nodules, thickening of the skin, irregular contours, hypertrophy of connective tissue and hyperplasia of sebaceous glands. Phyma most frequently occurs in the nose (Rhinophyma) giving it either a shiny bulbous appearance or in severe cases, an irregular shape with skin resembling that of an orange surface. It is less frequent elsewhere on the face but can still occur. Women only experience the glandular features of stage 3. The exact reason is unknown but hormone may be a factor.

Ocular Rosacea

Ocular symptoms can present simultaneously, or develop after skin symptoms, but may not affect all patients. They can experience itching, stinging, burning, grittiness and erythema and swelling of the eyelids. It can commonly manifest as conjunctivitis and blepharitis in severe cases, keratitis, which can potentially lead to blindness. Pain and photophobia may also present.

Treatments

Currently, there is no cure for rosacea but there are effective ways of managing the disease by treating the symptoms. If left untreated, the disease will progressively aggravate. Treatment of rosacea also depends on the sub-type present as each has its own symptoms.

Measures need to be taken to avoid stimuli that can trigger rosacea to minimize the frequency and severity of outbreaks. This includes avoiding hot and spicy foods, cosmetics/irritants and the sun or UV exposure. Symptomatic treatments are outlined below.

Topical treatments

In general topical agents such as Metronidazole and Azelaic acid have been used to improve skin condition and reduce lesions in PPR, but there is a lack of evidence that suggest that it improves the flushing reactions. Some people may experience burning and stinging side effects so use of topical treatments should be avoided in sensitive patients.

Oral treatments

Although there is little proof that microorganisms are involved in rosacea, the use of antibiotics has been approved by the FDA and have been shown to have beneficial effects, so clinicians are sometimes reluctant to exclude it as a form of therapy. Antibiotics tend to be used as a long term therapy due to the chronicity of the disease but prolonged use could lead to resistant strains of bacteria and irregular levels of natural flora, which raises several health issues.

Also approved by the FDA, tetracyclines such as doxycycline have been shown to be very effective in managing papulapustules and the inflammation associated with them. Its anti-inflammatory effects include down regulating the production of pro-inflammatory cytokines such as IL-1 and TNF-α and modulating the inflammatory pathway.

Other oral treatments currently used include β-blockers, calcineurin inhibitors, clonidine, selective serotonin re-uptake inhibitors, macrolides and anti-androgenic agents, most of which are used in reducing the severity of flushing.

Laser and light treatments

Intense pulsed light (IPL) therapy and vascular lasers are good alternatives to oral and topical treatments. They may be used in adjunct with them and seem to be the most successful form of treatment in reducing erythema and telangiectasias. They generally exert the same effect as each other, removing telangiectasias and some other blood vessels in the face associated with erythema but they differ simply by the wavelengths they are used at. It has also been reported that it can extend remission time. Scarring rarely occurs in these procedures but drawbacks such as cost might be a major issue for many patients.

Treatment of phyma

Due to phyma causing morphological changes in the skin structure, advanced cases generally require surgical approaches to eradicate lesions and/or to reshape the phyma. In early stages Isotretinoin appears to be efficient in reducing the size of enlarged sebaceous glands and halting the progression of the disease. Particular surgical techniques have excellent results with minimal scarring and low chance of reoccurrence.

Ocular treatment

As the eye is a vital organ and it is estimated that over 50% of rosacea sufferers will present with ocular symptoms, it is important that they are treated to prevent damage. Most ocular symptoms respond well to topical treatments and basic eyelid hygiene with regular washing using gentle cleansers. If they are inadequate then most antibiotics should be able to clear up symptoms.

In summary, to effectively treat rosacea, clinicians need to understand the broad symptoms that rosacea can present with and which of those apply to the patient. Treatment is considered to be successful if symptoms are minimized and controlled along with reducing the risk of relapsing in the long term.

Prevention

As the pathology of rosacea is unknown, preventative measures might be very broad and restrict the patient unnecessarily. If the triggers for each individual can be identified, patients should be stressed to avoid those stimuli. Some people may have a genetic predisposition to develop veins so preventative measures might not be as useful.

Prognosis

Rosacea is not a fatal disease although severe cases can result in blindness and/or facial disfigurement which may have devastating effects on a person’s self-esteem, emotions and psychological well being.

References

• 2004, Therapeutic Guidelines: Dermatology, North Melbourne, Therapeutic guidelines Limited.
• Baldwin, H. E., (2007) ‘Systemic Therapy for Rosacea’, Vol 12. [Online] Available from http://www.skintherapyletter.com/2007/12.2/1.html [Accessed 25/11/08.
• Berg M, Liden S., (1989) ‘An epidemiological study of Rosacea’. Acta Dermto-Venereologica, Vol 69, pp.419-423.
• Crawford, G.H., Pelle, M.T., James, W. D., (2004) ‘Rosacea: I. Etiology, pathogenesis, and subtype classification’ Journal of the American Academy of Dermatology, Vol 51, pp.327-341.
• Forton, F. et al., (2005) ‘Demodicosis and rosacea: Epidemiology and significance in daily dermatologic practice’. Journal of the American Academy of Dermatology, Vol 52, pp.74-87.
• Jansen. T., Plewig, G., (1997) ‘Rosacea: classification and treatment’. Journal of the Royal Society of Medicine, Vol 90, pp.44-150.
• Lount, B. W., and Pelletier, A. L., (2002) ‘Rosacea: A Common, Yet Commonly Overlooked, Condition.’ American Family Physician, Vol 66, pp.435-442.
• Woolff, K., Goldsmith, L.A., Katz, S.I., Gilchrest, B.A., Paller, A.S., Leffer, D.J., (2003). Fitzpatrick’s Dermatology in General Medicine, 7e. Ch. 79. The McGraw Hill Companies.