Rosacea

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For other meanings, see Rosacea (disambiguation).
Rosacea
Domenico ghirlandaio, ritratto di nonno con nipote.jpg
An Old Man and His Grandson, by Domenico Ghirlandaio shows skin damage from rhinophyma1
Classification and external resources
Specialty Dermatology
ICD-10 L71
ICD-9-CM 695.3
DiseasesDB 96
MedlinePlus 000879
eMedicine derm/377
MeSH D012393

Rosacea /rˈzʃiə/ is a chronic skin condition characterized by facial redness, small and superficial dilated blood vessels on facial skin, papules, pustules, and swelling.2 Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting the eyes (ocular type). Left untreated it worsens over time. Treatment in the form of topical steroids can aggravate the condition.3

It primarily affects people of northwestern European descent and has been nicknamed the "curse of the Celts" by some in Britain and Ireland, although recently this has been questioned.4 Rosacea affects both sexes, but is almost three times more common in women. Rosacea is commonly found in people between the ages of 30 and 50 and is more common in those of Caucasian descent.2

Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp.5 In some cases, additional signs, such as semi-permanent redness, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.

Cause

The exact cause of rosacea is unknown.2 Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one such as heated shops and offices during the winter can each cause the face to become flushed.2 Certain foods and drinks can also trigger flushing such as alcohol, foods and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines, and spicy food.6

Medications and topical irritants have also been known to trigger rosacea flares. Some acne and wrinkle treatments that have been reported to cause rosacea including microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids (steroid rosacea). These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.

Cathelicidins

Richard Gallo and colleagues recently noticed that patients with rosacea had high levels of the antimicrobial peptide cathelicidin7 and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea but they may only work because they inhibit some SCTEs.8

Demodex mites

Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite,6 especially those with steroid-induced rosacea. When large numbers are present they may play a role along with other triggers. On other occasions demodicidosis (mange) is a separate condition that may have "rosacea-like" appearances.9 Demodex has also been implicated in rosacea in that it is theorized to be caused by a reaction to bacteria in the mite's feces.10medical citation needed

Intestinal bacteria

Small intestinal bacterial overgrowth (SIBO) was demonstrated to have greater prevalence in rosacea patients and its eradication led to skin lesion improvement in two studies and in rosacea patients who were SIBO negative the antibiotic therapy had no effect on the skin lesions.11 The effectiveness of SIBO eradication in rosacea may suggest that these bacteria play a role in the pathogenesis of rosacea lesions.

Diagnosis

Most people with rosacea have only mild redness and are never formally diagnosed or treated. There is no single, specific test for rosacea.

In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.

The disorder can be confused with, and co-exist with acne vulgaris and/or seborrheic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.

Classification

Zones

There are four identified rosacea subtypes12 and patients may have more than one subtype present:13:176

  1. Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily.6 It is also common to have small widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and/or itching sensations.6 People with this ETR type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp.14
  2. Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (can last 1–4 days or longer; extremely varied signs); this subtype can be easily confused with acne.
  3. Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).15 Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
  4. Ocular rosacea: Eyes and eyelids affected by ocular rosacea may appear red (due to telangiectasias) and inflammation and may feel dry, irritated, or gritty. Other symptoms of ocular roseate include foreign body sensations, itching, burning, stinging, and sensitivity to light.16 Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and vision loss can occur if the cornea is affected.16

There are a number of variants of rosacea, including:17:689

  • Pyoderma faciale (also known as rosacea fulminans17) is a conglobate, nodular disease springing up abruptly on the face.1718
  • Rosacea conglobata is a severe rosacea that shows a reaction that mimics acne conglobata with hemorrhagic nodular abscesses and indurated plaques.17
  • Phymatous rosacea is a cutaneous condition characterized by overgrowth of sebaceous glands.18 "Phyma" is the Greek word for swelling, mass, or bulb, and these can occur in various areas of the face and ears in associated with rosacea.17:693

Treatments

Acne rosacea on face.

Treating rosacea varies depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists.19 Mild cases are often not treated at all, or are simply covered up with normal cosmetics.

Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions, decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents.20 Laser therapy has also been classified as a form of treatment.20 While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually one to two years, may result in permanent control of the condition for some patients.2021 Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.21

Behavior

Avoiding things that worsen the condition. Trigger avoidance can help reduce the onset of rosacea but alone will not normally lead to remission except in mild cases. It is sometimes recommended that a journal be kept to help identify and reduce food and beverage triggers.

Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims. Like sunlight, emotional stress can also trigger rosacea. People who develop infections of the eyelids must practice frequent eyelid hygiene.

A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.22

Medications

Medications for which there is good evidence include ivermectin and azelaic acid creams and brimonidine, doxycycline, and isotretinoin by mouth.23 Lesser evidence supports metronidazole cream and tetracycline by mouth.23

Metronidazole is thought to act through anti-inflammatory mechanisms while azelaic acid is thought to decrease cathelicidin production. Oral antibiotics of the tetracycline class such as doxycycline and oxytetracycline are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.6

Using alpha-hydroxy acid peels may help relieve redness caused by irritation, and reduce papules and pustules associated with rosacea.24 Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.25

The flushing and blushing that typically accompanies rosacea is typically treated with the topical application of alpha agonists such as brimonidine and less commonly oxymetazoline or xylometazoline.6

Laser

Laser treatment for rosacea using a V-Beam laser
Laser treatment for rosacea using a V-Beam laser

Dermatological vascular laser (single wavelength) or intense pulsed light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin.26 They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxy-hemoglobin, which heat up, causing the capillary walls to heat up to 70 °C (158 °F), damaging them, causing them to be absorbed by the body's natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly formed capillaries.20

CO2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporize tissue. Low level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it.272829

Notable cases

Famous people with rosacea include:

See also

References

  1. ^ Koepsell, Thomas (2002). "Domenico Ghirlandaio: An Old Man and His Grandson (ca 1480-1490)". Arch Pediatr Adolesc Med 156: 966. doi:10.1001/archpedi.156.10.966. 
  2. ^ a b c d Tüzün Y, Wolf R, Kutlubay Z, Karakuş O, Engin B (February 2014). "Rosacea and rhinophyma". Clinics in Dermatology 32 (1): 35–46. doi:10.1016/j.clindermatol.2013.05.024. PMID 24314376. 
  3. ^ "Rosacea". DermNet, New Zealand Dermatological Society. Retrieved 2011-02-03. 
  4. ^ Wollina, U; Verma, SB (September 2009). "Rosacea and rhinophyma: not curse of the Celts but Indo Eurasians.". Journal of cosmetic dermatology 8 (3): 234–5. doi:10.1111/j.1473-2165.2009.00456.x. PMID 19735524. 
  5. ^ "All About Rosacea". National Rosacea Society. Retrieved 2008-11-10. 
  6. ^ a b c d e f Del Rosso JQ (October 2014). "Management of cutaneous rosacea: emphasis on new medical therapies". Expert Opin Pharmacother 15 (14): 2029–38. doi:10.1517/14656566.2014.945423. PMID 25186025. 
  7. ^ Yamasaki K, Di Nardo A, Bardan A et al. (August 2007). "Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea". Nat. Med. 13 (8): 975–80. doi:10.1038/nm1616. PMID 17676051. 
  8. ^ See the August 5, 2007, issue of Nature Medicine for details.
  9. ^ a b Baima B, Sticherling M (2002). "Demodicidosis revisited". Acta Derm Venereol 82 (1): 3–6. doi:10.1080/000155502753600795. PMID 12013194. 
  10. ^ MacKenzie, Debora (30 August 2012). "Rosacea may be caused by mite faeces in your pores". New Scientist. 
  11. ^ Elizabeth Lazaridou, Christina Giannopoulou, Christina Fotiadou, Eustratios Vakirlis, Anastasia Trigoni, Demetris Ioannides (November 2010). "The potential role of microorganisms in the development of rosacea". JDDG: Journal der Deutschen Dermatologischen Gesellschaft 9 (1): 21–25. doi:10.1111/j.1610-0387.2010.07513.x. PMID 21059171. 
  12. ^ Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell F (2004). "Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea" (PDF reprint). J Am Acad Dermatol 50 (6): 907–12. doi:10.1016/j.jaad.2004.01.048. PMID 15153893. 
  13. ^ Marks, James G; Miller, Jeffery (2006). Lookingbill and Marks' Principles of Dermatology (4th ed.). Elsevier Inc. ISBN 1-4160-3185-5.
  14. ^ "What Rosacea Looks Like". Retrieved 2013-01-30. 
  15. ^ Jansen T, Plewig G (1998). "Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities". Facial Plast Surg 14 (4): 241–53. doi:10.1055/s-2008-1064456. PMID 11816064. 
  16. ^ a b Vieira AC, Mannis MJ (December 2013). "Ocular rosacea: common and commonly missed". J Am Acad Dermatol 69 (6 (Suppl 1)): S36–41. doi:10.1016/j.jaad.2013.04.042. PMID 24229635. 
  17. ^ a b c d e Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
  18. ^ a b Rapini, Ronald P.; Bolognia, Jean L.; Jorizzo, Joseph L. (2007). Dermatology: 2-Volume Set. St. Louis: Mosby. ISBN 1-4160-2999-0. 
  19. ^ Aaron F. Cohen, MD, and Jeffrey D. Tiemstra, MD (May–June 2002). "Diagnosis and treatment of rosacea". J Am Board Fam Pract 15 (3): 214–7. PMID 12038728. 
  20. ^ a b c d Noah Scheinfeld, MD, JD, and Thomas Berk, BA (January 2010). "A Review of the Diagnosis and Treatment of Rosacea". Postgraduate Medicine. 122 (1): 139–43. doi:10.3810/pgm.2010.01.2107. PMID 20107297. 
  21. ^ a b Culp B, Scheinfeld N. (Jan 2009). "Rosacea: a review.". P&T 34 (1): 38–45. PMC 2700634. PMID 19562004. 
  22. ^ Dahl, Colin (2008). A Practical Understanding of Rosacea - part one. Australian Sciences. 
  23. ^ a b van Zuuren, EJ; Fedorowicz, Z; Carter, B; van der Linden, MM; Charland, L (28 April 2015). "Interventions for rosacea.". The Cochrane database of systematic reviews 4: CD003262. PMID 25919144. 
  24. ^ Tung, RC; Bergfeld, WF; Vidimos, AT; Remzi, BK (2000). "alpha-Hydroxy acid-based cosmetic procedures. Guid... [Am J Clin Dermatol. 2000 Mar-Apr] - PubMed result". American journal of clinical dermatology 1 (2): 81–8. PMID 11702315. 
  25. ^ Hoting E, Paul E, Plewig G (December 1986). "Treatment of rosacea with isotretinoin". Int J Dermatol 25 (10): 660–3. doi:10.1111/j.1365-4362.1986.tb04533.x. PMID 2948928. 
  26. ^ Marla C Angermeier (1999). "Treatment of facial vascular lesions with intense pulsed light". J Cutan Laser Ther. 1 (2): 95–100. doi:10.1080/14628839950516922. PMID 11357295. 
  27. ^ Rigel, Darrell S.; Robert A. Weiss; Henry W. Lim; Jeffrey S. Dover (2004). Photoaging. Informa Health Care. p. 174. ISBN 0-8247-5450-6. 
  28. ^ "PHOTO REJUVENATION". Archived from the original on 2008-08-04. Retrieved 2008-08-14. 
  29. ^ "Research a cosmetic surgery procedure". Retrieved 2008-08-14. 
  30. ^ Subscription Center - News Archive
  31. ^ 4 May 2009-4-5 p.m.
  32. ^ Armstrong, Lisa (2007-02-16). "Ive got thighs and buttocks Im never going to be a size zero". The Times (London). Retrieved 2010-05-22. 
  33. ^ a b c Jane E. Brody (March 16, 2004). "Sometimes Rosy Cheeks Are Just Rosy Cheeks". New York Times. 
  34. ^ Lisa Faulkner: My unslightly rosacea - Celebrity gossip on Now Magazine
  35. ^ Fergie back in business after heart scare - ABC News (Australian Broadcasting Corporation)
  36. ^ 11 June 2012 (2012-06-11). "Diane Kruger: Make-up swamps me". Belfasttelegraph.co.uk. Retrieved 2013-02-23. 
  37. ^ Burnham, Virginia (2003). The Two-Edged Sword: A Study of the Paranoid Personality in Action. Sunstone Press. p. 61. ISBN 978-0-86534-147-0. 
  38. ^ "Rosacea - Living with Rosacea: An Interview with Cynthia Nixon". Empowher.com. 2012-04-19. Retrieved 2013-02-23. 
  39. ^ Rosie O'Donnell - ELLE
  40. ^ Appleyard, Diana (2011-02-27). "I'm not drunk I have rosacea: Carol Smillie tells embarrassing story of facial flushes". Daily Mail (London). 
  41. ^ Swords Against the Senate: The Rise of the Roman Army and the Fall of the Republic, by Erik Hildinger. Da Capo Press, 2003, p.99
  42. ^ Dita Von Teese on conquering rosacea
  43. ^ Amstell, Simon (2005-08-21). "Q&A". The Guardian (London). Retrieved 2010-05-22. 

Rosacea Uncovered - Symptoms, Causes and Treatments Interview with Michelle Osbourne

External links