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    Rosacea

    What is Rosacea?

    Rosacea is a very common, chronic condition characterized by facial redness and flushing of the face mainly over the cheeks but it can also cause redness of the eyes with a gritty sensation.  It can also present with pustules and papular lesions on the face and can sometimes be confused with acne.  The texture of the skin can also be affected, especially the nose.    It is an inflammatory dermatitis and predominantly affects 30 to 60 year olds with women tending to present earlier and the condition becoming much less common in the elderly.  The condition is seen more commonly in fair-skinned people (skin type I and II) and in particular Celtic skin (typically red hair and blue-eyes).   It is believed that the incidence in women is probably similar to men  but when it occurs in men it tends to be  more severe.  There may be some bias with this observation as it may reflect the fact that men may be less likely to present to their doctor or dermatologist, only attending once the condition becomes more severe.  The severity of the condition can fluctuate with time.
    There are four main subtypes of rosacea.

    1. Erythematotelangiectatic rosacea
    2. Papulopustular rosacea
    3. Phymatous rosacea
    4. Ocular rosacea

    Patients can present with a combination of these subtypes.  Some clinicians also refer to pre-rosacea which is frequent facial flushing is noted to various triggers however the skin returns back to normal with no background redness after the flushing episode.  In some people, this is considered a prodrome to developing erythematotelangiectatic rosacea.

    What causes Rosacea?

    The cause of rosacea is unknown.  There are many theories about what causes rosacea but nothing has been definitively proven as yet.  It may be caused by a number of factors including blood vessel abnormalities, demodex mite reaction, environmental factors and bacteria in the digestive system.  As rosacea presents in different ways there may be different causative agents for the different types of presentations.

    Recently, the Demodex theory has gained popularity as a cause for papulopustular rosacea due to a number of observations.  The Demodex mite is a minuscule mite which can live in the pilosebaceous units on human facial skin.  The mites are far too small to be seen by the naked eye.  There are many reports that the presence of Demodex mites are more common in patients with rosacea and are usually present in increased numbers however not everyone who harbours Demodex mites on the skin develops rosacea.  One theory, is therefore that in some susceptible individuals the presence of the Demodex mite can induce a host immune response leading to inflammation.  The fact that 1% ivermectin cream, which is known to be toxic to the Demodex mite resulting in death of the mite, has been shown to improve papulopustular rosacea also supports this theory.   Demodex mites have also been associated with ocular rosacea being found in the scale and crusting around the glands along the eyelid margin.  The Demodex mite also often harbours a bacteria called Bacillus oleronius and so some investigators believe that this may be implicated in the pathogenesis of rosacea.  The incidence of Demodex mites on facial skin does increase with age and is almost ubiquitous in the elderly, however, we find that rosacea is less of an issue in the elderly.

    Due to the fact that rosacea is more common in patients with fair skin it has been questioned if sun damage may be a precipitant for developing rosacea.  Some of the long-term effects of actinic (sun) damage are very similar to what is found in the skin of patients with rosacea, namely the background redness and enlarged (telangiectatic) blood vessels seen in erythematotelangiectatic rosacea.  Sun damage to certain structures in the skin may elicit an ongoing inflammatory response as the body tries to repair the damaged structures of the skin.

    Rosacea seems to run in families, and as mentioned is more common in fair skinned people, however, there is no clear genetic link as yet discovered. The condition is not contagious but there are a variety of triggers that may worsen the symptoms.  The most common triggers for rosacea are heat(such as walking into a warm room or steam rooms), alcohol, exercise, spicy foods, hot foods and drinks  and sunlight (UV exposure). Some skin care products may irritate the skin and exacerbate rosacea.   Oral and topical steroids and some other medications may also trigger flushing in patients with rosacea.

    What are the symptoms of Rosacea?

    This depends on the subtype of rosacea however all patients seem to have some degree of increased redness of the facial skin.  For the erythematotelangiectatic type of rosacea facial flushing and fixed redness of the face, especially the cheeks are the main symptoms.

    Symptoms include flushing (facial blushing) and redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp. Rosacea often starts with a tendency to flush easily with the skin returning to normal after an episode of flushing.  Some clinicians call this pre-rosacea.  The next stage after this is episodic flushing where the skin does not return back to normal but rather has a permanent background redness.  Fixed dilated blood vessels, often called telangiectasia, can also be a feature of erythematotelangiectatic rosacea.  The inflamed areas can also be swollen.  Often patients report that their skin feels as if it is burning or stinging, can be extremely sensitive to the sun, will often react to cosmetics and moisturisers with redness and a stinging sensation.  In extreme cases people can report that their skin is exquisitely tender or painful.

    Rosacea can also be papular and pustular and can look like acne however the distinguishing feature is the distribution and the fact that it is usually on a background of facial redness with an absence of comedones.  Acne can coexist with rosacea.

    Phymatous rosacea is when the texture of the skin changes with dilated pores and swelling of the affected areas.  This is due to hyperplasia (enlargement) of the sebaceous glands and is most commonly seen on the nose when it is called rhinophyma.  As the condition progresses the shape of the nose changes and becomes more bulbous and squeezing the skin of the nose can result in easy extraction of whitish-yellow sebaceous material.  This is often accompanied with background redness some degree of telangiectasia.  The condition is more common in men but can occur in women and can be quite disfiguring.

    Ocular rosacea can present as non-specific blepharitis which is inflammation and redness along the eyelid margin or a dry or gritty sensation of the eyes with or without redness of the sclera (the white part of the eye).  Ocular rosacea can coexist with the other subtypes of rosacea which makes its diagnosis easier.  When it occurs alone, a number of other differential diagnoses need to be considered.

    There is also an overlap with rosacea and seborrhoeic dermatitis with the two conditions coexisting in some patients.  This can represent a spectrum where some people are affected more by rosacea and less by seborrhoeic dermatitis or vice versa.  Is important to recognise the coexistence of seborrhoeic dermatitis with rosacea as separate specific treatment is required for the seborrhoeic dermatitis component.

    Rosacea can lead to embarrassment, lowered self-esteem and can also influence behaviour with people avoiding certain situations or circumstances that the person knows will exacerbate the condition.

    How does a Dermatologist diagnose Rosacea?

    A Dermatologist diagnoses rosacea based on the patient’s  history and clinical examination. It is important to distinguish between rosacea and acne vulgaris as the two conditions are treated differently and many acne treatments may exacerbate rosacea. The two conditions can co-exist. Blood tests or a skin biopsy may occasionally be required to rule out other causes of facial redness such as lupus, facial eczema or seborrhoeic dermatitis.

    How does a Dermatologist treat Rosacea?

    Although there is no cure, long-term treatments can be very effective and sometimes rosacea can go into remission. Treating rosacea varies from patient to patient depending on the severity and type of rosacea.

    The first aim of management is to identify and avoid the triggers of rosacea where possible and so a Dermatologist may encourage you to keep a diary to help identify what may be triggering your rosacea.  This applies mainly to erythematotelangiectatic rosacea.  If possible these triggers should be avoided. In general you should look to protect your skin from exposure to UV light, changes in temperature, spicy food, hot foods and drinks, alcohol and stress, however these measures are not always practical or sustainable. A Dermatologist can also advise on suitable skin care products to use to avoid triggering the rosacea.  It is important to use gentle, bland products on the skin such as a pH-balanced soap substitute to cleanse the face and a moisturiser for sensitive skin.  In many patients with rosacea the skin is very sensitive and the barrier function of the epidermis has been compromised which leads to further irritation.  Trying to rebuild this barrier function can be helpful with improving the skin in patients with rosacea.  Avoiding topical corticosteroids is paramount and many anti-ageing products, especially those containing retinol, are contraindicated in patients with rosacea due to the potential for irritation.  The product causes stinging all redness of the facial skin when applied it should be avoided in patients with rosacea.

    For eythematotelangiectatic rosacea a sunscreen should be used on a daily basis to help prevent any further actinic damage which may be a contributing factor in this type of rosacea.  Some patients do respond to systemic tetracycline antibiotics either in a regular dose or as a sub-bacteriocidal dose of doxycycline in a sustained-release formulation.  These treatments, however generally a more effective for the papulopustular rosacea type.  The mechanism of action for eythematotelangiectatic rosacea is due to their anti-inflammatory effects.  Topical brimonidine gel, which is an alpha-2 adrenergic agonist, causes vasoconstriction of the blood vessels when applied topically to facial skin.  This can give a temporary blanching (reduction in redness of the skin) and some protection against flushing and can be used on a daily basis as symptom control.  Eythematotelangiectatic rosacea responds extremely well to treatment with the vascular laser and or IPL.  These devices are able to ablate to legit tactic vessels and reduce background redness.  They can also have an effect to stabilise the flushing tendency with this type of rosacea.

    Results can be long lasting however a maintenance programme of one treatment every 6 to 12 months may be required after the initial treatment schedule.  Very low dose oral isotretinoin therapy can also be effective for this subset of rosacea.

    Finally, camouflage therapy can be used to disguise the degree of redness of the face.  Foundations containing green pigment to counteract the redness can be very effective as a base layer to make up as well as heavy foundations that provide an opaque covering over the red skin.

    First-line treatment for patients with papulopustular rosacea, unless very severe, is the use of topical formulations containing either metronidazole, azelaic acid or ivermectin.  These are used until resolution occurs and the maintenance programme can then be devised.  If this is insufficient then systemic tetracycline antibiotics can be used usually over a period of 6 to 8 weeks.  Once again a maintenance face of treatment or repeat treatments may be required.  With increasing concern about antibiotic resistance an alternative is a sustained-release low-dose doxycycline tablet taken once a day in the morning which works as an anti-inflammatory agent and has no bacteriocidal effect.  If sufficient to control the rosacea this can be used on a long-term basis.  If the papulopustular rosacea is resistant to the above treatment then low-dose oral isotretinoin therapy could be considered.

    The phymatous subtype of rosacea if treated early can also respond to oral isotretinoin in a low-dose.  If however the changes are more advanced than physical therapies need to be considered.  This includes either laser resurfacing, electrodesiccation of the thickened skin or surgical reshaping of the nose.

    Ocular rosacea can be treated with good ocular hygiene including using the looted baby shampoo as a wash to the eyelid margin with a cotton tip.  Some patients also respond to systemic tetracycline therapy.  If ocular rosacea is more severe or not responsive to treatment that referral to an ophthalmologist is indicated.

    Patients with rosacea can suffer from lower self-esteem and so support from patient groups can be helpful in providing strategies for people living with rosacea.  Psychological counselling can also be helpful for patients who flush very easily in situations of stress or anxiety.

    A Dermatologist can recommend the most appropriate treatment for rosacea following a consultation.

    Where can I find patient support for Rosacea?

    The National Rosacea Society – https://www.rosacea.org/

    The Rosacea Forum – https://rosaceagroup.org/The_Rosacea_Forum/

    The British Association of Skin Camouflage – http://www.skin-camouflage.net/

    Changing Faces – http://www.changingfaces.org.uk

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