Rosacea

LAST UPDATED: Dec 03, 2023

Patient Information Leaflet
Link: Rosacea

https://www.pcds.org.uk/patient-info-leaflets/rosacea

Introduction

Rosacea is a common rash, usually occurring on the face, and which predominantly affects both middle-aged (age range 30 to 60) and fair-skinned people.

This chapter is set out as follows:


Aetiology

  • While rosacea is more common in patients with fair skin and blue eyes, the cause is largely unknown, although chronic vasodilatation (perhaps due to a primary error in vascular control) appears to be a factor

History

  • Age
    • Affects adults and older patients
    • It has a bi-modal prevalence of 20 to 30 years of age with a larger peak at 40 to 50 years
  • Aggravating factors
    • ​Anything that predisposes to flushing eg sunlight, caffeine, alcohol, spicy food
    • Drugs that cause vasodilatation
    • Topical steroids
  • Symptoms
    • The onset of rosacea is often preceded by a history of episodic flushing
    • The erythema associated with rosacea if often described as burning or stinging

Clinical findings

Rosacea 

  • Distribution
    • The central face (forehead, nose, cheeks and chin) with sparing of peri-oral and peri-orbital skin
  • Morphology
    • Erythema - initially intermittent but becomes more permanent
    • Telangiectasia
    • Papules and pustules
    • Absence of open comedones (blackheads), unlike in acne vulgaris
    • Thickening of the skin can occur as the condition becomes chronic
  • A rhinopyhma, representing marked thickening of the nasal skin, effects some patients with rosacea and can cause serious disfigurement
  • Ocular involvement
    • Occurs in over 50% of patients
    • Can cause gritty eyes, conjunctivitis, blepharitis, episcleritis and chalazion. Keratitis is a more serious complication

Granulomatous rosacea syn. acne agminata; lupus miliaris disseminatus faciei

    • ​Is a rare variant of rosacea, characterised by the presence of persistent, firm, non‐tender, red-brown, monomorphic (ie lesions look the same) papules or nodules on otherwise normal‐appearing skin
    • Lesions are distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. Lesions can also affect around the mouth and the cheeks
    • Although it is more common in younger patients, any age can be affected 
    • Histological evaluation of lesions shows granulomatous changes (sometimes clearly related to follicular rupture) and often foci of caseation necrosis
    • This pattern of rosacea can be resistant to conventional treatment, for example systemic tetracyclines. Another treatment occasionally used, under specialist supervision, is dapsone 
    • Untreated, the condition usually persists for 2–3 years and then regresses with scarring

    Images

    Please refer to notes on image rights at bottom of the page with regards to individual image ownership.


    Management

    General measures

    • Refer to the top right of the page for a patient information leaflet available through a QR code or printable PDF
    • Minimise factors that may aggravate symptoms:
      • Tea and coffee, especially taken hot or strong
      • Alcohol
      • Mustard, pepper, vinegar, pickles or spicy foods
      • Excessive heat
      • Direct sunshine
      • Topical steroids
    • Emollients are generally helpful and soothing

    Management of papules, pustules and nodules

    • Topical treatments - mild symptoms 
      • First-line: Soolantra ® (ivermectin 10 mg/g) cream OD for three months
      • Second-line: options include Finacea ® (azealic acid 15%) cream BD, or Rozex ® (metronidazole 0.75%) gel or cream BD 
    • Systemic treatments
      • Use if topical agents fail or if presenting symptoms more severe
      • First-line: the tetracycline's (contraindicated in pregnancy). Consider doxycycline 40mg OD as the smaller dose reduces the risk of antibiotic resistance. Other options include lymecycline 408 mg OD and doxycycline 100 mg OD. Unlike oxytetracycline, these drugs can be taken with (or without) food
      • Second-line: clarithromycin or erythromycin 250-500 mg BD 
      • A standard course is three months, although sometimes a shorter course will suffice 
    • Recurrent symptoms
      • For infrequent recurrences a course of treatment can be repeated as above
      • If symptoms recur frequently, once symptoms have settled on a standard dose of treatment the patient can then be kept on a lower dose of the antibiotic to reduce flare-ups (a lower dose for many refers to taking the medication 2-3 days a week) 
    • More severe symptoms that respond poorly to treatment
      • Refer to a dermatologist for consideration of other treatments such isotretinoin

    Management of flushing / erythema / telangiectasia

    • Can sometimes be the predominant symptoms and does NOT respond to antibiotics
    • Flushing may be helped by a non-selective cardiovascular beta-blocker such as propranolol 40 mg BD, or clonidine 50 micrograms BD
    • Persistent erythema / telangiectasia:
      • Mirvaso® (brimonidine) topical gel, 0.33% is an alpha adrenergic agonist indicated for the topical treatment of persistent (nontransient) facial erythema of rosacea in adults 18 years of age or older. Applied thinly once a day, it will benefit some, but not all, patients with persistent erythema. Adverse reactions include erythema, flushing, skin burning sensation and contact dermatitis
      • Carvedilol has demonstrated significant improvements in very small studies. A small dose of 12.5mg per day may suffice, although it can take 3-6 months for the optimal response
      • Laser therapy using a pulsed-dye laser can be very effective although improvement is not permanent. Only a few commissioners will provide laser treatment for rosacea on the NHS
    • Consider camouflage eg using green cream (can be purchased directly by the patient), refer to a camouflage department in outpatients (if available), or refer to the British Red Cross, which run free clinics across the UK, sometimes in association with hospital dermatology departments. Alternatively the patient can be directed to Changing Faces

    Management of rhinophyma


    Management of ocular symptoms 

    • Lid hygiene - clean the eyelids using cotton wool soaked in cooled, boiled water
    • Artificial tears - should be applied liberally throughout the day. If necessary a lubricating ointment, sometimes containing an antibiotic preparation may be used at night
    • Systemic tetracyclines are the most effective treatment for ocular rosacea. Erythromycin can be taken orally for patients intolerant of tetracyclines
    • Retinoids should be avoided in patients with significant ocular problems as they can worsen symptoms and lead to a severe keratitis
    • Troublesome ocular symptoms that persist despite of treatment should be referred to an ophthalmologist. Patients with potentially more serious symptoms such as keratitis should be seen without delay


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