Rosacea / Reading and Sharing

Rosacea is a chronic and relapsing inflammatory skin disorder affecting primarily the central face.  This disorder is characterized by papules and pustules to the face including facial erythema and telangiectasias (Maier, 2018).  Maier (2018) further states that patient seek therapy due to physical appearance of the face and that there is no cure for rosacea, but that treatment is focused on symptom suppression.  Rosacea is usually exacerbated by sun exposure and other environmental triggers including hot or cold weather and winds; overheating during exercise, excessive alcohol ingestion or hot beverages; spicy or aged food products such as cheese; emotional stress; irritating cosmetics; hot baths, saunas, or hot tubs; smoking; caffeine; and excessive washing of the face (Dunphy, Winland-Brown, Porter and Thomas, 2015).

Rosacea is a fairly common skin condition that is frequently seen in the primary care setting. It affects over 14 million people in the United States (Jarell, 2017).  The onset is between 30 and 50 years of age affecting mostly fair-skinned white people, with a disproportionately high distribution among people of Celtic origin (Jarell, 2017), but research speculates that the hyperpigmentations of other ethnicities limit the accuracy of proper diagnosing rosacea in different cultural groups (Ferri, 2018). This condition is also more densely found in the female population. Ferri (2018) states the ratio between female and males is 3:1.

Underlying pathogenesis of the vascular dilation characteristic of rosacea which is idiopathic with no recognizable causes other than certain triggers that exacerbate the condition.  Dunphy et al. (2015), states that several researchers have suggested that Heliocobacter pylori, is an organism found in the stomach that may possibly be a cause, as well as the Demodex species of mite, which has been found in the hair follicles of patients with rosacea.  Unfortunately, there remain major gaps in the basic scientific knowledge underlying the pathophysiology of this disease.

The initial assessment starts with inspecting the patient’s skin primarily the face.  A thorough inspection of the skin can help determine how advance the disease has progressed.  For example, the patient’s forehead, cheek, nose, or chin may appear to have a rosy hue without comedones (Dunphy et al., 2015).  During the early diagnostic feature of rosacea, patients may present with flushing and/or erythema of the face.  As the disease progresses they present with papules and pustules on their faces and telangiectasias, which are superficial capillaries which are one of the hallmark of the disease and often the most bothersome (Jarell, 2017).  Other features of rosacea include ocular manifestation which patients may complain of a foreign body sensation in the eye, often tearing, pain, and blurry vision.  Chalazion or hordeolum, keratitis, episcleritis, and sclerites may also be more ocular manifestations of rosacea.  As the disease continue to progress, there could severe papulopustular rosacea which can evolve with coalescent lesions forming erythematous or violaceous plaques or a facial distribution of rosacea throughout the central face including the cheeks, chin, nose, and central forehead.  Lastly, phymatous changes which is the rhinophyma also known as the “whiskey nose” or “rum blossom” and the end-stage of rosacea but can also be seen with other features of the disease are mild (Jared, 2017).  Jared (2017), states that this is a severe form of sebaceous gland hyperplasia which is 20 times more common in men than in women.

According to Dunphy et al. (2015), there are four subtypes of rosacea classified by the pattern or grouping of symptoms:

• Subtype 1: Erythematotelangiectatic rosacea- flushing and persistent redness, which may include visible blood vessel.
• Subtype 2: Papulopustular rosacea-persistent redness with transient bumps and pimples.
• Subtype 3: Phymatous rosacea- skin thickening usually with hyperplasia of the nose resulting in a large, bumpy, and bulbous appearance.
• Subtype 4: Ocular rosacea-ocular manifestations with dry eye, tearing and burning, erythematous eyelids, recurrent styes, and the possibility of vision loss from corneal damage.

The best treatment plan when treating rosacea include early diagnosis and avoidance of triggers of flushing which may include extremes of temperature, sunlight, spicy foods, alcohol, exercise, acute psychological stressors, medications, menopausal hot flushes (Maier, 2018).  Medication therapy for rosacea may include metronidazole cream 0.75% or 1% for 6 to 8 weeks for a therapeutic response (Dunphy et al. 2015).  If this mediation is not effective, then topical erythromycin 2% apply to affected area twice a day or clindamycin 1% apply to affected area twice a day can be used (Jarell, 2017).  Oral antibiotics could be used but reserved for flare-ups or when initiating therapy with topical medications, and then antibiotics should be discontinued.  Oral antibiotic of choice is minocycline 100mg by mouth twice a day.  Using oral antibiotics is effective in reducing acneiform lesions and more as an anti-inflammatory agent rather than antibiotics (Dunphy et al. 2015).  Non-pharmacological therapy includes laser therapy.  Electrocautery with a small needle may be used to destroy small telangiectatic vessels.  For men with rhinophyma, a surgical reduction may be necessary to reduce the bulbous appearance of the nose (Dunphy et al. 2015).

Patient education may consist of events or circumstances that may flare-up rosacea and ways to prevent them.  Patients should be educated on wearing sunscreen on exposed skin when outdoors, protecting their faces on hot days and cold days, not getting over heated when exercising, wearing a cool towel around neck and drinking fluids when outside on a hot day, and cleansing their faces with fragrance-free facial cleaners (Dunphy et al. 2015).  Patients should also be educated on avoiding foods that may stimulate flushing such as spicy foods, hot drinks, and alcohol (Jarell, 2017).

Patients should be instructed to follow-up in the office if condition worsen or does not improve.  Dermatological referrals may be necessary if rosacea results in telangiectasias for electrodesiccation or if laser treatment is requested for cosmetic purposes.

References:

Dunphy, L. M., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Skin problems. In Primary care: The art and science of advanced practice nursing (4th ed., pp. 213-215). Philadelphia, PA: F.A. Davis Company.

Ferri, F. F. (2018). Ferri’s clinical advisor 2018. Philadelphia, PA: Elsevier.

Jarell, A. (2017). Rosacea Epidemiology – Epocrates online. Retrieved fromhttps://online.epocrates.com/diseases/10223/Rosacea/Epidemiology

Jarell, A. (2017). Rosacea Treatment Options – Epocrates online. Retrieved fromhttps://online.epocrates.com/diseases/10242/Rosacea/Treatment-Options

Jarell, J. (2017). Rosacea History & Exam – Epocrates online. Retrieved fromhttps://online.epocrates.com/diseases/10233/Rosacea/History-Exam

Maier, L. (2018). Management of rosacea. Retrieved fromhttps://www.uptodate.com/contents/management-of-rosacea?