DEFINITION INCIDENCE PATHOGENESIS HISTORY PHYSICAL EXAMINATION Differential Diagnosis LABORATORY AND BIOPSY TREATMENT COURSE AND COMPLICATIONS

1. NAZANIN AYAREH
ROSACEA

2. TABLE OF
CONTENTS
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DEFINITION
INCIDENCE
PATHOGENESIS
HISTORY
PHYSICAL EXAMINATION
Differential Diagnosis
LABORATORY AND BIOPSY
TREATMENT
COURSE AND COMPLICATIONS

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Rosacea is a chronic inflammatory
disorder affecting the blood vessels
and pilosebaceous units of the face.
The etiology is unknown. Clinically,
papules and pustules are
superimposed on a background of
erythema and telangiectasia.
DEFINITION

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Rosacea is a relatively common
disorder that affects primarily
middle-aged adults.
INCIDENCE

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For the vascular component,
investigators have suggested
that sun exposure damages the
collagen support of the vascular
network, thereby resulting in
vasodilation.
Immune mechanisms have also been
implicated, with immunoglobulin
deposition occurring at the dermal–
epidermal interface. The pathogenetic
significance of this finding remains
unclear. Clearly, genetics play a role
as a family history for rosacea is often
positive in a patient with rosacea.
Other aggravating factors that
have been incriminated, but not
well proved, include the ingestion
of foods that cause vasodilation
(e.g., hot liquids, alcohol, and
spicy foods) and psychologic
stress.
PATHOGENESIS
The pathogenetic
mechanisms in this
disease are not
well understood.

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HISTORY
The disorder often has a gradual onset. Usually,
the patient first notices erythema; with time,
telangiectasia appears. The development of
papules and pustules is usually sufficient for the
patient to bring the problem to a physician’s
attention. Trigger factors, such as exercise and
alcohol, cause a flare of the redness. Most
patients have a fair complexion and light colored
irises.

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PHYSICAL
EXAMINATION
The four major clinical subtypes of rosacea are
(1) vascular;
(2) papulopustular;
(3) rhinophyma; and
(4) ocular.
Each type may occur independently and there is no typical
progression from one to the other. Usually a patient with
rosacea presents with a combination of vascular,
papulopustular, and ocular findings. Typically, papules and
pustules are superimposed on a background of erythema
and telangiectasia. Sometimes, only the erythema and
telangiectasia are present. Characteristically, comedones
are not found. The disease affects the central third
of the face and spares the lateral aspects of the forehead
and cheeks. Blepharitis and conjunctivitis are common.
Bulbous thickening of the nose is rare and occurs most
commonly in men.

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Differential
Diagnosis of
Rosacea
How to distinguish
acne vulgaris
absence of comedones, the background of erythema
and telangiectasia, the onset in middle life, and the
distribution in the central third of the face in Rosacea
Lupus/
dermatomyositis
Rashes that may be confused with the vascular
element in rosacea occur in
lupus erythematosus, dermatomyositis,
photodermatitis, and, most commonly, seborrheic
dermatitis but none of these exhibit pustules
Seborrheic
dermatitis
Seborrheic dermatitis is often seen in conjunction with
rosacea. Seborrheic dermatitis affects the concave
surfaces (nasolabial fold) whereas rosacea affects the
convex surfaces.
Carcinoid
syndrome
In patients with rosacea with a prominent flushing
component, the carcinoid syndrome sometimes enters
the differential diagnosis.
Acneiform
eruption from
epidermal
growth factor
Epidermal growth factor inhibitors, used to treat a
variety of malignancies, can lead to a facial acneiform
eruption, which can be confused with rosacea

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LABORATORY
AND BIOPSY
The diagnosis is almost always made clinically. A biopsy is
rarely needed, but if performed, shows vascular dilation, often with degenerative
changes in the collagen and elastic fibers in the upper dermis. The papules and
pustules in rosacea are similar histologically to those found in acne vulgaris, but
in rosacea, the inflammatory
infiltrate is more likely to have a
granulomatous component. This represents
a foreign body reaction in the dermis to the
extravasated contents of affected
Pilosebaceous units. The granulomatous
response can be impressive and has been
confused occasionally with granulomatous
disorders such as sarcoidosis and tuberculosis.

11. Topical metronidazole
0.75% (MetroGel,
MetroCream) or topical
azelaic acid 15%
(Finacea) applied twice
daily is also effective in
treating the papules,
pustules, and erythema of
rosacea. The mechanism
of action is unknown.
Systemic antibiotics are
used frequently for the
papular and pustular
components and are
especially beneficial in
treating ocular rosacea.
Sometimes, the erythema
is also improved.
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TREATMENT
Low-dose doxycycline
(20 mg twice daily) exerts
an anti-inflammatory
effect and is the usual
treatment. Most patients
respond within 1 month,
after which the drug often
can be tapered, but some
patients require long-term
maintenance treatment.
Systemic isotretinoin
(formerly Accutane),
usually in low doses, is
reserved for the rare
patient with severe
disease that has resisted
all other therapy but it
does not lead to a lasting
response as seen in acne.
Laser treatment (e.g.,
pulse-dye laser) is the
only effective and
definitive therapy for the
erythema of rosacea.
Topical steroids should
not be used because they
are well known to
aggravate the disease.
Sun exposure can also be
an aggravating factor,
and sun protective
measures should be
recommended.

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COURSE AND
COMPLICATIONS
The disease is usually chronic, but most patients respond
well to therapy. In many, however, therapy must be
continued for months to years. The erythematous
component may be improved by therapy, but the
telangiectasia persists.
Rhinophyma sometimes develops in
patients with rosacea. As the name
suggests, this disease involves
hyperplasia of the sebaceous glands,
connective tissue, and vascular bed of
the nose. The hyperplasia can be
striking, resulting in a bulbous nose. The
nose of W. C. Fields was a prototype,
but, contrary to popular belief, rosacea
is not a sign of excessive alcohol intake.
Ocular complications occur in some
patients with rosacea. Eye findings
range from blepharitis to conjunctivitis
and even keratitis. The latter can be
severe and has been known to result in
visual impairment. Oral doxycycline is
helpful for the ocular complications

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Initial
● Metronidazole gel or cream b.i.d.
● Azelaic acid gel b.i.d.
● Daily moisturizer containing
sunscreen
Alternative
● Doxycycline 20 mg b.i.d.
● Pulse dye laser (vascular
rosacea)
1. Papules and pustules with a
background of erythema affect
the central third of the face
2. Eye involvement is common
3. Treat with topical and oral
antibiotics
4. Disease of adults
● Acne
● Lupus/dermatomyositis
● Seborrheic dermatitis
● Carcinoid syndrome
● Acneiform eruption from epidermal
growth factor
KEY POINTS
Differential Diagnosis
Therapy for Rosacea
TAKEAWAY

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THANKS
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