Rosacea is a chronic skin condition that affects the face, characterized by flushing, persistent redness, small visible blood vessels, pimples or bumps, and thickened skin, especially on the nose, cheeks, chin, and forehead. It is classified into subtypes based on symptoms such as erythema, papules and pustules, and phymatous changes. Treatment aims to reduce inflammation and prevent worsening of symptoms. Left untreated, rosacea can progress and cause permanent changes to the facial structure over many years.

1. Rosacea

2. Objectives:
• Introduction and classification of
Rosacea
• Epidemiology
• Pathophysiology
• Clinical features
• Differential Diagnosis
• Treatment of Rosacea.

3. Definition:
It is a chronic disorder affecting the facial
convexities characterized:
• Frequent flushing
• Persistent erythema
• Telangiectasias,
• Interspersed by episodes
of inflammation characterized by swelling,
papules and pustules.

4. Classification and Grading of
Severity:
Classification:
1.Subtype 1:Erythematotelangiectatic
Rosacea (ETTR)
2.Subtype2:Papulopustular Rosacea
(PPR)
3.Subtype 3:Phymatous Rosacea (PR)
4.Subtype 4:Ocular Rosacea (OR)

5. Grading:
Grade 1: Mild disease
Grade 2: Moderate disease
Grade 3: Severe disease

6. Epidemiology:
• Disease of the fair-skinned, sun
sensitive individuals
• Males and females equally affected.
• Males affected with more severe
rosacea and with rhinophyma
• Peak age of incidence in 30-40 years.
• Subtype 1 (ETTR) is by far the
commonest type.

7. Pathophysiology:
1. Genetic Factors: 25% patients have a
family history
2.Ultraviolet Radiation and Adverse
weather conditions:
(a) Photo-exposed areas
(b) Condition is exacerbated by wind

8. 3.Causative Organisms:
(a) Demodex Mite
(b) Staphylococcus epidermidis
(c) Chlamydophilia pnuemoniae
(d) Bacillus Oleronius
4. Alteration in Cutaneous Microenvironment
(a) Changes in cutaneous pH
(b) Alteration in the skin barrier function
(c) Changes in lipid profile

9. 5.Meibomian Gland dysfunction:
(a) Reduced tear break up time
(b) Demodex mite infestation
6. Environmental Factors:
(a) Increased ambient temperature
(b) Ingestion of hot liquids, spicy foods
& large meals
(c) Alcohol consumption

10. Pathogenesis:
Altered Innate Immune response leads
to the following:
(a)Increased Toll like receptor 2 activity
(b)Increased protease activity and
cathelicidin production.
(c) Leukocyte chemotaxsis
(d) Increased angiogenesis
(e) Extracellular matrix production.

12. Histopathology of ETTR:
1.Enlarged bizarre shaped capillaries and
venules in upper part of dermis
2.Mild perivascular and interstial infiltrate of
lymphocytes and plasma cells
3.Occasionally demodex mites
4.Solar elastosis

13. Histopathology of Papulopustular
Rosacea:
• Dense follicular and perivascular infiltrate of
lymphocytes, plasma cells, neutrophils, and mast
cells.

14. Histopathology of Rhinophyma
• Sebaceous gland Hyperplasia
• Striking dermal fibrotic changes
• Variable degree of perivascular
lymphocytic/neutrophilic infiltrate.
• Demodex mites

15. Histopathology of Ocular Rosacea:
Posterior meibomian glands are
affected with lymphocytic, histiocytic
and neutrophilic infiltrate

16. Clinical Features:
1)Erythematotelangiectatic Rosacea:
• Gradual increase in facial redness.
• Episodes of flushing in response to
environmental changes and food
• Appearance of telangiectasia (broken
blood vessels)
• Increased sensitivity of the skin to topical
applications
• Evidence of solar damage (actinic
keratoses, actinic lentigines)

18. 2.Papulopustular Rosacea (PPR):
• Appearance of papules and pustules.
• Prominent perilesional erythema
• Larger pustules but all lesions are
superficial
• NODULES AND CYSTS ARE NOT A
FEATURE OF PPR
• Lesions at different stages of evolution
• Heal without scarring or leave persistent
post-inflammatory erythema.

20. 3.Phymatous Posacea (PR):
• Includes: Rhinophyma
Otophyma (Enlarged ears)
Metophyma (Thickening of the
skin of the forehead)
• Rhinophyma – the commonest form of
PR and seen mostly in males
• Thickening of skin of distal nose.
• Prominent follicular openings.
• Distal end of the nose becomes bulbous
and greasy.

21. Rhinophyma has also been called copper nose,
brandy nose or bulbous nose

22. 4.Ocular Rosacea:
• Sensation of grittiness and dryness
• Watery eyes
• Blephritis
• Stye formation
• Chalazion
• Conjunctival hyperemia and fibrosis
• Photophobia and blurred vision
• Keratitis

24. Clinical Variants:
Granulomatous Rosacea:
1.Persistent , firm, non tender red to brown papules
on normal skin.
2.Sites: around the mouth, eyes and cheeks
3.Monomorphic picture
4.Treatment resistant and heals with significant
scarring
5.Histopathology: granulomatous change with foci of
caseation necrosis.

25. Differential Diagnosis:
Erythematotelangiectatic Rosacea:
1.Chronic photodamage
2.Seborrhoeic Dermatitis
3.Lupus erythematosus
4.Contact dermatitis of face
5.Ulerythema ophyrogenes

26. Papulopustular Rosacea:
1. Acne vulgaris
2. Rosacea like dermatoses
3. Pityriasis folliculorum
4. Perioral dermatitis
5. Jessner’s lymphocytic
infiltrate
6. Tinea facei

27. Phymatous Rosacea:
1.Lupus pernio
2.Granuloma faciale
3.Lymphocytoma cutis
4.Solid facial lymphedema
5.Basal cell carcinoma,
squamous cell carcinoma and
lymphomas.
Ocular Rosacea:
Other causes of blepharitis.

28. Complications and Co-morbidities:
• Increased risk of cardiovascular disease
• OR leads to visual impairment through
recurrent episodes of keratitis.
• Basal cell carcinoma may be obscured
by phymatous tissue.
• Seborrheic dermatitis may co-exist with
roscea.
• Lymphedema affecting any part of the
face and ears leading to coarse features
and leonine facies

29. Disease Course and Prognosis:
Chronic condition with relapses and remissions.
ETTR: Skin becomes increasingly sensitive and flushing
more frequent.
PPR: Lesions heal with perilesional erythema contibuting
to overall erythema of face
Rhinophyma: Progresses from nose enlargement to
distortion.
OR: progresses to conjunctival fibrosis, punctate keratitis
and corneal revascularization