6. PATHOPHYSIOLOGY
• Unknown
Microbes:
• Staphylococcus epidermidis, Chlamydophila pneumonia, Demodex ‐ associated
bacterium Bacillus oleronius
• Increased Toll‐like receptor 2 activity, increased protease activity and cathelicidin
production Increase angiogenesis, leukocyte chemotaxis and extracellular
matrix production
7. • Demodex folliculorum: Commensal, Pathogenic potential Number of
mites
DEMODEX
FOLLICULORUM(100X)
8. • The role played by H. pylori and other intestinal bacteria is still unclear
• Few studies showed H.pylori seropositivity in rosacea patients while others
failed to demonstrate the same
9. Genetics:
• Family history +, Celtics
• No rosacea specific genes identified yet
• Polymorphisms in the glutathione S-transferase (GST) Increased oxidative
stress
• Two single-nucleotide polymorphisms code for butyrophilin-like 2 (BTNL2) and
HLA-DRA loci
• Polymorphism in NOD2/CARD15: Granulomatous rosacea
• Polymorphic variant of TACR3
10. Alterations in innate immunity:
• Elevated levels of cathelicidin and kallikrein 5 Regulate and promote
leukocyte chemotaxis, angiogenesis and expression of extracellular matrix
components
• Altered TLR 2 expression Increased susceptibility to various innate immune
stimuli Increased production of cathelicidin and kallikrein
• Increased MMP levels Promotes activity of kallikrein 5 Increased levels of
IL-37
11. Defective skin barrier:
• Decreased barrier function
• Increased TEWL and reduced hydration
• Increased levels of a serine protease Worsen the barrier function
12. Enviornmental factors:
• UV radiation: Activation of TRPV4 Induces neuro-inflammation
Promotes skin fibrosis or solar elastosis
• Heat and noxious cold: TRPV1 & TRPA1
• Dietary factors
• Exercise
• Stress
• Smoking: Decreases risk
16. CLINICAL FEATURES
• Common sites: Central face (Nose, chin, central cheeks, glabella)
• Hallmark: Flushing
• Comedones: Absent
• Gender and age dependent symptoms:
1. Younger female and males: Erythema and flushing are first signs
2. Elderly: Telengectasia is the first sign
3. Rhinophyma: Males>>Females
17. • Flushing:
Flushing involves reactive vascular changes in the face that can be observed in normal
individuals for a few seconds or few minutes
Physiological: Heat, certain foods, alcohol, exercising, or stressful emotional stimuli
Flushing in rosacea is a pathophysiological neurovascular process in the central face
experienced for more than 5 to 10 minutes because of neuropeptide release
Associated with burning pain/stinging
18. • Transient erythema
Prolonged non-physiological flushing that persists for more than 5 minutes and
possibly as long as weeks or a few months but for no more than 3 months
• Persistent erythema:
> 3 months
Caused by vasodilation of arterioles or capillaries Increased perfusion Redness
Usually perilesional
• Telengiectasia:
Permanent visible dilated blood vessel on the skin or mucosal surface
19. Erythematotelangiectatic rosacea:
• Skin type 1 or 2
• Facial erythema with telangiectases
• Tendency to flush with triggers
• Skin sensitivity and dryness – easily irritated skin, frequent burning and
stinging sensation
• Intolerance of sunlight/harsh winds
21. Papulopustular rosacea:
• Erythema: Mainly centrofacial & perilesional erythema
• Telangiectases may be present
• Dome‐shaped erythematous papules and papulopustules mainly on the
central face
• Flushing and skin sensitivity ++
• Dryness/dermatitis may be present in severe cases
22.
23. Phymatous rosacea:
• Persistent, firm, painless, non-pitting swelling of the tissue
• Nose (rhinophyma)
• Chin (gnathophyma)
• Forehead (metophyma)
• Ears (otophyma)
• Eyelids (blepharophyma)
24. • Brandy nose/potato nose/copper nose/bulbous nose
• > 40 yrs
• Males >> Females
• Begins initially in the skin of the alae nasi and at the distal end of the nose as
dilated patulous follicles
• Overlying skin is oily
• Compression White pasty matter
27. Ocular rosacea:
• Bilateral>>Unilateral
• Dry, gritty sensation, watering of eyes
• Conjunctival telangiectasia
• Collarettes of scale around base of the eyelashes
• Blepharitis with crusting
• Chalazia (painless) and hordeola (painful)
• Conjunctivitis, keratitis, episcleritis, scleritis, iritis
28. ATYPICAL VARIANTS:
1) Granulomatous rosacea:
Acne agminata, Acnitis, Lupus miliaris disseminatus faciei, Lupoid rosacea of
Lewandowsky
Rare clinicopathological entity in which persistent, firm, non‐tender, red to
brown papules or nodules around mouth, eyes or cheeks
Monomorphic lesions
May resolve with scarring
29. Small, firm, monomorphic, plum‐red
papules
Granulomatous inflammatory infiltrates
destroying the hair follicles with the presence
of Demodex folliculorum at the follicular
ostium
30. 2) Rosacea conglobate:
Rare, chronic, and severe form of rosacea
Haemorrhagic nodular abscesses and indurated plaques on erythematous
background
31. 3) Rosacea fulminans/Pyoderma faciale-O’Leary:
Rare disorder
Mainly affects women
20-30 yrs
Onset: Days to weeks
Sites: Affects complete face—particularly chin, cheeks, forehead, and nose—or
remain localized, especially when present on the neck or trunk
32. Lesions: Papulopustules and coalescent purplish nodules, abscesses,
fistulae that drain a serous, sero-purulent, or mucoid discharge
Systemic symptoms: Absent
Rosacea fulminans: Marked erythema with coalescing
nodules and pustules on the face
33. 4) Halogen rosacea:
Ingestion of Iodides/Bromides might cause a rosacea-like reaction or
deteriorate a pre-existing rosacea
Sources: Citrus-flavored soft drinks (cola drinks), sea food, diagnostic
radiocontrast media, pool disinfectants, certain topical antiseptics,
permanent hair wave formulations, drugs (eg: thyroid medication,
chemotherapeutics)
34. Features: Erythematous pustules, vegetative nodules, fungating nodules,
small to large blisters, exudative plaques, ulcer, a circumscribed
panniculitis, or combinations of these presentations
Condition typically improves in 4 to 6 weeks after elimination of the
exposure
Scarring and post-inflammatory pigmentation might occur
35. 5) Steroid rosacea:
When a patient with rosacea is treated with topical corticosteroids for a prolonged time
1. Atrophic side effects of the medication sometimes lead to an aggravation of the
condition
2. Immunosuppression Increased colonization of Demodex mites
Patient develops telangiectasia, atrophy, follicular papulopustules & nodules
The presentation is typically restricted to the area of corticosteroid application
Associated with pain
37. 6) Gram-Negative Rosacea:
Due to prolonged treatment of a rosacea patient with a topical or systemic
antibiotic that covers gram-positive bacteria
Characteristic clinical finding is the development of miniscule yellow
pustules on an erythematous background
38. 7) Persistent edema of Rosacea:
Diffuse idiopathic solid upper-facial edema Morbihan
disease/Edematous rosacea
Seen as hard, non-pitting swellings of mainly of the forehead, eyelids,
cheeks, nose & glabella.
Accompanied by erythema in later stages
40. DIAGNOSTIC CRITERIA:
• National rosacea Society Expert committee (One or more primary features
with or without secondary features)
PRIMARY FEATURES SECONDARY FEATURES
• Flushing
• Non-transient erythema
• Papules and pustules
• Telangiectasia
• Burning or stinging
• Plaques
• Dry appearance
• Edema
• Ocular manifestations
• Peripheral location
• Phymatous changes
43. DIAGNOSIS
• Mainly clinical
• Biopsy:
• Different sub-types Different findings
• Common finding: Histological evidence of chronic actinic damage
44. 1) ETTR:
• Enlarged and dilated bizarre‐shaped capillaries and venules in the upper part
of the dermis
• Mild perivascular and interstitial lymphocytic infiltrate with frequent plasma
cells
• Occasional Demodex mites may be present within the follicles
• Solar elastosis ++
45. 2) PPR:
• Inflammatory infiltrate Follicles>>perivascular numerous
neutrophils, plasma cells and less commonly eosinophils,
lymphocytes
• Ruptured follicles with granulomatous changes Remnants of
Demodex mite
47. TREATMENT
GENERAL MEASURES:
(1) Avoidance of trigger factors
(2) Photoprotection:
• Physical measures
• Sunscreens: Broad spectrum, SPF >30, Physical >> Chemical suncreens
(3) Regular use of gentle cleansers for the whole face Soap‐free, pH‐balanced
cleansers and lukewarm water to wash the face
48. (4) Frequent use of moisturizers if dry skin is an issue
(5) Usage of foundations (Matte-green toned) and facial coverage without
aggravating symptoms of rosacea: Containing silicone, water soluble cosmetics
(6) Avoidance of rubbing the face
(7) Avoid astringents, toners and abrasive exfoliators, and procedures such as
dermabrasion, water proof cosmetics, cosmetics that contain alcohol, menthols,
camphor, fragrance, peppermint and eucalyptus oil
49. BOTANICALS:
• Anti-oxidant and vasomotor properties: Reduces inflammation, irritation
and facial redness
• Green tea extract
• Aloe vera
• Allantoin
• Ginkgo biloba
50. TOPICAL:
• Azelaic acid 15%, 20% (Reduces the levels of kallikrein 5 and cathelicidin)
• Metronidazole 0.75%, 1% (Reduces ROS)
• Sodium sulfacetamide 10% (Anti-inflammatory action)
• Alpha adrenergic agonists (Vasoconstriction Reduces erythema)
• Brimonidine 0.5% gel OD
• Oxymetazoline (Phase III trials)
58. REFERENCES
1) Fitzpatrick’s textbook of dermatology
2) Rook’s textbook of dermatology
3) Bolognia dermatology
4) Rosacea: a Clinical Review by Mikkelsen et al
5) Recent advances in understanding and managing rosacea by Buddenkotte
et al
6) Rosacea in skin of color: A comprehensive review by Sarkar et al
