Publish date: Posted on
Last updated: October 22, 2023
Keywords #
rosacea
acne rosacea
demodex
rhinophyma
flushing
Diagnosis #
Rosacea is a common chronic inflammatory skin disorder primarily of the central face. Rosacea often presents with flushing, erythema, pustules, edema, burning, and stinging; which can result in physical and emotional discomfort.[1]
Rosacea has historically been classified based on clinical subtypes (e.g. erythematotelangiectatic, papulopustular, phymatous, or ocular rosacea); however, a more recent recommendation is to characterize patients by their individual clinical manifestations. These include central facial erythema, with or without papulopustular lesions, phymatous changes, ocular signs and symptoms, facial telangiectasias, and persistent facial erythema that remains between flares of rosacea.[2,3]
Recent research suggests that both genetics and the environment play a role in the development of rosacea. Dysregulation of growth factors and cytokines of the immune system, including vascular endothelial growth factor (VEGF), matrix metalloproteinases (MMPs), interleukin-26 (IL-26), and T-helper type 1 (TH1) and T-helper type 17 (TH17) cells, have been implicated in initiating neurovascular and pro-inflammatory changes in the skin, which may lead to the cutaneous features of rosacea.[1]
Key Concepts #
- Rosacea is a common, chronic inflammatory skin disorder.
- Rosacea can often be distinguished from acne vulgaris by its distribution primarily over the central face, the presence of underlying erythema, flushing tendency, and the absence of comedones.
- Triggers that aggravate rosacea flares include changes in temperature, sunlight, caffeine, spicy food, alcohol, and stress.
- Treatments include topical therapies like metronidazole, sodium sulfacetamide-sulfur, azelaic acid, ivermectin, brimonidine, and oxymetazoline; systemic therapies include doxycycline, ivermectin, and isotretinoin. Demodex infestation warrants topical or oral ivermectin.
Epidemiology #
The worldwide incidence of rosacea is approximately 18% and is found predominately in regions of traditionally fair-skinned individuals.[1,4] It has been observed that Demodex mite infestations are increased in some patients affected by rosacea, though a direct causation has yet to be established.[1] Rosacea is typically diagnosed after age 30 years with a slight female predominance.[4] Of note, the phymatous features of rosacea are predominately seen in men.[4] Rosacea has been associated with respiratory disease, hypertension, and metabolic disorder.[5] Several genome-wide association studies have shown single nucleotide polymorphisms in butyrophilin-like 2 (BTLN2) and human leukocyte antigen-DRA genes.[1]
Clinical Features #
- Hallmark features of rosacea include central facial erythema with or without papules, pustules, telangiectasias, and rhinophyma.[6]
- Patients may have sensations of stinging, burning, or pruritus that may extend from the face onto the chest.
- Additionally, individuals may experience a “gritty” sensation in the eyes which may be a symptom of ocular rosacea.[6]
Differential Diagnoses #
- Acne vulgaris
- Seborrheic dermatitis
- Contact dermatitis
- Demodicosis
- Periorificial dermatitis
- Photodamage
- Carcinoid syndrome
- Cutaneous lupus erythematosus
Distinguishing acne rosacea from acne vulgaris is difficult, but several distinguishing features in rosacea are: the absence of comedones and the presence of telangiectasias and underlying erythema.[7] Age of onset may also be considered when distinguishing rosacea from other similar-appearing cutaneous disorders.
Diagnostic Workup #
The diagnosis of rosacea is clinical and made in the context of a patient’s history and physical exam findings.
Treatment #
Rosacea is a chronic disorder. Proper skin hygiene, sun protection, and trigger avoidance are essential in the management of rosacea, however there are numerous medical and procedural therapies available for the diverse clinical features of rosacea.
For flushing and erythema, topical beta-2-adrenergic agonist, brimonidine, and an alpha-1A-adrenergic agonist, oxymetazoline hydrochloride, may be used.[1] For erythema and telangiectasia, pulsed-dye laser and intense pulsed light therapy are effective.[1] For inflammatory rosacea with papules and pustules, topical ivermectin, metronidazole, azelaic acid, and sodium sulfacetamide sulfur, or oral doxycycline, ivermectin, or isotretinoin are commonly used.[1] For phymatous changes, medical therapy with tetracyclines may reduce inflammation and sebaceous gland proliferation and physical modalities such as phymectomy or laser ablation can sculpt phymatous tissue.[1]
Slide Viewer #
https://utahderm.med.utah.edu/image-viewer/References #
- Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000Res. 2018;7:F1000 Faculty Rev-1885.
- Gallo RL, Granstein RD, Kang S et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148–155.
- Del Rosso JQ, Tanghetti E, Webster G, Stein Gold L, Thiboutot D, Gallo RL. Update on the Management of Rosacea from the American Acne & Rosacea Society (AARS). J Clin Aesthet Dermatol. 2019;12(6):17–24.
- Rainer BM, Kang S, Chien AL. Rosacea: Epidemiology, pathogenesis, and treatment. Dermatoendocrinol. 2017;9(1):e1361574.
- Rainer BM, Fischer AH, Luz Felipe da Silva D, Kang S, Chien AL. Rosacea is associated with chronic systemic diseases in a skin severity-dependent manner: results of a case-control study. J Am Acad Dermatol. 2015;73:604-8.
- Johnson SM, Berg A, Barr C. Recognizing Rosacea: Tips on Differential Diagnosis. J Drugs Dermatol. 2019;18(9):888-894.
- Wolf JE. Acne and rosacea: Differential diagnosis and treatment in the primary care setting. Medscape CME/CE. September 18th, 2019. https://www.medscape.org/viewarticle/441986
