ROSACEA
By Dan Ladd, D.O.
Texas/KCOM Dermatology Residency Program
Program Director
Bill V. Way, D.O.
CC: ITCHY RASH ON FACE• “STINGS”
• “BURNS”
• ONSET 2 DAYS
• TOPICAL CREAMS NOT HELPFUL
• PMX: NONE
• NO NEW MEDS
• NO NEW SOAPS OR PERFUMES
WHAT IS ROSACEA?
• VARIABLE DEGRESS OF…..
• CENTROFACIAL ERYTHEMA
• TELANGIECTASIAS
• PAPULES
• PUSTULES
• NODULES
• EDEMATOUS PLAQUES
EARLY ROSACEA (STAGE I)
• “FLUSHER-BLUSHERS”
• OFTEN < AGE 20
• NOSE/CHEEKS
• RECURRENT EPISODES OF BLUSHING.
• ERYTHEMA PERSISTS
• FEW TELANGIECTASIAS
STAGE I - TELANGIECTASIAS
STAGE I
• TELANGIECTASIAS BECOME PROGRESSIVELY PROMINENT, FORMING SPRAYS ON THE NOSE, NASOLABIAL FOLDS, CHEEKS AND GLABELLA
STAGE IIPAPULES & PUSTULES BEGIN, INCREASED ERYTHEMA AND TELANGIECTASIAS
STAGE III
DENSE ERYTHEMA
PAPULES, PUSTULES, NODULES.
TELANGIECTASIAS SEVERE, DIFFUSE
VARIABLE PLAQUE-LIKE EDEMA
ROSACEA VS. ACNE
• ADULTS
• PAPULES
• PUSTULES
• NO COMEDONES
• ERYTHEMA
• TELANGIECTASIAS
• TEENS
• PAPULES
• PUSTULES
• COMEDONES
• NO ERYTHEMA
• NO TELANGIECTASIAS
WHAT CAUSES ROSACEA?
• “VIRTUALLY NOTHING IS KNOWN ABOUT CAUSATION……….THE INFLUENCE OF HEREDITY IS MOOT, AS IS ALMOST EVERYTHING THAT HAS BEEN WRITTEN ABOUT ETIOLOGY” --A. Kligman
• Vasomotor lability? Hypertension?• Demodex mite infestation?• Solar damage? Heat? Caffiene?• Lymphatic obstruction? Emotional stress?
Found within follicular infundibula & sebaceous ducts…
Commensal organisms….
NOT Pathogenic organisms….
TRIGGERS
• HOT LIQUID BEVERAGES, SOUPS
• ALCOHOL / CAFFEINE
• SPICY FOODS
• SUN EXPOSURE
• IRRITATING COSMETICS/OTC
• HEAT – EXERCISE IN COOL AREAS.
COMPLICATIONS
• COMPLICATIONS:
• RHINOPHYMA – DISFIGURING, NOSE
• OPHTHALMIC ROSACEA
• LESS COMMON VARIANTS: GRANULOMATOUS, STEROID, GRAM-NEGATIVE, CONGLOBATA, FULMINANS
RHINOPHYMA - EARLY
RHINOPHYMAMODERATE
SEVERE
RHINOPHYMA
• OCCURS EXCLUSIVELY IN MEN.
• PROGRESSIVE INCREASE IN CONNECTIVE TISSUE, SEBACEOUS GLAND HYPERPLASIA, ECTATIC VEINS AND CHRONIC DEEP INFLAMMATION.
• MAY OCCUE WITH STAGE III ROSACEA, BUT SURPRISINGLY, PATIENTS WITH RHINOPHYMA MAY ONLY HAVE MILD ROSACEA.
Treatment – Cosmetic Repair
OCULAR ROSACEA
OCULAR ROSACEA
COMMON, MAY BE FIRST SIGN OF ROSACEA
VARIABLE PRESENTATION
OCULAR ROSACEA
• BLEPHARITIS
• CONJUNCTIVITIS
• PAIN, PHOTOPHOBIA
• IRITIS, IRIDOCYLITIS, KERATITIS
• MAY NEED OPHTHALMOLOGY CONS
• KERATITIS MAY LEAD TO BLINDNESS
TREATMENT - MILD
• SUNSCREENS
• TOPICAL SULFACETAMIDE/SULFUR
• TOPICAL METRONIDAZOLE
• ORAL TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE
Topicals- Sulfacetamide/Sulfur
• Klaron 10% Lotion
• Rosula Lotion (with Urea)
• Sulfacet R
• Rosanil Cleanser
• Ovace Cleanser
• Plexion Cleanser, Suspension and SCT
Topical Metronidazoles
• Noritate 1% cream, Once a Day
• Metrocream 0.75% BID
• Metrolotion 0.75% BID
• Metrogel 0.75% BID
Tetracyclines• Tetracycline 250-500mg QD or BID
• Very cheap, but must take 1 hour before or 2 hours after meals, less compliance
• Doxycycline 50-75-100mg QD or BID
• Generic, Doryx Pellets, Adoxa.
• Minocycline 50-75-100mg QD or BID
• Generic, Vectrin, Dynacin, Minocin
Tetracyclines
• Not for children due to teeth discoloration, may cause hyperpigmetation at sites of trauma in adults, stop medication if worsening headache occurs (pseudotumor cerebri)
• Photosensitivity reactions rare if patients on sunscreens
TREATMENT – SEVERE
• ORAL METRONIDAZOLE
• CLONIDINE 0.1mg QD or BID FOR FLUSHING HELPS
• PREDNISONE TAPER
• ISOTRETINOIN (ACCUTANE)
A SIMPLE REGIMEN FOR THE VAST MAJORITY OF
ROSACEA PATIENTS
• WASH FACE GENTLY WITH CETAPHIL DAILY FACIAL CLEANSER
• APPLY KLARON LOTION QAM
• APPLY SUNSCREEN
• WASH FACE AGAIN AT NIGHT
• APPLY NORITATE CREAM QHS
A GOOD START….
•KLARON LOTION, 4oz., apply qAM to face
•NORITATE CREAM, 30g, apply qHS to face
EXPECTATIONS
• TELL THEM TO EXPECT IMPROVEMENT IN 4-6 WEEKS
• TELL THEM TO CONTINUE REGIMEN UNTIL NEXT VISIT
• MAY GIVE ORAL TETRACYCLINES FOR FLARES
• INFORM THEM THERE IS NO CURE FOR ROSACEA!!!!!!!!!!!!!!!!!!!!
QUESTIONS