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Latest update 29/06/2010
This chapter is set out as follows:
Aetiology
- The cause in largely unknown
- Chronic vasodilatation (perhaps due to a primary error in vascular control) predisposes this condition
Key diagnostic features
- Age - adults and older patients. Bi-modal prevalence of 20-30 years of age with a larger peak at 40-50 years
- More common in patients with fair skin and blue eyes
- Aggravating factors
- Anything that aggravates flushing including sunlight, caffeine, alcohol, spicy food
- Drugs that cause vasodilatation
- Topical steroids
- Symptoms
- The onset of rosacea is often preceded by a history of episodic flushing
- The erythema associated with rosacea if often described as burning or stinging
- Clinical features
- Erythema - initially intermittent but becomes more permanent
- Telangiectasia
- Papules and pustules
- Absence of open comedones (blackheads), unlike in acne vulgaris
- Thickening of the skin can occur when chronic
- Distribution – central face (forehead, nose, cheeks and chin) with sparing of the peri-oral and peri-orbital areas
- A rhinopyhma represents marked thickening of the nasal skin and can cause serious disfigurement
- Eye involvement
- Occurs in over 50% of patients
- A wide range of presentations such as gritty eyes, conjunctivitis, blepharitis, episcleritis and chalazion. Keratitis is a more serious complication
Management
- Minimise factors that may aggravate symptoms
- Tea and coffee, especially taken hot or strong
- Alcohol
- Mustard, pepper, vinegar, pickles or spicy foods
- Excessive heat
- Direct sunshine
- Topical steroid
- Emollients
- Papular / pustular lesions
- Topical agents – if symptoms mild, topical agents should be sufficient as first line e.g. Metronidazole 0.75% gel or cream BD, or Azealic acid 15% cream BD
- Systemic treatments – use if topical agents fail or if presenting symptoms more severe. Use a tetracycline (e.g. oxytetracycline 500 mg BD, lymecycline 408mg OD - both on an empty stomach) or erythromycin 500mg BD. Initial treatment should be for at least 3 months
- Recurrent symptoms – for infrequent recurrences a course of treatment can be repeated as above. If symptoms recur frequently the patient may choose to remain on a lower dose of an antibiotic to reduce flare-ups
- More severe symptoms that respond poorly - refer to a dermatologist for consideration of other treatments such as low dose isotretinoin
- Flushing / erythema / telangiectasia
- Can sometimes be the predominant symptoms
- They tend not to respond to antibiotics
- Flushing may he helped by a non-selective cardiovascular beta-blocker such as propranolol 40 mg BD or clonidine 50 micrograms BD
- Persistant erythema / telangiectasia - laser therapy using a pulsed-dye laser can be very effective although improvement is not permanent. Only a few commissioners will provide laser treatment for rosacea on the NHS
- Consider camouflage e.g. green cream, or refer to the British Red Cross, which run free clinics across the UK, normally in association with hospital dermatology departments
- Rhinophyma
- Responds very well to CO2 laser ablation
- Ocular symptoms
- Lid hygiene: clean the eyelids using cotton wool soaked in cooled boiled water
- Artificial tears: should be applied liberally throughout the day. If necessary a lubricating ointment, sometimes containing an antibiotic preparation may be used at night
- Systemic tetracyclines are the most effective treatment for ocular rosacea. Erythromycin can be taken orally for patients intolerant to tetracyclines
- Retinoids should be avoided in patients with significant ocular symptoms as they can worsen symptoms and lead to a severe keratitis
- Troublesome ocular symptoms that persist despite of treatment should be referred to an ophthalmologist. Patients with potentially more serious symptoms such as keratitis should be seen without delay
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