Rosacea: Relieving a Chronic Inflammatory Facial Disorder
Rosacea is a common, but frequently misunderstood, skin condition. As it affects the face and is unsightly, rosacea can cause considerable social distress, especially because of the historical belief that alcohol is involved in its causation. This article outlines the clinical features of rosacea and the standard subtype classification of the condition. The theories of pathogenesis are outlined and the management approaches are discussed.
Key words: rosacea, classification, rhinophyma, ocular disease, management.
Introduction
Rosacea is a chronic recurrent inflammatory dermatosis primarily affecting the central areas of the face and is characterized by varying degrees of facial redness (erythema), inflammatory lesions (papules and pustules), puffiness (edema), a high colour and broken blood vessels (telangiectasias), enlargement of the nose (rhinophyma), discomfort or inflammation of the eyes (ocular rosacea), and a propensity to flush.1 Ocular involvement occurs in over 50% of patients.2
Rosacea is relatively common and is estimated to affect up to 14 million people in the United States.3 The prevalence of rosacea is highest among fair-skinned individuals, especially those of Celtic origin, and is uncommon in dark- skinned individuals.1
The onset of rosacea in the majority of patients is between thirty and sixty years of age, and the disease continues to remit and relapse for many years into old age. It affects more women than men. However, males more frequently develop rhinophyma, the swelling and distortion of the nose due to sebaceous gland and connective tissue hyperplasia. Rosacea has been reported to be associated with seborrheic dermatitis, migraine headaches in women, and possibly H. pylori infection of the stomach.1 A rosaceiform eruption can be induced by the topical application of fluorinated cortico-steroids and tacrolimus ointment.1
Like all facial eruptions, rosacea has a significant psychosocial impact and therefore a sympathetic approach by the physician to the diagnosis and management of this condition is critical. The common misconception that rosacea may be linked with alcohol misuse means this condition can be particularly socially distressing for the sufferer. An association between rosacea and depression has been suggested in one study.18
Clinical Features
Symptoms and signs of rosacea include facial flushing, persistent centrofacial erythema, inflammatory papules and pustules, telangiectatic vessels, and hypertrophy of the sebaceous glands with fibrosis. Ocular changes can range from mild blepharitis and conjunctivitis through to sight-threatening keratitis.2 Typically, rosacea follows a pattern of remission and exacerbation. While there is often an overlap of clinical features, in the majority of patients a particular aspect of the clinical presentation of rosacea dominates. This allows clinicians to classify rosacea into four subtypes: erythematotelangiectatic (subtype 1), papulopustular (subtype 2), phymatous (subtype 3), and ocular (subtype 4) (Table 1).4 The severity of each subtype can be graded as 1 (mild), 2 (moderate), or 3 (severe).4 The significance of classifying rosacea relates to the selection of appropriate therapy.
Diagnosis and Differential Diagnoses
The diagnosis of rosacea is based on the clinical features (Table 1). There is no laboratory test (including histological examination of affected skin biopsy material) that will confirm the diagnosis. Tests are usually undertaken to exclude alternative conditions (e.g., skin biopsy, antibody screens) (Table 2). The clinical presentation of rosacea is discussed under the four classified subtypes.
Clinical Presentation
Subtype 1
Patients with erythematotelangiectatic rosacea often complain of troublesome flushing and have persistent central facial