Rosacea

Published on 02/04/2015 by admin

Filed under Internal Medicine

Last modified 22/04/2025

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177 Rosacea

Instruction

Look at this patient.

Salient features

History

• Age (typically occurs between the ages of 30 and 50 years)

• Intermittent facial flushing

• Blushing of the face with caffeine, alcohol or spicy foods

• History of unilateral headaches (an increased incidence of migranous headaches accompanying rosacea has been reported).

Examination

• Red patch with telangiectasia, acneiform papules and pustules overlying the flush areas of the face: cheeks, chin and nose (Fig. 177.1). (The papules and pustules distinguish it from the rash of SLE.)

• Comment on the following:

• Rhinophyma or ‘whiskey nose’ or ‘rum blossom’ (Fig. 177.2) (irregular thickening of the skin of the nose with enlarged follicular orifices caused by hyperplasia of the sebaceous glands and hyperplasia of connective tissue); although rhinophyma is often referred to as ‘end-stage rosacea’, it may occur in patients with few or no other features of rosacea
• Blepharitis, conjunctivitis.

• Tell the examiner that you would like to obtain an opthalmological evaluation for chalazion and progressive keratitis, which can lead to scarring and blindness.

image

Fig. 177.1 Papulopustular rosacea.

image

Fig. 177.2 Rhinopyma.

Remember: The common misconception that both the facial redness and the rhinophyma associated with rosacea are caused by excessive alcohol consumption makes rosacea a socially stigmatizing condition for many patients.

Diagnosis

This patient has a red patch on the face with papules and pustules (lesion) caused by rosacea (aetiology), which is cosmetically disfiguring (functional status).

Advanced-level questions

How many types of rosacea have been described?

There are four subtypes of rosacea, with the severity of each subtype graded as 1 (mild), 2 (moderate), or 3 (severe):

1: Erythemato telangiectatic

2: Papulopustular

3: Phymatous rosacea, e.g. rhinophyma

4: Ocular.

How would you distinguish rosacea from acne?

Rosacea is distinguished from acne by age (middle-aged and older people), the presence of a vascular component (i.e. rosy hue, erythema and telangiectasia) and the absence of comedones.

Remember: The diagnosis of rosacea is a clinical one. There is no confirmatory laboratory test. Biopsy is warranted only to rule out alternative diagnoses, since histopathological findings are not diagnostic.

How would you manage such a patient?

• Avoid factors that provoke facial flushing

• Avoid sun; sunscreens to limit photodamage

• Topical therapy: metronidazole, sodium sulfacetamide, azelaic acid; these are usually effective in eliminating erythematous papules and pustules

• Oral tetracycline in those who fail to respond to topical therapy. Also useful in ameliorating nodular lesions and eye symptoms

• Hydrocortisone cream

• Retinoids: in resistant disease

• Yellow light laser for telangiectasia

• Surgical removal for rhinophyma.

What are the causes of red face in an adult?

• Malar rash of SLE

• Heliotrope rash of dermatomyositis

• Seborrheic dermatitis

• Perioral dermatitis.

What is the role of vascular endothelial growth factor in rosacea?

Vascular endothelial growth factor (VEGF) receptor–ligand binding may contribute to the vascular changes and cellular infiltration that occurs in rosacea. Expression of receptors for VEGF on both vascular endothelium and infiltrating mononuclear cells is observed in rosacea. Although not produced by endothelium, VEGF is present in epidermis and epithelium and is released from infiltrating cells (Br J Ophthalmol 2007;91:226–9).

It has been suggested that the painter Rembrandt had rosacea, which he depicted in his self portrait (Lancet 1997;350:1835–7).

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