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