ROSACEA(ACNE ROSACEA)

WHAT IS ROSACEA?CHRONIC RELAPSING DISORDER WITH CHRONIC RELAPSING DISORDER WITH VARIABLE DEGRESS OF…..VARIABLE DEGRESS OF…..

•Persistent centrofacial erythema

•Telangiectasias

•Inflammatory papules

•Inflammatory pustules

•Nodules

•Edematous plaques (non-pitting)

•Ocular inflammation

•Phymatous changes

ROSACEA

• Onset during middle age, with women being affected somewhat earlier than men.

• Rosacea occurs most frequently in Caucasians and in those with fair sun-sensitive skin, i.e. skin phototypes I and II.

• There may be a genetic predisposition to the disorder, as 10–20% of patients report a family history of rosacea.

CLINICAL PICTURE OF ROSACEA

SYMPTOMS OF ROSACEA

• ITCHY RASH ON FACE

• “STINGS”

• “BURNS”

• TOPICAL CREAMS NOT HELPFUL

• NO NEW MEDS

• NO NEW SOAPS OR PERFUMES

• In 2002, a consensus publication provided a classification scheme for rosacea into four major forms with distinct clinical characteristics.

• Each subtype is graded into mild, moderate and severe (grades 1–3).

CLASSIFICATION OF ROSACEASubtypeSubtype Predominant clinical featuresPredominant clinical features

Erythemato-Erythemato-telangiectatictelangiectatic

1.1. Persistent centrofacial erythemaPersistent centrofacial erythema2.2. FlushingFlushing3.3. TelangiectasiasTelangiectasias4.4. Skin sensitivitySkin sensitivity

PapulopustularPapulopustular1.1. Persistent centrofacial erythemaPersistent centrofacial erythema2.2. PapulesPapules3.3. Pustules/papulopustulesPustules/papulopustules4.4. Overlap with other subtypes may occurOverlap with other subtypes may occur

PhymatousPhymatous

1.1. Thickened, nodular skin Thickened, nodular skin 2.2. Prominent poresProminent pores3.3. Can affect nose (rhinophyma), chin (gnathophyma), Can affect nose (rhinophyma), chin (gnathophyma),

forehead (metophyma), ears (otophyma), eyelids forehead (metophyma), ears (otophyma), eyelids (blepharophyma)(blepharophyma)

4.4. May be associated with other features of rosacea or May be associated with other features of rosacea or occur in isolationoccur in isolation

OcularOcular1.1. Dry, gritty sensation, pain or photophobiaDry, gritty sensation, pain or photophobia2.2. Blepharitis & ConjunctivitisBlepharitis & Conjunctivitis3.3. Chalazia and hordeolaChalazia and hordeola4.4. Keratitis, episcleritis, scleritis, uveitis (rare)Keratitis, episcleritis, scleritis, uveitis (rare)

1. ERYTHEMATOTELANGIECTATIC ROSACEA

Patients typically have skin phototypes I or II

Severity of Erythematotelangiectatic rosacea

Erythematotelangiectatic rosacea. Persistent erythema of the medial and lateral

cheeks is seen. In this patient, there are no telangiectasias, indicating mild (grade 1) disease.

Telangiectasias

Telangiectasias become progressively

prominent, forming sprays on the nose,

nasolabial folds, cheeks and glabella

2. PAPULOPUSTULAR ROSACEA

• C/O: C/O: slight tenderness or itch but social distress caused by the appearance of the eruption far exceeds the physical symptoms.

• C/F:C/F: Centrofacial eruption of multiple, small (<3 mm), dome-shaped, erythematous papules, some of which are surmounted by a seropustule can appear singly or in crops.

• Individual lesions last about 2 weeks then subside into a blotchy erythema, which gradually fades & others appear.

• Usually no resultant scarring.

Severity of papulopustular rosacea

Mild papulopustular rosacea

Moderate papulopustular rosacea of the forehead. Note the superficial nature of the

inflammatory lesions. 

Moderate to severe papulopustular rosacea.

There is a typical centrofacial distribution. In addition, the skin has a scaly, crusty surface and

this is often a sign of more severe disease. 

Severe papulopustular rosacea

Dense erythema, Papules, pustules,

nodules.Telangiectasias severe, diffuse. Variable

plaque-like edema

3. PHYMATOUS ROSACEA • Most commonly rhinophyma

• Occurs primarily in men.

• Reflects hypertrophy of the sebaceous glands & connective tissue in nasal skin.

• May occur with sever rosacea, but surprisingly, patients with rhinophyma may only have mild rosacea.

• Rhinophyma is usually seen in patients with other features of rosacea but may occur in patients with acne vulgaris; occasionally it is due to chronic actinic damage or may arise de novo.

Severity of phymatous rosacea

The earliest clinical sign of rhinophyma is the appearance of dilated pores (patulous follicles)

on the distal portions of the nose

RHINOPHYMA – EARLYTelangiectatic vessels of the distal nose may

predispose to subsequent development of hypertrophic changes of rhinophyma

RHINOPHYMAMODERATE

SEVERE RHINOPHYMAHypertrophy of tissue with nasal distortion as soft, fleshy, nodular growths increase in size.

4. OCULAR ROSACEA

• Can occur without accompanying cutaneous changes or it may be seen in patients with any of the other subtypes of rosacea.

• C/OC/O: nonspecific; itching, tearing, dryness, gritty sensations, crusting of eyelids & an inability to wear contact lenses, as well as frequent styes.

Severity of ocular rosacea

OCULAR ROSACEAOCULAR ROSACEA

There may be tiny concretions at the bases of the cilia (conical dandruff), or mild scaling of the

eyelid margins (scurf).

Hordeolum

Common, may be first sign of rosaceavariable presentation

4. OCULAR ROSACEA

• May need ophthalmological consultation especially (grade 3) disease

• Keratitis may lead to blindness

VARIANTS OF ROSACEA1. GRANULOMATOUS ROSACEA:

Persistent red–brown to skin-colored facial papules with a characteristic non-caseating granulomatous histology.

2. ROSACEA CONGLOBATA: inflammatory facial cysts with associated scarring.

3. ROSACEA FULMINANS (pyoderma faciale): characterized by explosive onset of inflammatory papules and pustules superimposed on a back-ground of facial erythema & fever may occur.

PATHOGENESIS OF ROSACEA

WHAT CAUSES ROSACEA?

• The exact cause is unknown.• May be; • Demodex mite infestation?• Solar damage? Heat? Caffiene?• Lymphatic obstruction? Emotional stress?

TRIGGERS OF ROSACEA

1.1. Sun exposure 81%Sun exposure 81%2.2. Emotional stress 79%Emotional stress 79%3.3. Hot weather 75%Hot weather 75%4.4. Wind 57%Wind 57%5.5. Heavy exercise 56%Heavy exercise 56%6.6. Alcohol consumption Alcohol consumption

52%52%7.7. Hot baths 51%Hot baths 51%8.8. Cold weather 46%Cold weather 46%9.9. Spicy foods 45%Spicy foods 45%10.10.Humidity 44%Humidity 44%11.11.Indoor heat 41%Indoor heat 41%

12.12. Certain skin-care Certain skin-care products 41%products 41%

13.13. Heated beverages 36%Heated beverages 36%14.14. Certain cosmetics 27%Certain cosmetics 27%15.15. Medications(specificallMedications(specificall

yy stimulants) 15%stimulants) 15%16.16. Medical conditions Medical conditions

15%15%17.17. Certain fruits 13%Certain fruits 13%18.18. Marinated meats 10%Marinated meats 10%19.19. Certain vegetables 9%Certain vegetables 9%20.20. Dairy products 8%Dairy products 8%

• H. pylori

Demodex Found within follicular infundibula & sebaceous ducts…

Commensal organisms….

Edematous papules of Demodex folliculitis

(demodicidosis) superimposed upon the

characteristic background erythema .

Microscopic findings of follicular contents obtained via scraping

of Demodex folliculitis.

HISTOPATHOLOGY OF ROSACEA

Erythematotelangiectatic rosacea

Papulopustular rosacea

Rhinophyma

Granulomatous rosacea

Demodex folliculorum residing in hair follicle

Histopathology of rosacea

• Telangiectasia of superficial blood vessels;

• Perivascular infiltrates of lymphocytes (mild to moderate in intensity) and, sometimes, plasma cells.

• Active pustular lesions show superficial folliculitis.

• Older lesions show granulomatous perifolliculitis.

• Demodex mites are noted (20-50% cases)

Histopathology of rosacea

• Well-circumscribed collections of epithelioid histiocytes, usually peri-infundibular.

• Granulomas surrounded usually by lymphocytes and, sometimes, plasma cells.

• Small collections of neutrophils in some granulomas.• Caseous necrosis may be present within some

granulomas. • Rhinophyma: Sebaceous gland hypertrophy and

scattered follicular plugging.

DDx OF ROSACEA

SubtypeSubtype DDxDDx

Erythemato-Erythemato-telangiectatictelangiectatic

1.1. Chronic actinic damage (dermatoheliosis) in fair-Chronic actinic damage (dermatoheliosis) in fair-skinned individualsskinned individuals

2.2. Seborrheic dermatitis Seborrheic dermatitis 3.3. Cutaneous lupus erythematosusCutaneous lupus erythematosus4.4. Keratosis pilaris rubra faciei Keratosis pilaris rubra faciei 5.5. Contact dermatitis (Allergic or Irritant)Contact dermatitis (Allergic or Irritant)

PapulopustularPapulopustular1.1. Acne vulgarisAcne vulgaris2.2. Seborrheic dermatitisSeborrheic dermatitis3.3. Periorificial dermatitis Periorificial dermatitis 4.4. Steroid-induced rosacea. Steroid-induced rosacea. 5.5. Demodex folliculitis.Demodex folliculitis.

PhymatousPhymatous 1.1. Lupus pernio Lupus pernio 2.2. Lupus vulgarisLupus vulgaris

OcularOcular1.1. Seborrheic dermatitis Seborrheic dermatitis 2.2. Allergic contact dermatitis.Allergic contact dermatitis.3.3. Periocular dermatitis Periocular dermatitis 

DDx OF ROSACEA

Dermatoheliosis

Seborrheic dermatitis

Malar flush

Keratosis pilaris rubra faciei Keratosis pilaris rubra faciei

Contact dermatitis Contact dermatitis

ROSACEA VS. ACNE

ROSACEA ROSACEA ACNEACNE

ADULTSPAPULESPUSTULESNO COMEDONESERYTHEMATELANGIECTASIAS

TEENSPAPULESPUSTULESCOMEDONESNO ERYTHEMANO TELANGIECTASIAS

Steroid rosacea

Demodex folliculitis.Demodex folliculitis.

Lupus Pernio

Lupus Vulgaris

TREATMENT OF ROSACEA

Treatment of rosacea

Treatment of rosacea• On 2013, FDA approved

brimonidine (Mirvaso®) topical gel, 0.33% for the (first and only) topical treatment of persistent facial erythema of rosacea in adults 18 years of age or older.

• It is not indicated for the treatment of inflammatory lesions (papules and pustules) of rosacea.

• It is selective alpha-2 adrenergic agonist causing cutaneous vasoconstriction.

Treatment of rosacea

250

Treatment – Cosmetic Repair

Treatment: CO2 laser, one treatment. Heal time was just

over 12 days.

• Avoid precipitating factors.

• Sometimes, successful treatment of the inflammatory lesions of papulopustular rosacea reveals background telangiectasias (the PERT phenomenon – “post-erythema-revealed telangiectasias”)

• Topical and systemic therapies used to treat papulopustular rosacea are often ineffective in the treatment of erythematotelangiectatic rosacea and may irritate the skin.

EXPECTATIONS

• Tell them to expect improvement in 4-6 weeks• Tell them to continue regimen until next visit• May give topicals for maintenance otherwise,

relapse is likely 3 to 6 months after discontinuation of treatment.

• Inform them there is no cure for rosacea!!!!!!!!

LUPUS MILIARIS DISSEMINATUS FACIEI

(LMDF)

LMDF

• Uncommon chronic inflammatory facial dermatosis. It presents with pale papules which may be confused with sarcoid or syringoma clinically.

• Many authors now consider LMDF to be an extreme variant of granulomatous rosacea. Others believe it is a distinct entity because of its characteristic histopathology and occasional involvement of non-central facial areas.

LMDF• Age; Young adults in their 20s most often

are affected.

• Etiology; and pathogenesis are unknown.

• Active disease usually involves a 1- to 3-year course and resolves spontaneously.

• Recurrences are not described.

• LMDF may result in disfiguring scarring.

• Educate patients about the nature of the disease to help alleviate anxiety and to establish realistic treatment expectations.

C/P of LMDF

• Papules singly or in crops that are red, brown, or yellow-brown and appear on the central face, especially on and around the eyelids.

• Lesions occasionally may be generalized and appear on the extremities or trunk

• May present later as crusts, pustules ultimately, scars.

Histopathology of LMDF• In LMDF, sections show

round granulomas composed of epithelioid cells with central caseating necrosis.

• The granulomas may appear sarcoidal or tuberculoid typically arise adjacent to adnexal structures.

• A chronic inflammatory infiltrate often present.

• Late lesions show fibrosis

Treatment of LMDF

• Surgical: Scar revision procedures (laser resurfacing,

dermabrasion, chemical peel) may benefit patients after the disease has run its course.

REFERENCES

• Dan Ladd, D.O. Texas/KCOM Dermatology Residency Program Program Director Bill V. Way, D.O.

• Bolognia 3rd ed.

• http://dermnetnz.org/acne/rosacea.html

• http://emedicine.medscape.com

THANK YOU