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Rosacea

Rosacea

Rosacea is a common chronic disorder of the face that tends to occur in middle age but may start as early as 20 to 30 years of age. It is more common in cold climates and is said to be most common amongst the Celtic race. The condition is frequently associated with flushing and characteristically fluctuates from day to day. Clinical signs include erythema, telangiectasia, papules, pustules and nodules. Unlike acne vulgaris, comedones are not seen. Long-term disease may contribute to the development of rhinophyma. The disease generally affects the mid-facial region, ie nose, glabella area, cheeks and chin, and may be associated with ocular complications.

The aetiology of rosacea is unknown. Its relationship to the commensal skin mite Demodex folliculorum]remains obscure; however, some therapies aimed at controlling this mite (eg topical permethrin) can be effective in treating rosacea. Because of its association with flushing, it has been suggested it is a disorder of vascular regulation. An association with Helicobacter pylori infection has been postulated but the exact relationship is unclear.

Management of rosacea

Aggravating factors in rosacea are those which contribute to facial flushing, eg sun exposure, alcohol consumption, overindulgence in spicy foods, tea and coffee; these should be limited.

Although rosacea is not primarily an infective process, antibiotics remain the mainstays of therapy. The tetracyclines have an anti-inflammatory action mediated by inhibition of neutrophil chemotaxis and phagocytosis and suppression of granuloma formation. A direct effect of the tetracyclines on vascular endothelium has also been proposed.

Initial treatment is with topical antibiotics

metronidazole 0.75% gel OR erythromycin 2% gel OR clindamycin 1% solution, topically to affected areas, twice daily.

Topical corticosteroids should not be used. Sulfur 2% in sorbolene cream is an older but still effective topical treatment and may be suitable when antibiotics are contraindicated, eg pregnant or breastfeeding women.

Systemic treatment is necessary for more severe cases or when topical therapy alone is unsuccessful. Long-term use of some antibiotics is controversial because of the increasing evidence of antibiotic resistance in organisms worldwide. However, the disease is a chronic, relapsing process, which may need either repeated courses of antibiotics or permanent therapy with one of the following agents.

Initial treatment is with

doxycycline OR minocycline 50 to 100mg orally, daily with food.

If there is an inadequate response in 4 weeks, other antibiotics can be considered. Use

erythromycin OR tetracycline 500mg orally, daily in 2 to 4 divided doses.

Lack of success with one antibiotic does not infer any of the others will not be useful in treatment of this condition. Doxycycline and minocycline are the preferred antibiotics because of better patient compliance. Very severe cases can be referred to a dermatologist for therapy with isotretinoin.

 Rhinophyma

This hypertrophy of nasal sebaceous glands produces a swelling of the nose that may become disfiguring. Although it is popularly believed that rhinophyma is caused by excess alcohol intake, there is no specific association between the two. It is more common in men over the age of 45 years.

The proposed mechanism is chronic inflammation, vascular proliferation and chronic oedema leading to fibrosis.

Specialist referral for surgical correction is advisable. The treatment of choice is carbon dioxide laser therapy. Shave excision is also effective. Active rosacea should also be treated long term, as it is presumed, though never proven, that long-term control of rosacea prevents development of rhinophyma and prevents recurrence in patients who have had laser surgery for rhinophyma.

 Perioral dermatitis

This eruption is seen predominantly in women between the ages of 20 and 50 years. It is usually papular but may be pustular. It is most commonly found on the chin, paranasal area and lower eyelids.

Although the application of potent topical corticosteroids has long been implicated in its aetiology, many patients will not have been applying topical corticosteroids when the eruption appears. The occlusive effect of cosmetics probably plays a crucial role.

Initial therapy is with oral antibiotics. Use

minocycline 100mg OR doxycycline 100mg OR tetracycline 500 to 1000mg orally, daily for 3 to 6 weeks.

Topical therapy is not as effective but can be used when oral antibiotics are refused or contraindicated. Use

metronidazole 0.75% OR erythromycin 2% gel applied twice daily

OR

sulfur 1% in sorbolene cream applied at night.

However, topical agents often are very irritating and bland lotions or bathing may need to be used instead.

Treatment in pregnancy can be difficult, but erythromycin is safe to use. The eruption may persist into the puerperium, when tetracyclines can be used if the patient is not breastfeeding.

The eruption can be persistent if cosmetic use is not modified. Any further use of potent corticosteroids on the face is to be strongly discouraged.

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