Rosacea

Dr Pooya
February 24, 2025
12:17 am
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Overview

Rosacea is a chronic inflammatory skin condition primarily affecting the central face, typically starting between the ages of 30 and 60. Characterized by persistent facial redness, rosacea has a relapsing and remitting course, with symptoms managed through lifestyle measures, skincare, medications, and procedural interventions.

Causes of Rosacea

The pathogenesis of rosacea is multifactorial, including:

Genetic Susceptibility: Single nucleotide polymorphisms related to the class II major histocompatibility complex.
Altered Microbiome: Bacterial overgrowth in the small intestine, Helicobacter pylori infection, and increased density of Demodex folliculorum and Staphylococcus epidermidis.
Immune Dysregulation: Excessive inflammation, vasodilation, lymphatic dilatation, and angiogenesis due to dysregulated immune responses.
Neurocutaneous Mechanisms: Triggers such as UV radiation, temperature changes, exercise, spicy foods, alcohol, psychological stress, air pollution, and tobacco smoking.
Impaired Skin Barrier: Features of skin barrier impairment allow bacterial colonization and inflammation.
Innate and Adaptive Immunity: Increased expression and activity of toll-like receptor 2, cathelicidins, kallikrein 5, and mast cells, alongside dominant T-helper (Th)1/Th17 gene expression, contributing to inflammation.

Symptoms of Rosacea

Cutaneous features include:

Transient Recurrent Erythema: Flushing
Persistent Facial Erythema: Long-lasting redness
Telangiectasia: Visible blood vessels
Papulopustular Rosacea: Inflammatory papules and pustules
Phymatous Changes: Skin thickening, particularly on the nose (rhinophyma), more common in men
Ocular Rosacea: Inflammatory eye complications like blepharokeratoconjunctivitis and sclerokeratitis

Diagnosis of Rosacea

Rosacea is primarily diagnosed clinically based on the 2017 global ROSacea COnsensus (ROSCO) panel criteria, requiring one diagnostic criterion or two major criteria:

Diagnostic Criteria: Persistent centrofacial erythema, phymatous changes.
Major Criteria: Flushing, inflammatory papules and pustules, telangiectasia, ocular rosacea.
Minor Features: Burning, stinging, edema, dry skin sensation.

In cases of diagnostic uncertainty, a skin biopsy may be considered. Differential diagnoses include acne vulgaris, dermatitis, lupus, and others.

Treatment for rosacea can be highly effective but often targets only one feature, requiring combination therapies for multiple features or severe cases:

Treatment of Rosacea

Transient Erythema: Topical alpha-adrenergic agonists (brimonidine, oxymetazoline), oral beta-blockers (carvedilol), oral clonidine.
Persistent Erythema: Topical alpha-adrenergic agonists, intense pulsed light therapy, vascular laser.
Inflammatory Papules/Pustules: Topical azelaic acid, ivermectin, metronidazole, erythromycin, oral tetracyclines (oxytetracycline, lymecycline, doxycycline), oral macrolides (erythromycin, azithromycin), oral isotretinoin (for refractory cases).
Telangiectasia: Electrodesiccation, intense pulsed light therapy, vascular laser.
Neurogenic Rosacea: Gabapentin, amitriptyline, oral beta-blockers, endoscopic sympathectomy.
Phymatous Rosacea: Doxycycline, isotretinoin for inflamed cases, physical modalities (ablative CO2 laser, erbium laser, radiofrequency, surgical debulking) for non-inflamed cases.
Ocular Rosacea: Increased dietary omega-3 fatty acids, warm compresses, eyelid cleansing, topical azithromycin or calcineurin inhibitors for mild to moderate cases, oral azithromycin or doxycycline for severe cases.

Complications of Rosacea

Complications of rosacea can include:

Phymatous Rosacea: Thickened skin, particularly on the nose.
Ocular Complications: Conditions like blepharokeratoconjunctivitis and sclerokeratitis.
Psychosocial Impact: Increased anxiety, depression, low self-esteem, and social isolation.
Lifestyle Limitations: Avoidance of triggers leading to lifestyle restrictions.

Living with Rosacea

Rosacea can significantly impact quality of life, requiring ongoing management and support from healthcare providers. Patients should adhere to prescribed treatments, avoid triggers, and maintain a consistent skincare routine. Psychological support may also be beneficial for those experiencing significant psychosocial distress.

Conclusion

While rosacea cannot be cured, its symptoms can be effectively managed with a combination of lifestyle modifications, skincare, medications, and procedural interventions. Proper diagnosis and tailored treatment plans can significantly improve the quality of life for individuals with rosacea.