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Rosacea

Rosacea

Rosacea (commonly referred to as adult acne) is a chronic inflammatory condition affecting the central face of adults (it is rare in children) and manifested by redness of the forehead, eyelids, cheeks, nose, and chin.

 

Rosacea is often accompanied by inflammatory papules (raised bumps) and pustules (bumps containing pus), or rarely with enlargement of the connective tissues beneath the skin (termed phymatous rosacea), including the nasal tissues (known as rhinophyma).

 

Pimples are sometimes included as part of the definition. Unless it affects the eyes, it is typically a harmless cosmetic condition. Treatment in the form of topical steroids can aggravate the condition.

 

It primarily affects Caucasians of mainly northwestern European descent and has been nicknamed the 'curse of the Celts' by some in Britain and Ireland, but can also affect people of other ethnicities. Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.

 

Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp. In some cases, additional symptoms, such as semi-permanent redness, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.

Symptoms

People with rosacea have red faces often accompanied by inflammatory papules and pustules. Patients can appear to have acne, but they lack comedones (blackheads). Occasionally, the eyelids and conjunctiva can become involved, resulting in ocular irritation and rarely to chronic corneal damage.

 

More rarely, there is fibrosis (scarring) of the connective tissue of the facial skin associated with hypertrophy (enlargement) of the sebaceous glands, resulting in a thickened appearance. Thickening of the skin of the nose (rhinophyma) can be cosmetically debilitating.

 

Adults with persistently red facial skin associated with papules and pustules should visit a physician. This is especially true if the eyelids are involved.

Causes

Ultimately, the cause of rosacea is unknown, but it is generally agreed that affected people have an unusual degree of vascular hyper-reactivity in that they tend to manifest vigorous and prolonged facial flushing in response to the ingestion of hot liquids. After a time, the flushing becomes permanent due to persistent enlargement of small facial blood vessels (telangiectasia).

 

It seems likely that genes also play some role in this condition. The frequency of rosacea has been estimated to be as high as 10% of an adult Swedish population. It is said to be most common among in those of Celtic ancestry and is less common in darkly pigmented races. In a recently published study, a family history of rosacea, smoking, and sensitivity to sunlight were the only significant predictive factors for rosacea.

 

Many people with rosacea seem to have a lowered threshold for facial irritation. This predisposition seems to be correlated with elevated levels of certain inflammatory mediators and a defective barrier function of the skin. When the skin's normal barrier function is restored, levels of these inflammatory peptides decrease to normal.

 

There seems to be no association between the presence of Helicobacter pylori(bacteria that cause inflammation and ulcer development) in the gastrointestinal tract and rosacea, as had been proposed by some authors.

 

Excessive use of potent topical steroids on facial skin can induce a rosacea-like condition. Although the relationship to rosacea is controversial, some people have facial follicles that are infested by a mite, Demodex folliculorum, which may create a clinical picture easily confused with rosacea. This diagnosis can be made by a physician and then treated successfully with appropriate topical medications (permethrin cream).

 

High levels of serum ferritin, an iron-carrying protein found in serum, may play a role in the exacerbation of certain cases of rosacea.

Treatment

Depending on the severity of this condition, topical or systemic treatment may be necessary. Topical therapy includes the application of topical antibiotics such asmetronidazole (MetroCream, MetroGel, MetroLotion, Noritate), sulfacetamide (Novacet, Plexion, Plexion SCT, Plexion TS, Rosanil Cleanser, Rosula, Rosula Cleanser, Sulfacet-R, Zetacet Wash), or perhaps azelaic acid (Azelex, Finacea, Finevin).

 

If topical therapy is insufficient, oral antibiotics are frequently beneficial. Frequently used oral antibiotics include amoxicillin and tetracycline or one of its analogues like doxycycline and minocycline. Systemic treatment with antibiotics may inhibit the development of rhinophyma and is effective in controlling blepharitis (inflammation of the eyelid) . Rarely, very severe cases may requireisotretinoin (Accutane, Amnesteem, Claravis, Sotret), an oral retinoid. The overall goal of treatment is control the symptoms rather than cure the condition.

 

Treatment of the telangiectatic component (dilated blood vessels) of rosacea with lasers or intense pulsed light of the appropriate wavelength can diminish the redness. Individual blood vessels can also be treated with electrosurgical destruction. Rhinophyma can be improved by "paring down" excess nasal tissues using electrosurgical or microwave devices.

 

In 2009, a Cochrane review which claims to evaluate medical evidence objectively found that there is evidence that topical metronidazole and azelaic acid are effective treatments for rosacea. There is evidence that oral metronidazole and tetracycline are effective as well. However, these reviewers noted the lack of good studies regarding the treatment of rosacea.

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