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Five things...you may not know about rosacea

Dermatology

GPSI Dr Clare Kendall gives

key tips on the diagnosis and management of this troublesome skin condition

1. Rosacea is not related to acne

Although sometimes misleadingly referred to as 'acne rosacea', this is quite a different disease from 'acne vulgaris', which is more commonly found in teenagers. Unlike acne, it is not centred on the pilosebaceous unit, there is no increase in sebum and there are no comedones. Its precise aetiology is unknown but is likely to involve an abnormality of small blood vessels and dermal architecture, leading to a cycle of inflammation and further damage. The role of Helicobacter pylori and the demodox mite is uncertain.

Although rosacea is more common in middle life it can occur at any age, and is

particularly found in women and fair-skinned individuals. Prevalence is thought to be about 10 per cent.

Unlike acne, which affects sebaceous hair-bearing areas, rosacea is found predominantly on the convex areas of the central face – the nose, forehead and cheeks. Occasionally it affects other regions such as the scalp and behind the ears, upper neck and chest. The skin is usually dry rather than oily and the patient may complain of burning, itching and tenderness. Papules, when they occur, are more dome-shaped than in acne.

2. Rosacea is a syndrome with recognised subtypes

Rosacea is now classified into four subtypes depending on the clinical features and it is no longer thought that there is an inevitable progression from one to

another. Diagnosis can be made on the presence of one or more primary features of rosacea, which may occur together or independently:

• Flushing (transient erythema)

• Nontransient erythema (persistent

redness)

• Papules and/or pustules

• Telangiectasia (dilated blood vessels)

Secondary features that may also occur, sometimes independently, are:

• Burning or stinging sensation

• Elevated plaques

• Dryness and scaling of the central face

• Oedema, which may be transient or

persisting

• Ocular manifestations

• Phymatous changes (most commonly as rhinophyma affecting the nose)

Some patients may complain just of recurrent flushing and may or may not show the presence of telangiectasia. These are classified as erythematotelangiectatic rosacea. Patients presenting with the papulopustular form more closely resemble those with acne, although comedones will be absent unless the condition co-exists. Phymatous rosacea includes the purple bulbous nose, which is sometimes mistakenly attributed to alcohol, but thickened nodular skin may occur elsewhere, particularly on the chin, forehead, cheeks and ears.

3. Ocular rosacea

is common and under-recognised

Ocular rosacea is classified as the fourth subtype and is much more common and serious than generally realised. Ocular symptoms occur in more than half of patients with rosacea and of these, up to 20 per cent of

patients present before they notice any skin involvement.

Common symptoms are dryness, itching and stinging of the eyes with a sensation of grittiness; there may be telangiectasia affecting the conjunctivae or lid margins; blepharitis, conjunctivitis and recurrent styes also occur, along with other lid margin abnormalities.

Keratitis can develop in 5 per cent of patients and can lead to loss of vision. Hence it is vitally important to ask about eye symptoms in all patients with rosacea and refer urgently any patient complaining of any blurring of vision. Treatment is focussed on eyelid hygiene including lid massage together with oral antibiotics.

4. Sunlight is one of the important trigger factors for rosacea

Sunlight almost certainly plays an important role in the aetiology of rosacea; the condition is much more common in Celtic skin and occurs mainly on the sun exposed convex areas of the face, sparing protected sites around the eyes. Hence it is important to

encourage patients to avoid sunlight if this acts as a trigger for them and advise them to apply sunscreen.

Other recognised triggers are exposure to extreme temperatures (especially heat), spicy foods, alcohol, hot drinks, strenuous exercise and stressful situations. Most

patients are very sensitive to anything that dries or irritates the skin and should be

given advice about the importance of using a regular emollient, cleansing with lukewarm water and avoiding products containing acetone, alcohol or fragrances.

5. There is no cure for rosacea

It is important to realise that this is a chronic, relapsing condition for which we have no permanent cure. The patient needs to be advised that treatment is suppressive and may need to be continued. For some patients, avoidance of trigger factors and frequent

application of emollient may be all that is

required. Further treatment depends on the nature and severity of their disease.

The papulopustular form is most amenable to therapy. For mild disease, topical metronidazole cream or gel is the only licensed topical agent. It should be applied twice daily, applying an emollient beforehand if causing irritation; metronidazole cream is better than the gel for sensitive skin. If this is not tolerated, azelaic acid cream has recently been shown to be equally effective both in reducing papules, pustules and erythema. Other topical antibiotics, including clindamycin, are sometimes used although there have been no trials to demonstrate their effectiveness.

For resistant cases and more extensive disease, oral tetracyclines (500mg bd) are the antibiotics of choice. If compliance with oxytetracycline is a problem, lymecycline 408mg once daily (unlicensed) or doxycycline 100mg daily is a useful alternative. Erythromycin 250mg-500mg twice a day is also frequently used.

If the condition is particularly severe, the antibiotic can be prescribed at a higher dose and reduced as it comes under control. Treatment should continue for at least 12 weeks, when the patient may be switched to a topical agent. Maintenance treatment should be continued for six months but repeated courses may well be required.

Patients with severe disease who have

not responded after 12 weeks should be referred to a dermatologist for consideration of second-line treatment with isotretinoin, dapsone, hydroxychloroquine or oral metronidazole.

Drug treatment is of little benefit for flushing and persistent redness. Cosmetic camouflage can help with the more severe cases, and is provided free by the Red Cross. Laser treatment can help with prominent telangiectasia but is not generally available on the NHS. Rhinophyma can be treated with laser or plastic surgery.

It needs to be recognised that rosacea can cause marked psychological and social distress and patients should receive prompt treatment, information and advice.

Clare Kendall is a GPSI in dermatology in Maidstone, Kent and obtained the Cardiff diploma in dermatology in 2005 – she has also worked as a hospital practitioner in dermatology

Competing interests None declared

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