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Need to Know - Acne Rosacea

GP Dr Tonia Myers wanted to know how antibiotics help with flushing, how lasers can help and how best to stop rhinophyma developing – dermatologists Dr Tom Oliphant, Dr Lyndsey Paul and Dr Shernaz Walton answered her questions

GP Dr Tonia Myers wanted to know how antibiotics help with flushing, how lasers can help and how best to stop rhinophyma developing – dermatologists Dr Tom Oliphant, Dr Lyndsey Paul and Dr Shernaz Walton answered her questions

1. What is the natural history and prognosis for women with rosacea?

The duration of the disease and the eventual outcome are very variable and difficult to predict. Duration of disease can vary between one and 25 years. It tends to follow a fluctuating course. Most symptoms of rosacea can be successfully controlled, though facial flushing is often difficult to suppress.

2. Are we any closer to understanding why acne occurs in middle age? Is it becoming commoner?

Studies have shown that up to 12% of women and 3% of men, over the age of 25 years, will have clinical acne. This could be due to persisting teenage acne or a flare of previously settled teenage acne. Questionnaire based studies have shown that up to 80% of patients treated for acne will continue to have some disease activity that persists into their 5th decade.

True late-onset acne (onset after the age of 25 years) was seen in 18% of women and 8% of men in one study that reviewed all patients over the age of 25 years, who had been referred with acne to a dermatology department. 50% of these patients had a first degree relative with post adolescent acne and 37% of the women had features of hyperadrogenicity requiring further investigation. External factors, such as cosmetics and occupation, were not found to be significant aetiological factors.

A number of drugs are known to induce acne or acneiform eruptions. These include corticosteroids and androgens such as anabolic steroids. Numerous other drugs can cause an idiosyncratic acneiform reaction.

Some clinicians believe that there is an increase in the number of patients with mature acne. However this could be due to increased diagnosis, more awareness of available treatments by patients who then seek advice, or possible misdiagnosis of rosacea. Rosacea most commonly occurs in adults between the ages of 30 and 60 years. It is characterised by recurrent episodes of facial flushing, erythema, telangiectasia and papules and pustules that occur in a central facial distribution. It does not usually have comedones, nodules or scarring that can be seen in acne. There are 4 main types;

  • erythematelangiectatic - characterised by facial flushing, erythema and telangectasia
  • papulopustular – characterised by papules and pustules with milder facial flushing and telangiectasia
  • phymatous – characterised by skin thickening and irregular surface nodularities
  • ocular – characterised by ocular manifestations, most commonly blepharitis and conjunctivitis

3. Are there any lifestyle options or modifiable triggers for women with rosacea that really work?

Modifiable triggers tend to exacerbate the erythema and facial flushing of rosacea. They are different for different individuals and a survey by the American Rosacea Society determined the most important triggers for more than 1,000 patients (see left).

They suggest asking patients to keep a diary to help identify triggers that are significant for their individual condition.

Some authors have suggested sun exposure may improve rosacea but the clinical guidelines from Prodigy advocate the use of a sunscreen with a high SPF and both UVA and UVB protection.

They also recommend that these patients should avoid alcohol-based cleansers, exfoliators and oil-based or waterproof make-up, because they have more sensitive skin.

The most successful lifestyle option is the use of cosmetic camouflage. The British Red Cross runs free clinics, which provide expert advice- details are available on their website

4. I find topical metronidazole generally unhelpful for rosacea because patients find it leaves a cosmetically unacceptable residue – any suggestions?

Topical metronidazole (0.75%, for example Metrogel) has been shown to be an effective treatment for the erythema, papules and pustules of rosacea. Onset of improvement can occur as early as two weeks but may take up to three months.

Metronidazole (Rozex) is available as either a cream or a gel. Some patients find that the cream formulation results in less obvious residue. Cosmetics can be applied over the topical preparation.

A randomised controlled trial showed once-daily use of metronidazole was as effective as twice-daily use, independent of the strength of the application. If patients are concerned about the cosmetic appearance of any residue, application once-daily at night may be more acceptable.

An alternative topical treatment that could be tried is 15% azelaic acid (Finacea). The manufacturers claim it is light and easily absorbed. However, up to 40% of patients experience burning, stinging or itching though this is transient in 70%.

If using oral antibiotics, topical treatment may not be required, but it is useful for remission maintenance if recurrence occurs.

5. What is the mechanism by which oral antibiotics help with the facial flushing associated with rosacea?

Oral antibiotics are effective in the control of the papules, pustules and erythema of rosacea, due to their anti-inflammatory and, possibly their antibacterial effect. But facial flushing is more difficult to control. The facial flushing seen in rosacea is usually more prolonged than that seen in the normal physiological response to embarrassment, exercise or hot environments.

It can involve the ears, neck and upper chest as well as the face and be associated with burning or stinging of the skin. The pathophysiology remains unclear. It is thought to involve either abnormalities in cutaneous vascular homeostasis precipitated by neural stimuli or humoral substances, or damage to the cutaneous vasculature and surrounding connective tissue.

Non-cardioselective ß-blockers such as propranolol 40mg twice-daily can be tried but often have limited effect. Clonidine 40µg twice-daily may produce modest benefit. Treatment of the telangiectasia with lasers or intense pulsed light can help with flushing. The most successful treatment is the avoidance of triggers and the use of cosmetic camouflage (see above).

6. I sometimes find it hard to distinguish seborrhoeic eczema from acne rosacea. Can the two occur together? Is one more likely if you have the other? Obviously the more severe/typical ones are not a problem but do you have any tips if there is diagnostic uncertainty?

Some clinicians believe there is an increased prevalence of seborrhoeic eczema in patients with rosacea but there is no documented evidence to support this. Seborrhoeic eczema is characterised by red sharply marginated scaly lesions in a typical distribution affecting the scalp, upper trunk and the nasolabial folds, glabellar and eyebrows of the face. It is more common in men than women.

Topical steroids used in the treatment of seborrhoeic eczema can mimic the symptoms and signs of rosacea, particularly after prolonged use. Treatment of this condition requires withdrawal of the topical steroid as well as use of rosacea treatments, including topical and, possibly, oral antibiotics.

A dry scaly appearance to the skin can be one of the minor features of rosacea, particularly of the erythematotelangiectatic type. However, this would occur with the other features of rosacea such as flushing, papules, pustules and erythema.

Topical metronidazole has been shown to be an effective treatment for seborrhoeic eczema as well as rosacea. This may be a good treatment option if both conditions coexist or, if there is diagnostic uncertainty.

7. I notice some dermatologists use treatments we would often use in acne vulgaris such as Zineryt or topical retinoids. Should we consider using these too?

Treatment of rosacea is dependent on the type. For papulopustular rosacea, the first-line topical treatment is metronidazole. If this is ineffective or not tolerated, topical azelaic acid would be the next choice. If there are more extensive papules and pustules, or topical treatment has failed, oral antibiotics should be prescribed.

This could include tetracycline 250mg bd or oxytetracycline 250mg twice-daily. These have to be taken on an empty stomach and this, together with the twice-daily dosing regime, can lead to poor compliance. Lymecycline 408mg once a day or doxycycline 100mg once a day are alternatives.

If intolerant or allergic to the tetracyclines, or pregnant or breast-feeding, erythromycin 250mg twice-daily can be used safely.

If these treatment options fail, it is important to consider whether the diagnosis is correct, or if there is lack of compliance with the treatment regime.

Second-line treatments include some preparations used for acne vulgaris but robust clinical evidence for these treatments is lacking. Benzoyl peroxide is thought to be beneficial for the inflammatory lesions of rosacea, but many patients experience intolerable stinging and erythema.

Topical clindamycin twice-daily was found to be more effective than oral tetracyclines in controlling the pustules of rosacea in one small study. There are no clinical trials providing evidence for the use of Zineryt, though anecdotally it is thought to have some effect. Small clinical trials have shown some improvement with topical retinoids. However, there is no substantial evidence for any of these treatments.

Referral to secondary care for consideration of systemic isotretinoin is appropriate if first-line treatment is not controlling the condition adequately.

8. Many middle-aged patients get fed up with long-term treatment – what is the best long-term maintenance regime? And I hate to mention lasers again after last week's acne questions, but two patients with rosacea have asked me recently!

Improvement with topical and oral antibiotics can take up to four months. Recurrence after stopping oral antibiotics is common with relapse rates of up to 25% within the first month and 60% within six months of stopping oral tetracycline.

If relapse occurs, further courses of oral antibiotics at the same dose are required. To maintain remission, topical treatments such as metronidazole should be continued once oral antibiotics are stopped. The duration of topical treatment needed is unclear but in the first instance should be prescribed for six months. Topical treatment can then be used as required.

Lasers have been used in the treatment of rosacea since the early 1980s. Pulsed dye lasers emit light that is selectively absorbed by oxyhaemoglobin leading to vessel damage without collateral tissue damage. It is therefore used to reduce erythema and telangiectasia and is successful in the majority of patients. However, it has minimal effect on the papules and pustules, and there is a small risk of scarring and hyperpigmentation.

Intense pulsed light consists of light of multiple wavelengths, which penetrates deeper into the skin than vascular lasers. Its mode of action is unclear but is thought to promote remodelling of dermal collagen, vascular and elastic tissue. It is useful for the erythema and telangiectasia of rosacea.

In a study of 32 patients, 83% had reduced erythema and 75% had reduced flushing2. Interestingly, 64% had fewer inflammatory lesions. There were minimal side-effects, but results are operator dependent, and so it is essential to find an individual who is experienced in this area for optimal results.

9. Is rhinophyma always related to poor treatment control?

Rhinophyma is a localised swelling of the soft tissues of the nose due to a combination of fibrosis, sebaceous hyperplasia and lymphoedema. It occurs almost entirely in men, who may have no previous history of rosacea. The mythical link with excess alcohol consumption was dispelled by a retrospective case-controlled study.

Some clinicians believe rhinophyma is a late-stage complication of rosacea and may be prevented by active treatment of early rosacea. But there is no clinical evidence to support this hypothesis.

Development of rhinophyma should prompt early referral as systemic isotretin-oin has been shown to reduce nasal volume, particularly in young patients with less advanced disease. Established rhinophyma has to be treated by physical ablation or removal.

Dr Lyndsey Paul and Dr Tom Oliphant are specialist registrars in dermatology at Princess Royal Hospital, Hull. Dr Shernaz Walton is a consultant dermatologist and honorary clinical senior lecturer at Hull and East Yorkshire Hospitals NHS Trust and Hull York Medical School.

Competing interests: none declared

acne take home triggers What I will do now What I will do now

Dr Myers considers how the answers might change her practice

• I will prescribe metronidazole cream in preference to gel as a first-line treatment to reduce the residue which some patients find unacceptable.
• I will suggest 15% azelaic acid as second-line treatment before resorting to oral tetracycline.
• I will advise patients to use topical treatments as maintenance when coming off antibiotics to prevent relapse.
• I will recommend that patients avoid alcohol and oil-based products because they may affect sensitive skin.
• I will suggest cosmetic camouflage for distressing erythema that is resistant to treatment and give patients information about the free clinics run by the Red Cross.
• I will warn patients that though the results with laser treatment for erythema and telangectasia are promising, they are operator dependent and this should only be done by experienced clinicians.
Dr Tonia Myers is a GP in Chingford, Essex

Women with rosacea should avoid oil-based or waterproof make up Women with rosacea should avoid oil-based or waterproof make up

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