The patient’s unmet needs (PUNs)
A 50-year-old man attends with a facial rash. He is stoical and has put up with the problem for months but his partner has insisted he seek help. He has previously had treatment for facial seborrhoeic eczema but this seems different. Examination reveals papules and pustules, mainly on the forehead and cheeks, on an erythematous base. Some telangiectasia are present and there is some soft tissue swelling of his nose. Further enquiry reveals that he experiences a lot of flushing and suffers intermittently sore, red eyes too. You diagnose rosacea and explain the condition. He’s not keen on medication and wants to discuss possible management strategies and the likely natural course of the condition.
The Doctor’s educational needs (DENs)
How can rosacea confidently be distinguished from facial seborrhoeic eczema? What are the other possible differentials?
Rosacea is characterised by flushing, persistent redness, telangiectasia and eruptions of papules and pustules. But these features are not all necessarily present at any one time and other conditions – such as seborrhoeic eczema – share some of the features. So it can be difficult to be certain about the diagnosis.
There are factors in the history and examination which can help you to distinguish rosacea from sebhorrhoeic eczema. Patients with rosacea will give a history of flushing and a burning sensation in the affected areas, which isn’t reported in seborrhoeic eczema. Rosacea is exacerbated by a warm environment, emotion, hot drinks, spicy foods and alcohol, but this doesn’t occur with seborrhoeic eczema. Rosacea tends to produce a bright red appearance on the nose, cheeks, forehead and chin without scale, whereas seborrhoeic eczema tends to produce a brown-red scaly rash affecting the nasolabial folds, eyebrows, ears, central chest and middle of the back. Papules and pustules may be present in rosacea but not in seborrhoeic eczema. Telangiectasia is not associated with seborrhoeic eczema but is common on sun-exposed cheeks so may cause diagnostic confusion. Other distinguishing features include rhinophyma, which may be present in rosacea, while patients with seborrhoeic eczema often have seborrhoea capitis (dandruff). In rosacea, sore, gritty eyes with evidence of conjunctivitis, keratitis and blepharitis may occur, although blepharitis can also be a feature of seborrhoeic eczema.
Other differentials include:
- Atopic eczema - usually starts at an earlier age than rosacea and affects other areas as well as the face. Scale is present.
- Contact dermatitis – scale is present. Other areas may be affected depending on the allergen.
- Photo-aggravated eczema – look for patches partly covered by clothes where there will be a cut-off in redness.
- Systemic lupus erythematosus – presents as a butterfly rash on the cheeks and usually occurs with systemic features such as malaise, arthralgia and diffuse alopecia. Pustules are absent in SLE.
- Steroid-induced rosacea – produces redness and telangiectasia on the cheeks and papules around the mouth. It is important to take a drug history.
- Acne vulgaris – comedones are absent in rosacea, which is the big differentiator.
What is the prognosis of the condition? Are there any self-help measures he can take?
The prognosis of rosacea is variable and there are no predictive factors. The condition can last over 20 years and its severity may fluctuate. Time to resolution is not affected by treatment, which is purely suppressive and which may be needed long term.
Advise the patient to avoid any factors which exacerbate his rosacea. For example, avoid hot drinks, spicy foods, hot environments and sun exposure. Frequent use of emollients may help to reduce the burning sensation felt in the affected areas. Dry eyes may be relieved by frequent use of ocular lubricants.
Avoid irritants such as soap and alcohol-based cleansers, and advise patients that facials and saunas may make rosacea worse. Sunscreen with high UVA and UVB protection should be used daily.
Cosmetic camouflage may benefit patients who are embarrassed by persistent facial redness. In particular, a green-based foundation may be helpful.
What are the merits of topical versus oral antibiotic treatment? If oral antibiotics are prescribed, which are preferred, at what dose, and for how long?
Both topical and oral antibiotics can be very effective, particularly for the papules and pustules, and will produce some visible improvement within one month – more rapidly than when used for acne vulgaris.
The advantage of topical antibiotics is that they don’t cause systemic side effects, but oral antibiotics appear to work more rapidly. So a sensible approach would be to start with oral antibiotics and then change to topical therapy after six to 12 weeks. Oral antibiotics should be prescribed for patients with ocular symptoms as topical treatment to the skin does not help these symptoms.
Oral antibiotics such as tetracyclines or erythromycin are effective and only need to be given twice a day (250mg bd). Lymecycline (408mg od) and doxycycline are more expensive but only need to be given once per day and can be taken with food. Recently, doxycycline has been shown to be effective in a 40mg daily dose.
Topical treatment includes metronidazole cream or gel (both applied bd) and azelaic acid gel. Combinations of topical and systemic treatment may be more effective than either used alone. As mentioned, treatment may need to be given for years.
Neither oral nor topical antibiotics affect the flushing or burning discomfort which are the most difficult characteristics to treat. The treatment of erythema and telangiectasia is best performed with pulsed dye laser which is not normally available on the NHS.
What are the ocular effects of rosacea? Do standard rosacea treatments ease ocular complications or do these need specific treatment in their own right?
The ocular effects of rosacea include dry eyes, conjunctivitis, blepharitis and keratitis. These ophthalmological complications are common – occurring in up to 50% of rosacea cases.
Artificial tears (ophthalmic formulation of liquid paraffin, carbomer or hypromellose) may be helpful and systemic tetracyclines such as oxytetracycline, lymecycline or minocycline are effective and are thought to work by their anti-inflammatory effect. If you are not able to control the ocular symptoms with lubricants and oral tetracyclines, refer to an ophthalmologist.
What treatments help the associated flushing? And what can be done to prevent or treat the complication of rhinophyma?
Flushing is extremely difficult to treat and when you start treatment for rosacea it is important to explain to the patient that the flushing is not going to be affected by topical or oral antibiotic therapy.
Non-cardioselective ß-blockers and clonidine have been tried but are not particularly effective. Vascular laser therapy which can improve telangiectasia and erythema may also help the flushing, but as mentioned, this treatment is not usually available on the NHS.
Rhinophyma (enlargement of the nose by sebaceous hyperplasia) may occur as a late-stage complication or may occur with minimal evidence of other features of rosacea. It is more common in men than women. Excellent cosmetic results can be achieved by removing the excess tissue with electro-surgery or laser removal.
It is thought that treatment of rosacea with oral or topical antibiotics reduces the risk of rhinophyma developing, but this is unproven. Systemic isotretinoin can reduce the bulk of rhinophyma but should not be started in primary care.
Dr Andy Jordan is a GP and hospital practitioner in dermatology in Amersham, Buckinghamshire
- White GM and Cox NH. Diseases of the Skin – A Colour Atlas and Text (2005); UK. ISBN 0-323-02997-3.
- Burns T, Breathnach S, Cox N and Griffiths C. Rook’s Textbook of Dermatology (March 2010), Wiley-Blackwell. ISBN 978-1-4051-6169-5
- Primary Care Dermatology. pcds.org.uk. Accessed 26/11/12