Rosacea

Rosacea   is a chronic skin condition characterized by facial redness, small and superficial dilated blood vessels on facial skin, papules, pustules, and swelling.[2] Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting the eyes (ocular type). Left untreated it worsens over time. Treatment in the form of topical steroids can aggravate the condition.[3]

It primarily affects people of northwestern European descent and has been nicknamed the "curse of the Celts" by some in Britain and Ireland, although recently this has been questioned.[4] Rosacea affects both sexes, but is almost three times more common in women. Rosacea is commonly found in people between the ages of 30 and 50 and is more common in those of Caucasian descent.[2]

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.[5] In some cases, additional signs, 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.

Classification  

There are four identified rosacea subtypes[6] and patients may have more than one subtype present:[7]:176

Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily.[8] It is also common to have small widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and/or itching sensations.[8] People with this ETR type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp.[9]

Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (can last 1–4 days or longer; extremely varied signs); this subtype can be easily confused with acne.

Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).[10] Small blood vessels visible near the surface of the skin (telangiectasias) may be present.

Ocular rosacea: Eyes and eyelids affected by ocular rosacea may appear red (due to telangiectasias) and inflammation and may feel dry, irritated, or gritty. Other symptoms of ocular roseate include foreign body sensations, itching, burning, stinging, and sensitivity to light.[11] Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and vision loss can occur if the cornea is affected.[11]

There are a number of variants of rosacea, including:[12]:689

Rosacea conglobata

Rosacea fulminans

Phymatous rosacea

Cause 

The exact cause of rosacea is unknown.[2] Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one such as heated shops and offices during the winter.[2] There are also some food and drinks that can trigger flushing, including alcohol, food and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food.[8]

Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.

Cathelicidins  

Richard Gallo and colleagues recently noticed that patients with rosacea had high levels of the antimicrobial peptide cathelicidin[13] and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea but they may only work because they inhibit some SCTEs.[14]

Demodex mites  

Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite,[8] especially those with steroid-induced rosacea.[15] When large numbers are present they may play a role along with other triggers. On other occasions demodicidosis (mange) is a separate condition that may have "rosacea-like" appearances.[16] Demodex has also been implicated in rosacea in that it is theorized to be caused by a reaction to bacteria in the mite's feces.[17][medical citation needed]

Diagnosis  

Most people with rosacea have only mild redness and are never formally diagnosed or treated. There is no single, specific test for rosacea.

In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.

The disorder can be confused with, and co-exist with acne vulgaris and/or seborrheic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.

Treatments  

Treating rosacea varies depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists.[18] Mild cases are often not treated at all, or are simply covered up with normal cosmetics.

Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions, decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents.[19] Laser therapy has also been classified as a form of treatment.[19] While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually one to two years, may result in permanent control of the condition for some patients.[19][20] Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.[20]

Behavior  

Avoiding physical things or mental states that increase the ability to visibly detect rosacea by a physician is considered trigger avoidance. Trigger avoidance can help reduce the onset of rosacea but alone will not normally lead to remission except in mild cases. It is sometimes recommended that a journal be kept to help identify and reduce food and beverage triggers.[21]

Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims. Like sunlight, emotional stress can also trigger rosacea. People who develop infections of the eyelids must practice frequent eyelid hygiene.

A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.[22]

Medications   

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Topical formulations of azelaic acid and the antibiotic metronidazole are effective in reducing the inflammatory lesions characteristic of papulopustular rosacea.[8] Metronidazole is thought to act through anti-inflammatory mechanisms while azelaic acid is thought to decrease cathelicidin production. Oral antibiotics of the tetracycline class such as doxycycline and oxytetracycline are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.[8]

Using alpha-hydroxy acid peels may help relieve redness caused by irritation, and reduce papules and pustules associated with rosacea.[23] Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.[24] Isotretinoin has many side effects and is normally used to treat severe acne but in low dosages is proven to be effective against papulopustular and phymatous rosacea.

The flushing and blushing that typically accompanies rosacea is typically treated with the topical application of alpha agonists such as brimonidine and less commonly oxymetazoline or xylometazoline.[8] The same is true of the beta-blockers like nadolol and propranolol.

Newer therapies approved by the United States' Food and Drug Administration for the treatment of rosacea include topical ivermectin and brimonidine.[8]

Laser  

Dermatological vascular laser (single wavelength) or intense pulsed light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin.[25] They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxy-hemoglobin, which heat up, causing the capillary walls to heat up to 70 °C (158 °F), damaging them, causing them to be absorbed by the body's natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly formed capillaries.[19]

CO2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporize tissue. Low level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it.[26][27][28]

Notable cases  

Famous people with rosacea include:

Margaret Bobonich[29]

Meg Cabot[30]

Mariah Carey[31]

Bill Clinton[32]

Cristina Fernández de Kirchner[32]

Lisa Faulkner[33]

Sir Alex Ferguson[34]

W. C. Fields[32]

Diane Kruger[35]

J. P. Morgan[36]

Cynthia Nixon[37]

Rosie O'Donnell[38]

Carol Smillie[39]

Lucius Cornelius Sulla[40]

Dita Von Teese[41]

Ricky Wilson[42]

Vojislav Šešelj

 

 

References    

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