Rosacea: Diagnosis And Treatment - AAFP Home
Rosacea: Diagnosis and TreatmentLINDA K. OGE’, MD, Louisiana State University Department of Family Medicine, University Hospital and Clinics,Lafayette, LouisianaHERBERT L. MUNCIE, MD, Louisiana State University Department of Family Medicine, New Orleans, LouisianaAMANDA R. PHILLIPS-SAVOY, MD, MPH, Louisiana State University Department of Family Medicine, UniversityHospital and Clinics, Lafayette, LouisianaRosacea is a chronic facial skin condition of unknown cause. It is characterized by marked involvement of the centralface with transient or persistent erythema, telangiectasia, inflammatory papules and pustules, or hyperplasia of the connective tissue. Transient erythema, or flushing, is often accompanied by a feeling of warmth. It usually lasts for less thanfive minutes and may spread to the neck and chest. Less common findings include erythematous plaques, scaling, edema,phymatous changes (thickening of skin due to hyperplasia of sebaceous glands), and ocular symptoms. The NationalRosacea Society Expert Committee defines four subtypes of rosacea (erythematotelangiectatic, papulopustular, phymatous, and ocular) and one variant (granulomatous). Treatment starts with avoidance of triggers and use of mildcleansing agents and moisturizing regimens, as well as photoprotection with wide-brimmed hats and broad-spectrumsunscreens (minimum sun protection factor of 30). For inflammatory lesions and erythema, the recommended initial treatments are topical metronidazole or azelaic acid. Once-daily brimonidine, a topical alpha-adrenergic receptoragonist, is effective in reducing erythema. Papulopustular rosacea can be treated with systemic therapy including tetracyclines, most commonly subantimicrobial-dose doxycycline. Phymatous rosacea is treated primarily with laser orlight-based therapies. Ocular rosacea is managed with lid hygiene, topical cyclosporine, and topical or systemic antibiotics. (Am Fam Physician. 2015;92(3):187-196. Copyright 2015 American Academy of Family Physicians.)More onlineat http://www.aafp.org/afp.CME This clinical contentconforms to AAFP criteriafor continuing medicaleducation (CME). SeeCME Quiz Questions onpage 180.Author disclosure: No relevant financial affiliations. Patient information:A handout on this topic isavailable at acea is a chronic facial skin condition characterized by markedinvolvement of the central facewith transient or persistent erythema, inflammatory papules or pustules,telangiectasia, or hyperplasia of the connective tissue.1,2 Transient erythema, orflushing, usually lasts less than five minutesand may spread to the neck and chest, oftenaccompanied by a feeling of warmth. Lesscommon findings include erythematousplaques, scaling, edema, phymatous changes(thickening of skin due to hyperplasia ofsebaceous glands), and ocular symptoms.Rosacea can be associated with low selfesteem, embarrassment, and diminishedquality of life. In a national survey, 65% ofpatients with rosacea reported symptoms ofdepression.3The exact prevalence of rosacea in theUnited States is unknown4,5 ; however, itis probably between 1.3% and 2.1%, andmay be as high as 5%.6 Women are affectedmore often than men, but men are morelikely to have phymatous changes, especiallyrhinophyma.7SubtypesThe National Rosacea Society Expert Committee defined four subtypes (Table 1) andone variant.8 Granulomatous rosacea is thesole variant with firm, indurated papulesor nodules. Many dermatologists considerrosacea fulminans and perioral dermatitisas rosacea variants. Patients may experiencefluctuation in symptoms and overlapping ofsymptoms between subtypes.9PathophysiologyThe etiology of rosacea is unknown but islikely multifactorial. Factors involved in thepathophysiology include the dense presenceof sebaceous glands on the face, the physiology of the nerve innervation, and the vascular composition of the skin.10 Numeroustriggers initiate or aggravate the clinicalmanifestations of rosacea, including ultraviolet light, heat, spicy foods, and alcohol(Table 2).4,11A predilection for fair-skinned individuals of Celtic or northern European descentsuggests a genetic component to rosacea.10 However, no specific gene has beenAugust1, 2015Volume92,FamilyNumber3 website at www.aafp.org/afp.www.aafp.org/afp American Academy of FamilyAmericanFamily187Downloadedfrom theAmericanPhysicianCopyright 2015Physicians.For thePhysicianprivate, noncommercial use of one individual user of the website. All other rights reserved. Contact copyrights@aafp.org for copyright questions and/or permission requests.
RosaceaTable 1. Subtypes and Variants of Rosacea andTheir CharacteristicsClassificationTable 2. Triggers Associated with WorseningRosacea SymptomsCharacteristicsPatients with rosaceawho report trigger (%)TriggerSubtypeErythemato telangiectaticFlushing and persistent central facialerythema with or without telangiectasiaSun exposure81Emotional stress79PapulopustularPersistent central facial erythema withtransient, central facial papules or pustulesor bothHot weather75Wind57Strenuous exercise56PhymatousOcularThickening skin, irregular surface nodularitiesand enlargement; may occur on the nose,chin, forehead, cheeks, or earsAlcohol consumption52Cold weather46Foreign body sensation in the eye,burning or stinging, dryness, itching,ocular photosensitivity, blurred vision,telangiectasia of the sclera or other partsof the eye, or periorbital edemaSpicy foods45Noninflammatory; hard; brown, yellow,or red cutaneous papules; or nodules ofuniform sizeDairy products8Other factors24VariantGranulomatousPhotos of these subtypes of acne rosacea are available at eprinted with permission from Wilkin J, Dahl M, Detmar M, et al.Standard classification of rosacea: Report of the National RosaceaSociety Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):586. 622/.identified.4 Patients with the genetic predisposition havea receptor that mediates neovascular regulation. Whenexposed to triggers, neuropeptide release (flushing,edema) occurs, resulting in recruitment of proinflammatory cells to the skin.10DiagnosisRosacea is diagnosed based on a compatible history andphysical examination12 (Table 38). One of the followingcentrofacial features is required: flushing, nontransienterythema (Figures 1A and 1B), telangiectasia (Figure 1C),or papules/pustules8 (Figures 2A and 2B). Laboratorytesting is not useful.Patients may receive a misdiagnosis of skin conditions that share similar features. Rosacea is commonlymisdiagnosed as adult acne vulgaris, photodermatitis,seborrheic dermatitis, or contact dermatitis. Table 4 listsfeatures that distinguish these conditions from rosacea.Less common mimicking conditions include systemiclupus erythematosus, atopic dermatitis, folliculitis, bromoderma, and mastocytosis.188 American Family PhysicianCertain skin care products41Heated beverages36Certain cosmetics (comedogenic)27Medications (topical steroids, niacin,beta blockers)15Information from references 4 and 11.Table 3. Guidelines for the Diagnosis of RosaceaPresence of one ormore of the followingprimary features:May include one or more ofthe following secondaryfeatures:Flushing (transienterythema)Burning or stingingNontransient erythemaDry appearancePapules and pustulesEdemaTelangiectasiaOcular manifestationsPlaquePeripheral locationPhymatous changesReprinted with permission from Wilkin J, Dahl M, Detmar M, et al.Standard classification of rosacea: Report of the National RosaceaSociety Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002;46(4):585. 622/.TreatmentGENERAL MEASURESAlthough rosacea findings may change over time, noproven natural progression exists.13 Treatment decisionsare based on the patient’s current clinical manifestations(Table 5).Because rosacea can be triggered by a variety of stimuli, avoidance of known triggers is recommended. Towww.aafp.org/afpVolume 92, Number 3 August 1, 2015
RosaceaABCFigure 1. Facial erythema with telangiectasia. (A) Frontal view of centrofacial erythema. (B) Close-up view of centrofacial erythema with scaling. (C) Close-up view of telangiectasias on lateral chin.Dimethicone- and simethicone-basedproducts containing titanium dioxide andzinc oxide may be better tolerated.2 Cosmetics with green or yellow tint applied tothe central facial erythema may concealredness.14FDA-APPROVED TOPICAL THERAPIESTopical agents are first-line therapy in thetreatment of mild to moderate rosacea(Table 6).17,18 Medication therapy is basedABon the presence or absence of persistentcentral facial erythema or inflammaFigure 2. Inflammatory lesions (papules and pustules). (A) Papulopustular lesions and scaling on the lateral nose. (B) Close-up view of papulo- tion (e.g., papules, pustules, lesional andperilesional erythema), the severity ofpustular rosacea.symptoms, and the patient’s response toidentify potential triggers, patients should be encour- previous therapeutic interventions.aged to keep a journal documenting exposures, diet, andFive topical agents are approved by the U.S. Food andactivities that cause flare-ups.14Drug Administration (FDA) for the treatment of rosaProperly selected skin care products improve and cea: metronidazole 0.75% lotion (Metrolotion), 0.75%maintain the integrity of the stratum corneum permea- cream (Metrocream), and 1% gel (Metrogel); azelaicbility barrier and reduce skin sensitivity.15 Mild cleansing acid 15% gel (Finacea); sulfacetamide 10%/sulfur 5%and moisturizing regimens improve patient satisfac- cream, foam, lotion, or suspension; brimonidine 0.33%tion. Cleansers should be fragrance- and abrasive-freewith a mildly acidic to neutral pH. Recommended skinTable 4. Skin Conditions That Share Similarcleansers include lipid-free, nonalkaline cleansers (e.g.,Features with RosaceaCetaphil) and sensitive skin synthetic detergent bars16(e.g., Dove Sensitive Skin Bar). Patients should cleanseConditionDistinguishing featuresgently with their fingertips, avoid use of abrasive materials, and pat dry for better absorption of moisturizers.Acne vulgarisComedone formationMoisturizers should contain emollients and occlusives.14No ocular symptomsAlthough no individual skin care product has beenContactAssociated with itching and often improvesdermatitisover time when causative agent iswell studied, some products found to improve dryremovedness include polyhydroxy acid (Neostrata), lipid-freePhotodermatitisRash appears on multiple body parts withnonalkaline (Cetaphil), and ceramide-based formulassunlight exposure(Cerave).16 Patients should avoid astringents, toners, senSeborrheicHas distinct distribution pattern involvingsory stimulants, and potentially irritating ingredients.16dermatitisthe scalp, eyebrows, and nasolabial foldsPhotoprotection is universally recommended, includingSystemic lupusRarely has pustuleserythematosusthe use of wide-brimmed hats and broad-spectrum sunscreens (minimum sun protection factor [SPF] of 30).13August 1, 2015 Volume 92, Number 3www.aafp.org/afp American Family Physician 189
Rosaceagel (Mirvaso); and most recently, topical ivermectin 1%cream (Soolantra).Metronidazole. Metronidazole is hypothesized toreduce oxidative stress, and has proven effective inreducing erythema and inflammation.19 No significantdifference in clinical benefit was found using differentvehicles (gel, cream, or lotion) or strengths (0.75% or1%). Adverse effects were mild, including pruritus, irritation, and dryness.14Azelaic Acid. Azelaic acid is effective against erythemaand inflammatory lesions via inhibiting production ofreactive oxygen species in neutrophils.19 No differencein effectiveness was found between once- or twice-dailydosing.20 Adverse events include mild and transientburning, stinging, and irritation.19Metronidazole vs. Azelaic Acid. Three studies assessedthe effectiveness of metronidazole vs. azelaic acid.Although physician-assessed outcomes suggested thatazelaic acid may be more effective than metronidazole,patient evaluations found no statistically significant differences. Azelaic acid had a higher incidence of adverseevents, including dryness, stinging, scaling, itching, andburning. Symptoms were mild to moderate, and transient in both groups. Neither agent was found to be effective against telangiectasia.19Sulfacetamide/Sulfur. FDA approval of sulfacetamide/sulfur was granted primarily based on historicaluse before the implementation of more rigorous standards. Studies demonstrated effectiveness, but werealso characterized by high or uncertain risk of bias.17,19Table 5. Management of RosaceaCentral facial erythemaWithout papulopustular lesionsWith papulopustular lesionsMild to moderateGeneralmeasuresEvaluate severity of erythema, inflammation, telangiectasia, and associated symptomsBegin mild nonalkaline skin cleansing and moisturizing regimenAvoid astringents, toners, abrasives, fragrances, and sensory stimulants (e.g., camphor, menthol, alcohol, acetone)Use broad-spectrum sunscreen; sun protection factor (SPF) 30 or greater (zinc oxide or titanium dioxide)Educate on trigger avoidanceConsider use of yellow- or green-tinted cosmetics to conceal rednessFirst-linetherapyTopical metronidazole (Metrogel,Metrocream, Metrolotion); azelaic acid(Finacea), or brimonidine (Mirvaso) forerythemaVascular laser therapy (pulsed dye laser,intense pulsed light, Nd:YAG laser) forerythema and telangiectasiaSecond-linetherapy—Topical metronidazole or azelaic acid for inflammation and erythemaTopical brimonidine for erythema if needed as adjunctive therapy; may be usedin combination with metronidazole or azelaic acid for erythemaTopical ivermectin for inflammation; may be used in combination with azelaicacid or metronidazoleVascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAG laser) fortelangiectasiaAlternate topical therapies (sulfacetamide/sulfur, benzoyl peroxide,erythromycin, clindamycin)orSubantimicrobial (anti-inflammatory) dose doxycycline, 40 mg once per day or20 mg twice per day, alone or in combination with topical agentsThird-linetherapy—If limited or no response at 8 to 12 weeks, consider antimicrobial (antibiotic)dose of doxycycline (100 to 200 mg once per day)Topical retinoidsRefractory—Consider treatment in the moderate to severe categoryNd:YAG neodymium:yttrium-aluminum-garnet.190 American Family Physicianwww.aafp.org/afpVolume 92, Number 3 August 1, 2015
RosaceaTransient application site reactions occur, and somepatients comment about the odor. Use of this second-lineagent should be avoided in persons with sulfa allergy.Brimonidine. Topical metronidazole, topical azelaicacid, and oral doxycycline reduce erythema relatedto vascular inflammation; however, they have negligible effects on background erythema caused bypermanently dilated superficial vessels. Conversely,alpha-adrenergic receptor agonists promote vasoconstriction but have no effect on papulopustular rosacea.Once-daily brimonidine, a topical alpha-adrenergicreceptor agonist, is effective in reducing erythema. Notachyphylaxis, rebound erythema, or aggravation ofinflammatory lesions was noted. Adverse events weremild, including irritation, burning, dry skin, pruritus,and erythema.21 Oxymetazoline 0.05% nasal solution(Afrin), also an alpha-adrenergic receptor agonist,applied once daily reduces diffuse central erythemabased on case reports.22Ivermectin. Topical ivermectin was approved by theFDA in 2014 for the treatment of papulopustular rosacea.23 Two studies demonstrated effectiveness vs. placebo, and a third found that ivermectin was slightlymore effective than topical metronidazole in patientand physician-assessed outcomes and quality of life.18,23NON–FDA-APPROVED TOPICAL THERAPIESOne study of permethrin (Elimite) vs. azelaic acid vs.metronidazole demonstrated similar effectiveness inreducing erythema and lesion counts. Two additionalPhymatousOcularSame as for mild to moderateSame as for central facialerythemaLid hygiene (warmcompresses and cleansingof lashes and lids withbaby shampoo scrubs)Topical metronidazole or azelaic acid for inflammation plussubantimicrobial (anti-inflammatory) dose of doxycycline (Oracea),40 mg once per day or 20 mg twice per dayIsotretinoin, 0.3 to 1 mg per kgper day for 12 to 28 weeksTopical antibiotics(metronidazole orerythromycin)Moderate to severeTopical brimonidine for erythema if needed as adjunctive therapyMicrodose therapy formaintenanceVascular laser therapy (pulsed dye laser, intense pulsed light, Nd:YAGlaser) for telangiectasiaIf limited or no response at 8 to 12 weeks, consider antimicrobial(antibiotic) dose of doxycycline (100 to 200 mg once per day)Vascular laser therapy (pulseddye laser, intense pulsed light,Nd:YAG laser, and carbondioxide laser)Dermabrasion, electroscalpel,electrosurgery, loop cauteryOral tetracyclines (preferred),or metronidazole orazithromycin (Zithromax)Cyclosporine ophthalmicemulsion (Restasis)Ophthalmologic referralIf limited or no response at reassessment, consider alternative oralantibiotic (tetracycline, minocycline [Minocin], metronidazole [Flagyl],azithromycin) and/or topical treatment (sulfacetamide/sulfur, benzoylperoxide, erythromycin, clindamycin, permethrin [Elimite])——If refractory to treatment, consider oral isotretinoin (requiresparticipation in online risk reduction program, iPledge: https://www.ipledgeprogram.com)——August 1, 2015 Volume 92, Number 3www.aafp.org/afp American Family Physician 191
Rosaceastudies of permethrin vs. metronidazole demonstratedcomparable effectiveness in reducing erythema andpapules but not pustules.19Benzoyl peroxide alone or in combination withclindamycin has proven effective; however, adverseevents included burning, stinging, and itching.19 Erythromycin 2% gel had no statistically significant effectiveness in physician- or patient-assessed outcomes.17,19Table 6. Topical Therapies for RosaceaTherapyFormulation and dosageEffectivenessAdverse effectsMetronidazole†(Metrogel, Metrocream,Metrolotion)0.75% gel, cream, or lotion: twiceper dayPapules, pustules,erythemaPruritus, stinging, irritation, drynessAzelaic acid† (Finacea)15% gel once or twice per dayPapules, pustules,erythemaStinging, irritation, burningSulfacetamide/sulfur†(several brands)10%/5% cream and otherformulations; once or twice per dayPapules, pustules,erythemaIrritation, malodorous, avoid in persons withsulfa allergyBrimonidine† (Mirvaso)0.33% gel once per dayErythemaPruritus, burning, irritation, dryness, erythema;use with caution in patients with CAD or CVDIvermectin† (Soolantra)1% cream once per dayPapules, pustulesBurning, skin irritationPermethrin (Elimite)5% cream once per dayPapules, erythemaIrritation, burningBenzoyl peroxide5% gel once or twice per dayPapules, pustules,erythemaErythema, burningClindamycin1% gel twice per dayPapules, pustulesPruritus, burning, irritation, drynessErythromycin2% gel twice per dayPapules, pustulesPruritus, erythema, irritation, drynessPimecrolimus (Elidel)1% cream twice per dayErythemaBurningTretinoinCream: 0.025%, 0.05%, 0.1%Papules, pustules,erythema, possiblytelangiectasiaPeeling, erythema, pruritus, dryness, irritation,may exacerbate rosacea photosensitivity1% gel: once per dayGel: 0.01%, 0.025%Once per night at bedtimeOxymetazoline (Afrin)0.05% nasal solution every six hoursErythemaIrritation, burningCyclosporine (Restasis)0.5% ophthalmic emulsion every12 hoursOcularHyperemia, burning, blurred vision, tearingCAD coronary artery disease; CVD cardiovascular disease; KLK5 kallikrein-related peptidase 5; NA not available; OTC over the counter;RCTs randomized controlled trials.*—Estimated retail price based on information obtained from http://www.goodrx.com (accessed April 3, 2015). Discounts available from multiple retailers.Generic price li
Rosacea is a chronic facial skin condition of unknown cause. It is characterized by marked involvement of the central face with transient or persistent erythema, telangiectasia, inflammatory .
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Rosacea is a chronic and inflammatory skin disease, characterized by flushing, nontransient erythema, papules/pustules, telangiectasia, and phymatous changes. With the update of diagnosis and classification of rosacea in 2017, treatment options for rosacea patients also attracted the attention of dermatologists. The latest advances in .
Rosacea can seriously affect a patient’s quality of life. This should prompt clinicians to diagnose it early and start treatment.1 Diagnosis The diagnosis of rosacea is usually made on history and clinical features. If it is not clear, differential diagnoses must be considered and ruled out (see Box).1,5,6 Clinical manifestations The presence of at least one of the following primary features .
Rosacea is an inflammatory facial skin disease that can cause patients embarrassment and reduce their quality of life. There are several different subtypes of rosacea and multiple treatments may be required to achieve satisfactory symptom relief. Topical treatments are first-line with oral treatments reserved for patients with persistent and severe rosacea. It should be noted that there is a .
Rosacea is a skin condition that usually affects people in their 30s or 40s. Both men and women are affected, but the disorder appears to be more common in women, with men generally having more severe disease. Once the Rosacea starts it usually persists, fluctuating in severity over many months or even years. Eventually rosacea clears or ‘burns itself out” and it is rarely seen in elderly .
Rosacea is a chronic inflammatory skin disease whose pathophysiological mechanism is obscure. Rosacea is most frequently seen in a familial setting and appears after puberty, when sebaceous glands are fully developed. Most individuals affected by rosacea are of northern European origin and up to 1/3 report a family history, indicating that a genetic factor is involved (1). First reported by .
rosacea, marked by pustules and facial erythema, is a particularly serious entity, as it may also involve the conjunctiva and sclera. The cause of rosacea is unclear, but the pathogenesis may involve vascular abnormalities, dermal matrix degeneration, and microorganisms such as Demodex folliculorum and Helicobacter pylori.18 Since there is no laboratory benchmark test for rosacea, diagnosis is .
Citation: Oliver P (2017) Rosacea - An overview on the diagnosis and assessment. Dermatological Nursing 17(2):10-14 Dermatological Nursing, 2017, Vol 16, No 2 www.bdng.org.uk D ERM Qu EST. C OM Introduction Rosacea is a common chronic inflammatory disorder of the skin predominantly affecting the central
