Symptoms
Rosacea is a chronic inflammatory skin disorder of the face that typically affects the cheeks, nose, chin, and central forehead symmetrically (Figure). The skin around the eyes is left out. It occurs more often in people with fair skin and in middle age, but it can occur in any skin type and at any age, even in children and adolescents. The following is a list of possible symptoms. The clinical picture varies and not all of these symptoms occur in all patients:
- Transient reddening of the skin (flushing).
- Persistent skin redness (erythema)
- Visible and dilated blood vessels (telangiectasia).
- Skin burning, stabbing pain, itching.
- Sensitive skin
- Dry skin, reduced fat content
- Papules, pustules
- Nodes, plaques
- Water retention
- Phyme, “bulbous nose” (rhinophyma), skin thickening, hyperplasia of the sebaceous glands.
- Infestation outside the face, e.g. ears, scalp, neck, upper body, chest.
- Inflammatory reactions on the eye, e.g. conjunctivitis and corneal inflammation, even without skin involvement, dry eyes, eyelid rim inflammation.
Because the disease process takes place in the middle of the face, rosacea can be a psychosocial problem. Although it is a very common condition – figures between 2-10% of the population are mentioned – it is little known to the public. For example, rhinophyma is often mistaken for a drinking nose.
Classification into subtypes
Rosacea is now classified into four different subtypes based on symptoms. These are to be understood as discrete manifestations rather than progressive stages, as in the earlier staging (after Wilkin ., National Rosacea Society, 2004). In addition, other special forms are possible. This classification is not undisputed and has been criticized as being too simplistic.
| 1) Erythematous-teleangiectatic rosacea. | Skin redness, flushing, flushing, possibly telangiectasia. |
| 2) Papulopustular rosacea. | Permanent redness of the skin, papules, pustules, possibly burning, stinging sensation |
| 3) Phymatous rosacea | Skin thickening, tissue proliferation, nodules, rhinophyma |
| 4) Ocular rosacea | Ocular symptoms |
Causes
The exact cause is unknown, but there are several hypotheses for disease development, and it appears that inflammatory processes and a genetic predisposition underlie. Disorders of natural immunity, vascular changes, UV light, oxygen radicals, and bacteria are discussed (see, e.g., Yamasaki, Gallo, 2009). A number of triggers are known to cause or worsen the symptoms. Many are vasoactive (examples):
- Certain foods and beverages: cheese, hot spices, red wine, alcohol, warm beverages.
- Irritants: soaps, peeling agents, cosmetics.
- Medications: Niacin, vasodilators, glucocorticoids, acetone, alcohol.
- Heat, environmental factors: sauna, hot shower, baths, hot weather, wind, cold weather.
- Emotions: Anger, stress, anxiety, feelings of shame.
- Physical activity
Diagnosis
The diagnosis is usually made in medical treatment based on the patient interview and clinical picture alone. It is necessary to exclude other skin diseases that cause similar symptoms. Acne vulgaris resembles the papulopustular subtype but differs in the presence of comedones. Other possible differential diagnoses include lupus erythematosus (butterfly erythema), steroid acne, seborrheic dermatitis, perioral dermatitis, contact dermatitis, photodermatoses, polycythaemia vera, mastocytosis, hot flushes, cholinergic urticaria, carcinoid syndrome, dermatomyositis, and other ocular diseases.
Nonpharmacologic treatment
- Special cosmetics are available for treatment.
- The triggers should be avoided: Due to high skin sensitivity, irritating substances such as alcohols, aggressive soaps and caustics should not be brought into contact with the skin.
- Since heat and UV radiation from sunlight worsen the disease, the skin should be protected from overheating and a suitable UV protection should be applied.
- When cleaning the skin, use lukewarm water and not too hot or too cold.
- For non-drug treatment, surgical procedures, laser treatments and photodynamic therapy are also used, depending on the subtype.
Drug treatment
Drug therapy is symptomatic and can significantly improve symptoms, but so far not permanently cured. Well treatable is papulopustular rosacea, with less success for skin redness. Numerous active ingredients are used, but some have been insufficiently investigated scientifically in this indication and some are not approved, so they must be prescribed off-label on a doctor’s responsibility. Not all agents listed are effective against all subtypes.
External treatment
Metronidazole is usually the 1st-line agent for external drug treatment. It is an antibiotic and antiparasitic from the nitroimidazole group that is applied as a cream, gel, or lotion and is approved for this indication. It is usually applied in the morning and evening, and visible results can be expected within a few weeks. According to clinical studies, once-daily application is sufficient. The efficacy is probably primarily due to the anti-inflammatory properties of the drug. Possible adverse effects include local reactions such as skin dryness, stinging and burning. Metronidazole is absorbed through the skin only to a very small extent. see Metronidazole for External Treatment of Rosacea. Azelaic acid is approved in the U.S. (Finacea Gel 15%) and in Germany (Skinoren Gel 15%) as a gel for the treatment of papulopustular rosacea and is also effective, but may irritate the skin somewhat more severely and is therefore considered a second-line agent. The drug is commercially available in many countries but has not yet been approved by the authorities in this indication. Brimonidine is approved in the form of a gel (Mirvaso) for the symptomatic treatment of facial erythema. It is an alpha2-adrenoceptor agonist, which has vasoconstrictor properties. Ivermectin (Soolantra) was approved in Switzerland in 2016 for external treatment in the form of a cream. See under ivermectin cream
Internal treatment
For internal treatment, tetracyclines such as doxycycline are often used in low doses. Doxycycline is approved in sustained-release and subantimicrobial anti-inflammatory doses (Oracea, Oraycea, 40 mg). Precautions must be observed; for example, tetracyclines should not be taken during pregnancy or by children up to 8 years of age and may further sensitize the skin to solar radiation see under Doxycycline for Rosacea Treatment Isotretinoin is given in low doses for rhinophyma and for the treatment of papulopustular rosacea and is well effective for treatment. However, it can cause numerous adverse effects and is not suitable for pregnant women because it is harmful to fertility.
Other options
In the United States, a combination of the sulfonamide sulfacetamide 10% and sulfur 5% (eg, Rosanil, Plexion) is a common agent for external treatment. It is not commercially available in many countries. Other possible options mentioned in the literature include retinoids, adapalene, clindamycin, erythromycin, benzoyl peroxide, topical calcineurin inhibitors, an oxymetazoline cream, permethrin, and crotamiton. Skin care products are used to hydrate dry skin. Other antibiotics, for example, macrolides such as clarithromycin or azithromycin. Metronidazole can also be used internally, but is less well tolerated. For flushing symptoms, drugs that have been used include beta-blockers, clonidine, naloxone, low-dose acetylsalicylic acid, oral contraceptives, ondansetron, amitriptyline, and SSRIs; their efficacy is poorly documented scientifically, and many of these drugs can cause numerous side effects. Finally, the use of numerous other agents has been described. We do not know whether alternative medical approaches are also successful. Topical glucocorticoids may worsen the course of the disease and are contraindicated!