Acne Rosacea

1. Epidemiology
   1. Most common in ages 30 to 50 years old
   2. Northern european descent
   3. More common in women by factor of 2-3
   4. Prevalence: 14 Million cases in United States
2. Definition
   1. Acneiform eruption
3. Predisposing conditions
   1. Sun Exposure, hot weather, and hot baths
   2. Emotional stressors
   3. Alcohol
   4. Hot drinks
   5. Exercise
   6. Nose Hair Follicle mites (Demodex folliculorum)
4. Types
   1. Subtype 1: Erythematotelangiectatic (most difficult to treat)
      1. Persistent central face macular erythema with telangiectasias and Flushing
      2. Possible ocular involvement
   2. Subtype 2: Papulopustular (easiest to treat)
      1. Persistent central face erythema with small Papules and tiny Pustules (acne-like)
      2. Periocular sparing
   3. Subtype 3: Phymatous (more common in men)
      1. Skin thickening and nodular irregularities
      2. Distribution: Nose (Rhinophyma), chin, ears, forehead or Eyelid
   4. Subtype 4: Ocular
      1. Watery, bloodshot eyes may become dry with foreign body sensation and photophobia
      2. Distribution: Blepharitis, Conjunctivitis, and Eyelid Inflammation
5. Symptoms
   1. Stinging pain may accompany facial Flushing
6. Signs
   1. Course is variable
      1. Stages listed below are for organization only
   2. Distribution for all lesions
      1. Affects middle third of face (forehead to chin)
   3. Stage 1: Initial presentation
      1. Intermittent facial Flushing
   4. Stage 2: Early vascular changes
      1. Facial erythema
      2. Telangiectasis
      3. Eye changes (see ocular signs below)
   5. Stage 3: Inflammatory changes
      1. Papules
      2. Sterile Pustules
      3. Comedones are typically absent
   6. Stage 4: Rhinophyma (Red bulbous nose)
      1. More common in men
      2. Thickening of facial skin (especially nose)
         1. Connective tissue hypertrophy
         2. Sebaceous Gland hypertrophy
      3. Previously thought to be a sign Alcohol Abuse
         1. Example: W. C. Fields
   7. Variant: Granulomatous Rosacea
      1. May appear similar to facial sarcoid
7. Signs: Ocular involvement (50% of Rosacea cases)
   1. Eyelid Inflammation (may be presenting sign)
      1. Acne involving Eyelids
      2. Eyelid redness and swelling
      3. Eyelid margin telangiectasia
   2. Inflammatory Conjunctivitis
      1. Blepharitis may accompany Conjunctivitis
      2. Eyes that itch or burn
      3. Dry Eyes with sandpaper or foreign body sensation
   3. Other less common changes
      1. Corneal neovascularization
      2. Keratitis
      3. Corneal scarring
8. Differential Diagnosis: Skin
   1. Late-onset Acne Vulgaris
      1. Comedones present
      2. No telangiectasis
      3. No eye symptoms or signs
   2. Steroid-induced Acne
      1. Results from Corticosteroid use on face
      2. Perioral changes
   3. Perioral Dermatitis
   4. Polymorphous Light Eruption or other Photodermatitis
   5. Polymyositis
   6. Sarcoidosis
   7. Systemic Lupus Erythematosus
   8. Allergic Conjunctivitis
   9. Seborrheic Dermatitis
   10. Carcinoid Syndrome (severe facial Flushing)
9. Differential Diagnosis: Ocular Rosacea
   1. Blepharokeratoconjunctivitis (staphylococcal or seborrheic)
   2. Sebaceous Gland carcinoma
10. Management: General Measures
    1. Avoid Alcohol
    2. Avoid prolonged heat exposure
    3. Avoid hot liquids (coffee, tea)
    4. Avoid heavy cosmetics
    5. Use sun screen regularly (better tolerated agents are listed)
       1. Base: Simethicone, dimethicone or cyclomethicone
       2. Active ingredient: Titanium dioxide or zinc oxide
    6. Avoid provocative medications
       1. Benzoyl Peroxide (avoid in erythematotelangiectatic Rosacea - subtype 1)
       2. Topical Corticosteroids
11. Management: Papular and pustular Rosacea
    1. Step 1
       1. Apply across entire face
       2. First Line agents (most effective agents)
          1. MetronidazoleTopical Gel
             1. Effective in 80% of cases
          2. Azelaic Acid (Azelex) 15% gel
             1. Slight benefit over Metrogel, but less tolerated
             2. Irritation may be reduced with gentle skin cleansers (e.g. cetaphil) and Skin Lubricants (e.g. vanicream)
             3. Elewski (2003) Arch Dermatol 139:1444-50
       3. Alternative agents
          1. Clindamycin (Cleocin-T)
          2. Permethrin 5% cream
             1. Kocak (2002) Dermatology 205:265-70
    2. Step 2: May use the following oral agents in combination with topicals listed above
       1. Oral Antibiotics for 1 month, then taper dose to once daily
          1. Tetracycline 250 mg twice daily or
          2. Doxycycline 100 mg twice daily or
          3. Erythromycin 250 mg twice daily
          4. Amoxicillin 250 mg twice daily
       2. Efficacy
          1. Useful in treating Blepharitis, Keratitis
          2. Most effective treatment
    3. Step 3: Additional topical agents to consider
       1. Precaution: Avoid in erythematotelangiectatic Rosacea - subtype 1 (may worsen)
       2. Topical Benzoyl Peroxide with Erythromycin (e.g. Benzamycin)
       3. Topical Benzoyl Peroxide with Clindamycin (e.g. Benzaclin)
    4. Step 4: Refractory Cases
       1. Topical Tretinoin (Retin A)
          1. May exacerbate erythema and telangiectasis
       2. Accutane for 20 weeks
          1. Variably effective
       3. Consider mite or tinea management
          1. Examine sample with Potassium Hydroxide
          2. Crotamiton (Eurax)
12. Management: Associated conditions
    1. Facial Flushing and Erythema
       1. First-line: See general measures above
       2. Second-line
          1. See Vasomotor Symptoms of Menopause
          2. Clonidine 0.05 mg bid
          3. Propranolol (Inderal LA) 80 mg PO qd
    2. Telangiectasis
       1. Green-tinted cosmetics
       2. Pulsed dye laser
    3. Ocular changes
       1. First-line therapy
          1. Oral Tetracycline or Doxycycline
          2. Artificial tears for eye dryness
          3. Lid cleansing
          4. Topical metrogel to Eyelid if involved
       2. Second-line therapy for refractory cases
          1. Ocular steroids (by ophthalmology)
          2. Accutane
    4. Rhinophyma
       1. Early cases: Antibiotics as listed above
       2. Advanced cases: Surgery
          1. Dermabrasion
          2. Hypertrophic tissue excision
13. References
    1. Habif (1996) Clinical Dermatology, p. 182-4
    2. Blount (2002) Am Fam Physician 66(3):435-40
    3. Goldgar (2009) Am Fam Physician 80(5): 461-8
    4. Powell (2005) N Engl J Med 352(8):793-803
    5. Zuber (2000) Prim Care 27(2):309-18