| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
IN THE TRENCHES |
 |
ABSTRACT |
|---|
TOP
 ABSTRACT HISTORY AND EXAMINATIONQUESTIONS AND COMMENTARYREFERENCES |
|---|
On examination, her face appears slightly sunburned. The skin under her eyes and over her cheeks is dry and has minimal flaking. On her chin and around her nose are 8–10 small red solid papules without blackheads. Her examination shows a normal female hair pattern and no evidence of androgenization. Her gynecologist counsels her on the importance of avoiding direct sun exposure and wearing sunscreen and prescribes a third-generation oral contraceptive pill to aid in both contraception and acne.
One year later, the patient returns for her annual examination. She remains healthy but is still concerned about her facial skin. She notes that her face is now generally red and irritated, despite daily use of sunscreen. The pimples are present on most days. She has bought various expensive skin care products and used them faithfully, with no effect. In addition, her eyes feel irritated and watery most of the time. On examination there is diffuse erythema of the nose, medial cheeks, forehead, and chin. There are small acne-like lesions around the nose. The chest and back are uninvolved. Her gynecologist refers her to a dermatologist.
|
HISTORY AND EXAMINATION |
|---|
|
TOP
ABSTRACTHISTORY AND EXAMINATIONQUESTIONS AND COMMENTARYREFERENCES |
|---|
Examination of the face is remarkable for a dense network of prominent telangiectasias over the nasal bridge, forehead, and central cheeks. There are scattered inflammatory papules and pustules over the nose and medial cheeks. There are no visible comedones. Examination of the chest, back, and bilateral upper extremities reveals no other cutaneous findings. The dermatologist suspects rosacea to be the most likely diagnosis.
|
QUESTIONS AND COMMENTARY |
|---|
|
TOP
ABSTRACTHISTORY AND EXAMINATIONQUESTIONS AND COMMENTARYREFERENCES |
|---|
Some studies have suggested that rosacea patients have a higher follicular density of Demodex folliculorum (a mite that lives in sebaceous follicles) than unaffected patients.2 However, there are methodological problems in uniformly sampling follicular contents.
How common is rosacea?
Reliable incidence data are lacking, but rosacea is commonly diagnosed in the third or fourth decade of life in fair-skinned people of Celtic or northern European heritage.3 One Swedish study found a prevalence of 10%4 among office-based employees. According to data from the National Ambulatory Medical Care Survey, there was an average of 1.1 million annual outpatient visits for rosacea in the United States from 1990 to 1997.5
What is the differential diagnosis for rosacea and what distinguishes it from other skin conditions?
Acne Vulgaris
Typically, acne vulgaris occurs in a younger age group and is characterized by the presence of comedonal (blackheads and whiteheads) lesions with or without associated inflammatory papules and pustules. The presence of acne lesions on the chest and back is not typical of rosacea. Although acne patients may present with facial erythema, it is usually secondary to the inflammatory papules and lacks the telangiectatic component that is characteristic of rosacea.
Seborrheic dermatitis
Seborrheic dermatitis typically presents as erythema and scaling of the nasolabial folds, eyebrows, scalp, postauricular folds, and ear canals. It may also involve the central chest, axillae, or groin. Flushing or the presence of inflammatory papules and pustules is not characteristic of seborrheic dermatitis.
Systemic lupus erythematosus (SLE)
Because rosacea typically affects the central face and can be exacerbated by sun exposure, it may be mistaken for the malar rash of SLE. However, the characteristic malar rash of SLE lacks papules or pustules. Other cutaneous features of lupus, such as follicular plugging, atrophy, scarring, and adherent scale are not characteristic of rosacea. A negative review of systems is also helpful in eliminating SLE from the differential. Because a low antinuclear antibody titer is a nonspecific finding, blood studies are not helpful in differentiating SLE from rosacea in the absence of other systemic findings and need not be done.
Perioral dermatitis
The papules and vesicles of perioral dermatitis appear in groups primarily in the perioral region and are generally smaller than those occurring with rosacea. Telangiectasia is observed less often in perioral dermatitis than in rosacea, and no flushing or blushing is present.
Irritant or allergic contact dermatitis
Contact dermatitis may resemble rosacea, but it is invariably pruritic. Its geometric shape or pattern often follows the size and shape of the external causal agent.
How is rosacea diagnosed?
Despite its apparent high incidence, the nosology of rosacea is not well established. There are no laboratory markers that aid in the diagnosis of rosacea. However, the National Rosacea Society has developed guidelines for the diagnosis of rosacea (see box, "Guidelines for Diagnosis of Rosacea") and a standard classification system outlining the manifestations and subtypes of rosacea (see box, "Subtypes and Characteristics of Rosacea").6 A biopsy is almost never indicated to diagnose rosacea. Figures 1, 2, and 3 show common appearances of rosacea.
|
|
|
What are the risk factors?
No specific risk factors have been identified, but rosacea is more commonly diagnosed in patients with northern European ethnicity.3 Exacerbating factors for rosacea flares should not be confused with risk factors for the development of disease. For example, alcoholic beverages may precipitate rosacea-associated flushing, but there is no evidence that alcohol consumption contributes to the development of rosacea or the phymatous changes associated with certain subtypes of rosacea.7,8
What happens if rosacea remains untreated?
Rosacea is characterized by remissions and exacerbations. The disorder can involve various combinations of erythema, flushing, papules and pustules, and phymatous changes (see box, "Subtypes and Characteristics of Rosacea").6 However, the signs are variable, and each may occur independently. Evolution from one subtype to another may or may not occur. Regardless of subtype, each individual characteristic may progress from mild to moderate to severe.
The psychological affects of untreated rosacea can be disabling9 and can significantly impact the patient's quality of life.10 Although the natural course of the disease is variable, untreated rosacea may result in chronic inflammatory changes such as permanent and severe erythema, edema, and phymatous changes.7
How is rosacea initially treated?
Like most chronic skin diseases, rosacea requires long-term treatment to suppress inflammation. Treatment should be tailored to the specific variant of rosacea.3 Avoiding known triggers such as sun, alcohol, hot beverages, certain foods, and irritating cosmetics is recommended for all patients, regardless of rosacea subtype. Because both acute and chronic sun exposure are thought to exacerbate rosacea, regular use of sunscreens is an important part of all treatment plans. Medical management is summarized in Table 1.
|
Topical Therapy
There is considerable controversy over both the therapeutic effect and mechanism of action of topical therapy. If the patient has mild erythema and a limited number of papules and pustules, topical metronidazole,11,12 clindamycin,13 azelaic acid,14 sodium sulfacetamide, and sulfur15 are helpful. Response is not immediate and often requires several weeks of treatment before a benefit is visible.
Oral Therapy
Antiinflammatory antibiotics:
If the papular or pustular component is more extensive, or if mild edematous changes are seen, oral tetracyclines are recommended to decrease the overall inflammatory component of the disease.1,3,11,14,16 Oral treatment is frequently combined with topical treatment. As the rosacea improves, the oral treatment can be discontinued and the improvement maintained by continuation of the topical treatment.8
Isotretinoin:
More severe inflammatory, refractory, or persistent cases may be treated with oral 13-cis-retinoic acid (isotretinoin) therapy.17 Because it has many adverse effects, including dry skin and mucosae, dry eyes, pruritus, and dermatitis, isotretinoin is indicated only for treatment-resistant rosacea. More serious, but less common, adverse effects include myalgia and elevated levels of liver enzymes, cholesterol, and triglycerides. Isotretinoin is a potent teratogen. Therefore, counseling is required and effective contraception is mandatory in view of the risk of teratogenicity. The U.S. Food and Drug Administration requires monthly pregnancy tests for women of childbearing potential.
Oral treatment of flushing symptoms:
If the patient suffers from significant, symptomatic facial flushing, oral medications such as centrally active 
-blocking hypotensive drugs or low dose ß-blockers may be used.16 However, the use of nadolol and clonidine for rosacea is off label, and the response is variable. Common adverse effects include orthostatic hypotension and xerostomia.
Procedural Treatment
The prominent telangiectasias associated with rosacea can be treated with a variety of lasers (those using hemoglobin as a chromophore) or intense pulsed light treatments.18 It should be emphasized that the effects of current laser treatment are transient in the setting of progressive or untreated rosacea. Although many lasers and intense pulsed light devices are marketed for treatment of facial erythema, very few have demonstrated clear-cut clinical efficacy. Clinical improvement is dependent on the correct selection of the type of laser and the correct fluency settings. Proper training is mandatory.
Contraindicated Therapy
Topical steroids may initially decrease the erythematous component of rosacea. However, prolonged use can produce telangiectasias and exacerbate both flushing and erythema upon treatment withdrawal.8
When should the primary care provider refer to a dermatology specialist?
If the diagnosis is in doubt or if patients fail to respond to first-line therapy, referral to a dermatologist may be helpful. Complications of laser or intense pulsed light therapy in rosacea patients are common when performed by a health care provider who is not properly trained in the basic science of lasers and laser therapy techniques. These complications can lead to permanent scarring or disability.
|
Footnotes |
|---|
The editors thank the following individuals who, in addition to members of our Editorial Board, will serve as referees for this series: Sanford M. Markham, MD, Hope K. Haefner, MD, Ronald S. Gibbs, MD, Neil J. Murphy, MD, Linda T. Taylor, MD, and Jerry Rozeboom, MD.
Corresponding author: Ingrid Nygaard, MD, MS, University of Iowa Health Care, Department of Obstetrics and Gynecology, 200 Hawkins Drive, 2 BT, Iowa City, IA 52242; e-mail: ingrid-nygaard{at}uiowa.edu.
doi:10.1097/01.AOG.0000151956.00804.78
|
REFERENCES |
|---|
|
TOP
ABSTRACTHISTORY AND EXAMINATIONQUESTIONS AND COMMENTARYREFERENCES |
|---|
2. Forton F, Seys B. Density of Demodex folliculorum in rosacea: a case-control study using standardized skin surface biopsy. Br J Dermatol 1993;128:650–9.[Medline]
3. Jansen T, Plewig G. Rosacea: classification and treatment. J R Soc Med 1997;90:144–50.[Medline]
4. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol 1989;69:419–23.[Medline]
5. Feldman SR, Hollar CB, Gupta AK, Fleischer AB Jr. Women commonly seek care for rosacea: dermatologists frequently provide the care. Cutis 2001;68:156–60.[Medline]
6. Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002;46:584–7.[Medline]
7. Millikan L. Recognizing rosacea. Postgrad Med 1999;105:149–50, 153–8.
8. Webster G. Rosacea and related disorders. In: Bolognia J, Jorizzo JL, Rapini RP, editors. Dermatology. New York (NY): Mosby; 2003. p. 545–51.
9. Garnis-Jones S. Psychological aspects of rosacea. J Cut Med Surg 1998;2(suppl 4):S4–16.
10. Boehncke WH, Ochsendorf F, Paeslack I, Kaufmann R, Zollner TM. Decorative cosmetics improve the quality of life in patients with disfiguring skin diseases. Eur J Dermatol 2002;12:577–80.[Medline]
11. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK. Interventions for rosacea (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Oxford: Update Software.
12. Monk BE, Logan RA, Cook J, White JE, Mason RBS. Topical metronidazole in the treatment of rosacea. J Dermatol Treat 1991;2:91–3.
13. Wilkin JK, De Witt S. Treatment of rosacea: topical clindamycin versus oral tetracycline. Int J Dermatol 1993;32:65–7.[Medline]
14. Maddin S. A comparison of topical azelaic acid 20% cream and topical metronidazole 0.75% cream in the treatment of patients with papulopustular rosacea. J Am Acad Dermatol 1999;40:961–5.[Medline]
15. Sauder DN, Miller R, Gratton D, Danby W, Griffiths C, Philips SB. The treatment of rosacea: the safety and efficacy of sodium sulfacetamide 10% and sulfur 5% lotion (Novacet) is demonstrated in a double-blind study. J Dermatol Treat 1997;8:79–85.
16. Rebora A. The management of rosacea. Am J Clin Dermatol 2002;3:489–96.[Medline]
17. Ertl GA, Levine N, Kligman AM. A comparison of the efficacy of topical tretinoin and low-dose oral isotreinoin in rosacea. Arch Dermatol 1994;130:319–24.[Abstract]
18. Bikowski JB, Goldman MP. Rosacea: where are we now? J Drugs Dermatol 2004;3:251–61.[Medline]
This article has been cited by other articles:
|
|
 |
|
  N. Meirowitz Flushing and Papules in a Middle-Aged Woman Obstet. Gynecol., June 1, 2005; 105(6): 1482 - 1482. [Full Text] [PDF]
|
|
|
|
|
|
I. Nygaard Flushing and Papules in a Middle-Aged Woman Obstet. Gynecol., June 1, 2005; 105(6): 1482 - 1483. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
