Dr Rebecca Mawson shares some key points for managing rosacea in primary care and how people with rosacea can reduce trigger events

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Read this article to learn more about:

  • diagnosing and managing rosacea in primary care
  • different types of rosacea and general measures for treatment
  • topical and oral treatments for rosacea.

 

Rosacea is a common skin complaint and can have a detrimental impact on an individual's life, with some people reporting that their condition was trivialised when they presented to primary care. This article looks at rosacea diagnosis and management, combining evidence from various sources and guidelines. Rosacea is defined as a chronic acneiform disorder of the pilosebaceous glands, with increased reactivity of capillaries to heat causing flushing and then telangiectasia (blood vessel growth).1 It is three times more likely to occur in women than men, mainly affecting Caucasian individuals.2

Rosacea predominantly affects fair-skinned adults and has a bimodal prevalence at 20 to 30 years of age and then a larger peak at 40 to 50 years.3 In Europe there is an increasing prevalence from south to north, with Germany having a prevalence of 2.2% and Sweden 10%.4 This study on the epidemiology of rosacea in the UK found an overall incidence for diagnosed rosacea in the UK of 1.65 per 1000 person-years, with 80% of cases being diagnosed after the age of 30 years.4 Ocular symptoms were recorded in approximately 20% of cases.4 This study also reported that only 7.3% of cases were referred to secondary care.4

1 Understand possible causes of rosacea

Rosacea is thought to be related to an altered immune response that is aggravated by environmental or physical factors. There has been debate about the role of the Demodex mite, which is found in higher concentrations in rosacea skin biopsies; it is thought there is an immune response that triggers vascular changes.5 Other triggers include medication (e.g. calcium channel blockers), topical steroids, and the environment (e.g. sunlight, caffeine, alcohol, emotional stress).6 An increased incidence of rosacea has been reported in those who carry the stomach bacterium Helicobacter pylori, but most dermatologists do not believe it to be the cause of rosacea.7

2 At diagnosis avoid confusion with acne

The onset of rosacea is often preceded by a history of episodic flushing and patients may describe experiencing a burning or stinging sensation.6 The skin is not greasy as with acne, and the usual areas affected include forehead, cheeks, and chin (see Figure 1, below), with pustules overlying erythema.3

Figure 1: Usual areas affected by rosacea in men and women
Usual areas affected by rosacea in men and women

Morphology3

  • Erythema
  • Telangiectasia
  • Papules and pustules
  • Absence of open comedones (blackheads)—differentiates from acne vulgaris
  • Thickening of skin, which can become chronic.

Differential diagnosis includes acne vulgaris, seborrheic dermatitis, systemic lupus erythematosus, and photosensitive eruptions.2 Acne is the condition that is most commonly mistaken for or managed as rosacea.2 Table 1 (see below) lists the differences between the two conditions to enable diagnosis.

Table 1: The differences between rosacea and acne
Comparative featureRosaceaAcne vulgaris
Areas affected Central region of the face, usually the cheeks and nose, sometimes the chin or forehead Primarily the face, but the back, chest, and shoulders may also be affected to a lesser degree
Symptoms Typically starts as a redness, sometimes with tiny dilated blood vessels becoming visible. Bumps and pimples may appear as inflammation increases, and the eyes may feel gritty or appear bloodshot. In advanced cases, the nose may become swollen from excess tissue Characterised by a great variety of lesions, with blackheads often predominant. Pimples, bumps, and nodules may also develop on the face and other affected areas. The skin may become oily from overly active sebaceous glands
Treatment Prescription oral and topical medications and avoidance of lifestyle factors that may trigger flare-ups Over-the-counter acne preparations and prescription medications for severe cases
National Rosacea Society website. Acne or rosacea? A case of mistaken identity.
Reproduced with permission

3 Be aware of the different types of rosacea

Rosacea is classified into four types, each having a different presentation:8

  • papulopustular rosacea is the classic presentation. Patients are typically middle-aged women with a red central portion of their face that contains small erythematous papules with pinpoint pustules. They may have flushing. Telangiectasia is often present but may be difficult to distinguish from the erythematous background
  • phymatous rosacea shows marked skin thickenings and irregular surface nodules of the nose, chin, forehead, one or both ears, and/or the eyelids. Rhinophyma is included in this classification
  • ocular rosacea may precede the cutaneous form by years, but they can often develop simultaneously. It is characterised by symptoms such as dry eye, tearing and burning, swollen eyelids, recurrent styes, and potential vision loss from corneal damage
  • erythematotelangiectatic rosacea presents with central facial flushing, often with burning, stinging, or itching. The redness usually spares the area around the eyes. It is characterised by flushing and persistent redness, with visible blood vessels. The flushing often progresses to a permanent erythema and telangiectasia over the affected areas.

4 Offer lifestyle advice on avoidance of rosacea flare-ups

General measures to avoid outbreaks of rosacea can be seen in Box 1 (see below).9

Box 1: General measures for the treatment of rosacea9

Advise people with rosacea on the following points:

  • where possible, reduce factors that cause facial flushing—medications included
  • avoid oil-based facial creams. Use water-based make-up. Judicious use of cosmetics may improve appearance significantly and, in doing so, greatly reduce distress. If the skin is dry, use emollients (hypoallergenic and non-comedogenic emollient creams)
  • never apply a topical steroid to the rosacea as, although short-term improvement may be observed (vasoconstriction and anti-inflammatory effect), it makes the rosacea more severe over the next weeks (possibly by increased production of nitric oxide). Avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents to be removed, or products containing sodium lauryl sulfate
  • protect themselves from the sun. Use light oil-free facial sunscreens. Sunscreens should be applied daily (SPF 30 minimum)
  • keep their face cool to reduce flushing: minimise their exposure to hot or spicy foods, alcohol, hot showers and baths, and warm rooms
  • some people find they can reduce facial redness for short periods by holding an ice block in their mouth between the gum and cheek.

SPF=sun protection factor.

5 Decide on treatment and management of papulopustular rosacea according to the skin condition

Papulopustular rosacea is the most commonly seen type5 and treatment depends on the severity of the skin condition as shown in Table 2 (see below). Topical and oral medications are available for the treatment of rosacea and these are outlined in Table 3 (see below).6 There is evidence that using a combination of topical and oral medication is better than oral monotherapy.10 In secondary care isotretinoin is sometimes used for refractory rosacea.10

Table 2: Classification and management of papulopustular rosacea according to skin condition6,9
ClassificationManagementPhoto
Mild papules and erythema

Lifestyle changes

Avoidance of exacerbating medications

rosacea1
Moderate papules and early pustules Topical medications, e.g. metronidazole gel, azelaic acid rosacea2
Severe erythema, papules, and pustules Oral medications, e.g. oxytetracycline rosacea3
Images from DermNet NZ
Reproduced with permission

Table 3: Topical and oral medications for the treatment of rosacea6
Topical or oralMedicationDose
Topical Metronidazole gel or cream 0.75%:
  • first-line treatment
Twice daily for 6-9 weeks
Azelaic acid 15%:
  • useful with inflammatory rosacea
Twice daily for 6-9 weeks
Oral Doxycycline (off licence) 100 mg daily for 12 weeks
Doxycycline modified release 40 mg daily for 16 weeks
Erythromycin (off licence) 500 mg twice daily for 6-12 weeks
Option for pregnant or breastfeeding women
Lymecycline (off licence) 408 mg daily for 12 weeks
Oxytetracycline or tetracyclinee 500 mg twice daily for 6-12 weeks

6 Prescribe appropriate treatments to limit facial flushing

Facial flushing might be the predominant symptom of rosacea and can cause a great deal of distress due to social embarrassment. Antibiotics tend not to be effective for treatment of flushing symptoms and it may be necessary to use alternatives.3 Brimonidine gel 0.33% is an alpha agonist that causes vasoconstriction in the skin when applied topically once daily and is licensed for facial flushing.2 Laser therapy can be effective at reducing flushing but is unlikely to be funded within the NHS.3 Occasionally medications such as non-cardio-selective beta blockers might be used, such as propranolol.3

7 Remember to ask about eye symptoms

Ocular rosacea (see Figure 2, below) can occur in 50% of people with rosacea and symptoms include gritty eyes with blepharitis, conjunctivitis, inflammation of the lids and meibomian glands, conjunctival hyperaemia, and conjunctival telangiectasia.3 There may be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation.11 Systemic tetracyclines are an effective treatment for ocular rosacea.3 Ocular rosacea may sometimes be confused with blepharitis.

Figure 2: An example of ocular rosacea11
An example of ocular rosacea

Images from DermNet NZ
Reproduced with permission.

Advice for patients with ocular rosacea should include undertaking regular lid hygiene (as in the treatment of blepharitis) using diluted baby shampoo (diluted 1:10 in warm water) and a cotton bud with warm compress.12 Artificial tears should be used at frequent intervals.3

8 Discuss the best treatment for rhinophyma

Rhinophyma (see Figure 3, below) is a form of rosacea that affects the nose; the skin is thickened and the sebaceous glands are enlarged. The skin appears purple or red and often has prominent blood vessels.13 Rhinophyma typically responds poorly to medical treatment and often surgery is needed; this may include mechanical dermabrasion, laser peel, and CO2 laser abrasion.13 The British Association of Dermatologists has produced a patient leaflet with further information on rhinophyma.14

Figure 3: An example of advanced rhinophyma9
An example of advanced rhinophyma

Images from DermNet NZ
Reproduced with permission.

9 Refer patients to the appropriate specialist

Referral to secondary care should be made as follows:6

  • routine dermatology referral for: persistent symptoms that are causing psychological or social distress and have not responded to lifestyle changes; papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment. If diagnosis is uncertain then specialist involvement will help tailor management
  • routine referral to a plastic surgeon: for severe phymatous disease or prominent rhinophyma
  • routine referral to an ophthalmologist: when ocular symptoms are severe or fail to respond to maximal treatment in primary care
  • urgent referral to an ophthalmologist: if there is suspected keratitis—eye pain, blurred vision, or sensitivity to light.

A recent Danish study has shown a significant relationship between having rosacea and development of dementia, more specifically Alzheimer's disease.15 The pathophysiology is unknown but there are theories regarding links between immune responses and proinflammatory mediators, which are present in both conditions.15

11 Give your patient as much information as possible about their rosacea

There is no cure for rosacea and patients need to understand the remitting course of the condition.6 The following resources might help them to engage more in management of their condition:

References

  1. Ashton R, Leppard B. Differential Diagnosis in Dermatology, 3rd ed. Radcliffe, 2005: p.196.
  2. Tuzun Y, Wolf R, Kutlubay Z et al. Rosacea and rhinophyma. Clin Dermatol 2014; 32 (1): 35–46.
  3. Primary Care Dermatological Society. Rosacea. Clinical Guideline, updated May 2016. PCDS, 2012. Available at: www.pcds.org.uk/clinical-guidance/rosacea (accessed 2 June 2016).
  4. Spoendlin J, Voegel J, Jick S, Meier C. A study on the epidemiology of rosacea in the UK. Br J Dermatol 2012; 167 (3): 598–605.
  5. van Zuuren E, Fedorowicz Z, Carter B et al. Interventions for rosacea. Cochrane Database Syst 2015; 28 (4).
  6. NICE. Clinical knowledge summaries: rosacea—acne. Updated January 2016. NICE, 2016. Available at: cks.nice.org.uk/rosacea-acne (accessed 2 May 2016).
  7. Szlachcic A. The link between Helicobacter pylori infection and rosacea. J Eur Acad Dermatol Venereol 2002; 16 (4): 328–33.
  8. Wilkin J, Dahl M, Detmar M et al. Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol 2004; 50 (6): 907–912.
  9. DermNet New Zealand Trust website. Rosacea. www.dermnetnz.org/acne/rosacea.html (accessed 13 May 2016).
  10. Weinkle A, Doktor V, Emer J. Update on the management of rosacea. Clin Cosmet Investig Dermatol 2015; 8: 159–177.
  11. DermNet New Zealand Trust website. Ocular Rosacea. www.dermnetnz.org/acne/ocular-rosacea.html (accessed 13 May 2016).
  12. NICE. Clinical knowledge summaries: blepharitis. Available at: cks.nice.org.uk/blepharitis#!scenario (accessed 13 May 2016).
  13. DermNet New Zealand Trust website. Rhinophyma. Available at: www.dermnetnz.org/acne/rhinophyma.html (accessed 2 June 2016).
  14. British Association of Dermatologists. Patient information leaflet: rhinophyma. Available at: www.bad.org.uk/for-the-public/patient-information-leaflets?sitesectionid=159&group=00016001000200010004&range=P-T&l=0 (accessed 30 May 2016).
  15. Egeberg A, Hansen P, Gislason G, Thyssen J. Patients with rosacea have increased risk of dementia. Ann Neurol 2016; 79 (6): 921–928. G