Rosacea

Rosacea - Ruddy Beginnings

• Definition: Chronic inflammatory disorder primarily affecting central facial skin (cheeks, nose, chin, forehead).
• Age of Onset: Typically 30-50 years.
• Gender Predilection: Females > Males; however, males often develop more severe manifestations like rhinophyma.
• Key Risk Factors:
  • Fair skin types (e.g., Celtic ancestry)
  • Positive family history
  • Chronic UV radiation exposure
  • Demodex folliculorum mite infestation
  • H. pylori infection (role remains debated)

⭐ Rhinophyma, characterized by a thickened, bulbous, and erythematous nose, is a subtype of rosacea predominantly seen in older men.

Rosacea - The Why Behind

• Neurovascular Dysregulation:
  • TRP channels (TRPV1, TRPA1) on nerves/endothelium.
  • Causes flushing, persistent erythema, telangiectasias.
• Innate Immune Activation:
  • ↑ Cathelicidin LL-37 (abnormally processed).
  • TLR2 activation by various triggers.
• Microbial Factors:
  • Demodex folliculorum mites (↑ density).
  • Bacillus oleronius (Demodex-associated).
• Mast Cell Activation:
  • Releases key inflammatory mediators (histamine, proteases).
• Chronic Inflammation:
  • Common pathway driving persistent skin changes.

⭐ Aberrant cathelicidin LL-37 (↑ levels, altered peptides) is a pivotal driver of inflammation and vascular effects in rosacea.

Rosacea - Faces of Redness

Rosacea: A chronic inflammatory disorder affecting the centrofacial skin, characterized by remissions and exacerbations. Common triggers include heat, sunlight, spicy foods, and alcohol.

Four Main Subtypes:

-   Granulomatous rosacea: Characterized by monomorphic yellow-brown or reddish papules/nodules, often periorificial.

⭐ Ocular involvement occurs in up to 50-75% of rosacea patients and can sometimes precede skin changes.

Rosacea - Nailing the Diagnosis

Diagnosis is clinical, based on characteristic findings.

• Key Diagnostic Features (≥1 needed):
  • Persistent centrofacial erythema
  • Phymatous changes (e.g., rhinophyma)
• Major Features (≥2 needed if key features absent):
  • Papules/pustules
  • Flushing
  • Telangiectasias
  • Ocular manifestations
• Secondary Features: Burning/stinging, edema, dry appearance.
• Differential Diagnosis:
  • Acne vulgaris (comedones present)
  • Seborrheic dermatitis (greasy scales)
  • Lupus (malar rash, spares nasolabial folds, ANA+)
  • Perioral dermatitis

⭐ Rosacea is distinguished from acne vulgaris by the absence of comedones.

Rosacea - Calming the Crimson

• General Measures: Avoid triggers (sun, heat, alcohol, spicy food); gentle skincare; broad-spectrum sunscreen (SPF ≥30).

• Topical: Metronidazole, Azelaic acid, Ivermectin, Brimonidine (erythema), Sulfacetamide-sulfur.
• Systemic:
  • Oral antibiotics: Doxycycline (40mg MR or 100mg), Minocycline.
  • Severe/refractory: Oral Isotretinoin.
• Physical: Laser/IPL (telangiectasias, persistent erythema); Surgical debulking (rhinophyma).
• Ocular: Lid hygiene, artificial tears, topical/oral antibiotics.

⭐ Doxycycline at a 40mg modified-release dose provides anti-inflammatory action for rosacea, below antimicrobial thresholds.

High‑Yield Points - ⚡ Biggest Takeaways

• Characterized by chronic facial erythema, telangiectasias, papules/pustules; crucially, no comedones.
• Main subtypes: Erythematotelangiectatic (ETR), Papulopustular (PPR), Phymatous (e.g., rhinophyma), and Ocular.
• Rhinophyma, a phymatous change of the nose, is more common in men.
• Ocular rosacea presents with conjunctivitis, blepharitis, potentially keratitis.
• Common triggers: sunlight, heat, alcohol, spicy food, stress.
• First-line treatments: Topical metronidazole, azelaic acid, ivermectin; oral tetracyclines (e.g., doxycycline).