Common clinical problem, Rosacea

The Feb. 24, 2005, issue of New England Journal of Medicine (NEJM) features a case study of a common clinical problem, Rosacea.

A number of clinical symptoms and signs are included under the broad group Rosacea. Facial flushing, the appearance of broken blood vessels and persistent redness of the face, eruption of inflamed spots & pimples, on the face and thickening of the sebaceous glands of the nose, with swelling & congestion in that area. Changes in the eyes are present in more than 50 percent of patients and range from mild dryness and irritation with inflammation of the eyelid and & conjunctivitis (common symptoms), to a sight-threatening, but rare, disease of the cornea.

Patients with Rosacea may experience increased sensitivity of the facial skin and may have dry, flaking facial dermatitis, swelling of the upper face, or persistent spots & pimples. Clinical features can overlap, but in the majority of patients, a particular manifestation of Rosacea dominates the clinical picture.

The disease can be classified into four subtypes: -

1. Erythematotelangiectatic - rash,
2. Papulopustular - skin eruptions,
3. Phymatous - swelling,
4. Ocular - eye infections.

Each subtype is graded according to the severity of the condition; 1 (mild), 2 (moderate), or 3 (severe). The disease can have serious psychological, social, and occupational effects on the patient and these factors should be considered when treatment decisions are being made.

The onset of Rosacea usually occurs between the ages of 30 and 50 years. The course of the disease is typically chronic, with remissions and relapses. Some patients can identify exacerbating factors such as heat, alcohol, sunlight, hot beverages, stress, menstruation, certain medications, and certain foods. Rosacea is more common in women than in men, but men with Rosacea are more prone to the development of thickening and distorting skin changes. Rosacea has been reported to be associated with an oily, greasy skin condition-Seborrheic Dermatitis, with migraine headaches in women, and with an infectious gastric disease -Helicobacter pylori. A Rosacea-like eruption can sometimes occur when fluorinated Corticosteroids and Tacrolimus ointments are used on the facial skin. Two European population studies illustrating the prevalence of Rosacea reported a 1.5 percent and 10 percent incidence, but estimates are complicated by the difficulty of distinguishing between sun damaged skin and genuine cases of Rosacea.

Rosacea can occur in all racial and ethnic groups, but is more common in white, Anglo Saxon groups; it is rarely seen in dark complexions. There is evidence that Rosacea is an hereditary condition.

Unfortunately the common misconception generally held that both the facial redness and the thickening of the nose area are a direct result of excessive alcohol consumption makes Rosacea a socially embarrassing and stigmatizing condition for many patient.

The diagnosis of Rosacea is a clinical one. There is no reliable laboratory test, and biopsy is only justified in ruling out alternative diagnoses;

Diagnosis and therapy varies according to subtype.

1. Erythematotelangiectatic - rash

Flushing, one of the most common presentation of rosacea, is difficult to treat, but the condition may improve with the management of other manifestations, [ psychosocial factors, anxiety or menopause], and the avoidance of provoking or triggering factors,[ certain foods, alcohol or drugs]. Skin inflammations are usually responsive to medical therapies and heal without scarring, whereas damaged blood vessels and swollen areas often require laser or surgical intervention. Prolonged episodes of severe flushing accompanied by sweating, flushing that is not limited to the face, and, especially, symptoms such as diarrhea, wheezing, headache, palpitations, or weakness need further investigations to rule out rare conditions .

Abnormal blood vessels are usually prominent on the cheeks and nose in grades 2 and 3 of this subtype 1, and cause the facial rash. This form of Rosacea is difficult to distinguish from the effects of sun damage sensitive, easily irritated skin, which may be another factor. It is poorly responsive to treatment . The two conditions require similar treatment. Similarities to facial contact dermatitis, & other conditions suggest further investigations may be needed. Studies of the effectiveness of medical treatments offer little evidence to support the effectiveness of treatments.

2. Papulopustular – skin eruptions

Small, eruptions, some of which have tiny pustules, on the central portion of the face, with a background rash distinguish this form of Rosacea. In grade 3 of the disease, inflammed lesions, abnormal blood vessels, swelling, eye inflammation, flushing are all common. Acne and forms of dermatitis are included in this group.

Antibiotics are often the main therapy used. Moderate-to-severe cases may require a variety of therapy to achieve results; milder cases of the disease can often be treated with topical medications alone. Many clinicians recommend a combination of topical and systemic therapies for the treatment of moderate-to-severe cases.

Oral treatments also proved effective, some research suggesting that intermittent low-dose antibiotic treatment may be as effective as multiple daily doses. About one quarter of patients relapse within weeks of therapy ceasing; remission may be maintained with topical therapy for up to six months . some patients skin free of lesions by applying topical therapy on alternate days or twice weekly.

3. Phymatous - swelling

Phymatous Rosacea is rare; the most common symptom being the swelling & redness of the nose. This is a disfiguring condition which occurs much more often in men than women. The diagnosis is usually made on a clinical basis, but a biopsy may be necessary to eliminate other conditions. Clinical experience has shown good results with surgery electrosurgery,& laser therapy.

4. Ocular - eye infections

Ocular Rosacea is common but often not recognized. It may precede, follow, or occur simultaneously with the skin changes typical of Rosacea. In the absence of accompanying skin changes, ocular rosacea can be difficult to diagnose, and there is no test that will confirm the diagnosis. Patients usually have mild, symptoms, such as burning or stinging of the eyes, dryness with poor tear secretion. Mild-to-moderate Ocular Rosacea occurs frequently, whereas serious (grade 3) disease with the potential for visual loss, occurs rarely.

Artificial tears, eyelid hygiene (i.e., cleaning the lids with warm water twice daily), fucidic acid, and metronidazole gel applied to lid margins are treatments that are frequently used to treat mild ocular rosacea. Antibiotics are often additionally required for grade-2-to-3 disease, although limited data are available to support these approaches. such treatment may be inadequate for moderate-to-severe ocular rosacea, and patients with persistent or potentially serious ocular symptoms should be referred to an ophthalmologist.

The causes of Rosacea remain unclear. The possibility of emergence and carriage on the skin of resistant organisms is a concern with regard to the prolonged use of topical and systemic antibiotics. There are no specific guidelines for the management of rosacea.

Source: http://www.nejm.org/