Rosacea
Rosacea | |
---|---|
Other names | Acne rosacea |
Antibiotics either by mouth or applied to the skin[3] | |
Frequency | ~5%[2] |
Rosacea is a
The cause of rosacea is unknown.[2] Risk factors are believed to include a family history of the condition.[3] Factors that may potentially worsen the condition include heat, exercise, sunlight, cold, spicy food, alcohol, menopause, psychological stress, or steroid cream on the face.[3] Diagnosis is based on symptoms.[2]
While not curable, treatment usually improves symptoms.[3] Treatment is typically with metronidazole, doxycycline, minocycline, or tetracycline.[4] When the eyes are affected, azithromycin eye drops may help.[5] Other treatments with tentative benefit include brimonidine cream, ivermectin cream, and isotretinoin.[4] Dermabrasion or laser surgery may also be used.[3] The use of sunscreen is typically recommended.[3]
Rosacea affects between 1% and 10% of people.[2] Those affected are most often 30 to 50 years old and female.[2] People with paler skin or European ancestry are more frequently affected.[2] The condition was described in The Canterbury Tales in the 1300s, and possibly as early as the 200s BC by Theocritus.[6][7]
Signs and symptoms
Rosacea typically begins with
Skin problems tend to be aggravated by particular trigger factors, that differ for different people. Common triggers are ultraviolet light, heat, cold, or certain foods or beverages.[9]
Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea
Glandular rosacea
In glandular rosacea, men with thick sebaceous skin predominate, a disease in which the papules are edematous, and the pustules are often 0.5 to 1.0 cm in size, with nodulocystic lesions often present.[11]
Cause
The exact cause of rosacea is unknown.
Medications and topical irritants have also been known to trigger rosacea flares. Some
.Cathelicidins
In 2007,
Demodex folliculitis and Demodex mites
Studies of rosacea and
A 2007,
Intestinal bacteria
Small intestinal bacterial overgrowth (SIBO) was demonstrated to have greater prevalence in rosacea patients and treating it with locally acting antibiotics led to rosacea lesion improvement in two studies. Conversely in rosacea patients who were SIBO negative, antibiotic therapy had no effect.[17] The effectiveness of treating SIBO in rosacea patients may suggest that gut bacteria play a role in the pathogenesis of rosacea lesions.
Diagnosis
Most people with rosacea have only mild redness and are never formally diagnosed or treated. No test for rosacea is known. In many cases, simple visual inspection by a trained health-care professional is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face is present, a trial of common treatments is useful for confirming a suspected diagnosis. The disorder can be confused or co-exist with
Classification
Four rosacea subtypes exist,[19] and a patient may have more than one subtype:[20]: 176
- Erythematotelangiectatic rosacea exhibits permanent redness (erythema) with a tendency to flush and
- Papulopustular rosacea presents with some permanent redness with red bumps (papules); some pus-filled pustules can last 1–4 days or longer. This subtype is often confused with acne.
- Phymatous rosacea is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).[22] Telangiectasias may be present.
- In telangiectasias and inflammation, and may feel dry, irritated, or gritty. Other symptoms include foreign-body sensations, itching, burning, stinging, and sensitivity to light.[23] Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Keratitis is a rare complication which is characterized by blurry vision and vision loss as the cornea is affected.[23][24]
Variants
Variants of rosacea include:[25]: 689
- Pyoderma faciale, also known as rosacea fulminans,[25] is a conglobate, nodular disease that arises abruptly on the face.[10][25]
- Rosacea conglobata is a severe rosacea that can mimic acne conglobata, with hemorrhagic nodular abscesses and indurated plaques.[25]
- Phymatous rosacea is a sebaceous glands.[10] Phyma is Greek for swelling, mass, or bulb, and these can occur on the face and ears.[25]: 693
Treatment
The type of rosacea a person has informs the choice of treatment.[26] Mild cases are often not treated at all, or are simply covered up with normal cosmetics.
Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions, a decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents.[27] Laser therapy has also been classified as a form of treatment.[27] While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually 1–2 years, may result in permanent control of the condition for some patients.[27][28] Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.[28] Other cases, if left untreated, worsen over time.[29] Some people have also reported better results after changing diet. This is not confirmed by medical studies, even though some studies relate the histamine production to outbreak of rosacea.[30]
Behavior
Certain behavioral changes may improve the symptoms of rosacea or help to prevent exacerbations. Keeping a symptoms diary to document potential symptom triggers and avoiding those triggers is recommended.[24] Common exacerbating triggers include ultraviolet light and irritant cosmetics, therefore it is recommended that those with rosacea wear sunscreen (with a sun factor protection (SPF) of 30 or greater) and avoid cosmetics.[24] If using cosmetics or makeup is desired, then oil free foundation and concealer should be used.[24] Skin astringents, products that can dry the skin and impair the skin barrier, including products with alcohol, menthol, peppermint, camphor, or eucalyptus oil, should generally be avoided. People should avoid using exfoliating skin scrubs, cosmetics or soaps containing sodium laureth sulfate, or waterproof makeup to the affected area as these products can compromise the skin barrier protection and be difficult to remove.[24] Using soap-free cleansers and non-oily moisturizers are preferred if used on the affected area. Many skin care products have been specifically formulated for those with sensitive skin or for those with conditions such as rosacea.[24] Ocular rosacea may be treated with daily gentle eyelid washing using warm water, and artificial tears to lubricate the eye.[24]
Managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm-room flushing.[31]
Medications
Medications with good evidence include topical
Metronidazole is thought to act through anti-inflammatory mechanisms, while azelaic acid is thought to decrease cathelicidin production. Oral antibiotics of the tetracycline class such as doxycycline, minocycline, and oxytetracycline are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.[12]
Topical minocycline applied as a foam is a newer treatment option for rosacea that the FDA has approved. Minocycline shows a targeted approach for managing inflammatory lesions of rosacea while minimizing systemic side effects commonly associated with oral antibiotic use. It is available in foam formulation and is applied to the affected areas once daily. Minocycline belongs to the tetracycline family of antibiotics and exhibits antimicrobial properties and anti-inflammatory activity, similar to other members of this class, such as doxycycline. Topical minocycline reduces inflammatory lesions associated with rosacea; however, rare adverse events such as folliculitis have been reported.[32]
Topical metronidazole is a commonly used treatment for rosacea; it is available in various formulations such as creams, gels, or lotions and applied to clean, dry skin once or twice daily. Topical metronidazole has been shown to effectively reduce inflammatory lesions and perilesional erythema associated with rosacea by inhibiting both microbial growth and pro-inflammatory mediators generated by neutrophils. Benefits of topical metronidazole include its effectiveness in reducing symptoms, extensive clinical experience supporting its use, and generally good tolerability with minimal systemic side effects; still, some patients may experience mild local irritation upon initial use, and it may have limited impact on persistent facial redness (erythema).[32]
Topical azelaic acid is available in gel or cream formulations; it exerts its effects by reducing inflammation through its activity on the cathelicidin pathway, which is upregulated in rosacea-affected skin; it also reduces inflammatory lesions and improves overall symptoms of rosacea; it has been well-studied and shown to be effective in clinical trials; still, some patients may experience mild local irritation during the first few weeks of use.[32]
Using
Oral
Topical ivermectin is a treatment option for rosacea that targets Demodex mites, which are associated with inflammation in the skin of patients with rosacea; the cream is applied once daily to clean, dry skin. Topical ivermectin has been shown to reduce Demodex mite density and improve cutaneous inflammatory markers in clinical studies; overall, it decreases Demodex mite density and improves the symptoms of inflammation associated with rosacea; however, some patients may experience transient burning or itching upon application. Topical ivermectin offers a targeted approach for managing rosacea by addressing the role of Demodex mites in the disease process.
Systemic doxycycline modified-release capsules are commonly used for the treatment of rosacea. The capsules are taken orally once daily, usually in a low dose, to achieve anti-inflammatory effects. Doxycycline acts by inhibiting inflammation and reducing the production of reactive oxygen species associated with rosacea symptoms. The benefits of systemic doxycycline include its effectiveness in reducing inflammatory lesions, improving erythema, and controlling symptoms related to ocular involvement in rosacea patients; it is also well-tolerated at lower doses compared to traditional higher-dose regimens used for other indications. However, potential cons include gastrointestinal side effects such as nausea or abdominal pain, photosensitivity reactions that require sun protection measures during treatment, and rare instances of antibiotic-associated diarrhea or bacterial resistance development with long-term use.[32]
Encapsulated benzoyl peroxide (E-BPO) cream, a newly FDA-approved topical agent for inflammatory lesions of rosacea, utilizes porous silica microcapsule technology to slow the absorption of benzoyl peroxide and diminish potential irritation.[32]
Laser
Evidence for the use of laser and intense pulsed-light therapy in rosacea is poor.[42]
Outcomes
The highly visible nature of rosacea symptoms are often psychologically challenging for those affected. People with rosacea can experience issues with self-esteem, socializing, and changes to their thoughts, feelings, and coping mechanisms.[9]
Epidemiology
Rosaceae affects around 5% of people worldwide.[9] Incidence varies by ethnicity, and is particularly prevalent in those with Celtic heritage.[9] Men and women are equally likely to develop rosacea.[9]
See also
- Seborrheic dermatitis
- Keratosis pilaris
References
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External links
- Rosacea at Curlie
- Rosacea photo library at Dermnet Archived 26 October 2011 at the Wayback Machine
- Questions and Answers about Rosacea, from the US National Institute of Arthritis and Musculoskeletal and Skin Diseases