ROSACEA
By Dan Ladd, D.O.
Texas/KCOM Dermatology Residency Program
Program Director
Bill V. Way, D.O.
CC: ITCHY RASH ON FACE
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“STINGS”
“BURNS”
ONSET 2 DAYS
TOPICAL CREAMS
NOT HELPFUL
• PMX: NONE
• NO NEW MEDS
• NO NEW SOAPS OR
PERFUMES
WHAT IS ROSACEA?
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VARIABLE DEGRESS OF…..
CENTROFACIAL ERYTHEMA
TELANGIECTASIAS
PAPULES
PUSTULES
NODULES
EDEMATOUS PLAQUES
EARLY ROSACEA (STAGE I)
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“FLUSHER-BLUSHERS”
OFTEN < AGE 20
NOSE/CHEEKS
RECURRENT EPISODES
OF BLUSHING.
• ERYTHEMA PERSISTS
• FEW TELANGIECTASIAS
STAGE I - TELANGIECTASIAS
STAGE I
• TELANGIECTASIAS
BECOME
PROGRESSIVELY
PROMINENT,
FORMING SPRAYS
ON THE NOSE,
NASOLABIAL
FOLDS, CHEEKS
AND GLABELLA
STAGE II
PAPULES & PUSTULES BEGIN, INCREASED
ERYTHEMA AND TELANGIECTASIAS
STAGE III
DENSE ERYTHEMA
PAPULES,
PUSTULES,
NODULES.
TELANGIECTASIAS
SEVERE, DIFFUSE
VARIABLE
PLAQUE-LIKE
EDEMA
ROSACEA VS. ACNE
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ADULTS
PAPULES
PUSTULES
NO COMEDONES
ERYTHEMA
TELANGIECTASIAS
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TEENS
PAPULES
PUSTULES
COMEDONES
NO ERYTHEMA
NO
TELANGIECTASIAS
WHAT CAUSES ROSACEA?
• “VIRTUALLY NOTHING IS KNOWN ABOUT
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CAUSATION……….THE INFLUENCE OF
HEREDITY IS MOOT, AS IS ALMOST
EVERYTHING THAT HAS BEEN WRITTEN
ABOUT ETIOLOGY” --A. Kligman
Vasomotor lability? Hypertension?
Demodex mite infestation?
Solar damage? Heat? Caffiene?
Lymphatic obstruction? Emotional stress?
Found within follicular
infundibula & sebaceous ducts…
Commensal organisms….
NOT Pathogenic organisms….
TRIGGERS
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HOT LIQUID BEVERAGES, SOUPS
ALCOHOL / CAFFEINE
SPICY FOODS
SUN EXPOSURE
IRRITATING COSMETICS/OTC
HEAT – EXERCISE IN COOL AREAS.
COMPLICATIONS
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COMPLICATIONS:
RHINOPHYMA – DISFIGURING, NOSE
OPHTHALMIC ROSACEA
LESS COMMON VARIANTS:
GRANULOMATOUS, STEROID, GRAMNEGATIVE, CONGLOBATA,
FULMINANS
RHINOPHYMA - EARLY
RHINOPHYMA
MODERATE
SEVERE
RHINOPHYMA
• OCCURS EXCLUSIVELY IN MEN.
• PROGRESSIVE INCREASE IN CONNECTIVE
TISSUE, SEBACEOUS GLAND
HYPERPLASIA, ECTATIC VEINS AND
CHRONIC DEEP INFLAMMATION.
• MAY OCCUE WITH STAGE III ROSACEA,
BUT SURPRISINGLY, PATIENTS WITH
RHINOPHYMA MAY ONLY HAVE MILD
ROSACEA.
Treatment – Cosmetic Repair
OCULAR ROSACEA
OCULAR ROSACEA
COMMON, MAY BE FIRST
SIGN OF ROSACEA
VARIABLE PRESENTATION
OCULAR ROSACEA
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BLEPHARITIS
CONJUNCTIVITIS
PAIN, PHOTOPHOBIA
IRITIS, IRIDOCYLITIS, KERATITIS
MAY NEED OPHTHALMOLOGY CONS
KERATITIS MAY LEAD TO BLINDNESS
TREATMENT - MILD
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SUNSCREENS
TOPICAL SULFACETAMIDE/SULFUR
TOPICAL METRONIDAZOLE
ORAL TETRACYCLINE,
DOXYCYCLINE, MINOCYCLINE
Topicals- Sulfacetamide/Sulfur
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Klaron 10% Lotion
Rosula Lotion (with Urea)
Sulfacet R
Rosanil Cleanser
Ovace Cleanser
Plexion Cleanser, Suspension and SCT
Topical Metronidazoles
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Noritate 1% cream, Once a Day
Metrocream 0.75% BID
Metrolotion 0.75% BID
Metrogel 0.75% BID
Tetracyclines
• Tetracycline 250-500mg QD or BID
• Very cheap, but must take 1 hour before or
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2 hours after meals, less compliance
Doxycycline 50-75-100mg QD or BID
Generic, Doryx Pellets, Adoxa.
Minocycline 50-75-100mg QD or BID
Generic, Vectrin, Dynacin, Minocin
Tetracyclines
• Not for children due to teeth discoloration,
may cause hyperpigmetation at sites of
trauma in adults, stop medication if
worsening headache occurs (pseudotumor
cerebri)
• Photosensitivity reactions rare if patients on
sunscreens
TREATMENT – SEVERE
• ORAL METRONIDAZOLE
• CLONIDINE 0.1mg QD or BID FOR
FLUSHING HELPS
• PREDNISONE TAPER
• ISOTRETINOIN (ACCUTANE)
A SIMPLE REGIMEN FOR
THE VAST MAJORITY OF
ROSACEA PATIENTS
• WASH FACE GENTLY WITH CETAPHIL
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DAILY FACIAL CLEANSER
APPLY KLARON LOTION QAM
APPLY SUNSCREEN
WASH FACE AGAIN AT NIGHT
APPLY NORITATE CREAM QHS
A GOOD START….
• KLARON LOTION,
4oz., apply qAM to face
• NORITATE CREAM,
30g, apply qHS to face
EXPECTATIONS
• TELL THEM TO EXPECT
IMPROVEMENT IN 4-6 WEEKS
• TELL THEM TO CONTINUE REGIMEN
UNTIL NEXT VISIT
• MAY GIVE ORAL TETRACYCLINES
FOR FLARES
• INFORM THEM THERE IS NO CURE
FOR ROSACEA!!!!!!!!!!!!!!!!!!!!
QUESTIONS