Summary

Rosacea is a chronic inflammatory skin disease that may be triggered by a number of factors (e.g., alcohol, stress). The etiology is unclear; however, the disease is more common in females and middle-aged individuals with fair skin. The disease presents with central facial erythema, telangiectasias, and papules/pustules. In severe cases, the nose develops a large, bulbous shape (rhinophyma). In contrast to acne, comedones are not present. Treatment options include the avoidance of triggers, topical agents (e.g., metronidazole, brimonidine) for mild disease, and oral agents (e.g., metronidazole) for more severe disease.

Epidemiology

Sex: ♀ > ♂
Age range: 30–60 years

References:^[1]

Epidemiological data refers to the US, unless otherwise specified.

Etiology

The cause of rosacea is not entirely understood; , but is especially associated with triggers that increase body temperature.

Trigger factors
- Hot weather, hot drinks, spicy food
- Stress, alcohol, nicotine
- Demodex mites

References:^[2]^[3]

Clinical features

There are four different clinical subtypes of rosacea:

Erythematotelangiectatic rosacea
- Facial flushing
- Persistent erythema of the face (together with telangiectasias)

Papulopustular rosacea
- Papules, pustules, and erythema

Phymatous rosacea
- Skin and sebaceous glands thicken
- Inflammatory, widespread nodules
- Rhinophyma: enlarged, bulbous nose (almost exclusively in males)
- Similar changes may occur on the chin, forehead, cheeks, and ears

Ocular rosacea
- Conjunctival hyperemia (most common)
- Blepharitis (inflammation of the eyelid margin), stye (hordeolum externum), chalazion
- Dry eyes and foreign-body sensation
- Keratitis

In contrast to acne, comedones are NOT present!

References:^[4]^[5]

Differential diagnoses

Demodicosis
- Rare disease with lesions similar to rosacea
- Erythema, papules, and pustules appearing unilaterally on a cheek and an eyelid
- Infection of the sebaceous glands by Demodex mites (Demodex folliculorum and Demodex brevis)

The differential diagnoses listed here are not exhaustive.

Treatment

Behavioral: avoid trigger factors (see "Etiology" above)
Medical therapy
- For erythema, flushing, skin sensitivity, xerosis:
  - Topical brimonidine
  - Topical oxymetazoline
- For papules and pustules:
  - Topical agents for mild disease
    - Metronidazole (also for ocular rosacea)
    - Azelaic acid
    - Ivermectin
    - Sodium sulfacetamide
  - Oral agents for moderate to severe disease and refractory disease
    - Tetracyclines: e.g., doxycycline (also for ocular rosacea), tetracycline, minocycline
    - Isotretinoin (first-line for phymatous rosacea)
Laser therapy: for erythema, telangiectasias, and phymatous rosacea
Surgical therapy: for phymatous rosacea; includes electrocautery and dermabrasion

References:^[4]^[6]^[7]^[8]

Complications

Eye involvement (common)
- Blepharitis
- Conjunctivitis
- Keratitis (rare)
Granulomatous lesions
- Small brown papules, especially around the mouth and eyes
- Granulomatous lesions may occur on their own, without other symptoms of rosacea
- Histology: tuberculoid granulomas

All patients with rosacea and concurrent eye problems should have their eyes examined by an ophthalmologist!

We list the most important complications. The selection is not exhaustive.