Rosacea: classification and treatment

Rosacea and its management: an overview

BACKGROUND

Rosacea is a chronic inflammatory disorder that affects 10% of the population. The prevalence of rosacea is highest among fair-skinned individuals, particularly those of Celtic and northern European descent. Since a cure for rosacea does not yet exist, management and treatment regimens are designed to suppress the inflammatory lesions, erythema, and to a lesser extent, the telangiectasia involved with rosacea.

OBJECTIVES

This review outlines the treatment options that are available to patients with rosacea.

METHODS

Published literature involving the treatment or management of rosacea was examined and summarized.

RESULTS

Patients who find that they blush and flush frequently, or have a family history of rosacea are advised to avoid the physiological and environmental stimuli that can cause increased facial redness. Topical agents such as metronidazole, azelaic acid cream or sulfur preparations are effective in managing rosacea. Patients who have progressed to erythematotelangiectatic and papulopustular rosacea may benefit from the use of an oral antibiotic, such as tetracycline, and in severe or recalcitrant cases, isotretinoin to bring the rosacea flare-up under control. Treatment with a topical agent, such as metronidazole, may help maintain remission. Patients with ocular involvement may benefit from a long-term course of an antibiotic and the use of metronidazole gel. A surgical alternative, laser therapy, is recommended for the treatment of telangiectasias and rhinophyma. Patients with distraught feelings due to their rosacea may consider cosmetic camouflage to cover the signs of rosacea.

CONCLUSIONS

With the wide variety of oral and topical agents available for the effective management of rosacea, patients no longer need to feel self-conscious because of their disorder.

Rosacea: An Update

Rosacea is a common chronic cutaneous disorder of unknown etiology which occurs most commonly in middle-aged individuals. Cutaneous manifestations include transient or persistent facial erythema, telangiectasia, edema, papules and pustules that are usually confined to the central portion of the face. The National Rosacea Society's Expert Committee on the Classification and Staging of Rosacea identified four subtypes of rosacea: erythematotelangiectatic, papulopustular, phymatous and ocular. Recently, a standard grading system for assessing gradations of the severity of rosacea has been reported. Little is known about the cause of rosacea. Genetic, environmental, vascular, inflammatory factors and microorganisms such as Demodex folliculorum and Helicobacter pylori have been considered. Topical metronidazole and azelaic acid have been demonstrated to be effective treatments for rosacea. Severer or persistent cases may be treated with oral metronidazole, tetracyclines or isotretinoin.

Pulsed dye laser therapy for rosacea

Rosacea is a chronic and progressive inflammatory skin disorder affecting the facial convexities for which no curative measure is currently available. Forty consecutive patients with rosacea were treated with the Cynosure PhotoGenica V pulsed dye laser. The improvement following laser therapy was assessed according to a sliding scale: 1 (worse after treatment), 2 (no improvement), 3 (slight improvement), 4 (moderate improvement), 5 (marked improvement). Following an average of 2.4 (range 1-10) laser treatments, a mean score of 4.4 and 4.3 for overall improvement was achieved as judged by the patients and independently assessed by a family member or a close friend of the patients, respectively. The response of erythema and telangiectasia to laser therapy, evaluated by an independent panel of 10 members, showed a mean score of 3.7. Three patients experienced an exacerbation of rosacea during the treatment period requiring antibiotic therapy. During the follow-up period of 6.0-55.5 (mean, 23.3) months after completion of laser therapy, no patient (including 13 patients in whom papulation and pustulation which were amongst the presenting symptoms) required medical treatment. Six patients developed post-inflammatory hyper-pigmentation necessitating skin bleach but no other complication such as scarring was observed. Three patients reported that the residual erythema had progressed after an initial improvement during follow-up periods of 52.4, 15.8 and 6.0 months. All patients felt that laser therapy was worthwhile. We conclude that pulsed dye laser therapy is a useful treatment for rosacea.

Morbihan's disease: treatment with CO2 laser blepharoplasty

Morbihan's disease is a rare condition characterized by chronic persistent erythema and edema of the upper half of the face. Therapeutic regimens such as X-ray irradiation, lymphatic massage, interferon gamma injections, antihistamines, and high-dose antibiotics are often unsatisfactory. Promising results in some patients have been achieved by a systemic combination therapy of isotretinoin with ketotifen or clofazimine. Excision of redundant edematous tissue may be an alternative. We present a 67-year-old Caucasian patient with a two-year history of right lower and upper eyelid swelling and erythema. Systemic therapies with corticocosteroids and antibiotics were not successful, but CO2 laser blepharoplasty led to good cosmetic results with marked improvement of visual impairment and no recurrence during the six-month follow-up period.

Interventions for rosacea

BACKGROUND

Rosacea is a common skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often also involved. The cause of rosacea is unclear. It is a chronic disease, which can be controlled in most cases with appropriate treatment. Numerous treatments are in use although it is unclear which are best, and which are most appropriate for the different types of rosacea.

OBJECTIVES

To assess and summarise current evidence for the efficacy and safety of treatments for rosacea.

SEARCH STRATEGY

We searched the Skin Group Specialised Trials Register (March 2002), Cochrane Central Register of Controlled Trials (CENTRAL, March 2002), MEDLINE (from 1966 to March 2002), EMBASE (from 1980 to March 2002), Biosis (from 1970 to March 2002) and the Science Citation Index (from 1988 to March 2002). Reference lists of trials and key review articles were also searched. Relevant manufacturers and experts were contacted.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea were included. Studies judged by the reviewers to have seriously flawed methodology were excluded.

DATA COLLECTION AND ANALYSIS

Study selection, assessment of methodological quality, data extraction and analysis were carried out by two independent reviewers.

MAIN RESULTS

The evidence provided by twenty-two included studies was generally weak because of poor methodology and reporting. One of our primary outcome measures, 'quality of life', was not assessed in any of the studies. Only two studies of ocular rosacea could be included. Pooled data from two trials involving 174 participants indicated that topical metronidazole is more effective than placebo (odds ratio 5.96, 95% confidence interval 2.95 to 12.06). Data from a between-patient trial (114 patients) and a within-patient trial (33 patients) of azelaic cream versus placebo were not pooled, but both showed good evidence of efficacy. Data pooled from three studies of oral tetracycline versus placebo involving 152 participants showed that, according to physicians' ratings, tetracycline was effective (odds ratio 6.06, 95% confidence interval 2.96 to 12.42). Some evidence of efficacy of oral metronidazole was provided by one small study.

REVIEWER'S CONCLUSIONS

The quality of studies evaluating rosacea treatments was generally poor. There is evidence that topical metronidazole and azelaic acid cream have a therapeutic effect. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. As many of these treatments are used for rosacea, good RCTs are urgently needed.

Identifying rosacea: what all dentists should know

BACKGROUND

Dentists frequently encounter adult patients who have facial rosacea. This common dermatologic condition can undermine a patient's appearance. Although rosacea can be progressive, the condition responds well to treatment, especially when started early.

RESULTS

This article will help dentists recognize rosacea and differentiate it from other dermatologic disorders. Clinicians then will be able to refer patients suspected of having rosacea to the appropriate medical specialist for confirmation of the diagnosis and treatment.

CONCLUSION

Dentists can provide a service to patients to improve their overall health and appearance by early recognition of this condition.

CLINICAL IMPLICATIONS

Recognizing rosacea in dental patients and properly referring them for diagnosis and treatment constitutes a medical service that is relatively easy for dentists to perform. This service, in addition to others, such as measuring blood pressure, will make the dental examination more comprehensive.

The proposed inflammatory pathophysiology of rosacea: implications for treatment

The pathophysiology of the vascular and inflammatory stages of facial rosacea and proposes an underlying cause is reviewed. It can be argued that all the stigmata of rosacea are manifestations of an inflammatory process: neutrophilic dermatosis. For this reason, treatments that block neutrophil involvement in the development of rosacea, such as topical metronidazole and systemic antibodies, should be considered first-line therapy for all stages of the disease.

Potential antioxidant mechanism of action for metronidazole: implications for rosacea management

Chronic inflammation is believed to account for some symptoms of rosacea. The efficacy of topical metronidazole in the treatment of rosacea may be due to its antimicrobial as well as anti-inflammatory activity. Neutrophils release potent inflammatory mediators, including reactive oxygen species (ROS), and intrafollicular neutrophils have been observed in stage II disease. ROS and other free radicals may contribute to intrinsic and extrinsic aging, both of which accentuate clinical manifestations of rosacea. If, as in vitro data suggest, metronidazole has antioxidant activity, it may help subdue the oxidative tissue damage of intrinsic and extrinsic aging as well as prevent and treat rosacea symptoms.

Identifying and treating rosacea

Rosacea is a chronic, cutaneous vascular disorder that affects approximately 13 million Americans. The facial disorder, which often affects people of Northern European descent, is characterized by four stages. Although rosacea is not curable, early recognition and treatment can prevent progression to permanent disfigurement or blindness. Pharmacologic therapy, patient education, and symptom management can provide symptom control and remission.

A clinicopathological classification of granulomatous disorders

Granulomatous disorders comprise a large family sharing the histological denominator of granuloma formation. A granuloma is a focal compact collection of inflammatory cells, mononuclear cells predominating, usually as a result of the persistence of a non-degradable product and of active cell mediated hypersensitivity. There is a complex interplay between invading organism or prolonged antigenaemia, macrophage activity, a Th1 cell response, B cell overactivity and a vast array of biological mediators. Differential diagnosis and management demand a skilful interpretation of clinical findings and pathological evidence. They are classified into infections, vasculitis, immunological aberration, leucocyte oxidase deficiency, hypersensitivity, chemicals, and neoplasia.

An unusual case of a relationship between rosacea and dental foci

Rosacea is a chronic disorder affecting the facial convexities, characterized by frequent flushing, persistent erythema, and telangiectases. During episodes of inflammation, additional features are swelling, papules, and pustules. The exact etiology of this dermatitis is unknown, and theories abound. Infectious foci, especially dental foci, seem to be rarely associated with the onset and progression of this disease. Dermatologic treatments are determined by the severity of the disease. But eradication of infectious foci, and in this case eradication of dental foci, may generate a significant improvement and may lead to a recovery.