ROSACEA

    Rosacea is an inflammatory condition of the hair follicles primarily of the face.  It is often referred to as adult acne becasue of its similarity of having inflamed follicle-based lesions that can sometimes become pustular like acne but unlike acne, rosacea does not have blackheads.  Rosacea has three main components:

    1. vascular reactivity/flushing (erythematotelangiectatic rosacea)--this often is the presenting sign of rosacea nd it is comprised of a tendency to easily turn red on the face.  Patients with this condition will often mention that certain triggers set off the condition.  These triggers include ingestables like alcohol, caffeine-containing beverages, citrus, hot liquids, etc. or weather such as sunlight, heat, cold or wind.  Those afflicted may mention a burning sensation when the redness occurs.  Over a period of years the redness which used to come and go can result in permanent vascular changes such that blood vessels become apparent on the cheeks and sides of the nostrils.  Early treatments include topicals which control vessels from reacting (e.g. oxymetazoline and brimotidine); antiinflammatories and agents used to treat other forms of rosacea may also be effective.  When the vascular changes are permanant, vascular laser or IPL (intense pulsed light) treatment can be quite effective therapies.

    2. acne-like (papulopustular rosacea)--this tends to occur as red and occasionally pustular follicle-based lesions on the central face in middle-aged and older individuals.  The same triggers found in the flushing form of rosacea can be associated with this form of rosacea although it may take days to evolve as opposed to minutes to hours.  In addition, there may be a mechanism for rosacea relating to immune reactions to the Demodex mite which inhabits hair follicles on oily facial skin.  Treatments for papulopustular rosacea traditionally focus upon antibiotics that have anti-inflammatory properties as well--this includes the topicals clindamycin, metronidazole, azelaic acid and sodium sulfacetamide/sulfur; orals include the tetracyclines (minocycline and doxycycline).  The oral retinoid isotretinoin can be beneficial as can the topical non-steroid anti-inflammatories pimecrolimus and tacrolimus.  Steroid-use is contraindicated for rosacea as it can cause dramatic flares once removed or may be causative ("steroid rosacea").  Topical ivermectin which can reduce colonization of facial skin by the Demodex mite has been FDA-approved for treating rosacea; non-approved treatments that work similarly include topical permethrin and oral ivermectin.

    3.  phymatous rosacea--this is associated with coarsening of the skin of the nose as the skin thickens and the pores widen giving a bulbar appearance; it is much more common in men than women.  There are no effective treatments for this type of rosacea other than destructive modailities such as dermabrasion or laser.

    4.  ocular rosacea--red, bloodshot often watering eyes which may or may not be associated with rosacea of the skin.  Treatments are generally the same as for papulopustular rosacea with oral tetracyclines; severe cases are referred to Ophthalmology.

    In general much like acne, treatment of rosacea becomes a game of finding what works best for the individual. There is no one best treatment and patients can often get frustrated by the trial and error nature of treatment.  Patients are advised to be patient and allow 6-8 weeks for an individual therapy to work.  Once control is achieved, tapering off of any oral tetracyclines is advised slowly--the goal is always to be able to maintain control with the least amount of medication especially oral medications. 

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