Rosacea

Last Updated: 2021-10-04

Author(s): Anzengruber, Navarini

Rosacea, coupe rose, copper rose, facial rose, acne erythematosa, acne rosacea.

Common inflammatory dermatosis that affects the face and in some cases also the scalp, neck, back and chest.

Depending on the study

  • Incidence: 1.65/1,000 person-years (UK)
  • Prevalence: 2.3% (Germany)
  • Prevalence: 10% (Sweden)
  • Prevalence: 22% (Estonia)
  • While women are most often affected from the age of 35, the initial manifestation in men is not common until around the age of 50
  • In rare cases, children can also be affected
  • Peak in age: 76-80 y.
  • Pat. with skin type I-II (n. Fitzpatrick) are more frequently affected
  • Ocular involvement: in 20% (3-58% depending on study)
  • In 20% ocular involvement before cutaneous manifestation visible
  • Morbus Morbihan: More common in males
  • Rosacea fulminans: More common in females
  • Preliminary stage (rosacea diathesis):
    • Sudden onset and subsiding erythema ("flushing and blushing") triggered by endogenous and exogenous stimuli
  • Subtye I: Rosacea erythemato-teleangiectatica
    • Persistent erythema, telangiectasias, pruritus, stinging, burning, scaling, dry skin
  • Subtype II: Rosacea papulopustulosa
    • Erythematous, often multiple, partly succulent papules and pustules with finely lamellar scaling, lymphoedema
  • Subtype III: Glandular-hyperplastic rosacea
    • Mostly men, connective tissue and sebaceous gland hyperplasia on nose (rhinophyma), chin/jaw (gnathophyma), forehead (metophyma), ear (otophyma) or eyelid (blepharophyma)

Not yet conclusively clarified.

  • Multifactorial aetiology (genetics, immunological, neurological, inflammatory causes, UV radiation, dysregulation of blood and lymph vessels) is assumed. Demodex mites are seen as a cofactor.
  • Predisposing factors
    • Irritating chemical substances, e.g. cosmetics such as soap
    • Abrupt temperature change, heat/cold, wind
    • Hot food
    • Alcohol (in men still controversial, however in women shown clear association with white wine and spirits)
    • Psychological stress
    • Nicotine probably has no influence on the course
  • Functional erythema
    • Fleeting (flush-like), to prolonged erythema is the first sign of rosacea
  • Subtype I (rosacea erythemato-teleangiectatica):
    • Erythema persisting for hours to days. In addition, increased telangiectasias (rosacea teleangiectatica) are seen
  • Subtype II (rosacea papulopustulosa):
    • Erythematous, often grouped, finely lamellar scaling and succulent papules. Pustules (sterile) may also occur. There may also be extensive oedema. Demodex mites may be visible.
  • Subtype III (phymatous rosacea/ rosacea glandulohyperplastica):
    • Large, inflammatory nodules and infiltrates. Connective tissue and sebaceous gland hyperplasia (phymosis) occur especially on the nose (rhinophyma).
  • Ocular rosacea, "stage" IV (ophthalmorosazea): ocular involvement with blepharitis, conjunctival irritation, keratitis.
  • History of present illness
  • Deterioration due to trigger factors?
  • Clinical picture (telangiectasias, no comedones, beginnings of phymatous hypertrophy)
    • ROSCO criteria: Diagnostic is persistent facial erythema and phyma. Major criteria are flushing and papulopustules, and telangiectasia.
  • Biopsy

Face, sometimes upper body.

Avoid sun exposure, rapid temperature changes, spicy food, alcohol, caffeine, other triggers that may have been observed by the patient

Chronic disease, provide for longer-term therapy.

Facial Care

  • Non-occlusive moisturiser such as Rosaliac UV light
  • Syndet washing solution such as Cetaphil cleansing lotion

Topical therapy

  • Subtype I
    • First line: Laser therapy with Nd:YAG, KTP or dye laser
    • No longer prescribed by us: Brimonidine 1%.
    • Off-label: β-blocker p.o. initial 12.5 mg 1x daily, increase as needed and internally possible
  • Subtype II
    • First line: Ivermectin 1x daily
    • Second line: Ivermectin 1x tgl and Metronidazole 1x daily
    • Azelaic acid gel/cream 1-2x daily
    • Off-label use:
      • Tacrolimus cream 0.03% / 0.1% 2x daily for 2 weeks
      • Pimecrolimus cream 1% 2x daily for 2 weeks
    • Doxycycline p.o. 40 mg 1x daily
    • Minocycline p.o. 50 mg 2x daily
    • Isotretinoin p.o. 10-30 mg 1x daily
  • Subtype III
    • Isotretinoin p.o. 10-30 mg 1x daily
    • Dermabrasio
    • Ablative laser
  • Stage IV: Ocular rosacea
    • Lid margin hygiene
    • Lipid-containing tear substitutes
    • Topical therapy
    • Ciclosporin A
    • Azithromycin
    • Tetracycline
    • Topical steroids (only rosacea stage without contraindication of topical steroids)
    • Doxycycline p.o.  we recommend: 40 mg 1x daily (low-dose); alternatively 200 mg 1x daily for 12 weeks (high dose) or 
    • Isotretinoin p.o. 10-30 mg 1x daily
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