Rosacea

Definition/ciagnostic criteria Rosacea is a chronic, relapsing facial skin disorder, characterised by recurrent episodes of facial flushing, persistent erythema, telangiectasia, papules, and pustules. Some individuals also exhibit phymatous rosacea with thickening and distortion of the skin, notably around the nose, or ocular rosacea, often felt as a foreign-body sensation in the eyes. It typically first presents in fair-skinned individuals aged 30 to 50 years​​.

Epidemiology Rosacea predominantly affects middle-aged (30 to 60 years old) and fair-skinned people. Its exact aetiology is unknown, but chronic vasodilatation due to a primary error in vascular control may be a factor. It has a bi-modal prevalence: initially peaking at 20 to 30 years of age, and again at 40 to 50 years​​.

Diagnosis
Clinical features:

• Distribution: Central face, sparing peri-oral and peri-orbital skin.
• Morphology: Erythema, telangiectasia, papules, pustules, absence of open comedones and possible skin thickening.
• Rhinophyma: Thickening of nasal skin, potentially causing disfigurement.
• Ocular involvement: Over 50% of patients, causing gritty eyes, conjunctivitis, blepharitis, episcleritis, chalazion and potentially keratitis​​.

Investigations: Granulomatous rosacea, a rare variant, is characterised by red-brown papules or nodules, primarily affecting the upper face. Histological evaluation reveals granulomatous changes and sometimes caseation necrosis. This variant can be resistant to conventional treatments like systemic tetracyclines, and occasionally dapsone is used under specialist supervision​​.

Treatment
General measures:

• Avoidance of factors aggravating symptoms, such as hot/strong tea and coffee, alcohol, spicy foods, excessive heat, direct sunlight and topical steroids.
• Emollients are recommended for soothing skin​​.

Papules, pustules, and nodules:

• Topical treatments: First-line therapy includes ivermectin cream for mild symptoms. Second-line options encompass azelaic acid cream or metronidazole gel/cream.
• Systemic treatments: Tetracyclines (e.g., doxycycline, lymecycline) are first-line for more severe symptoms, with clarithromycin or erythromycin as second-line options. The treatment course usually lasts three months.
• Recurrent symptoms: For frequent recurrences, a lower dose of antibiotics may be maintained to reduce flare-ups​​​​.

Flushing/erythema/telangiectasia:

• Non-responsive to antibiotics, may benefit from beta-blockers like propranolol, or clonidine.
• Brimonidine topical gel and carvedilol have shown efficacy.
• Pulsed-dye laser therapy, though not permanent, can be effective​​.

Rhinophyma:

• Responds well to CO2 laser ablation or shave excision​​.

Ocular symptoms:

• Lid hygiene, artificial tears and systemic tetracyclines are effective.
• Ophthalmologist referral is advised for severe symptoms or if symptoms persist despite treatment​​.

Prognosis: Rosacea is a chronic condition with periods of exacerbation and remission. Early and appropriate management can control symptoms and improve quality of life. However, certain variants like granulomatous rosacea may persist untreated for 2-3 years and regress with scarring​​.