Acne
Acne Rosacea
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Acne Rosacea
, Rosacea, Rhinophyma
Epidemiology
Typical onset ages 30-50 years old
Northern european descent and fair skinned persons
More common in women by factor of 2-3
Prevalence
: 1.3-2.1% (14 Million cases) in United States
Risk Factors
Predisposing triggers and exacerbating factors
Sun Exposure
, hot weather, and hot baths
Emotional stressors
Alcohol
use
Hot drinks
Exercise
Nose
Hair Follicle
mites (Demodex folliculorum)
Pathophysiology
Acne
iform eruption
Nose
Hair Follicle
mites (Demodex folliculorum) appear to be involved in pathogenesis
Types
Subtype 1: Erythematotelangiectatic (most difficult to treat)
Persistent central face
Macula
r erythema with
Telangiectasia
s and
Flushing
Possible ocular involvement
Subtype 2: Papulopustular (easiest to treat)
Persistent central face erythema with small
Papule
s and tiny
Pustule
s (acne-like)
Periocular sparing
Subtype 3: Phymatous (more common in men)
Skin thickening and nodular irregularities (due to
Sebaceous Gland
hyperplasia)
Distribution: Nose (Rhinophyma), chin, ears, forehead or
Eyelid
Subtype 4: Ocular
Watery,
Bloodshot Eye
s may become dry with foreign body
Sensation
and photophobia
Distribution:
Blepharitis
,
Conjunctivitis
, and
Eyelid Inflammation
Variant:
Granuloma
tous
Brown, yellow or red firm, indurated non-inflammatory
Papule
s or
Nodule
s
Symptoms
Stinging pain may accompany facial
Flushing
Signs
Course is variable
Stages listed below are for organization only
Distribution for all lesions
Affects middle third of face (forehead to chin)
Stage 1: Initial presentation
Intermittent facial
Flushing
lasting 5 minutes or less
May involve neck and chest
Sensation
of warmth may be present
Stage 2: Early vascular changes
Facial erythema
Telangiectasis
Eye changes (see ocular signs below)
Stage 3: Inflammatory changes
Papule
s
Sterile
Pustule
s
Comedones are typically absent
Stage 4: Rhinophyma (Red bulbous nose)
More common in men
Thickening of facial skin (especially nose)
Connective tissue hypertrophy
Sebaceous Gland
hypertrophy
Previously thought to be a sign
Alcohol Abuse
Example: W. C. Fields
Variant:
Granuloma
tous Rosacea
May appear similar to facial sarcoid
Signs
Ocular involvement (50% of Rosacea cases)
Eyelid Inflammation
(may be presenting sign)
Acne
involving
Eyelid
s
Eyelid
redness and swelling
Eyelid
margin
Telangiectasia
Inflammatory
Conjunctivitis
Blepharitis
may accompany
Conjunctivitis
Eyes that itch or burn
Dry Eye
s with sandpaper or foreign body
Sensation
Other less common changes
Cornea
l neovascularization
Keratitis
Cornea
l scarring
Differential Diagnosis
Skin
Late-onset
Acne Vulgaris
Comedones present
No
Telangiectasis
No eye symptoms or signs
Steroid-induced
Acne
Results from
Corticosteroid
use on face
Perioral changes
Perioral Dermatitis
Some dermatologists consider
Perioral Dermatitis
a variant of Rosacea
Polymorphous Light Eruption or other
Photodermatitis
Seborrheic Dermatitis
Contact Dermatitis
Polymyositis
Sarcoidosis
Systemic Lupus Erythematosus
Carcinoid Syndrome
(severe facial
Flushing
)
Mastocytosis
Differential Diagnosis
Ocular Rosacea
Blepharokeratoconjunctivitis (staphylococcal or seborrheic)
Sebaceous Gland
carcinoma
Allergic Conjunctivitis
Diagnosis
Central face dermatitis with at least one of the following findings
Transient erythema (
Flushing
)
Nontransient erythema
Papule
s and
Pustule
s
Telangiectasia
Management
Gene
ral Measures
Avoid triggers
Avoid
Alcohol
Avoid prolonged heat exposure
Avoid hot liquids (coffee, tea)
Avoid heavy cosmetics
Use sun screen (minimum SPF 30) regularly (better tolerated agents are listed)
Avoid chemical
Sunscreen
s which may be irritating
Use a mineral or physical
Sunscreen
Base:
Simethicone
, dimethicone or cyclomethicone
Active ingredient:
Titanium Dioxide
or
Zinc Oxide
Choose gentle skin care products
Clear and free (dye and perfume free) products
Mild cleansers with near neutral pH (e.g. cetaphil, dove sensitive skin)
Skin
Moisturizer
s (
Emollient
s) applied to moist skin
Avoid abrasive skin products
Green or yellow tinted consmetics may hide facial erythema
Avoid provocative medications
Benzoyl Peroxide
(avoid in erythematotelangiectatic Rosacea - subtype 1)
Topical Corticosteroid
s
Management
Papular and pustular Rosacea
Step 1
Apply across entire central face
First Line agents (most effective agents)
Metronidazole
topical
Once daily (1% gel) or twice daily (0.75% gel, cream or lotion)
Effective in 80% of cases
Similar efficacy between 0.75% and 1%, as well as between once and twice daily dosing
Azelaic Acid
(
Azelex
) 15% gel
Slight benefit over Metrogel, but less tolerated (consider in those not responding to
Metronidazole
)
Gel is generic, while cream and foam are trade name only at twice the price
Irritation may be reduced with gentle skin cleansers (e.g. cetaphil) and
Skin Lubricant
s (e.g. vanicream)
Elewski (2003) Arch Dermatol 139:1444-50 [PubMed]
Alternative agents
Clindamycin
(
Cleocin-T
)
Sulfacetamide/Sulfur (10%/5%) cream, foam or lotion
Permethrin
5% cream
Effective for erythema and
Papule
s (but not as effective with
Pustule
s)
Kocak (2002) Dermatology 205:265-70 [PubMed]
Permethrin
2.5% with tea tree oil gel
Reduces inflammation and decreases Demodex mite population
Ebneyamin (2020) J Cosmet Dermatol 19(6):1426-31 +PMID: 31613050 [PubMed]
Step 2: May use the following oral agents in combination with topicals listed above
Doxycyline (preferred)
Moderate Rosacea
Doxycyline 40 mg daily or 20 mg twice daily (sub-antimicrobial dose)
Severe Rosacea or refractory to 8-12 weeks at lower dose
Doxycycline
Doxycycline
100 mg twice daily (then taper to once daily after the first month)
Alternative systemic antibiotics (tapering to once daily after the first month)
Tetracycline
250 mg twice daily or
Erythromycin
250 mg twice daily
Amoxicillin
250 mg twice daily
Efficacy
Useful in treating
Blepharitis
,
Keratitis
Most effective treatment
Step 3: Additional topical agents to consider
Erythema (without
Papule
s or
Pustule
s)
Brimonidine
gel 0.33% (
Mirvaso
) - see below
Oxymetazoline
1% (Rhofade) - see below
Inflammatory papular and pustular Rosacea
Precaution: Avoid in erythematotelangiectatic Rosacea (
Flushing
) - subtype 1 (may worsen)
Topical
Benzoyl Peroxide
with
Clindamycin
(e.g.
Benzaclin
)
Avoid Benzyl Peroxide with
Erythromycin
(no benefit to the
Erythromycin
)
Ivermectin
(Scolantra) 1% cream applied once daily
Very expensive (nearly $500 for 45 grams)
(2015) Presc Lett 22(3): 16
Minocycline
1.5% Foam (Zilxi)
Very expensive (nearly $500 for 30 grams)
No evidence of benefit over other Rosacea topicals
(2021) Presc Lett 28(6): 36
Step 4: Refractory Cases
Topical Tretinoin
(
Retin A
)
May exacerbate erythema and
Telangiectasis
Accutane
for 20 weeks
Variably effective
Consider mite or tinea management
Examine sample with
Potassium Hydroxide
Crotamiton
(
Eurax
)
Management
Associated conditions
Facial
Flushing
and Erythema
First-line: See general measures above
Second-line
See
Vasomotor Symptoms of Menopause
Clonidine
0.05 mg bid
Propranolol
(
Inderal
LA) 80 mg orally daily
Topical vasconstrictors (onset of action 4 hours, duration 12 hours)
Brimonidine
gel 0.33% (
Mirvaso
)
Topical
Vasoconstrictor
released in 2013 in U.S.
Can reduce facial redness (NNT 6 for significant benefit)
Very expensive ($400 for 30 grams)
Consider using generic
Brimonidine
0.2% eye drops topically on face (10% of cost)
(2013) Presc Lett 20(11): 65
Oxymetazoline
1% (Rhofade)
Topical
Vasoconstrictor
released in 2017 in U.S. (same ingredient as
Afrin
0.05%, but 1%)
Very expensive ($475 for 30 grams)
(2017) Presc Lett 24(5):30
Telangiectasis
Green-tinted cosmetics
Pulse
d dye laser
Ocular changes
Precautions
Risk of complications such as
Chalazion
,
Scleritis
,
Corneal Ulcer
Consider ophthalmology
Consultation
First-line therapy
Oral
Doxycycline
(or other oral antibiotics listed above)
Artificial tears for eye dryness
Lid and lashes cleansing with baby
Shampoo
Topical metrogel to
Eyelid
if involved
Omega-3 Fatty Acid Supplement
ation
Second-line therapy for refractory cases
Ocular steroids (by ophthalmology)
Cyclosporine Ophthalmic Emulsion
(
Restasis
) - by ophthalmology
Accutane
References
Oltz (2011) Optometry 82(2): 92-103 [PubMed]
Vieira (2013) J Am Acad Dermatol 69 (suppl 1): S36-41 [PubMed]
Rhinophyma
Mild to moderate
Antibiotics such as
Doxycycline
(as listed above)
Oral
Isotretinoin
(
Accutane
)
Advanced cases (Surgery)
Dermabrasion
Hypertrophic tissue excision
References
(2021) Presc Lett 28(6): 36
Habif (1996) Clinical Dermatology, p. 182-4
Blount (2002) Am Fam Physician 66(3):435-40 [PubMed]
Goldgar (2009) Am Fam Physician 80(5): 461-8 [PubMed]
Oge (2015) Am Fam Physician 92(3): 187-96 [PubMed]
Powell (2005) N Engl J Med 352(8):793-803 [PubMed]
Zuber (2000) Prim Care 27(2):309-18 [PubMed]
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