Rosacea is a common facial disorder characterized by centrofacial erythema, flushing, telangiectasia, edema, papules, and pustules.

Types:

  • Erythematotelangiectatic rosacea(ETR)- Flushing and persistent central facial erythema
  • Papulopustular rosacea(PPR) – Constant erythema and transient pustules and papules in the central facial distribution
  • Phymatous rosacea – Overgrowth and hyperplasia of sebaceous glands in certain facial areas causing disfigurement. The phymas associated with rosacea are rhinophyma, otophyma, gnathophyma, metophyma and blepharophyma
  • Ocular rosacea – Can cause blepharitis and conjunctivitis
  • Other variants of rosacea
  1. Rosacea fulminans – Sudden eruption of cystic nodules, papules, pustules over the chin, cheeks and forehead
  2. Granulomatous rosacea -Erythematous and monomorphic papules and nodules in a periorificial location.
  3. Steroid rosacea
  4. Gram negative rosacea
  5. Rosacea conglobata
  6. Extrafacial rosacea

Pathophysiology:

The etiology of rosacea is unknown however several factors such as climate, exposure to ultraviolet rays, cutaneous flora, etc. contribute to the development of abnormal superficial blood vessels. The resultant edemafavors the colonization and multiplication of Demodexfolliculorum.  This parasite creates inflammation, which is seen in the papules and pustules as well as granulomas. Other microbial agents reportedly associated with rosacea are Bacillus oleronius, Staphylococcus epidermidis,Helicobacter pylori, and Chlamydophilapneumonia.Inflammation from rosacea is also characterized by increase in the expression of epidermal proteases and production of pro-inflammatory cathelicidin peptides. In addition, facial hypersensitivity exists, even though the cutaneous barrier is not altered. Finally, rhinophyma remains poorly explained; the vascular abnormalities induce local production of transforming growth factor β1 (TGF-β1) capable of creating fibrosis and therefore cutaneous thickening. 

Diagnosis:

Histopathology

  • Nonpustular lesions show a nonspecific perivascular and perifollicularlymphohistiocytic infiltrate, accompanied by occasional multinucleated cells, plasma cells, neutrophils, and eosinophils.
  • PPR – Pronounced granulomatous inflammation and sometimes perifollicularabscesses. Demodexfolliculorum may be abundant in nearby follicles.
  • Granulomatous rosacea-Caseating and noncaseating granulomata with negative stains for mycobacteria and fungi.

Dermoscopy

  • ETR – Large polygonal vessels. Additional dermoscopic findings include follicular plugs, white scales and, rarely, features related to the presence of Demodex mites, namely ‘demodex tails’ and whitish amorphic follicular material.
  • PPR –  Clinically undetectable papules and pustules, while polygonal vessels are less prominent. Follicular disturbances (dilated follicles, follicular plugs, comedones) are more common.
  • Early glandular rosacea – Intense follicular abnormalities and minimal, if any, vascular alterations.
  • Phymatous rosacea exhibits structureless reddish-yellowish masses, in addition to the follicular abnormalities.

Treatment modalities:

The main treatment modalities for rosacea include topical, systemic, laser, and light therapies.

Topical :

  • Brimonidine tartrate gel 0.5%,an α-2 adrenergic receptor agonist, improvement in facial erythema within 30 minutes
  • Oxymetazoline nasal solution 0.05%, a potent α-1 and partial α-2 receptor agonist, reduces facial erythema within one hour
  • Metronidazole 0.75% ,1% gel
  • Azelaic acid gel 20%
  • Permethrin 5% cream, ivermectin 1% cream against dense colonization of D. folliculorum,
  • Benzoyl peroxide (BP) encapsulated in silica microcapsules, BP-clindamycin , BP-erythromycin- reduction of papulopustular lesions
  • Sodium sulfacetamide 10% + sulfur 5% cleansers efficacious for the treatment of inflammatory lesions and facial erythema based on small studies
  • Calcineurin inhibitors such as tacrolimus and pimecrolimus
  • Retinoids
  • Ketoconazole 2% cream
  • Antimicrobial peptide modulation- topical Omiganan

Natural ingredients reported in the literature that provide hydrating, anti-inflammatory, and antioxidant properties capable of calming the inflammatory manifestations of rosacea include colloidal oatmeal, niacinamide, feverfew, licorice, teas, coffeeberry, aloe vera, chamomile, turmeric, and mushroom extracts. Further, a novel topical lotion containing caffeine, zinc gluconate, bisabolol, Eperuafalcata bark extract, and palmitoyl tripeptide-8.

4% Quassiaamara extract topical gel for 6 weeks. Reportedly, Q. amara possesses antiparasitic and anti-inflammatory properties that have the capability to decrease the inflammatory response with few complications

Low molecular weight hyaluronic acid sodium salt 0.2% cream applied twice daily for 8 weeks showed a statistically significant reduction in papules, erythema, burning, stinging, and dryness.

Systemic:

  • Tetracyclines- doxycycline, minocycline
  • Isotretinoin-PPR and phymatous subtypes
  • Macrolides such as erythromycin, clindamycin, and azithromycin -reduction of inflammatory lestions
  • Metronidazole 200 mg taken twice daily for 6 weeks resulted in marked improvement in papular and pustular lesions.
  • Prednisolone –rosacea fulminans
  • Ivermectin
  • Zinc sulphate- antioxidant and anti-inflammatory properties
  • β-adrenergic blockers,clonidine (α-adrenergic agonist), naloxone (opiate antagonist), ondansetron (serotonin antagonist), and endoscopic thoracic sympathectomy. Traditional β-blockers nadolol and propranolol (20-40 mg, 2-3 times a day) can suppress flushing reactions
  • Carvedilol, a nonselective β-adrenergic blocker with α1 blocking activity and potent antioxidant activity, (3.125-6.25 mg, 2-3 times a day)

Lasers and lights:

  • Beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea
  • Pulsed dye laser (PDL, 585−595 nm)
  • Intense pulsed light (IPL, 500−1,200 nm)
  • Potassium titanyl phosphate (KTP, 532 nm) laser
  • Microsecond long-pulsed neodymium-yttrium aluminum garnet laser
  • Excel V laser combines KTP and Nd:YAG. KTP emits light at a wavelength of 532 nm, which targets redness, hyperpigmentation, and damaged capillaries at the surface of the skin, while Nd:YAG has a laser wavelength of 1,064 nm designed for treating more deep blood vessels with larger diameters. Following absorption of energy, abnormal blood vessels are thermosealed while hyperpigmented lesions are fragmented, resulting in an overall improved appearance.
  • Carbon dioxide (CO2)  and Erbium:yttrium-aluminum-garnet (Er:YAG) induce drastically higher target temperatures resulting in vaporization, and are therefore implemented in ablative correction of rhinophyma and other manifestations of phymatous rosacea.
  • δ-aminolaevulinic acid-photodynamic therapy (ALA-PDT) for granulomatous rosacea
  • polygonal vessels are less prominent (Fig. 1). Follicular
  • disturbances (dilated follicles, follicular plugs, comedones)
  • are more common in this subtype compared with ER.
  • Early glandular rosacea, instead, is typified by intense
  • follicular abnormalities and minimal, if any, vascular
  • alterations. Phymatous rosacea exhibits structureless
  • reddish-yellowish masses, in addition to the follicular
  • abnormalities. In acne vulgaris, dermoscopy highlights the
  • follicular disturbances and reveals papules and pustules,
  • in the absence of vascular alterations

Injectable botulinumtoxin:

Intralesionalmicrodroplet injections (0.05 mL) of onabotulinumtoxinA in a dilution of 7 mL of saline solution per 100 units. The results indicated the significant reduction in erythema and flushing of the affected area 2–4 weeks after treatment.