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A Handout for the Non-Dermatologist



Rosacea is a common skin disease that usually presents during the third or fourth decades with facial erythema, papules and pustules, telangiectasia, and eventually can result in diffuse hyperplasia of sebaceous glands and associated connective tissue. Women and people with lighter skin tones are more frequently affected. Rosacea is also usually seen in people who have incurred considerable sun damage

The initial signs include easy flushing with inciting factors such as emotional stress, temperature changes, spicy foods, but more commonly from food that are served too hot in temperature and caffeinated and alcoholic beverages. The erythema subsequently becomes persistent over the central face, spreading laterally to the ears, and rarely to the chest and back. Some patients will develop telangiectasia and erythematous papules, occasionally pustules, scattered over the nose, cheeks, and forehead.

While rosacea is frequently referred to as adult acne, comedones (blackheads) are not found in rosacea. Patients with rosacea can have ocular involvement manifesting as conjunctival irritation, grittiness, burning, and injection. Ophthalmic rosacea can include blepharitis, conjunctivitis, iritis, iridocycitis, and keratitis. If a patient has ocular involvement beyond mild conjunctival erythema, refer the patient to Ophthalmology for evaluation and treatment. Severe rosacea can result in rhinophyma (bulbous nose), a condition that has been culturally associated with excessive alcohol consumption, although this may not be true in any individual patient.

It is important to remember that the signs and symptoms of rosacea are slow to remit — or may never remit completely — even with a thorough regimen and a compliant patient.
Daily sunscreen use, SPF 15 or greater, AND Topical medications including: metronidazole (MetroCream, MetroLotion, MetroGel, Noritate) or sodium sulfacetamide (Klaron lotion).
Occasionally patients have good responses to Ovace wash, used in conjunction with Nicosyn.
Anecdotal reports have indicated that oral nicotinamide can be useful.

Treatment for Severe Rosacea
For patients with conjunctivitis, blepharitis, multiple papules/pustules, or rhinophyma: oral antibiotics, typically minocycline or tetracycline, for long-term courses are indicated. Start patients at minocycline 100mg or tetracycline 250mg PO BID. Two months is a minimum treatment; patient may end up taking the medication for years. When tapering, add topical treatments. When prescribing minocycline, warn patients about possible dizziness, headaches, and GI upset. If patients take minocycline with food, the nausea can be ameliorated. If a patient complains of mild dizziness, and does not have an occupation where dizziness could put him/herself or others in danger, then try to taper to a single 100mg dose QD. If a patient complains of moderate or severe dizziness or persistent headaches, then discontinue treatment. Long term use of minocycline can rarely lead to bluish discoloration of skin and nails.
Other oral medications that have been found efficacious include metronidazole, doxycycline, and clarithromycin.

Treatment for Telangiectasia and Rhinophyma
Telangiectasia will not remit with the above treatments. If the patient has considerable concern regarding the cosmesis of telangiectasia, referral to UM Cosmetic Dermatology & Laser Center for pulse-dye laser or electrocautery may be indicated. Be sure to advise the patient that this will not be covered by insurance, given its cosmetic indication.
Rhinophyma can be treated by ENT or Plastic surgery, with surgical debulking, laser, or electrosurgery.

Many patients believe they have rosacea. Often they have "physiologic rosacea" - red cheeks and some flushing that is a bit beyond average. Many of these patients are of English, German, or Irish extraction. Although these patients typically receive topical rosacea therapy, it is difficult to change normal physiology.