Rosacea

1. Introduction

  • Definition: Rosacea is a chronic inflammatory skin condition primarily affecting the face, characterised by facial redness, flushing, and, in some cases, pustules and thickened skin.
  • Epidemiology: Affects approximately 5–10% of the population, predominantly fair-skinned individuals aged 30–50, with a slight female predominance.
  • Significance: While not life-threatening, rosacea can significantly impact quality of life and self-esteem, particularly in severe cases.

2. Causes and Risk Factors

  • Causes:
    • Exact cause is unknown, but dysregulation of the immune system, abnormal neurovascular response, and Demodex mites on the skin play a role.
  • Risk Factors:
    • Fair skin and light eye colour.
    • Family history of rosacea.
    • Triggers such as heat, sunlight, stress, alcohol, spicy foods, and certain skincare products.

3. Pathophysiology

  • Chronic inflammation and vascular dysfunction lead to persistent redness, dilated blood vessels, and inflammatory lesions. Over time, repeated flare-ups may cause thickening of the skin, particularly on the nose (rhinophyma).

4. Symptoms and Features

  • Common Symptoms:
    • Persistent facial redness (erythema), primarily on the cheeks, nose, forehead, and chin.
    • Flushing and visible blood vessels (telangiectasia).
  • Subtypes of Rosacea:
    1. Erythematotelangiectatic Rosacea (ETR): Persistent redness and visible vessels.
    2. Papulopustular Rosacea: Redness with acne-like pustules and papules.
    3. Phymatous Rosacea: Skin thickening, often on the nose.
    4. Ocular Rosacea: Dry, irritated, and bloodshot eyes.

5. Complications

  • Permanent skin changes such as rhinophyma.
  • Psychological impact, including low self-esteem and anxiety.
  • Ocular complications like keratitis and blepharitis in untreated ocular rosacea.

6. Diagnosis

  • Clinical Features: Diagnosis is based on history and physical examination, particularly the presence of facial redness, flushing, and pustules.
  • Exclusion of Other Conditions: Rule out acne, lupus, and seborrheic dermatitis.
  • No specific tests: Diagnosis is clinical, but skin biopsy may rarely be needed in atypical cases.

7. Management Overview

  • Goals: Reduce symptoms, control inflammation, and minimise flare-ups.
  • Approach: Combination of lifestyle modifications, topical therapies, and systemic medications for severe cases.

8. Treatment Options with Cost (USD)

  • Topical Treatments:
    • Metronidazole cream: ~$20–$50 per tube.
    • Azelaic acid gel: ~$30–$70 per tube.
    • Brimonidine gel: ~$50–$100 per tube.
  • Systemic Treatments:
    • Oral doxycycline: ~$10–$40 per month.
    • Isotretinoin: ~$200–$400 per month.
  • Laser Therapy: ~$300–$600 per session for telangiectasia and persistent redness.

9. Advanced Treatment Options with Cost (USD)

  • Pulse Dye Laser (PDL) or Intense Pulsed Light (IPL): ~$500–$1,000 per session for severe redness and blood vessels.
  • Surgical Interventions: For advanced rhinophyma, cost varies ($3,000–$10,000).

10. Pharmacological Treatment

  • Topical Agents:
    • Metronidazole and azelaic acid for mild to moderate rosacea.
    • Brimonidine gel for temporary reduction of redness.
  • Systemic Agents:
    • Doxycycline for inflammatory lesions.
    • Isotretinoin for refractory cases.

11. Medication Tables

Table 1: Doses and Side Effects

DrugIndicationDoseCommon Side Effects
MetronidazoleFirst-line topical treatmentApply 1–2 times dailySkin irritation, dryness
Azelaic acidMild to moderate rosaceaApply 1–2 times dailyBurning, stinging, redness
Brimonidine gelErythema reductionApply once dailyFlushing rebound, irritation
DoxycyclineModerate to severe rosacea40–100 mg dailyGI upset, photosensitivity
IsotretinoinRefractory rosacea0.25–0.5 mg/kg dailyDry skin, teratogenicity

Table 2: Brand Names and Approximate Costs (USD)

DrugBrand NamesApprox. Cost
MetronidazoleMetrogel, Rozex$20–$50 per tube
Azelaic acidFinacea$30–$70 per tube
Brimonidine gelMirvaso$50–$100 per tube
DoxycyclineVibramycin$10–$40 per month
IsotretinoinAccutane, Roaccutane$200–$400 per month

12. Lifestyle Interventions

  • Avoid triggers such as sunlight, heat, alcohol, and spicy foods.
  • Use gentle, fragrance-free skincare products.
  • Apply broad-spectrum sunscreen daily with SPF ≥30.
  • Maintain hydration and a balanced diet rich in anti-inflammatory foods.

13. Monitoring Parameters

  • Symptom severity, including redness, papules, and patient-reported outcomes.
  • Side effects of systemic treatments like doxycycline or isotretinoin.
  • Response to laser or surgical interventions for refractory cases.

14. Patient Counseling Points

  • Emphasise the importance of avoiding known triggers and protecting skin from UV exposure.
  • Educate about the chronic nature of rosacea and the need for consistent treatment.
  • Discuss the gradual onset of improvements with topical and systemic therapies.
  • Address psychological impact and provide support for coping strategies.

15. Special Populations

  • In Children: Rare but may occur; mild topical treatments are preferred.
  • In Pregnancy: Avoid teratogenic drugs like isotretinoin; focus on safe options like azelaic acid.
  • In Elderly: Consider comorbidities and increased sensitivity to medications.

16. Prevention

  • Avoid known triggers through lifestyle modifications.
  • Consistent use of sunscreen and gentle skincare products.
  • Early treatment of minor symptoms to prevent progression.

17. FAQs

  1. What is rosacea?
    Answer: A chronic skin condition causing redness, flushing, and sometimes pustules or thickened skin.
  2. What triggers rosacea?
    Answer: Sunlight, stress, alcohol, spicy foods, and certain skincare products.
  3. How is rosacea treated?
    Answer: Through topical agents, oral medications, and sometimes laser therapy.
  4. Is rosacea contagious?
    Answer: No, rosacea is not contagious.
  5. Can rosacea be cured?
    Answer: No, but symptoms can be effectively managed.
  6. How long does it take for treatment to work?
    Answer: Improvement may take weeks to months, depending on the severity.
  7. What is rhinophyma?
    Answer: Thickened skin on the nose caused by severe rosacea.
  8. Does diet affect rosacea?
    Answer: Yes, avoiding alcohol, spicy foods, and hot beverages can reduce flare-ups.
  9. Can sunscreen help with rosacea?
    Answer: Yes, daily use of sunscreen protects against UV-induced flare-ups.
  10. What is ocular rosacea?
    Answer: A subtype causing dry, irritated, and bloodshot eyes.
  11. Are there natural remedies for rosacea?
    Answer: Aloe vera, chamomile, and green tea may soothe mild symptoms.
  12. How is laser therapy used in rosacea?
    Answer: It reduces redness and visible blood vessels.
  13. Can makeup worsen rosacea?
    Answer: Harsh products can irritate the skin; use non-comedogenic, gentle options.
  14. When should I see a dermatologist?
    Answer: If symptoms worsen or affect your quality of life.
  15. What are common side effects of rosacea treatments?
    Answer: Skin irritation with topicals and GI upset with oral medications.