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INTRODUCTION

Acne rosacea is a chronic vascular and acneiform disorder of the pilosebaceous unit that affects predominantly the central face including the central cheeks, nose, and chin. The eyes and the eyelids can occasionally be involved. Typically, there is an increased reactivity of capillaries to heat, leading to flushing and ultimately telangiectasia. Subtypes of rosacea include (1) vascular rosacea (erythematotelangiectatic), (2) papulopustular rosacea, (3) sebaceous hyperplasia (phymatous rosacea) including rhinophyma (nasal sebaceous hyperplasia), and (4) ocular rosacea. Granulomatous rosacea is a variant of rosacea.

EPIDEMIOLOGY

Incidence: common

Age: 30 to 50 years; peak incidence between 40 and 50 years

Sex: female predilection; male predominance for rhino phyma

Race: most common in fair-skinned individuals (skin phototypes I and II); rarely seen in darker-skinned individuals (skin phototypes IV–VI)

Precipitating factors: excessive sun exposure, caffeine, spicy foods, hot foods and beverages, heat, alcohol, seborrhea, topical corticosteroid use, and underlying Parkinson’s disease

PATHOGENESIS

Multiple factors are involved in the pathogenesis of rosacea including vascular hyperactivity, Demodex folliculorum mites, Helicobacter pylori, and hypersensitivity to Propionibacterium acnes.

PHYSICAL EXAMINATION

Variable clinical features can be present depending on the severity and the subtype of rosacea. Early features include transient and nontransient flushing, erythematous papules, and pustules. No comedones are noted. Late features include telangiectasias, sebaceous hyperplasia, nasal thickening and enlargement (rhinophyma), and lymphedema. Ocular involvement is frequently seen.

DIFFERENTIAL DIAGNOSIS

Acne vulgaris, seborrheic dermatitis, perioral dermatitis, steroid rosacea, systemic lupus erythematosus, and B lupus miliaris disseminatus faciei.

DERMATOPATHOLOGY

Vascular ectasia as well as perifollicular and perivascular lymphohistiocytic infiltrates are the most common findings. Demodex folliculorum is usually detected in the follicles. Noncaseating epithelioid granulomas are seen in the granulomatous variant. Sebaceous hyperplasia and fibrosis are seen in rhinophyma.

COURSE

Chronic with frequent recurrences. May spontaneously resolve after several years.

MANAGEMENT

Prevention, reduction, or elimination of exacerbants; sun avoidance.

Topical Therapy

Metronidazole (0.75%–1%) once or twice daily, 10% sodium sulfacetamide with 5% sulfur once daily, and azelaic acid once daily, alone or in combination, are helpful in suppressing the papulopustular component of rosacea.

Systemic Therapy

  • Tetracycline, 1,000 to 1,500 mg daily in divided doses, until clear; then taper to a maintenance dose of 250 to 500 mg daily.

  • Minocycline and doxycycline, 50 to 100 mg twice daily, with a tapering to once daily use.

  • Oral isotretinoin is reserved for severe cases not responding to oral antibiotics and requires close follow-up. A low-dose regimen may be effective.

Surgical Therapy

Rhinophyma

Multiple surgical modalities have been ...

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