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1、ROSACEAKey Points Rosacea has four different clinical presentations: erythemato-telangiectatic, papulo-pustular, phymatous, and ocular. It is essential to correctly identify the subtype of rosacea in order to select the appropriate medical or surgical therapy. Rosacea treatment should be tailored to
2、 the clinical subtype and disease severity to optimize therapy. Facial erythema is the primary feature of rosacea and presents ubiquitously in all subtypes. Persistent facial erythema has significant impact on quality of life. Erythemato-telangiectatic rosacea must be differentiated from chronic sun
3、 damage. Papulo-pustular rosacea must be distinguished from acne vulgaris, seborrheic dermatitis, perioral dermatitis, and Demodex folliculitis/demodicidosis. Rosacea can be distinguished from acne vulgaris by the lack of comedones, identification of triggers for flushing, absence of scarring, the p
4、resence of phymatous changes, and the predilection to affect older adults rather than teenage adults. Rosacea patients often have sensitive skin and suffer from intolerance to skin products and cosmetics. Patients with rosacea flush, have facial erythema, telangectasia, papules and pustules, sebaceo
5、us hyperplasia of the nose (rhinophyma), and/or ocular symptoms. Triggers for flushing include alcohol, sun exposure, hot weather, exercise, ingestion of hot or spicy foods/ drink or a medication, and emotional stress. Eliminating the triggers of flushing can alleviate rosacea symptoms. Newer topica
6、l treatments provide effective options for treating rosacea subtypes. The alpha adrenergic agonist brimonidine (Mirvaso) effectively reduces erythema in erythemato-telangiectactic rosacea, as well as in other subtypes. Ivermectin cream (Soolantra) is highly effective in reducing inflammatory lesions
7、 of papulo-pustular rosacea. Ocular rosacea requires systemic antibiotics. Phymatous rosacea may require laser treatment or other surgical intervention.Initial EvaluationErythemato-telangiectatic (E-T) subtype: Characterized by diffuse erythema and telangiectasias on the cheeks, forehead, dorsal nos
8、e, or entire face.Papulo-pustular subtype: Characterized by papules and pustules often on a blush of erythema primarily affecting the nose, cheeks, and forehead. Predilection of lesions is on the central aspect of the face, sometimes with central facial edema; associated with flushing.Phymatous subt
9、ype: Marked by thickening of the skin, irregular skin texture, edema, hypertrophy and hyperplasia of sebaceous glands, connective tissue, and vascular bed of the nose (rhinophyma). These changes can also be seen on the chin (gnathophyma), ears (otophyma), forehead (metophyma), and eyelids (blepharop
10、hyma); almost exclusively in males.Ocular subtype: Can be seen in the presence or absence of skin manifestations of rosacea. Characterized by conjunctival erythema and injection, sometimes accompanied by eyelid edema (blepharitis), foreign body sensation, and/or glandular inflammation (chalazion) al
11、ong the eyelid margin. Patients report subjective symptoms: foreign body sensations, dry eyes, itching and burning, photosensitivity. The vision is rarely affected. Because severe long-term consequences may result from untreated ocular rosacea, ongoing ophthalmologic evaluation is strongly recommend
12、ed.Differential diagnosisAcne vulgaris: Open (blackheads) and closed (whiteheads) 1-2 mm follicular-based papules. Some of the lesions are excoriated. Comedones are not a feature of rosacea.Nodular acne: Nodules are present on the upper right forehead and bilateral medial cheeks, in addition to infl
13、ammatory papules, pustules, and scars. Nodules and scars are not typical features of rosacea.Seborrheic dermatitis: Scaly, flaky, itchy, red skin on the scalp, face (nasolabial folds), and trunk.Peri-orificial dermatitis (i.e., peri-oral dermatitis): Papules and pustules are small in size, monomorph
14、ous, and occur around the mouth (rarely around eyes).Systemic lupus erythematosus: Malar erythema in a clearly photodistributed pattern on the face.Subtypes of rosacea and their treatmentsErythemato-telangiectatic (E-T) subtype Patients often complain of intolerance or sensitivity to topical product
15、s and cosmetics. This subtype is best treated with avoidance of flushing, photoprotection, and surgical or laser therapies (see table, Subtype Directed Therapy). Though considered the mildest form of rosacea, the E-T subtype is marked by significant impact on quality of life stemming from persistent
16、 facial erythema. A significant advancement in treatment of rosacea erythema is now commercially available; once-daily application of brimonidine gel 0.33% (Mirvaso) has been approved as an effective topical treatment for facial redness in rosacea.Papulo-pustular subtype This subtype is best treated with topical or systemic antibiotics and/or topical 5%
