The management of rosacea

Diagnose rosacea, understanding the various presentations, recognising triggers and management options.

The nose, cheeks and forehead are the usual areas affected, but other areas can also be involved (Photograph: Author Image)
The nose, cheeks and forehead are the usual areas affected, but other areas can also be involved (Photograph: Author Image)

Acne rosacea is a common chronic skin condition which presents as facial flushing and erythema and is exacerbated by triggers such as alcohol, heat, spicy food, caffeine and sunlight.

Primarily a condition of the white population, it is three times more common in women than in men and has a peak age of onset between 30 and 60 years. Although the usual areas affected are the nose, cheeks and forehead, other areas, such as the neck, chest and ears, can become involved.

For a diagnosis to be confirmed, the erythema should have been present for at least three months. The cause of rosacea is unknown, although the demodex mite, which usually inhabits human hair follicles, may play a part in the pathogenesis.

Signs and symptoms

Rosacea can be classified into one of four types, each having a different presentation.

Erythematotelangiectatic rosacea presents with flushing that progresses to a permanent erythema and telangiectasia over the affected areas. Affected skin may also itch and patients describe a burning sensation.

Patients with papulopustular rosacea have papules and pustules on a background of erythema, which appears similar to acne vulgaris.

In phymatous rosacea, the skin thickens and may become nodular and irregular. The nose is the most commonly affected area, resulting in a permanent enlargement called rhinophyma. Other areas, such as the chin, forehead, cheeks and eyelids, may also be affected. With ocular rosacea, the eyes as well as the skin can be affected, with red, inflamed, dry eyelids – this may be confused with blepharitis.

Diagnosis

Differential diagnoses
  • Lupus
  • Perioral dermatitis
  • Sarcoidosis
  • Acne
  • Seborrhoeic dermatitis

In all types of rosacea, the diagnosis is usually made clinically after taking a history and examining the patient. For many people, the symptoms will be mild and medical help will never be sought. A history of flushing preceding onset of the erythema, and an association with triggers, can be helpful.

Papulopustular rosacea may resemble acne vulgaris, but there should be no comedones, which can be a useful differentiating feature. Rosacea also tends to worsen with UV light, whereas acne tends to improve. Furthermore, rosacea occurs later in life in most cases.

The other main differential diagnosis is seborrhoeic dermatitis, a condition that sometimes coexists with rosacea. Flaking and dryness of the skin are more likely with seborrhoeic dermatitis, with a different distribution involving nasolabial folds, hairlines and other areas of the body, such as the axillae, presternal areas and groin.

Management

Treatment of patients with rosacea varies and depends on the severity and type of the disease. As part of the history-taking, it is important to try to determine anything that may be triggering the flushing and rash. Direct questioning may be required, especially with regard to alcohol consumption and emotional stress.

Other triggers include diet, exercise, sunlight, topical steroids and vasodilator medications such as calcium-channel blockers.

Once the triggers have been determined, advice regarding avoidance of these should reduce the severity of the condition. In the case of UV light, a daily application of sunscreen throughout the year can be helpful.

After managing triggers, the next step depends on the type and severity of the rosacea.

For flushing, brimonidine gel is an effective and fast-acting vasoconstrictor. Launched in 2014, this is an alpha-2 agonist. It needs to be initiated with a small amount only, to reduce the risk of exacerbating the condition, which can happen in 16% of patients.1 Applied daily, it will last for 12 hours. Telangiectasia and papules may be more apparent after using this, because the masking effect of the erythema is reduced.

For fixed erythema, intense pulsed light therapy or pulsed dye lasers can be very effective.

For mild to moderate papulopustular rosacea, the first line should be either ivermectin 1% gel (an antibiotic-free option) or a topical antibiotic, such as metronidazole. An alternative to these in inflammatory rosacea would be azelaic acid, but this may not be tolerated by everyone.

In more severe cases, ivermectin may also be effective, but an oral antibiotic may be required. Tetracycline is the usual first choice, but this needs to be avoided in pregnancy. Doxycycline can also be useful; a low-dose (40mg) preparation has been launched and is thought to work as an anti-inflammatory rather than an antibiotic.

For those with ocular rosacea, eyelid hygiene is important and should be followed as it is in blepharitis, using diluted baby shampoo and a cotton bud along with warm compresses.

In more severe cases a referral may be required to secondary care for treatment with isotretinoin. Other treatments include laser therapy and surgery for phymatous rosacea.

In most cases, treatment will allow a stable state in the condition to be reached. This will be followed by periods of relapse and remission throughout the patient’s life.

Key points
  • Rosacea is a common chronic condition.
  • Many cases are mild and do not require treatment.
  • There are many known triggers, including sunlight.
  • Diagnosis is usually clinical but in some cases a biopsy can be helpful.
  • Severe cases (for example, phymatous rosacea) may be disfiguring and surgery may be required.

Dr Stollery is a GP in Kibworth, Leicestershire

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This is an updated version of an article that was first published in April 2012.

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