Skin Disorders Guide

Diagnostic Hallmarks

1. Distribution: vertical, central third of the face
2. Pustules and papules against a background of erythema and telangiectasia

Clinical Presentation

Rosacea is characterized by macular erythema, overlaid with telangiectasia, on the nose and cheeks. Often, the glabella and chin are involved such that the eruption forms a vertical band down the central third of the face. In the more severe cases, pustules and inflammatory papules are superimposed against this erythematous background. Comedones do not occur. Men (and, only rarely, women) with longstanding rosacea may develop a distinctive connective tissue overgrowth of the nose known as rhinophyma. This condition is colloquially referred to as potato nose. Rosacea is seen primarily in middle-aged or older people. Those of Celtic and northern European background seem particularly predisposed to the disease. The diagnosis of rosacea is made on a clinical basis.

Course and Prognosis

Rosacea is a chronic disease characterized by periodic exacerbations and remissions. Gradual worsening, wherein the redness and telangiectasia become more constant, occurs in some patients, but in others the disease gradually fades out over a period of many years. Men with rosacea, as noted above, may eventually develop rhinophyma. Conjunctivitis, blepharitis, and keratitis accompany the disease in some patients with longstanding, untreated disease. Treatment leads to considerable cosmetic improvement but is probably only suppressive, in that recurrence is almost invariable when treatment is discontinued.

Pathogenesis

The cause of rosacea is unknown. Familial predisposition for the disease and the remarkable tendency for those of Celtic background to develop the problem suggest that genetic factors are important. Ingestants such as spicy foods, alcohol, and hot beverages are widely believed to worsen the disease.

Certainly, they temporarily increase the redness and the prominence of the telangiectasia, but I am unconvinced that they permanently alter the eventual course of the disease. Contrary to folklore, rosacea is not a sign of excess alcoholic intake. The pustules of rosacea appear to be follicular abscesses; they lack the component of keratinous plugging found in the pustules of acne vulgaris.

Therapy

Tetracycline administered orally in a dose of 500-1000 mg/ day is extremely effective in suppressing the occurrence of papules and pustules. It also has a useful but less dramatic defect on the underlying redness and telangiectasia. Topically applied steroids temporarily reduce the redness, but their prolonged use is contraindicated, since rebound flaring and eventual worsening of the process is quite likely. The preferred topical therapy today is metronidazole gel used twice daily. Response to this therapy is quite good, but visible evidence of eflectiveness is often not apparent for several months. The application of preparations containing sulfur have historically been viewed as helpful. Oil-based makeups might be avoided when possible, since they are said to worsen the process. Nervousness and stress are often associated with exacerbations of rosacea, but good control or psychologic factors is all too often difficult to obtain. orally administered retinoids, as used for acne, work very well, but cost and toxicity limit the usefulness of this approach. Residual redness and telangiectasia, remaining after maximum response has been obtained medically, can improve to some degree with laser therapy.