Acne Rosacea

Aka: Acne Rosacea, Rosacea, Rhinophyma

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II. Epidemiology

  1. Typical onset ages 30-50 years old
  2. Northern european descent and fair skinned persons
  3. More common in women by factor of 2-3
  4. Prevalence: 1.3-2.1% (14 Million cases) in United States

III. Risk Factors: Predisposing triggers and exacerbating factors

  1. Sun Exposure, hot weather, and hot baths
  2. Emotional stressors
  3. Alcohol use
  4. Hot drinks
  5. Exercise
  6. Nose Hair Follicle mites (Demodex folliculorum)

IV. Pathophysiology

  1. Acneiform eruption

V. Types

  1. Subtype 1: Erythematotelangiectatic (most difficult to treat)
    1. Persistent central face Macular erythema with Telangiectasias and Flushing
    2. Possible ocular involvement
  2. Subtype 2: Papulopustular (easiest to treat)
    1. Persistent central face erythema with small Papules and tiny Pustules (acne-like)
    2. Periocular sparing
  3. Subtype 3: Phymatous (more common in men)
    1. Skin thickening and nodular irregularities (due to Sebaceous Gland hyperplasia)
    2. Distribution: Nose (Rhinophyma), chin, ears, forehead or Eyelid
  4. Subtype 4: Ocular
    1. Watery, Bloodshot Eyes may become dry with foreign body Sensation and photophobia
    2. Distribution: Blepharitis, Conjunctivitis, and Eyelid Inflammation
  5. Variant: Granulomatous
    1. Brown, yellow or red firm, indurated non-inflammatory Papules or Nodules

VI. Symptoms

  1. Stinging pain may accompany facial Flushing

VII. Signs

  1. Course is variable
    1. Stages listed below are for organization only
  2. Distribution for all lesions
    1. Affects middle third of face (forehead to chin)
  3. Stage 1: Initial presentation
    1. Intermittent facial Flushing lasting 5 minutes or less
    2. May involve neck and chest
    3. Sensation of warmth may be present
  4. Stage 2: Early vascular changes
    1. Facial erythema
    2. Telangiectasis
    3. Eye changes (see ocular signs below)
  5. Stage 3: Inflammatory changes
    1. Papules
    2. Sterile Pustules
    3. Comedones are typically absent
  6. Stage 4: Rhinophyma (Red bulbous nose)
    1. More common in men
    2. Thickening of facial skin (especially nose)
      1. Connective tissue hypertrophy
      2. Sebaceous Gland hypertrophy
    3. Previously thought to be a sign Alcohol Abuse
      1. Example: W. C. Fields
  7. Variant: Granulomatous Rosacea
    1. May appear similar to facial sarcoid

VIII. Signs: Ocular involvement (50% of Rosacea cases)

  1. Eyelid Inflammation (may be presenting sign)
    1. Acne involving Eyelids
    2. Eyelid redness and swelling
    3. Eyelid margin Telangiectasia
  2. Inflammatory Conjunctivitis
    1. Blepharitis may accompany Conjunctivitis
    2. Eyes that itch or burn
    3. Dry Eyes with sandpaper or foreign body Sensation
  3. Other less common changes
    1. Corneal neovascularization
    2. Keratitis
    3. Corneal scarring

IX. Differential Diagnosis: Skin

  1. Late-onset Acne Vulgaris
    1. Comedones present
    2. No Telangiectasis
    3. No eye symptoms or signs
  2. Steroid-induced Acne
    1. Results from Corticosteroid use on face
    2. Perioral changes
  3. Perioral Dermatitis
    1. Some dermatologists consider Perioral Dermatitis a variant of Rosacea
  4. Polymorphous Light Eruption or other Photodermatitis
  5. Seborrheic Dermatitis
  6. Contact Dermatitis
  7. Polymyositis
  8. Sarcoidosis
  9. Systemic Lupus Erythematosus
  10. Carcinoid Syndrome (severe facial Flushing)
  11. Mastocytosis

X. Differential Diagnosis: Ocular Rosacea

  1. Blepharokeratoconjunctivitis (staphylococcal or seborrheic)
  2. Sebaceous Gland carcinoma
  3. Allergic Conjunctivitis

XI. Diagnosis

  1. Central face dermatitis with at least one of the following findings
    1. Transient erythema (Flushing)
    2. Nontransient erythema
    3. Papules and Pustules
    4. Telangiectasia

XII. Management: General Measures

  1. Avoid triggers
    1. Avoid Alcohol
    2. Avoid prolonged heat exposure
    3. Avoid hot liquids (coffee, tea)
    4. Avoid heavy cosmetics
  2. Use sun screen (minimum SPF 30) regularly (better tolerated agents are listed)
    1. Avoid chemical Sunscreens which may be irritating
    2. Use a mineral or physical Sunscreen
      1. Base: Simethicone, dimethicone or cyclomethicone
      2. Active ingredient: Titanium Dioxide or Zinc Oxide
  3. Choose gentle skin care products
    1. Clear and free (dye and perfume free) products
    2. Mild cleansers with near neutral pH (e.g. cetaphil, dove sensitive skin)
    3. Skin Moisturizers (Emollients) applied to moist skin
    4. Avoid abrasive skin products
    5. Green or yellow tinted consmetics may hide facial erythema
  4. Avoid provocative medications
    1. Benzoyl Peroxide (avoid in erythematotelangiectatic Rosacea - subtype 1)
    2. Topical Corticosteroids

XIII. Management: Papular and pustular Rosacea

  1. Step 1
    1. Apply across entire central face
    2. First Line agents (most effective agents)
      1. Metronidazole topical
        1. Once daily (1% gel) or twice daily (0.75% gel, cream or lotion)
        2. Effective in 80% of cases
        3. Similar efficacy between 0.75% and 1%, as well as between once and twice daily dosing
      2. Azelaic Acid (Azelex) 15% gel
        1. Slight benefit over Metrogel, but less tolerated (consider in those not responding to Metronidazole)
        2. Gel is generic, while cream and foam are trade name only at twice the price
        3. Irritation may be reduced with gentle skin cleansers (e.g. cetaphil) and Skin Lubricants (e.g. vanicream)
        4. Elewski (2003) Arch Dermatol 139:1444-50 [PubMed]
    3. Alternative agents
      1. Clindamycin (Cleocin-T)
      2. Sulfacetamide/Sulfur (10%/5%) cream, foam or lotion
      3. Permethrin 5% cream
        1. Effective for erythema and Papules (but not as effective with Pustules)
        2. Kocak (2002) Dermatology 205:265-70 [PubMed]
  2. Step 2: May use the following oral agents in combination with topicals listed above
    1. Doxycyline (preferred)
      1. Moderate Rosacea
        1. Doxycyline 40 mg daily or 20 mg twice daily (sub-antimicrobial dose)
      2. Severe Rosacea or refractory to 8-12 weeks at lower dose Doxycycline
        1. Doxycycline 100 mg twice daily (then taper to once daily after the first month)
    2. Alternative systemic antibiotics (tapering to once daily after the first month)
      1. Tetracycline 250 mg twice daily or
      2. Erythromycin 250 mg twice daily
      3. Amoxicillin 250 mg twice daily
    3. Efficacy
      1. Useful in treating Blepharitis, Keratitis
      2. Most effective treatment
  3. Step 3: Additional topical agents to consider
    1. Erythema (without Papules or Pustules)
      1. Brimonidine gel 0.33% (Mirvaso) - see below
      2. Oxymetazoline 1% (Rhofade) - see below
    2. Inflammatory papular and pustular Rosacea
      1. Precaution: Avoid in erythematotelangiectatic Rosacea (Flushing) - subtype 1 (may worsen)
      2. Topical Benzoyl Peroxide with Clindamycin (e.g. Benzaclin)
        1. Avoid Benzyl Peroxide with Erythromycin (no benefit to the Erythromycin)
      3. Ivermectin (Scolantra) 1% cream applied once daily
        1. Very expensive (nearly $500 for 45 grams)
        2. (2015) Presc Lett 22(3): 16
      4. Minocycline 1.5% Foam (Zilxi)
        1. Very expensive (nearly $500 for 30 grams)
        2. No evidence of benefit over other Rosacea topicals
        3. (2021) Presc Lett 28(6): 36
  4. Step 4: Refractory Cases
    1. Topical Tretinoin (Retin A)
      1. May exacerbate erythema and Telangiectasis
    2. Accutane for 20 weeks
      1. Variably effective
    3. Consider mite or tinea management
      1. Examine sample with Potassium Hydroxide
      2. Crotamiton (Eurax)

XIV. Management: Associated conditions

  1. Facial Flushing and Erythema
    1. First-line: See general measures above
    2. Second-line
      1. See Vasomotor Symptoms of Menopause
      2. Clonidine 0.05 mg bid
      3. Propranolol (Inderal LA) 80 mg orally daily
    3. Topical vasconstrictors (onset of action 4 hours, duration 12 hours)
      1. Brimonidine gel 0.33% (Mirvaso)
        1. Topical Vasoconstrictor released in 2013 in U.S.
        2. Can reduce facial redness (NNT 6 for significant benefit)
        3. Very expensive ($400 for 30 grams)
          1. Consider using generic Brimonidine 0.2% eye drops topically on face (10% of cost)
        4. (2013) Presc Lett 20(11): 65
      2. Oxymetazoline 1% (Rhofade)
        1. Topical Vasoconstrictor released in 2017 in U.S. (same ingredient as Afrin 0.05%, but 1%)
        2. Very expensive ($475 for 30 grams)
        3. (2017) Presc Lett 24(5):30
  2. Telangiectasis
    1. Green-tinted cosmetics
    2. Pulsed dye laser
  3. Ocular changes
    1. Precautions
      1. Risk of complications such as Chalazion, Scleritis, Corneal Ulcer
      2. Consider ophthalmology Consultation
    2. First-line therapy
      1. Oral Doxycycline (or other oral antibiotics listed above)
      2. Artificial tears for eye dryness
      3. Lid and lashes cleansing with baby Shampoo
      4. Topical metrogel to Eyelid if involved
      5. Omega-3 Fatty Acid Supplementation
    3. Second-line therapy for refractory cases
      1. Ocular steroids (by ophthalmology)
      2. Cyclosporine Ophthalmic Emulsion (Restasis) - by ophthalmology
      3. Accutane
    4. References
      1. Oltz (2011) Optometry 82(2): 92-103 [PubMed]
      2. Vieira (2013) J Am Acad Dermatol 69 (suppl 1): S36-41 [PubMed]
  4. Rhinophyma
    1. Mild to moderate
      1. Antibiotics such as Doxycycline (as listed above)
      2. Oral Isotretinoin (Accutane)
    2. Advanced cases (Surgery)
      1. Dermabrasion
      2. Hypertrophic tissue excision

XV. References

  1. (2021) Presc Lett 28(6): 36
  2. Habif (1996) Clinical Dermatology, p. 182-4
  3. Blount (2002) Am Fam Physician 66(3):435-40 [PubMed]
  4. Goldgar (2009) Am Fam Physician 80(5): 461-8 [PubMed]
  5. Oge (2015) Am Fam Physician 92(3): 187-96 [PubMed]
  6. Powell (2005) N Engl J Med 352(8):793-803 [PubMed]
  7. Zuber (2000) Prim Care 27(2):309-18 [PubMed]

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