Rosacea

Abstract

Rosacea is a common, chronic skin disease that affects the facial pilo-sebaceous glands. It is characterised by erythema, flushing and sometimes papules. It typically affects the convex surfaces of the face, most commonly the forehead, cheeks, chin and nose. Rosacea predominantly affects the Caucasian population, with prevalence being higher in northern Europe than southern Europe. It is three times more common in females and peaks between 30 and 60 years of age. Rosacea can usually be well managed with topical or oral treatments in primary care, although some forms of rosacea or treatment-resistant cases may need specialist input.

The GP curriculum and rosacea

Clinical module 3.21: Care of people with skin problems requires GPs to:

Understand how to recognise common skin conditions in primary care and instigate appropriate management

Be aware of primary care resources and when to refer to secondary care, so that the patient receives appropriate treatment

Aetiology

In rosacea, the facial capillaries develop a tendency to dilate easily. Vasodilatation and chronic inflammation is thought to stem from a change in the innate immune response (Schaller at al., 2017). A link between rosacea and bacteria on the skin or in the gut has been suggested by some researchers, but evidence is still inconclusive. Although antibiotics can be effective in treating rosacea, this is probably due to their anti-inflammatory rather than anti-microbial properties. The presence of the common skin mites Demodex folliculorum or Demodex brevis has been long associated with rosacea, however, they are thought to have an aggravating rather than causative effect.

Clinical presentation

Clinical presentation depends on the subtype of the disease, but in most cases, there is a history of episodic flushing of the face which is exacerbated by environmental and lifestyle factors. The subtypes of rosacea are listed in Table 1 with their common features (Wilkin et al., 2002). Papulopustular rosacea (see Fig. 1) is the commonest type, and can usually be managed well in primary care. Symptoms of episodic flushing commonly precede the onset of rosacea, sometimes even by a few years.

Figure 1.

Papulopustular rosacea.

Table 1.

The four subtypes of rosacea.

Type	Features
Papulopustular rosacea	Typically affects middle-aged females. Marked erythematous papules with pinpoint pustules. Papules respond well to oral antibiotics
Erythematotelengiectatic rosacea	Persistent flushing and presence of fine, thin vessels (telangiectasia) are the main features. This subtype is more difficult to manage in primary care
Phymatous rosacea	Marked thickening of the skin with irregular nodularity – commonly of the nose
Ocular rosacea	Involvement of the eyelids, conjunctiva and meibomian glands causing dry eyes, blepharitis, conjunctivitis and rarely even keratitis. Commonly presents with dryness, redness and a foreign body sensation in the eye

Although it is an acneiform disease, unlike acne, the skin is dry in rosacea. The most common areas involved are the forehead, nose, cheeks and chin, with sparing of peri-oral and peri-orbital skin. Less commonly, other body parts such as the eyes, ears and neck can be affected (Stollery, 2017). Sometimes a sensation like burning and stinging is associated with flushing and oedema. Rarely acne-like comedones can also be seen, which can lead to diagnostic uncertainty.

Not all flushing is due to rosacea. Other causes of flushing and dilatation of blood vessels of the face, which rosacea can be mistaken for or exacerbated by, are noted in Box 1. A common misconception is that alcohol can cause rosacea. However, it is a common cause of flushing, which can exacerbate rosacea symptoms.

Box 1.

Common causes of flushing.

• Temperature changes, direct sunlight

• Food: Spicy foods, caffeine, alcohol, food additives (e.g. mono-sodium-glutamate in large amounts can cause ‘Chinese restaurant syndrome’ characterised by excessive flushing)

• Emotional changes including stress or anxiety

• Drugs: Vasodilators (e.g. nitrates, calcium channel blocker), steroids, tamoxifen, ciclosporin

Like many skin conditions, rosacea often affects self-esteem. A poorly controlled rosacea can lead to low mood and anxiety. It is important in primary care to look at the skin condition in the context of its impact on the patient’s life.

Diagnosis

Rosacea is a clinical diagnosis. There are no fixed criteria or clear definition for rosacea diagnosis. Some suggest that for a diagnosis of rosacea, erythema should be present for at least 3 months.

The differential diagnosis of facial flushing and erythema is listed in Table 2. In cases of diagnostic uncertainty, investigations such as a punch biopsy or photosensitivity tests might be needed.

Table 2.

Differential diagnosis (see also Box 1 for causes of flushing).

Differential diagnosis	Features
Acne	Presence of comedones (blackheads, whiteheads) is pathognomonic of acne
Seborrheic dermatitis	Dryness and flaking of scalp, eyebrows and naso-labial fold. Related to the inflammatory response to overgrowth of a yeast malassezia, and responds well to topical anti-fungal treatment
Peri-oral dermatitis	Related to the use of topical steroids over face
Systemic lupus erythematosus	Presence of photosensitive rash along with systemic or hematological features
Photosensitive rashes	Rash limited to light-exposed areas
Lupus pernio	Related to sarcoidodsis. This is the main differential of rhinophyma

Management

Although there is no cure for rosacea, in most cases it can be managed quite well. Providing a good explanation regarding the disease process and management helps the patient to engage with treatment and empower them to self-care. The Patient UK and the British Association of Dermatologists websites have good patient information leaflets. Self-care advice, which can help to reduce flare ups and severity of symptoms, is listed in Box 2.

Box 2.

Self-care advice.

• Avoid lifestyle factors that can aggravate rosacea, especially alcohol, hot and spicy food

• Avoid topical steroids, unless specifically recommended by a clinician

• Regular use of sunscreens (SPF 30 or more)

• Use a soap substitute to wash your face. Using a regular emollient has soothing effects on the dryness caused by rosacea. A non-greasy, unperfumed emollient and make up with minimal irritation can help with the dryness and erythema of rosacea. The National Rosacea Society has further information about skin care and cosmetics (www.rosacea.org)

• Self-help with cosmetics and camouflage to cover up facial erythema. In cases of severe erythema, referral to a professional camouflage service could be made. More information can be found on the website of the British Association of Skin Camouflage (www.skin-camouflage.net)

Source: British Association of Dermatologists (2014).

Treatment options for rosacea depend on the subtype of rosacea from which the patient is suffering. These are summarised in Table 3. Depending on the severity of the condition, it can be managed in primary or secondary care.

Table 3.

Treatment options.

Type of rosacea	Primary care	Secondary care
Papulopustular	Mild-to-moderate symptoms: • Topical metronidazole • Azelaic acid • Ivermectin Moderate-to-severe symptoms: • Oral tetracycline or macrolide	Systemic isotretinoin
Erythematotelengiectatic	• Brimonidine gel • Oral propranolol or clonidine	• Laser therapy • Dermabrasion • Camouflage service
Phymatous	Combination therapy (topical treatment with oral antibiotics)	• Oral isotretinoin • Shave excision (Plastics)
Ocular	• Eyelid hygiene • Systemic tetracycline	• Topical steroids • Systemic ciclosporin • Urgent ophthalmology review for suspected keratitis

Papulopustular rosacea

Papulopustular type is one of the most common types of rosacea and can usually be managed in primary care. Treatment choices, depending on the severity of the presentation, could be either topical, systemic or a combination of both.

Topical treatment

Patients with mild-to-moderate papulopustular rosacea can be offered one of the topical treatments described in Box 3. There is high quality of evidence behind use of Azelaic acid and Ivermectin cream. The patient should be informed about the local irritant effects of Azelaic acid and initially they should try it on a small area of skin.

Box 3.

Topical treatment for papulopustular rosacea.

• Topical Metronidazole: Available as 0.75% gel or 1% cream. The gel preparation needs to be used twice daily and occasionally the alcohol content of the gel can irritate the skin. Metronidazole cream is usually applied once daily

• Azelaic acid 15% gel: Twice daily. May be more effective than Metronidazole gel, but can cause local irritation

• Ivermectin 1% cream: A newly licensed treatment for rosacea that is well-tolerated and has shown greater efficacy than topical Metronidazole. It is an anti-parasitic medicine that is being used due to its anti-inflammatory properties. It should be discontinued if there is no sign of improvement after 3 months of daily use

Oral medicines

Patients with moderate-to-severe rosacea, papulo-pustular rosacea and rosacea resistant to topical treatment should be treated with oral antibiotics, either on their own or preferably in combination with a topical treatment.

Tetracycline antibiotics such as lymecycline (408 mg once daily), oxytetracycline (500 mg twice daily) or doxycycline (40 mg once daily) are quite effective (PCDS, 2018). Tetracycline antibiotics are absolutely contraindicated in pregnancy and can also cause a photosensitive rash. Macrolide antibiotics, such as erythromycin 500 mg twice daily, are an alternative option. The dose of the antibiotics can later be reduced after the disease has been satisfactorily controlled. Treatment should be prescribed for at least 3 months. Gastrointestinal symptoms, such as nausea and abdominal pain, are the most common side effects with tetracyclines and macrolides. The patient should also be counselled regarding chronicity of the condition and treatment, otherwise it might lead to poor compliance.

Oral retinoids, for example, Isotretinoin, can be used in rosacea resistant to the above treatments. Oral retinoid treatment should be initiated only by a specialist and sometimes low-dose oral isotretinoin can be used for long-term control of rosacea.

Erythematotelengiectatic rosacea

Erythematotelengiectatic rosacea is a type that is more difficult to treat satisfactorily in primary care. Treatment options can be divided into primary and secondary care options. One primary care option is brimonidine gel (Mirvaso). This works as an alpha-2 receptor agonist to reduce flushing. Unfortunately, it can cause rebound erythema, and the patient should be clearly counselled to try it at a low dose for a week before increasing towards a maximum dose of 1 g a day (which is equivalent to roughly five pea-sized amounts applied to the forehead, chin, nose and each cheek). If redness or burning occurs, they should stop using the gel and contact you, their GP.

Other agents that can be used for flushing are non-selective beta-blockers, such as propranalol (40 mg twice daily), or clonidine (50 micrograms twice daily). Compared with papulopustular rosacea, patients with erythematotelengiectatic rosacea are more likely to be referred to secondary care.

Laser treatment can be a very effective option for facial telangiectasia, but availability on the NHS is variable. It is important to inform patients that in some cases telangiectasia can recur even after laser treatment. Another option is referral to camouflage services, which can be effective in hiding the severity of the erythematous changes, especially in treatment-resistant cases.

Phymatous rosacea

Thickening of skin can be related to the chronicity of the disease. Early and aggressive treatment of rosacea might help to slow down the process to rhinophyma. However, once phymatous changes appear (see Fig. 2), surgery usually is the most effective option. These patients should be routinely referred to plastic surgery for shave excision. Other options include dermabrasion and CO₂ laser peel.

Figure 2.

Rhinophyoma (phymatous changes seen over nose and cheek).

Ocular rosacea

Mild ocular involvement can be treated in primary care with advice regarding good eyelid hygiene with regular cleaning using cooled boiled water or sodium bicarbonate solution. If needed, over-the-counter or prescribed eye lubricants can be used to help with dry eye symptoms, which are commonly present in ocular rosacea. Treatment with oral antibiotics (tetracyclines) has been shown to be very effective for ocular rosacea.

If ocular symptoms persist despite treatment, the patient should be referred routinely to an ophthalmologist. One of the known complications of ocular rosacea is keratitis (see Fig. 3), which causes red, painful eyes or blurred vision. Development of keratitis symptoms warrants an urgent referral to ophthalmology.

Figure 3.

Ocular rosacea.

KEY POINTS

Rosacea is a common, chronic, facial rash that predominantly affects the Caucasian population

Although it is three times more common in females, it is often more severe in males

Presentation and treatment depends on the subtypes of the disease

As it commonly affects face, it can affect peoples’ confidence and mental health

Most cases of the rosacea can be managed in primary care

Severe or treatment-resistant cases can be appropriately referred to secondary care for dermatology, plastics or ophthalmology review

References

British Association of Dermatologists (2014) Patient information leaflet (rosacea). Available at: www.bad.org.uk/shared/get-file.ashx?id=229&itemtype=document (accessed 22 April 2018).

Cunliffe T (2018) Clinical-guidance/ rosacea. Available at: www.pcds.org.uk/clinical-guidance/rosacea (accessed 22 April 2018).

Frow H, Gupta G, Kownacki S, et al. (2016) Primary care treatment pathway. Available at: www.pcds.org.uk/ee/images/uploads/general/Rosacea-Guidelines-FINAL.pdf (accessed 22 April 2018).

Newson L (2015) Rosacea and rhinophyma. Available at: https://patient.info/doctor/rosacea-and-rhinophyma (accessed 22 April 2018).

PCDS (2018) Rosacea. Available at: http://www.pcds.org.uk/clinical-guidance/rosacea (accessed April 2018).

RCGP. Clinical example 3.21: Care of people with skin problems. Available at: www.rcgp-curriculum.org.uk/pdf/RCGP-Curriculum-3.21-Skin-Problems.pdf (accessed 22 April 2018).

RCGP. Core statement 1: Being a GP. Available at: www.gmc-uk.org/1_Being_a_GP_01.pdf_30450204.pdf (accessed 22 April 2018).

Schaller M, Almeida LMC, Bewley A, et al. (2017) Rosacea treatment update: Recommendations from the global ROSacea Consensus (ROSCO) panel. British Journal of Dermatology 176(2): 465–471. DOI: 10.1111/bjd.15173.

Stollery N (2017) Management of rosacea. Available at: www.gponline.com/management-rosacea/dermatology/article/1125463 (accessed 22 April 2018).

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