Chapter 206 Rosacea
• Chronic acneiform eruption on the face of middle-aged and older adults associated with facial flushing and telangiectasia.
• The acneiform component is characterized by papules, pustules, and seborrhea; the vascular component by erythema and telangiectasia; and the glandular component by hyperplasia of the soft tissue of the nose (rhinophyma).
• The primary involvement occurs over the flush areas of the cheeks and nose.
Rosacea is a common, chronic, progressive inflammatory skin disorder in which the nose and cheeks are abnormally red and may be covered with pimples similar to those seen in acne (see Chapter 141). Rosacea was originally called “acne rosacea” because its inflammatory papules and pustules so closely mimic those of acne vulgaris. Unlike acne vulgaris, whose etiology is based on the interaction of abnormal keratinization, increased sebum production, and bacterially induced inflammation, rosacea’s inflammation is vascular in nature. Rosacea generally occurs in patients between the ages of 25 and 70 years, and it is much more common in people with fair complexions. Women are three times more likely than men to have rosacea, although the disease is generally more severe in men. At least 13 million Americans are known to be affected.1,2
Rosacea is divided into three stages, but because progression does not necessarily occur, rosacea is also often divided into four specific subtypes (erythematous telangiectatic, papulopustular, phymatous, and ocular)1,3,4:
• Stage I: In this stage, or erythematous telangiectatic rosacea, erythema triggered by hot beverages, spicy foods, and alcohol may persist for hours; telangiectasias are noticeable on the central third of the face; and burning, stinging, and itching after the application of cosmetics, fragrances, and sunscreens become a major complaint.
• Stage II: In this stage, or papulopustular rosacea, the hallmarks are inflammatory papules and pustules. Flushing, telangiectasias, and seborrhea increase, and minimal enlargement of facial pores becomes obvious.
• Stage III: A small number of patients progress to this stage, or phymatous rosacea, which exhibits deep inflammatory nodules, large telangiectatic vessels, markedly dilated facial pores, sebaceous gland hyperplasia, and tissue hyperplasia, especially of the nose (rhinophyma).
Ocular rosacea describes the spectrum of eye findings associated with the skin involvement. Ocular rosacea can cause the eyes to have a watery or bloodshot appearance, the sensation of a foreign body, burning or stinging, dryness, itching, light sensitivity, and a host of other signs and symptoms. Sties are a common sign of rosacea-related ocular disease, and some individuals may have decreased visual acuity owing to corneal complications.
It is important to point out that what differentiates the flushing that rosacea patients experience is its prolonged nature and intensity. Many people without rosacea experience evanescent flushing in response to embarrassment, exercise, or hot environments. However, although evanescent flushing episodes last from several seconds to few minutes, the flushing that the typical rosacea patient describes lasts longer than 10 minutes and is more red than pink, with an accompanying burning or stinging sensation. The stimuli that bring on such flushing in rosacea patients may be acutely felt emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, or hot baths or showers. However, many times the episodes are without known stimuli.
The cause of rosacea is poorly understood, although numerous theories have been offered. Included in the factors that have been suspected of causing acne rosacea are the following:
• The mite Demodex folliculorum
Most cases of rosacea are associated with moderate to severe seborrhea, although sebum production is not increased in many. Vasomotor lability is prevalent, and migraine headaches are three times more common in persons with rosacea than in age- and gender-matched controls.
There is also emerging evidence for a role for Helicobacter pylori in rosacea (discussed below as well). It is known that H. pylori infection increases several vasoactive substances, such as histamines, prostaglandins, and leukotrienes, and various cytokines. However, these vascular mediators are found only with H. pylori strains that also produce a specific cytotoxin, cytotoxin-associated gene A (CagA). The presence of H. pylori capable of producing this cytotoxin may be more important in the etiology of rosacea than other strains. When the presence of CagA was assessed in 60 rosacea patients and compared with age- and gender-matched control subjects with nonulcer dyspepsia, researchers found that when infected with H. pylori, 67% of rosacea patients versus only 32% of controls had positive findings for CagA. In addition, these patients had elevated systemic levels of tumor necrosis factor-α and interleukin 8. After the eradication of H. pylori infection in the rosacea patients, symptoms disappeared in almost all of them (51 of 53) and tumor necrosis factor-α and interleukin 8 levels normalized.7,8
In regard to the etiology of rosacea, the bottom line is that because many of the implicated triggers of rosacea are experienced by healthy persons who never go on to develop the symptoms or signs of rosacea, it is believed that rosacea-prone individuals must have an inherent sensitivity to these triggers.