Rosacea, Acne Rosacea, erythematotelangiectatic, papulopustular. phymatous, ocular rosacea

1. ROSACEA
(ACNE ROSACEA)

4. WHAT IS ROSACEA?
CHRONIC RREELLAAPPSSIINNGG DDIISSOORRDDEERR WWIITTHH
VVAARRIIAABBLLEE DDEEGGRREESSSS OOFF……....
•Persistent centrofacial erythema
•Telangiectasias
•Inflammatory papules
•Inflammatory pustules
•Nodules
•Edematous plaques (non-pitting)
•Ocular inflammation
•Phymatous changes

5. ROSACEA
• Onset during middle age, with women
being affected somewhat earlier than men.
• Rosacea occurs most frequently in
Caucasians and in those with fair sun-sensitive
skin, i.e. skin phototypes I and II.
• There may be a genetic predisposition to the
disorder, as 10–20% of patients report a
family history of rosacea.

6. CLINICAL PICTURE OF
ROSACEA

7. SYMPTOMS OF ROSACEA
• ITCHY RASH ON
FACE
• “STINGS”
• “BURNS”
• TOPICAL CREAMS
NOT HELPFUL
• NO NEW MEDS
• NO NEW SOAPS OR
PERFUMES

8. • In 2002, a consensus publication provided a
classification scheme for rosacea into four
major forms with distinct clinical
characteristics.
• Each subtype is graded into mild, moderate and
severe (grades 1–3).

10. CLASSIFICATION OF ROSACEA
SSuubbttyyppee PPrreeddoommiinnaanntt cclliinniiccaall ffeeaattuurreess
EErryytthheemmaattoo--
tteellaannggiieeccttaattiicc
11.. PPeerrssiisstteenntt cceennttrrooffaacciiaall eerryytthheemmaa
22.. FFlluusshhiinngg
33.. TTeellaannggiieeccttaassiiaass
44.. SSkkiinn sseennssiittiivviittyy
PPaappuullooppuussttuullaarr
11.. PPeerrssiisstteenntt cceennttrrooffaacciiaall eerryytthheemmaa
22.. PPaappuulleess
33.. PPuussttuulleess//ppaappuullooppuussttuulleess
44.. OOvveerrllaapp wwiitthh ootthheerr ssuubbttyyppeess mmaayy ooccccuurr
PPhhyymmaattoouuss
11.. TThhiicckkeenneedd,, nnoodduullaarr sskkiinn
22.. PPrroommiinneenntt ppoorreess
33.. CCaann aaffffeecctt nnoossee ((rrhhiinnoopphhyymmaa)),, cchhiinn ((ggnnaatthhoopphhyymmaa)),,
ffoorreehheeaadd ((mmeettoopphhyymmaa)),, eeaarrss ((oottoopphhyymmaa)),, eeyyeelliiddss
((bblleepphhaarroopphhyymmaa))
44.. MMaayy bbee aassssoocciiaatteedd wwiitthh ootthheerr ffeeaattuurreess ooff rroossaacceeaa oorr
ooccccuurr iinn iissoollaattiioonn
OOccuullaarr
11.. DDrryy,, ggrriittttyy sseennssaattiioonn,, ppaaiinn oorr pphhoottoopphhoobbiiaa
22.. BBlleepphhaarriittiiss && CCoonnjjuunnccttiivviittiiss
33.. CChhaallaazziiaa aanndd hhoorrddeeoollaa
44.. KKeerraattiittiiss,, eeppiisscclleerriittiiss,, sscclleerriittiiss,, uuvveeiittiiss ((rraarree))

11. 1. ERYTHEMATOTELANGIECTATIC
ROSACEA
Patients typically have skin phototypes I or II

12. Severity of Erythematotelangiectatic rosacea

13. Erythematotelangiectatic rosacea.
Persistent erythema of the medial and lateral
cheeks is seen. In this patient, there are no
telangiectasias, indicating mild (grade 1) disease.

14. Telangiectasias

15. Telangiectasias become
progressively
prominent, forming
sprays on the nose,
nasolabial folds, cheeks
and glabella

16. 2. PAPULOPUSTULAR ROSACEA
• CC//OO: slight tenderness or itch but social distress
caused by the appearance of the eruption far
exceeds the physical symptoms.
• CC//FF: Centrofacial eruption of multiple, small
(<3 mm), dome-shaped, erythematous papules,
some of which are surmounted by a seropustule
can appear singly or in crops.
• Individual lesions last about 2 weeks then
subside into a blotchy erythema, which
gradually fades & others appear.
• Usually no resultant scarring.

17. Severity of papulopustular rosacea

18. Mild papulopustular rosacea

19. Moderate papulopustular
rosacea of the forehead.
Note the superficial nature of the
inflammatory lesions.

21. Moderate to severe
papulopustular rosacea.
There is a typical centrofacial distribution. In
addition, the skin has a scaly, crusty surface and
this is often a sign of more severe disease.

22. Severe papulopustular
rosacea
Dense erythema,
Papules, pustules,
nodules.Telangiectasias
severe, diffuse. Variable
plaque-like edema

23. 3. PHYMATOUS ROSACEA
• Most commonly rhinophyma
• Occurs primarily in men.
• Reflects hypertrophy of the sebaceous glands &
connective tissue in nasal skin.
• May occur with sever rosacea, but surprisingly,
patients with rhinophyma may only have mild
rosacea.
• Rhinophyma is usually seen in patients with other
features of rosacea but may occur in patients with
acne vulgaris; occasionally it is due to chronic actinic
damage or may arise de novo.

26. Severity of phymatous rosacea

27. The earliest clinical sign of rhinophyma is the
appearance of dilated pores (patulous follicles)
on the distal portions of the nose

28. RHINOPHYMA – EARLY
Telangiectatic vessels of the distal nose may
predispose to subsequent development of
hypertrophic changes of rhinophyma

30. RHINOPHYMA
MODERATE

31. SEVERE RHINOPHYMA
Hypertrophy of tissue with nasal distortion as
soft, fleshy, nodular growths increase in size.

32. 4. OCULAR ROSACEA
• Can occur without accompanying cutaneous
changes or it may be seen in patients with any
of the other subtypes of rosacea.
• CC//OO: nonspecific; itching, tearing, dryness,
gritty sensations, crusting of eyelids & an
inability to wear contact lenses, as well as
frequent styes.

33. Severity of ocular rosacea

34. OOCCUULLAARR RROOSSAACCEEAA
There may be tiny concretions at the bases of the
cilia (conical dandruff), or mild scaling of the
eyelid margins (scurf).

35. Hordeolum

37. Common, may be first sign of rosacea
variable presentation

38. 4. OCULAR ROSACEA
• May need ophthalmological consultation
especially (grade 3) disease
• Keratitis may lead to blindness

39. VARIANTS OF ROSACEA
1. GRANULOMATOUS
ROSACEA: Persistent red–brown
to skin-colored facial papules with
a characteristic non-caseating
granulomatous histology.
2. ROSACEA CONGLOBATA:
inflammatory facial cysts with
associated scarring.
3. ROSACEA FULMINANS
(pyoderma faciale): characterized
by explosive onset of inflammatory
papules and pustules superimposed
on a back-ground of facial
erythema & fever may occur.

40. PATHOGENESIS OF ROSACEA

41. WHAT CAUSES ROSACEA?
• The exact cause is unknown.
• May be;
• Demodex mite infestation?
• Solar damage? Heat? Caffiene?
• Lymphatic obstruction? Emotional stress?

42. TRIGGERS OF ROSACEA
11.. SSuunn eexxppoossuurree 8811%%
112.. CCeerrttaaiinn sskkiinn--ccaarree
2.. EEmmoottiioonnaall ssttrreessss 7799%%
pprroodduuccttss 4411%%
33.. HHoott wweeaatthheerr 7755%%
44.. WWiinndd 5577%%
55.. HHeeaavvyy eexxeerrcciissee 5566%%
66.. AAllccoohhooll ccoonnssuummppttiioonn
552%%
77.. HHoott bbaatthhss 5511%%
88.. CCoolldd wweeaatthheerr 4466%%
99.. SSppiiccyy ffooooddss 4455%%
1100..HHuummiiddiittyy 4444%%
1111..IInnddoooorr hheeaatt 4411%%
1133.. HHeeaatteedd bbeevveerraaggeess 3366%%
1144.. CCeerrttaaiinn ccoossmmeettiiccss 277%%
1155..MMeeddiiccaattiioonnss((ssppeecciiffiiccaallll
yy ssttiimmuullaannttss)) 1155%%
1166..MMeeddiiccaall ccoonnddiittiioonnss
1155%%
1177.. CCeerrttaaiinn ffrruuiittss 1133%%
1188..MMaarriinnaatteedd mmeeaattss 1100%%
1199.. CCeerrttaaiinn vveeggeettaabblleess 99%%
200.. DDaaiirryy pprroodduuccttss 88%%

44. • H. pylori

45. Demodex Found within follicular
infundibula & sebaceous ducts…

46. Commensal organisms….

51. Edematous papules of
Demodex folliculitis
(demodicidosis)
superimposed upon the
characteristic
background erythema .

52. Microscopic findings
of follicular contents
obtained via scraping
of Demodex
folliculitis.

53. HISTOPATHOLOGY OF
ROSACEA

54. Erythematotelangiectatic rosacea

55. Papulopustular rosacea

56. Rhinophyma

57. Granulomatous rosacea

58. Demodex folliculorum residing in
hair follicle

59. Histopathology of rosacea
• Telangiectasia of superficial blood vessels;
• Perivascular infiltrates of lymphocytes
(mild to moderate in intensity) and,
sometimes, plasma cells.
• Active pustular lesions show superficial
folliculitis.
• Older lesions show granulomatous
perifolliculitis.
• Demodex mites are noted (20-50% cases)

60. Histopathology of rosacea
• Well-circumscribed collections of epithelioid
histiocytes, usually peri-infundibular.
• Granulomas surrounded usually by
lymphocytes and, sometimes, plasma cells.
• Small collections of neutrophils in some
granulomas.
• Caseous necrosis may be present within some
granulomas.
• Rhinophyma: Sebaceous gland hypertrophy
and scattered follicular plugging.

61. DDx OF ROSACEA

62. DDx OF ROSACEA
SSuubbttyyppee DDDDxx
EErryytthheemmaattoo--
tteellaannggiieeccttaattiicc
11.. CChhrroonniicc aaccttiinniicc ddaammaaggee ((ddeerrmmaattoohheelliioossiiss)) iinn ffaaiirr--
sskkiinnnneedd iinnddiivviidduuaallss
22.. SSeebboorrrrhheeiicc ddeerrmmaattiittiiss
33.. CCuuttaanneeoouuss lluuppuuss eerryytthheemmaattoossuuss
44.. KKeerraattoossiiss ppiillaarriiss rruubbrraa ffaacciieeii
55.. CCoonnttaacctt ddeerrmmaattiittiiss ((AAlllleerrggiicc oorr IIrrrriittaanntt))
PPaappuullooppuussttuullaarr
11.. AAccnnee vvuullggaarriiss
22.. SSeebboorrrrhheeiicc ddeerrmmaattiittiiss
33.. PPeerriioorriiffiicciiaall ddeerrmmaattiittiiss
44.. SStteerrooiidd--iinndduucceedd rroossaacceeaa..
55.. DDeemmooddeexx ffoolllliiccuulliittiiss..
PPhhyymmaattoouuss 11.. LLuuppuuss ppeerrnniioo
22.. LLuuppuuss vvuullggaarriiss
OOccuullaarr 11.. SSeebboorrrrhheeiicc ddeerrmmaattiittiiss
22.. AAlllleerrggiicc ccoonnttaacctt ddeerrmmaattiittiiss..
33.. PPeerriiooccuullaarr ddeerrmmaattiittiiss

63. Dermatoheliosis

64. Seborrheic dermatitis

65. Malar flush

66. KKeerraattoossiiss ppiillaarriiss rruubbrraa ffaacciieeii

67. CCoonnttaacctt ddeerrmmaattiittiiss

68. ROSACEA VS. ACNE
RROOSSAACCEEAA AACCNNEE
ADULTS
PAPULES
PUSTULES
NO COMEDONES
ERYTHEMA
TELANGIECTASIAS
TEENS
PAPULES
PUSTULES
COMEDONES
NO ERYTHEMA
NO TELANGIECTASIAS

69. Steroid rosacea

70. DDeemmooddeexx ffoolllliiccuulliittiiss..

71. Lupus Pernio

72. Lupus Vulgaris

73. TREATMENT OF ROSACEA

75. Treatment of rosacea

76. Treatment of rosacea
• On 2013, FDA approved
brimonidine (Mirvaso®)
topical gel, 0.33% for the
(first and only) topical
treatment of persistent
facial erythema of rosacea
in adults 18 years of age or older.
• It is not indicated for the treatment of
inflammatory lesions (papules and pustules) of
rosacea.
• It is selective alpha-2 adrenergic agonist
causing cutaneous vasoconstriction.

77. Treatment of rosacea

80. 250

83. Treatment – Cosmetic Repair

84. Treatment: CO2 laser, one
treatment. Heal time was just
over 12 days.

86. • Avoid precipitating factors.
• Sometimes, successful treatment of the
inflammatory lesions of papulopustular
rosacea reveals background telangiectasias
(the PERT phenomenon – “post-erythema-revealed
telangiectasias”)
• Topical and systemic therapies used to treat
papulopustular rosacea are often ineffective
in the treatment of erythematotelangiectatic
rosacea and may irritate the skin.

87. EXPECTATIONS
• Tell them to expect improvement in 4-6 weeks
• Tell them to continue regimen until next visit
• May give topicals for maintenance otherwise,
relapse is likely 3 to 6 months after
discontinuation of treatment.
• Inform them there is no cure for rosacea!!!!!!!!

88. LUPUS MILIARIS
DISSEMINATUS FACIEI
(LMDF)

89. LMDF
• Uncommon chronic inflammatory facial
dermatosis. It presents with pale papules
which may be confused with sarcoid or
syringoma clinically.
• Many authors now consider LMDF to be an
extreme variant of granulomatous rosacea.
Others believe it is a distinct entity because
of its characteristic histopathology and
occasional involvement of non-central
facial areas.

90. LMDF
• Age; Young adults in their 20s most often
are affected.
• Etiology; and pathogenesis are unknown.
• Active disease usually involves a 1- to 3-
year course and resolves spontaneously.
• Recurrences are not described.
• LMDF may result in disfiguring scarring.
• Educate patients about the nature of the
disease to help alleviate anxiety and to
establish realistic treatment expectations.

91. C/P of LMDF
• Papules singly or in crops
that are red, brown, or
yellow-brown and appear on
the central face, especially on
and around the eyelids.
• Lesions occasionally may be
generalized and appear on
the extremities or trunk
• May present later as crusts,
pustules ultimately, scars.

93. Histopathology of LMDF
• In LMDF, sections show
round granulomas composed
of epithelioid cells with
central caseating necrosis.
• The granulomas may appear
sarcoidal or tuberculoid
typically arise adjacent to
adnexal structures.
• A chronic inflammatory
infiltrate often present.
• Late lesions show fibrosis

95. Treatment of LMDF
• Surgical:
Scar revision procedures (laser resurfacing,
dermabrasion, chemical peel) may benefit
patients after the disease has run its course.

96. REFERENCES
• Dan Ladd, D.O. Texas/KCOM
Dermatology Residency Program Program
Director Bill V. Way, D.O.
• Bolognia 3rd ed.
• http://dermnetnz.org/acne/rosacea.html
• http://emedicine.medscape.com

97. THANK YOU