Background
Rosacea is a common condition that presents with facial redness and a spectrum of clinical manifestations such as erythema, capillary dilatation, skin roughness, and acne-like inflammatory papulopustules. in April 2002, it was classified into 4 types based on specific clinical manifestations. Typing is important for treatment.
Diagnosis is mainly clinical, and skin biopsy can exclude other skin diseases, such as true erythroblastosis, connective tissue diseases (e.g., lupus erythematosus, dermatomyositis, mixed connective tissue disease), photosensitivity, carcinoid syndrome, mastocytosis, long-term topical hormone use, and contact dermatitis.
Rosacea was defined as erythema in the midface that persisted for at least 3 months. Supporting criteria included facial flushing, papules, pustules, and dilated capillaries in prominent areas of the face. Secondary features include burning and tingling sensations, edema, plaques, dry appearance, periocular manifestations, and nasal flaccid changes. Different manifestations define different subtypes of rosacea, and treatment varies by subtype. There are 3 subtypes: erythema capillarum; papulopustular; nasal flaccid rosacea; and periocular rosacea.
Pathophysiological mechanism
The etiology of rosacea is unknown. A variety of factors such as vascularity, climate, dermal matrix degeneration, chemicals and ingested substances, abnormalities of follicular sebaceous units, microorganisms, ferritin, reactive oxygen species, neovascularization, and dysfunctional antimicrobial peptides may drive the development of rosacea. In addition, different types of rosacea may determine unique sensitivities to these stimuli.
Blood vessels
Increased blood flow to the face and an increased number of blood vessels on the facial surface may be associated with facial redness and flushing. In addition, vasodilation is a normal response to hyperthermia and may be more pronounced in rosacea patients.
Climate
Extreme climates can damage skin blood vessels and dermal connective tissue. Likewise, exposure to UV light can do so, which is why rosacea tends to involve prominent areas of the face and tends to recur in the spring. However, some studies have shown the opposite, instead of aggravation during sun exposure and no relapse with acute UV exposure.
Dermal stromal degeneration
Rosacea damages the endothelium and dermal matrix. However, what is not known is whether the existing dermal stroma is involved, with subsequent destruction of the tissue supporting the skin vasculature, resulting in plasma aggregation, inflammatory mediators, and metabolic wastes, or whether the existing skin vasculature is abnormal, with subsequent extravasation and accumulation of plasma proteins, inflammatory mediators, and metabolic wastes, followed by stromal degeneration.
Chemical and ingested substances
Spicy foods, alcohol, and hot drinks can cause facial flushing in rosacea patients. However, most evidence suggests that diet is not the primary. In addition, certain medications, such as amiodarone, topical topical hormones, and high doses of vitamins B6 and B12, can cause recurrence of the condition.
Perivascular and perifollicular inflammation
The evidence is inconsistent for perivascular and/or perifollicular inflammatory infiltrates.
Microorganisms
Trichinella may have a role in the pathogenesis of rosacea. Several studies have found that Trichinella prefers areas of the nose and cheeks where rosacea is prevalent. Studies have found infiltration of helper T cells around the antigen of Trichinella. However, some studies have also found no such phenomenon. In addition, healthy individuals without rosacea also have large numbers of Trichinella spp. Further studies are needed to investigate the role of Trichinella.
Alternatively, H. pylori may be associated with rosacea. However, the results of the study could not exclude confounding factors, such as gender, age, socioeconomic status, and medications.
Ferritin expression
Iron catalysts convert hydrogen peroxide into free radicals, which cause tissue damage by damaging cell membranes, proteins, and DNA. At the cellular level, iron is stored in ferritin. 2009, skin biopsy specimens from rosacea patients were found to have a high number of ferritin-positive cells. The higher the number of ferritin positivity, the more progressive the rosacea. Ferritin releases free iron ions, leading to oxidative damage to the skin, which causes rosacea.
Reactive oxygen series
Early in inflammation, reactive oxygen species series (ROS) are released by neutrophils and are involved in the severity of rosacea. Free radicals such as superoxide ions, hydroxyl groups, and other reactive molecules such as molecular oxygen, singlet oxygen, and hydrogen peroxide lead to oxidative tissue damage.
Angiogenesis and vascular endothelial growth factor overexpression
Studies have shown capillaroscopy showing neovascularization and vasodilation. Immunohistochemistry showed increased expression of VEGF. Calcium hydroxybenzoate, an inhibitor of vascular growth factor, improved erythema and capillary dilation in rosacea patients after 2 weeks of application.
Antimicrobial peptides
Antimicrobial peptide (AMP) is a small molecular protein involved in the initial immune response with broad-spectrum antibacterial, viral, and fungal activity. It is released immediately after injury or infection and is involved in a variety of inflammatory skin diseases. Antimicrobial peptides and beta defensins are 2 well-known antimicrobial peptides that are highly expressed in the lesions of rosacea patients.
Epidemiology
Prevalence
In the United States, it is more common in light-skinned ethnic groups. In Sweden, 1 in 10 Swedish workers have rosacea, while caseous necrotizing-like rosacea (cluster acne) may be more common in subspecies or Africans.
Medical history
A background of facial flushing dating back to childhood or early adolescence. In adulthood, facial flushing can be exacerbated by hot drinks, emotions, and other factors that increase body temperature rapidly. Some patients drink alcohol with red faces, but there is no specificity.
Symptoms are usually intermittent but can progress gradually leading to persistent facial erythema, which presents as brightly pigmented with persistent capillary dilation. In addition, some patients present with gritty eyes and facial edema.
Physical examination
Different degrees of erythema and capillary dilation on the cheeks and forehead. Inflammatory papules and pustules predominantly on the nose, forehead, and cheeks. Extra-facial manifestations are uncommon and may involve the neck and upper chest. In individual patients, sebaceous glands may be seen and develop into thickened and deformed skin forming a nasal flaccid rosacea. Unlike acne, rosacea does not have oily skin; instead, dry skin and peeling can occur. The absence of acne is also a point of differentiation. Periocular lymphedema may be evident but is uncommon. This condition usually does not cause scarring.
Individual patients present with only a nasal flaccid phase and no other manifestations.
Occasionally, significant periocular lymphedema is present.
Symptoms of periocular rosacea may be accompanied by conjunctival congestion; blepharocysts and superficial sclerosis are rare.
Eruptive rosacea (facial pyoderma) is a rare complication that presents as nodules, abscesses, and sinus tract formation with systemic symptoms. Patients may present with hypothermia, rapid blood sedimentation, and elevated white blood cells.
Seborrhea and seborrheic dermatitis/blepharitis are commonly seen in patients with rosacea, and the mechanism of why this is relevant is unclear.
Cluster acne (facially disseminated acne vulgaris presents as inflammatory erythema or skin-colored papules symmetrically distributed on the face, especially around the eyes and nose.
Etiology
The rosacea-like syndrome (including perioral dermatitis) is associated with facial abuse of potent corticosteroids. Blood multiple aggravating factors such as wind and ultraviolet light can accelerate disease progression.
Diagnosis
Erythematous capillary dilated rosacea may resemble seborrheic inflammation, lupus erythematosus, and photodermatosis. Carcinoid syndrome and mitral valve closure insufficiency may be an easily overlooked cause of facial erythema and capillary dilation. Acne-like rosacea can resemble acne, iodine rash, bromhidrosis, perioral dermatitis, and pustular folliculitis. Cluster acne may be poorly differentiated from common lupus and cutaneous nodulosis.
Treatment
Before starting treatment, figure out the triggers and then avoid the triggers. Triggers vary from person to person. Some patients find that regular facial massage reduces lymphedema. Medium to high doses of prednisone (30-60 mg/d) can treat eruptive rosacea, followed by oral isotretinoin.
Sunscreens
A broad-spectrum physical sunscreen containing titanium dioxide and zinc oxide is recommended. In addition sunscreens should contain protective silicones, such as dimethicone or cyclomethicone. A green sunscreen can conceal redness.
In addition, patients should pathologically use astringents, toners, menthol, camphor, waterproof cosmetics that require solvent cleanup, or products containing sodium lauryl sulfate.
Laser
Non-ablative lasers can remodel the dermal connective tissue and improve the epidermal barrier, are expensive, and require 1-3 sessions, each 4-8 weeks apart.
Vascular lasers are the main treatment for rosacea and include pulsed dye lasers (585-nm and 595-nm), as well as 532-nm lasers. The wavelengths are selectively absorbed by hemoglobin, resulting in collapse of the vessels and mild damage or scarring of the surrounding tissue. To be effective on deep facial vessels, lasers with wide wavelengths of 810-nm, 755-nm, and 1064-nm can be used.
Intense pulsed light is a multi-chromatic laser that acts on multiple targets, including melanin and hemoglobin, and is suitable for facial remodeling, affecting blood vessels, melanin and hair.
Surgical Treatment
Persistent capillary dilation can be treated with electrocautery or a 585-nm laser. Cosmetic surgery for the nasal flaccid phase is performed with skin grinding, CO2 laser, and surgical chipping.
Diet
Moderate diet is mainly to avoid induced aggravation.
Summary of medication
The aim of pharmacological treatment is to reduce the incidence and prevent complications.
Topical metronidazole is the first-line treatment drug. Topical azelaic acid, sulfacetamide products, and topical acne medications are also often used. Topical and oral antibiotics are also very effective and are usually the first-line treatment for perioral rosacea. Retinoic acid is also recommended. in August 2013, the FDA approved the alpha-2 agonist brimonidine for the treatment of rosacea-associated erythema. Topical topical ivermectin may be used to treat the inflammatory lesions of rosacea. In addition, case reports of effective medications for the treatment of facial flushing include beta-blockers, colistin, naloxone, ondansetron, and selective pentoxifylline reuptake inhibitors. Oral contraceptives can be used for rosacea that worsens with hormonal cycles. Severe recalcitrant rosacea can be treated with aminophene, especially in patients who cannot take oral isotretinoin.
Immunosuppressive drugs such as tacrolimus ointment (Protopic). Antibiotics include 0.75% or 1% metronidazole gel. Erythromycin tablets or a 2% topical solution. 1% fusidic acid cream. Topical clindamycin. Tetracycline, minocycline, doxycycline, clarithromycin. Retinoids such as topical retinoic acid, isotretinoin. Hormones such as prednisone. Anti-hypertensive drugs such as spironolactone, amiloride, aminopterin. Topical acne medications such as benzoyl peroxide cream, azelaic acid cream, sulfacetamide and sulfur cream, topical brimonidine (for those with facial erythema).
Complications
Rosacea keratitis and dry keratoconjunctivitis. Eruptive rosacea rare. No scarring usually remains.
Prognosis
Most patients are treated and can have stable disease with some residual symptoms. Some patients have chronic recurrence or progression of the disease.
Patient education
Advise patients to avoid exposure to triggering aggravating factors such as hot or cold relief, wind, hot drinks, caffeine, exercise, spicy foods, strong emotions, alcohol, topical irritants and products that damage the skin barrier, and medications. Encourage patients to choose a broad-spectrum sunscreen that does not cause acne when they go out in the sun and wind.