Help for the patient with rosacea

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Help for the patient with rosacea
Apr 1, 2007
Steve Hoag, MD, LT MC USN, Robert F. Raspa, MD
Patient Care

Rosacea often goes unrecognized, but it is easily diagnosed and treated in primary care. Timely interventions can alter the outcome of this disease and significantly improve a patient's quality of life.

Rosacea is a disfiguring condition that affects more than 14 million people in the United States. Patients may experience as much damage to their self-image as to their skin. A curative treatment is lacking, but many well-characterized mechanisms of the disorder can be addressed in primary care with a variety of effective treatments.

EPIDEMIOLOGY

Almost entirely a disease of adults, rosacea commonly occurs after age 30.1 Its incidence peaks between the fourth and seventh decades. Rosacea is thought to occur most often in people of Celtic or northern European descent, whose fair skin makes the rash apparent and easy to detect. In rare cases, it affects African Americans, whose darker complexion partially hides the rash. Rosacea affects more women than men, but it tends to be more severe in men, sometimes causing significant facial distortion and rhinophyma.

CLINICAL MANIFESTATIONS

When the National Rosacea Society assembled a committee of experts to develop a standard classification system for the diagnosis and study of rosacea, the result was a delineation of primary features, secondary features, and subtypes of the disorder (see "Rosacea subtypes").2 The new criteria should help standardize terminology for clinicians and researchers.

The diagnosis requires 1 or more primary features in central distribution on the face. The primary features are

Flushing (transient erythema)
Nontransient erythema (persistent flushing)
Papules and pustules, usually in crops, which may be nodular but not comedonal
Telangiectasia, which is not always present.

Secondary features of rosacea that may appear include burning or stinging; plaques; dry appearance; edema, usually after prolonged erythema or flushing; ocular manifestations, including erythema, itching, or burning; occurrences in peripheral locations, with or without facial manifestations; and skin thickening and fibrosis, most often on the nose (rhinophyma).

DIFFERENTIAL DIAGNOSIS

Keep a fairly short differential diagnosis in mind for patients with red faces. Begin by ruling out acne vulgaris, which is the most similar in appearance.

Acne vulgaris may be confused with rosacea, especially in younger patients. Important differences include more comedones and cysts in vulgaris and more erythema and telangiectases in rosacea.

Seborrheic dermatitis, more common than rosacea along the medial eyebrows, nasolabial folds, and hairline, usually produces a yellow, greasy scale on an erythematous base and causes mild pruritus.

Systemic lupus erythematosus (SLE) is usually characterized by a malar or butterfly rash that is erythematous but has no papules or pustules. An antinuclear antibody (ANA) test and well-defined diagnostic criteria confirm the diagnosis of SLE.

Sarcoidosis may be accompanied by facial lesions that resemble those of granulomatous rosacea; biopsy is required for confirmation. In African-American patients, this diagnosis should be kept in mind, particularly if there are papules on the nose.

Folliculitis typically consists of scattered discrete pustules on a red base that are located in the hair follicles. Folliculitis is much less common in the central face.

Carcinoid syndrome, usually of sudden onset and manifested by severe facial flushing, can be diagnosed when a 24-hour urine test result shows an elevated hydroxyindoleacetic acid level.

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