Acne Rosacea Presentation and its treatment

Rosacea and its types along with treatment protocols

1. ROSACEA dermatology department INTERN AAYUSH YADAV

2. CONTENTS Introduction Epidemiology Associated diseases Pathogenesis Types and subtypes Diagnostic criteria Differential diagnosis Management

3. INTRODUCTION C hronic   inflammatory  skin condition predominantly affecting the central face and most often starts between the age of 30–60 years. C haracterized by  persistent  facial redness. H as a relapsing and remitting course, with symptoms controlled by lifestyle measures, general skin care, medications, and procedural interventions.

4. EPIDEMOLOGY Middle‐aged adults 30–50 years old 75% of cases - skin types 1 or 2 Up to 25% of patients with rosacea have a family history of the condition 2% to 18% of individuals in general population, highest level reported in Celtics Women more often than Men (3:1) Average age of onset women - 35 to 45 years men - 45 to 55 years On the basis of severity male>female with greater chance of developing rhinopyoma

5. ASSOCIATED DISEASE Associated facial seborrheic dermatitis. Helicobacter pylori infection of the stomach in more than 50% of rosacea patient( mostly erythematotalengiectatic variant). Migraine, depression and carcinoid syndrome have been suggested as occurring in association with rosacea.

6. PATHOGENESIS OF ROSACEA Ultraviolet light Innate immune response Demodex mite Cutaneous microenvironment Matrix metalloproteinases

7. TYPES AND SUBTYPES Erythematotalengiectatic (ETTR) Papulopustular(PPR) Phymatous Occular

8. Erythematotelangiectatic (ETTR) Grade I : Occasional mild flushing Faint persistent centrofacial erythema Few telangiectasias Grade II: Frequent troublesome flushing Moderate persistent centrofacial erythema Several distinct telangiectasias

9. Grade III: Frequent severe flushing Pronounced persistent centrofacial erythema Many prominent telangiectasias Possible edema

10. Erythematotelangiectatic rosacea

11. Papulopustular (PPR) GRADE I: Few papules and/or papulopustules (<5); Mild persistent centrofacial erythema GRADE II: Several papules and/or papulopustules (>5<10) Moderate persistent centrofacial erythema GRADE III: Extensive papules and/or papulopustules (>10) Pronounced persistent centrofacial erythema Inflammatory plaques or edema may be present

12. PAPULOPUSTULAR VARIANT

13. Phymatous GRADE I: Puffiness Mildly patulous follicles No clinically apparent hypertrophy of connective tissue or sebaceous glands No change in contour GRADE II: Moderate swelling Moderately dilated patulous follicles Clinically, mild hypertrophy of the sebaceous glands or connective tissue Change in nasal contour without nodular component

14. GRADE III: Marked swelling Large dilated follicles Distortion of contour due to hypertrophy of the sebaceous glands and/or connective tissue, with a nodular component

15. Rhinophyma

16. Ocular GRADE I: Mild itch Dryness or grittiness Fine scaling of eyelid margins Telangiectasia of eyelid margins Mild conjunctival injection GRADE II: Burning or stinging Crusting, irregularity, erythema and/or edema of eyelid margins Definite conjunctival injection; chalazion or hordeolum

17. GRADE III: Pain, photosensitivity, blurred vision Severe eyelid changes with loss of lashes Severe conjunctival inflammation Corneal changes, with potential loss of vision Episcleritis, scleritis; iritis

18. Marked injection of the conjunctivae, leading to the appearance of red eyes. Ectropion is also present Tiny concretions of keratin (conical dandruff) visible at the bases of eyelashes

19. DIAGNOSTIC CRITERIA recommended by 2017 global ROSacea COnsensus (ROSCO) panel

20. DIFFERENTIAL DIAGNOSIS

21. MANAGEMENT Although there is no cure for rosacea, symptoms can be managed with the following lifestyle measures, medical, and procedural interventions.

22. General Measures Wash with lukewarm water and use soap-free cleansers that are pH balanced Use sunscreens with both UVA and UVB protection and an SPF ≥30 Use cosmetics and sunscreens that contain protective silicones Avoid astringents, toners, and abrasive exfoliators Avoid cosmetics that contain alcohol, menthols, camphor, witch hazel, fragrance, peppermint. Avoid stressors like Alcohol, spicy food, extreme weathers.

23. Erythematotelangiectatic rosacea First line Sun avoidance and protection Non‐scented, colour ‐free moisturizer Soap‐free cleansers Cosmetic cover Avoid factors that provoke flushing Topical α‐ receptor agonists such as brimonidine or oxymetazoline

24. Erythematotelangiectatic rosacea Second line Laser therapy for facial erythema and telangiectasia Low‐dose β‐ blocking medications (propranolol, nadolol, carvedilol) Psychological counselling and group therapy sessions Third line Botulinum toxin Highly selective sympathectomy in disabling case

25. Papulopustular rosacea First line Sun avoidance, sun protection, moisturizing and cosmetic cover as for ETTR Topical metronidazole, azelaic acid, ivermectin or sodium sulfacetamide and Sulphur for active inflammatory lesions Topical α‐ receptor agonists such as brimonidine and oxymetazoline for perilesional erythema

26. Papulopustular rosacea Second line Systemic antibiotic therapy with tetracyclines, erythromycin or trimethoprim Third line Systemic metronidazole Isotretinoin low‐dose therapy Topical acaricide (ivermectin, crotamiton, permethrin) if Demodex proliferation is relevant

27. Efficacy of topical drugs used in Papulopustular variant

28. Phymatous rosacea First line As for PPR for accompanying inflammatory lesions Topical skin‐peeling agent if there are large occluded follicles Electrocautery or laser for telangiectases Second line Low‐dose isotretinoin therapy Third line Ablation of phymatous tissue with carbon dioxide laser Surgical remodelling of nose

29. Ocular rosacea First line Daily lid hygiene Oily tear‐substitute lubricating eye drops or aqueous gels Second line Careful lid massage Topical metronidazole, sodium sulfacetamide or ciclosporin Fusidic acid or erythromycin ophthalmic ointment if secondary bacterial infection is suspected

30. Ocular rosacea Third line Systemic tetracyclines or erythromycin Referral to ophthalmologist for specialist care

31. What is Steroid Rosacea Steroid rosacea is the name given to a rosacea-like condition on the mid-face caused by potent  topical steroids  or their withdrawal. Steroid rosacea may become especially severe when the topical steroid  cream  is discontinued. This is called a rebound flare. To minimise severe flare-up, slow withdrawal is recommended. Topical pimecrolimus cream may be helpful in short-term.

32. Steroid Induced Rosacea

33. REFERENCES Rook’s textbook of dermatology, Vol 1, 9 th edition Fitzpatrick’s dermatology in general medicine, Vol 1, 7 th edition IADVL textbook of dermatology, Vol 1, 4 th edition Bolognia dermatology, Vol 1, 3 rd edition