Module 3B Rosacea and related disorders

ROSACEA
This is acne without comedones in an older group of patients who also exhibit facial flushing. Oral treatments are similar to acne but the topicals are different. Remember rosacea also may have significant ocular features.Rosacea skin is also more easily irritated by topical treatments than acne skin.

look at this YouTube video on the images in Module 3B on rosacea and Seborrhoeic dermatitis . After clicking to start reset the 360 number to 1080 and click on the box under the sceeen with the arrows pointing out to view it full screen and high definition.



Rosacea looks like acne but there are no comedones and it occurs in a much older age group. It is characterised by sebaceous hyperplasia and overgrowth of an organism called demodex in grease glands. This is a tiny mite that we all have in our grease glands in small numbers. There are also papules, pustules and telangiectasia. The cause of the telangiectasia is not known. There are rare instances of granulomatous rosacea. Flushing is an integral part of rosacea. Ocular rosacea occurs more commonly than you think and patients may just have the ocular involvement with little in the way of skin involvement and they will be referred to an ophthalmologist for therapy. On page 259 Habif lists the various ocular signs.

Dermnet on Rosacea

Rhinophyma is a condition affecting the nose with irreversible hypertrophy of sebaceous glands and chronic infection. These patients need long term tetracycline antibiotics or courses of Isotretinoin.They may also need surgery to reduce gross sebaceous thickenings.

Globalskin Atlas on Rosacea and Rhinophyma

New drugs for erythematous rosacea

The first is brimonidine and the other is oxymetazoline. Both of these are alpha-adrenergic receptor agonists that actually constrict blood vessels. These are topically applied medications that constrict the smooth muscle of the blood vessels to reduce the appearance of background erythema.I must admit I thought most of the erythema in Rosacea was due to surface telangiectasia without any smooth muscle in these vessels!

Once daily topical brimonidine tartrate gel 0.5% is a novel treatment of moderate to severe facial erythema of rosacea: results of two multicenter, randomized and vehicle–controlled studies showed this. This preparation is now available in Australia under the name of Mirvaso gel 30gms Used once a day.

The following recommendation is from a Rosacea site in the USA. It refers to Brimonidine eye drops used in glaucoma but available here in Australia.

Prescription I put a dollop of Finacea in one palm, add a drop of water, and then add ONE DROP of Brimonidine to it. Stir with a finger and use that to paint half my face. Repeat on the other half of my face. Results after about one week of use, so far, are simply spectacular. And I’m hard to impress, with severe, progressive, debilitating flushes. ".

Also "Mix two drops of Alphagan P eyedrops into a blob of Azclear ( Azelaic acid) lotion in the palm of the hand and rub it on.
It really works on my patients.
The Azclear will work on the papulopustular component so that is an added benefit"

Diffuse erythema and pustules on the forehead. Consider steroid withdrawl as a cause of this presentation.

More typical case of rosacea, note the periocular sparing of the erythema.

Another typical example showing early rhinophyma as well.

Granulomatous rosacea This is a rare variant of rosacea. I have only seen three cases. It presents more as a papular rash extending beyond the butterfly areas of the cheeks as in the first image below. The papules have a yellowish colour about them when you apply a glass slide to the face and obliterate the vascular redness. Histologically these are non caseating granulomas and resemble those seen in sarcoidosis and a tuberculid called lupus miliaris disseminatus facei. Now I can hear you saying what has all this got to do with rosacea? Not much I fear except it looks superficially like erythematous rosacea without the pustules and responds to long term tetracyclines, doxycycline or minocycline.It needs between 3 and 6 months of therapy.

Dermnet on Rosacea generally

Granulomatous rosacea

Histology of granulomatous rosacea

Rhinophyma This can be a doozy of a condition. We all get a bit of sebaceous thickening of our noses as we get older but sometimes the sebaceous hyperplasia goes wild, secondary infection with a mite called demodex occurs and you have a pustular red enlarged nose that oozes a mixture of pus and cheesy grease material every time you squeeze it. Oral tetracyckines over 3 months will help the pustular component but does nothing for the sebaceous hyperplasia. Localised nasal enlargement is not uncommon and this is the easiest type of rhinophyma to treat with blade surgery reshaping. A case with marked thickening such as the second image on the forehead requires oral retinoids such as Isotretinoin (Roaccutane) to try to shrink it down.

View this remarkable case

To Summarise

What will I see? - Facial redness, papules, pustules, sebaceous hyperplasia. No comedones.

What mnemonic ? - Pustules or red nonscaly for the infiltrates of granulomatous rosacea.

What DD? II for facial pustules - Staph, Acne, Herpes simplex

What will I do next?- Swabs for staph and herpes if pustules prominent. If infiltrative consider punch biopsy. If just facial erythema consider lupus and dermatomyositis and do ANA and ENA antibodies.

Then come to your diagnosis and treatment.

Marked sebaceous hyperplasia

In this case the sebaceous thickening is mainly confined to the forehead.

Note the enlarged sebaceous glands

PERIORAL DERMATITIS

This condition has been a modern day epidemic brought about by the use of strong fluorinated steroids on the face. Admittedly some cases occur where exposure has not been identified but they are very rare. There is usually a few millimetres of sparing around the vermillion border of the lips. Lesions can also occur peri nasally and peri orbitally. Habif comments that perioral dermatitis can occur in areas where drying agents are poorly tolerated. He lists agents such as Benzoyl Peroxide, tretinoin and alcohol based antibiotic lotions as those which aggravate the eruption. He also notes that the combination of foundation creams and moisturisers was associated with this condition but that straight moisturisers alone were not.

Irrespective of the etiology the condition responds to either tetracyclines orally for four weeks or some erythromycin orally. I also use a little bit of 1% Sulphur in Sorbolene cream twice daily.

Dermnet on Perioral Dermatitis

Below is a video on some treatments for acne and rosacea from the Weekend Meeting

Typical perioral papules with sparing around the vermillion border and a lot of pustules associated with stopping topical steroid cream.

Perinasal rosacea from steroid use on the face probably for seborrhoeic dermatitis. Some pustules visible.

Periocular rosacea from steroid use. Larger infected papules under the skin.

Seborrhoeic dermatitis

Seborrhoeic dermatitis is often seen in association with rosacea. The typical areas involved are on the sebaceous face particularly behind the ears, nasolabial creases, eyebrows and the external ear canals. These areas are usually red and scaly but seldom actually weep. Most people with seborrhoeic dermatitis of the face will also have scalp dandruff. This is the same condition caused by a yeast organism occupying the grease glands. Hence therapy is with a topical antifungal cream rather than a topical steroid! Recently Elidel (Pimecrolimus ) cream has been shown to effectively reduce the inflammation of seborrhoeic dermatitis but in my opinion it should be used in conjunction with a topical antifungal cream.

Seborrhoeic dermatitis is a common disease particularly in adults where it presents with a bran like scale behind the ears, in the scalp, on the forehead, eyebrows and perinasal skin. There is also sometimes involvement of the anterior chest wall. In children it goes under the name of cradle cap and it is common in neonates from the effects of maternal hormones.

Some 2% Sulphur in Sorbolene with 2% Salicylic Acid cream added will allow the scale to soften if applied at night and washed off in the morning. Blepharitis is another manifestation of the condition. It is best managed with 1% Hycor eye ointment and a bit of Johnson’s baby shampoo and a cotton bud to get rid of the scales attached to the eyelashes. Sudden onset of seborrhoeic dermatitis in adults can be a manifestation of underlying immunosuppression, particularly HIV disease. The condition in adults is best managed with some Nizoral shampoo and Nizoral cream or with Nizoral tablets orally 1 daily for 10 days and 1 weekly for 10 weeks to keep the small fungus that is involved in this condition under control.
Nizoral (Oral Ketoconazole) is no longer available in Australia. It was withdrawn because of a low risk of hepatitis developing if used in the elderly over several months, usually inappropriately, for fungal nail infections. Your other options mnow are Fluconazole 100mgs daily for 3 days or Itraconazole 400mgs weekly for 3 weeks.

A colleague gave the following response when asked about treating this condition.

"Therapeutically I emphasise to them that this is a chronic relapsing condition that can be controlled but not cured. I give them a list of anti dandruff shampoos, the supermarket antiseb shampoos if used second daily control most average cases, if severe then escalate to pharmacy lines, Nizoral, Sebizole or Stieprox, daily initially then second daily as they settle, get them to extend use to chest face and back if involved. If really inflamed Hydrozole twice daily for 3-4 weeks, also will use 3% sulphur, 3% Sal. Acid in emulsifying ointment at night on face. If papular inflammation suggestive of rosacea, may give them 6 weeks Doxy. Pityrosporon folliculitis or even occasionally bad seb derm on face when inflammation damped down I find propylene glycol at night works well but folliculitis will take longer. Tell them it will take 6 weeks to settle and don’t see them before then."

Another suggested Tacrolimus 0.1% ointment (Protopic overseas). Also Stieprox shampoo rather than Nizoral.

Dermnet on Seborrhoeic dermatitis

To Summarise

What will I see? - Usually a red scaly rash confined to nasal cheek folds and eyebrows with a scaly scalp.

What mnemonic ? - Red scaly PMs PETAL

What DD? PMs PETAL! but mainly, seb derm, psoriasis, facial contact dermatitis, steroid modified tinea.

What will I do next?- Check the scalp for seb derm, the external ear canals and behind the ears and the anterior chest wall over the sternum. Look elsewhere for psoriasis as a DD. Check the flexures. Do a skin scraping if considering tinea. See if any Pit versicolor on the trunk. (same organism)

Then your diagnosis and treatment.

Fairly subtle red scaly involvement of the nasal creases

Eyebrow scale and associated blepharitis

More extensive facial involement perhaps with a bit of rosacea as well. Treat for both.

Facial flushing The commomest cause is emotional but then you consider perimenopausal, alcohol, drugs and then rosacea. In the latter after a while the flushing settles and the erythema becomes fixed. Other rarer causes to consider are hormone secreting tumours such as phaeochromocytoma and the carcinoid syndrome. They both give marked severe facial flushing and with carcinoid often giving a multicoloured flushing of the chest wall as well. ( Do not confuse this with the emotional facial and chest wall flushing seen commonly in females or after a hot bath!)Testing for phaeochromocytoma involves doing a 24 hour urine collection to measure levels of adrenaline and noradrenaline breakdown products, while for carcinoid syndrome you ask for hydroxy indole acetic acid levels in the urine.

View this Dermnet article on the causes of facial flushing

Brimonidine gel , an alpha adrenergic receptor agonist that constricts smooth muscle in the walls of facial blood vessels, may be helpful for flushers when it becomes available in Australia. Now available and known as Mirvaso 30gm tubes non PBS.

Look at this presentation on facial erythema.

Image of the extent of flushing with the carcinoid syndrome taken from the reference indicated above.

Histology of Rosacea

Histology of Granulomatous Rosacea

Some other examples of rosacea.Treat them all the same with an oral tetracycline such as Minomycin or Doxycycline and some 2% sulfur in sorbolene cream. Rosex gel or cream (topical metronidazole) is effective in mild papulo pustular rosacea but does nothing for the telangiectatic type. It takes 3 weeks to start working. The gel irritates some people so use the cream if this occurs. The gel is thought to be more effective than the cream form. Trial it over 3 months.

General measures Rosacea is worsened by UV light, alcohol, hot spicy foods and strenuous exercise exaccerbating the redness. Use sunscreens daily. Avoid direct radiant heat.

This is an example of erythematous rosacea

This is a purely papular rosacea without pustules

This is a papular rosacea with a few pustules.

Some extemporaneous Preps
For Rosacea
Oral metronidazole for 2-4 weeks
the following topical,gently massaged into face twice daily.
sulph.ppt 0.5
glycerin 20
in aqueous cream.
Sometimes the only thing that works is laser or IPL, and sometimes I wish I’d used it earlier.
There is an article about an eye medication compounded in a gel prep and used to treat facial rosacea with good success
Brimonidine tartrate gel 0.5%. Its in the BJD for March 2012. (See also above)

2% sulph/2%ichthammol/ in UEA or sorbolene.
Compliance? Always a consideration when 'nothing works'

Use of Botulinum Toxin to treat Rosacea
This is from Skin And Allergy News
To treat rosacea patients with botulinum toxin type A, "you have to map out the treatment area," Dr. Gilbert said. She uses 0.5-2 units in intradermal blebs spaced 1 cm apart.

She has observed improvements at 7-14 days after a single treatment, with a maximum effect evident in 2-8 weeks, but with effects persisting for an average of 4-6 months and sometimes as long as 7 months.

Her additional treatment pearls include reconstituting each of the three FDA-approved neurotoxins with 1 cc of saline, and using small syringes. She generally injects 7-10 units per cheek. "Don’t forget to treat the nose," she said.

Botulinum toxin type A (onabotulinumtoxinA) is not approved by the FDA to treat rosacea, but a randomized, double-blind, placebo-controlled pilot study comparing incobotulinumtoxinA to placebo for the treatment of rosacea is underway, conducted by Dr. Dayan and sponsored by Merz Pharmaceuticals.

Recently 1% Ivermectin cream has been introduced in the USA for the treatment of rosacea. Presumably it works by reducing demodex in the skin. It goes under the name Soolantra. It appears to be about twice as effective as 0.75% Metronidazole cream in reducing inflammatory lesions in rosacea.
Soolantra® (Ivermectin) Cream 1%: A new and innovative treatment for Rosacea. Soolantra is now available in Australia but non PBS. It appears over 3 months to be as effective as oral tetracyclines in reducing papules and pustules in Rosacea.

Typical case of rosacea with papules and pustules

Papules Pustules and erythema of rosacea No comedones

Rhinophyma

Habif ends this chapter with a discussion of miliaria. This is sweat retention. The clinical picture depends on the level of which the sweat gland is blocked and the condition is described as miliaria crystallina where the occlusion of the eccrine glands is at the surface, miliaria rubra where occlusion is in the intraepidermal section of the eccrine duct and miliaria profunda where the dermal section of the eccrine gland or duct is blocked. Miliaria crystallina rubra is self limiting. Miliaria profunda can give rise to secondary infection and take time to settle.It is particularly seen in soldiers in the tropics.It can also occur in some elderly immobile patients who lie on their back on a rubber undersheet and sweat excessively.

Sweating- Hyperhidrosis Is a major problem to some people. They may have excessive sweating from the axillae or hands and feet which can be socially disabling. Treatment options are limited. Cervical sympathectomy done via a laparoscope can be very effective but you have to watch out for compensatory hyperhidrosis where after surgery they start to sweat excessively either all over or rarely from another localised site! Botox has recently been used but you need about 100 units for each axilla or palm of hand. The injections last 6 -9 months before needing repeated. Needless to say injecting the palms is painful and a wrist block should be done. Oral therapies include probanthine and Ditropan which should be started in low dosage and slowly increased or try a tricyclic such as Doxepin where one of the side effects is anticholinergic. Rarely a personal iontophoresis machine can help and also Drysol solution can be painted on at night for 10 nights to block up the eccrine gland openings. There is a new treatment using electromagnetic energy directed at sweat gands in the axilla which shows promise of a permanent non surgical cure for the condition.

See Sweat Free website

Miliaria crystallina, the occlusion of the sweat duct is high in the epidermis giving these very fragile vesicles filled with sweat.

Infundibular sweat gland blockage but very extensive and confluent.

Deeper blockage and rupture of sweat glands sometimes called miliaria profunda

Now go to Image Diagnosis and Filter for Module 3 Images and look at these cases.. Your responses to these are not recorded but try to answer them before looking at the answers! You learn more that way!

 

Also look at this short 15 mins video on Acne and Rosacea for US Residents sitting their Board Examinations

When you have completed your reading for this module 3 by the Thursday of week 1 go to MCQs Module 3 in the www.aidexams.com website  and answer the questions Your results in this test will be recorded but do not count towards your final assessment. They are to help me prepare for the first week's teleconference.
Before the teleconference on Thursday of week 2 of this module, you should also take this Written online assessment on Module 3 also in the Exams section of www.aidexams.com  These answers have to be in by 7PM on the preceding Wed night for marking. Late submissions will not be marked.

NB Answer all 5 questions before pressing Submit at the bottom of the test.

View the Module 3 Webinar below.