Diagnosis and Treatment of Rosacea: State of the Art

June 2012 | Volume 11 | Issue 6 | Original Article | 725 | Copyright © June 2012


Hilary E. Baldwin MD FAAD

SUNY Downstate Medical Center, New York, NY

Abstract

Rosacea is a common disorder that is both under recognized and undertreated. Prevalence figures indicate that it may be present in 1 of every 10 adults in a primary care waiting room. Untreated, patients with rosacea can suffer significant emotional, workplace, and social impairments. While rosacea has been recognized since ancient times, only recently have investigators begun to identify the pathophysiologic elements responsible for the characteristic erythema, flushing, dysesthesias, and papulopustular manifestations of the disease. Although the etiology of rosacea is unclear, inflammation appears to be a central element. Experimental evidence suggests that abnormalities of the skin's innate and adaptive immune responses may play pivotal roles. Once recognized, effective topical and systemic therapies can be prescribed to lessen the impact of the disease on the patient's life. Although initially administered in an empiric fashion, it now seems clear that the role of antibiotics in patients with rosacea depends upon their anti-inflammatory rather than their antimicrobial properties. Consequently, practitioners have the opportunity to practice good antibiotic stewardship when treating the disease, particularly with systemic therapies. Therapy with subantimicrobial dosing and with topical treatments can modulate the inflammation of rosacea without exerting antibiotic pressure responsible for the emergence of antibiotic resistance.

J Drugs Dermatol.2012;11(6):725-730.

INTRODUCTION

Rosacea is a common inflammatory dermatosis.1 The National Rosacea Society (NRS) estimates that it affects approximately 16 million adults in the United States.2 The disease is 2 to 3 times more prevalent in women, but men are at higher risk of disfiguring skin changes.3,4 Most patients present between 30 and 50 years of age.5 Rosacea can impair quality of life (QOL), and it impairs body image and selfesteem. 6 Women shown pictures of subjects with and without the disease perceived those with rosacea as insecure, tired, unhealthy, and less likely to be in a relationship.7 Those with clear skin were most often described as confident, happy, and fun.
Rosacea is underdiagnosed and undertreated. According to NRS estimates, approximately 10% of adults in primary care waiting rooms have rosacea. However, approximately half of women in one survey reported waiting more than 7 months before receiving the correct diagnosis.7 Potential explanations for this delay include reluctance of patients to mention concerns about their skin, failure to remove makeup before examination, and failure of clinicians to recognize the disease. Other potential explanations include difficulties in recognizing the changes in ethnic skin and the fact that ocular manifestations may be ascribed to other conditions. Undertreatment may be due to failure to understand the improvements in QOL and interpersonal relationships that can occur after therapy, or a lack of knowledge regarding treatment options. This article provides an overview of the state of the art of the diagnosis and treatment of rosacea.

Pathophysiology

The etiology of rosacea is unclear. Demodex folliculorum mites have been proposed as a pathogenic factor in rosacea, but they are commonly commensal and may persist after the disease has been controlled.8 Helicobacter pylori has also been suggested as being etiologic in rosacea.8 However, H. pylori is prevalent in individuals with and without rosacea, and there are no robust data to support an etiologic relationship.6 Other proposed causes of rosacea include abnormal vascular reactivity, climatic exposures, dermal matrix degradation, diet, gastrointestinal disease, and pilosebaceous unit abnormalities.
Rosacea is an inflammatory disorder.9 While the perivascular lymphocytic infiltrate is sparse in the skin of a patient with erythematotelangiectatic rosacea (ETR), it increases and includes histiocytes and neutrophils in patients with papulopustular rosacea (PPR). In PPR, the perivascular infiltrate extends to surround sebaceous glands and ducts, and intrafollicular neutrophils may be present. Signs of actinic injury are also common. In phymatous disease, there is diffuse expansion of dermal connective tissue, elastosis, and sebaceous hyperplasia. Granulomatous inflammation can also be present.
The increased prevalence of rosacea in populations of northern European origin and the fact that as many as one-third of patients have a family history of the disorder suggests that it may be due to an abnormal response of the immune system in
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