A Clinical Survey of Rosacea Subtypes
By Dr. Guy Webster
Does one picture WC Fields-like rhinophyma, brilliantly red cheeks, or malar papules as the "basic rosacea"? Rosacea is a disease of diverse clinical presentations; in fact it is reasonable to state that there is no one classical type of rosacea and that all rosacea is part of one subtype or another. All rosacea patients share the feature of enhanced vascular reactivity to thermal and other stimuli. Some develop fixed erythema, others inflammatory lesions, rhinophyma or ocular involvement…or a mixture of some or all of them. The perception of what constitutes rosacea varies. In North America, red cheeks often are enough for the diagnosis. In northern Europe, this is not sufficiently different from the population's baseline and inflammation of some sort is required.
Vascular Rosacea—Patients with a fixed malar erythema and usually visible telangiectasia. Patients with facial keratosis pilaris are often incorrectly diagnosed as having rosacea, but can be easily separated by the distribution of erythema which is prominent on preauricular skin and relatively spares the center of the face. The effects of chronic sun damage can also be hard to separate from those of rosacea. Vascular rosacea is fairly unresponsive to currently topical or oral therapy (other than steroids which of course should be avoided in this setting). Physical methods such as intense pulsed light or pulsed dye laser usually give good results.
Inflammatory Rosacea—Papules and pustules in the malar regions. In the most severe patients the forehead may be involved and nodules may form. Patients with mild to moderate disease may be treated topically with metronidazole or azaleic acid. More severe disease requires oral therapy, typically with a tetracycline; in rare cases with isotretinoin (off-label).
Rhinophyma—Sebaceous overgrowth on the nose that becomes fibrotic as time passes. It is more common in men, but may be seen in women. Though classically linked to drunkenness, there really is no evidence that this is the case and I have seen many patients who "never touched a drop" yet looked like WC Fields. Isotretinoin (off label) may be of benefit early in the process, but once fibrosis begins there it has little utility. Physical methods such as hot loop cautery or laser destruction remain the mainstay of therapy.
Pyoderma Faciale—An explosive pustular rosacea that occurs more in women, but is of unknown etiology. With the appearance of a raging infection, it often falls into the hands of infectious disease specialists who uniformly fail to make the correct diagnosis and embark on a prolonged course of IV antibiotics. The proper therapy is prednisone plus doxycycline or minocycline and response is gratifyingly quick. The course is typically prolonged taking weeks or months to completely withdraw the prednisone.
Ocular Rosacea—Up to 50% of rosacea patients may have some eye involvement. In my practice it runs about 30%, and is manifest as meibomian inspissation, styes, blepharitis and tear film problems. The best treatment is oral doxycycline.
"Mixed Rosacea" is a neologism of my creation that includes rosacea patients with co-existent seborrheic dermatitis or atopic dermatitis. Often these patients have rosacea that is difficult to control by typical means. Trial and error usually reveals that the coexistent dermatitis is the more important disease to treat in that it seems to provoke the rosacea. I typically use pimecrolemus or tacrolimus topically.
Steroid Rosacea—Long term corticosteroid use in rosacea invariably causes problems or resistant disease and atrophy. Patients may be unaware of steroids that have been surreptitiously spiked into homeopathic products or may be intentionally applying them. Gentle withdrawal is difficult and tapering steroid potency typically accomplishes little. The best course is immediately stopping the steroid "cold turkey" and therapy with oral doxycycline or minocycline, and topical tacrolimus or pimecrolemus.
Rosacea in Skin of Color—Clearly not the expected fair-skinned blushers, patients with pigmented skin frequently have rosacea that goes untreated because of clinical stereotypes. The true incidence is unknown (a worthy topic for study) but is commonly seen in my patients of Asian and African descent.
References
- Powell FC. Clinical Practice. Rosacea. N Engl J Med 2005; 352:793-803.
- Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, et al. Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol. 2004;50:907-912.
- Bolognia J, Jorizzo J, Rapini R eds, Mosby. Rosacea and Related Disorders. Dermatology. 2003; 545-552.
