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ROSACEA. By Dan Ladd, D.O. Texas/KCOM Dermatology Residency Program Program Director Bill V. Way, D.O. CC: ITCHY RASH ON FACE. “STINGS” “BURNS” ONSET 2 DAYS TOPICAL CREAMS NOT HELPFUL PMX: NONE NO NEW MEDS NO NEW SOAPS OR PERFUMES. WHAT IS ROSACEA?. VARIABLE DEGRESS OF…..

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Rosacea l.jpg

ROSACEA

By Dan Ladd, D.O.

Texas/KCOM Dermatology Residency Program

Program Director

Bill V. Way, D.O.


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CC: ITCHY RASH ON FACE

  • “STINGS”

  • “BURNS”

  • ONSET 2 DAYS

  • TOPICAL CREAMS NOT HELPFUL

  • PMX: NONE

  • NO NEW MEDS

  • NO NEW SOAPS OR PERFUMES


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WHAT IS ROSACEA?

  • VARIABLE DEGRESS OF…..

  • CENTROFACIAL ERYTHEMA

  • TELANGIECTASIAS

  • PAPULES

  • PUSTULES

  • NODULES

  • EDEMATOUS PLAQUES


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EARLY ROSACEA (STAGE I)

  • “FLUSHER-BLUSHERS”

  • OFTEN < AGE 20

  • NOSE/CHEEKS

  • RECURRENT EPISODES OF BLUSHING.

  • ERYTHEMA PERSISTS

  • FEW TELANGIECTASIAS



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STAGE I

  • TELANGIECTASIAS BECOME PROGRESSIVELY PROMINENT, FORMING SPRAYS ON THE NOSE, NASOLABIAL FOLDS, CHEEKS AND GLABELLA


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STAGE II

PAPULES & PUSTULES BEGIN, INCREASED ERYTHEMA AND TELANGIECTASIAS


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STAGE III

DENSE ERYTHEMA

PAPULES, PUSTULES, NODULES.

TELANGIECTASIAS SEVERE, DIFFUSE

VARIABLE PLAQUE-LIKE EDEMA


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ADULTS

PAPULES

PUSTULES

NO COMEDONES

ERYTHEMA

TELANGIECTASIAS

TEENS

PAPULES

PUSTULES

COMEDONES

NO ERYTHEMA

NO TELANGIECTASIAS

ROSACEA VS. ACNE


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WHAT CAUSES ROSACEA?

  • “VIRTUALLY NOTHING IS KNOWN ABOUT CAUSATION……….THE INFLUENCE OF HEREDITY IS MOOT, AS IS ALMOST EVERYTHING THAT HAS BEEN WRITTEN ABOUT ETIOLOGY” --A. Kligman

  • Vasomotor lability? Hypertension?

  • Demodex mite infestation?

  • Solar damage? Heat? Caffiene?

  • Lymphatic obstruction? Emotional stress?





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TRIGGERS

  • HOT LIQUID BEVERAGES, SOUPS

  • ALCOHOL / CAFFEINE

  • SPICY FOODS

  • SUN EXPOSURE

  • IRRITATING COSMETICS/OTC

  • HEAT – EXERCISE IN COOL AREAS.


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COMPLICATIONS

  • COMPLICATIONS:

  • RHINOPHYMA – DISFIGURING, NOSE

  • OPHTHALMIC ROSACEA

  • LESS COMMON VARIANTS: GRANULOMATOUS, STEROID, GRAM-NEGATIVE, CONGLOBATA, FULMINANS



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RHINOPHYMAMODERATE



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RHINOPHYMA

  • OCCURS EXCLUSIVELY IN MEN.

  • PROGRESSIVE INCREASE IN CONNECTIVE TISSUE, SEBACEOUS GLAND HYPERPLASIA, ECTATIC VEINS AND CHRONIC DEEP INFLAMMATION.

  • MAY OCCUE WITH STAGE III ROSACEA, BUT SURPRISINGLY, PATIENTS WITH RHINOPHYMA MAY ONLY HAVE MILD ROSACEA.






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OCULAR ROSACEA

  • BLEPHARITIS

  • CONJUNCTIVITIS

  • PAIN, PHOTOPHOBIA

  • IRITIS, IRIDOCYLITIS, KERATITIS

  • MAY NEED OPHTHALMOLOGY CONS

  • KERATITIS MAY LEAD TO BLINDNESS


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TREATMENT - MILD

  • SUNSCREENS

  • TOPICAL SULFACETAMIDE/SULFUR

  • TOPICAL METRONIDAZOLE

  • ORAL TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE


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Topicals- Sulfacetamide/Sulfur

  • Klaron 10% Lotion

  • Rosula Lotion (with Urea)

  • Sulfacet R

  • Rosanil Cleanser

  • Ovace Cleanser

  • Plexion Cleanser, Suspension and SCT


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Topical Metronidazoles

  • Noritate 1% cream, Once a Day

  • Metrocream 0.75% BID

  • Metrolotion 0.75% BID

  • Metrogel 0.75% BID


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Tetracyclines

  • Tetracycline 250-500mg QD or BID

  • Very cheap, but must take 1 hour before or 2 hours after meals, less compliance

  • Doxycycline 50-75-100mg QD or BID

  • Generic, Doryx Pellets, Adoxa.

  • Minocycline 50-75-100mg QD or BID

  • Generic, Vectrin, Dynacin, Minocin


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Tetracyclines

  • Not for children due to teeth discoloration, may cause hyperpigmetation at sites of trauma in adults, stop medication if worsening headache occurs (pseudotumor cerebri)

  • Photosensitivity reactions rare if patients on sunscreens


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TREATMENT – SEVERE

  • ORAL METRONIDAZOLE

  • CLONIDINE 0.1mg QD or BID FOR FLUSHING HELPS

  • PREDNISONE TAPER

  • ISOTRETINOIN (ACCUTANE)


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A SIMPLE REGIMEN FOR THE VAST MAJORITY OF ROSACEA PATIENTS

  • WASH FACE GENTLY WITH CETAPHIL DAILY FACIAL CLEANSER

  • APPLY KLARON LOTION QAM

  • APPLY SUNSCREEN

  • WASH FACE AGAIN AT NIGHT

  • APPLY NORITATE CREAM QHS


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A GOOD START….

  • KLARON LOTION, 4oz., apply qAM to face

  • NORITATE CREAM, 30g, apply qHS to face


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EXPECTATIONS

  • TELL THEM TO EXPECT IMPROVEMENT IN 4-6 WEEKS

  • TELL THEM TO CONTINUE REGIMEN UNTIL NEXT VISIT

  • MAY GIVE ORAL TETRACYCLINES FOR FLARES

  • INFORM THEM THERE IS NO CURE FOR ROSACEA!!!!!!!!!!!!!!!!!!!!