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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

ROSACEA

By Dan Ladd, D.O.

Texas/KCOM Dermatology Residency Program

Program Director

Bill V. Way, D.O.

cc itchy rash on face
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
WHAT IS ROSACEA?
  • VARIABLE DEGRESS OF…..
  • CENTROFACIAL ERYTHEMA
  • TELANGIECTASIAS
  • PAPULES
  • PUSTULES
  • NODULES
  • EDEMATOUS PLAQUES
early rosacea stage i
EARLY ROSACEA (STAGE I)
  • “FLUSHER-BLUSHERS”
  • OFTEN < AGE 20
  • NOSE/CHEEKS
  • RECURRENT EPISODES OF BLUSHING.
  • ERYTHEMA PERSISTS
  • FEW TELANGIECTASIAS
stage i
STAGE I
  • TELANGIECTASIAS BECOME PROGRESSIVELY PROMINENT, FORMING SPRAYS ON THE NOSE, NASOLABIAL FOLDS, CHEEKS AND GLABELLA
stage ii
STAGE II

PAPULES & PUSTULES BEGIN, INCREASED ERYTHEMA AND TELANGIECTASIAS

slide8
STAGE III

DENSE ERYTHEMA

PAPULES, PUSTULES, NODULES.

TELANGIECTASIAS SEVERE, DIFFUSE

VARIABLE PLAQUE-LIKE EDEMA

rosacea vs acne
ADULTS

PAPULES

PUSTULES

NO COMEDONES

ERYTHEMA

TELANGIECTASIAS

TEENS

PAPULES

PUSTULES

COMEDONES

NO ERYTHEMA

NO TELANGIECTASIAS

ROSACEA VS. ACNE
what causes rosacea
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?
triggers
TRIGGERS
  • HOT LIQUID BEVERAGES, SOUPS
  • ALCOHOL / CAFFEINE
  • SPICY FOODS
  • SUN EXPOSURE
  • IRRITATING COSMETICS/OTC
  • HEAT – EXERCISE IN COOL AREAS.
complications
COMPLICATIONS
  • COMPLICATIONS:
  • RHINOPHYMA – DISFIGURING, NOSE
  • OPHTHALMIC ROSACEA
  • LESS COMMON VARIANTS: GRANULOMATOUS, STEROID, GRAM-NEGATIVE, CONGLOBATA, FULMINANS
rhinophyma
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.
ocular rosacea27
OCULAR ROSACEA
  • BLEPHARITIS
  • CONJUNCTIVITIS
  • PAIN, PHOTOPHOBIA
  • IRITIS, IRIDOCYLITIS, KERATITIS
  • MAY NEED OPHTHALMOLOGY CONS
  • KERATITIS MAY LEAD TO BLINDNESS
treatment mild
TREATMENT - MILD
  • SUNSCREENS
  • TOPICAL SULFACETAMIDE/SULFUR
  • TOPICAL METRONIDAZOLE
  • ORAL TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE
topicals sulfacetamide sulfur
Topicals- Sulfacetamide/Sulfur
  • Klaron 10% Lotion
  • Rosula Lotion (with Urea)
  • Sulfacet R
  • Rosanil Cleanser
  • Ovace Cleanser
  • Plexion Cleanser, Suspension and SCT
topical metronidazoles
Topical Metronidazoles
  • Noritate 1% cream, Once a Day
  • Metrocream 0.75% BID
  • Metrolotion 0.75% BID
  • Metrogel 0.75% BID
tetracyclines
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
tetracyclines32
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
treatment severe
TREATMENT – SEVERE
  • ORAL METRONIDAZOLE
  • CLONIDINE 0.1mg QD or BID FOR FLUSHING HELPS
  • PREDNISONE TAPER
  • ISOTRETINOIN (ACCUTANE)
a simple regimen for the vast majority of rosacea patients
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
a good start
A GOOD START….
  • KLARON LOTION, 4oz., apply qAM to face
  • NORITATE CREAM, 30g, apply qHS to face
expectations
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!!!!!!!!!!!!!!!!!!!!