Also known as acne rosacea.

Redness and flushing around the face, nose and cheeks.

Affects more than 14 million individual in the U.S.

Malar blush mildest manifestation.

The most common manifestations are flushing, dilated prominent telangiectases, persistent facial erythema, inflammatory papules, and pustules, edema, on the periorificial face.

Prominence of sebaceous glands on the nose may result in fibrosis and rhinophyma.

May have associated burning or stinging sensations, as well as ocular symptoms of foreign body sensation and dryness.

Typically appears between 30 and 60 years of age.

A clinical diagnosis.

No diagnostic test exists, rather than the disease consists of combinations of primary and secondary signs and symptoms, requiring a clinical diagnosis.

Manifestations of the disease is often transient and may not be present at the time a patient is seen, it is therefore important to have a good history about possible signs and symptoms.

A common chronic cutaneous disorder of the central face that is estimated to affect more than 16 million Americans.

Primary diagnostic features include:flushing, persistent redness of the facial skin, dome shaped papules with or without pustules, nodules may occur, and telangiectasia.

Rosacea usually targets the malar areas on the face, sparing the nasolabial folds, and does not have scales.

Secondary features include: burning or stinging with or without scaling or dermatitis, elevated plaques with out epidermal changes in surrounding skin, dry appearance that may be rough and scaling, soft or hard edema, ocular manifestations including burning, itching, hyperemia, inflammation, styes, chalazia,corneal damage, and peripheral location.

Pathophysiology unknwn but hypotheses include: innate immune system abnormality, UV radiation, vascular changes, epidermal barrier dysfunction, genetic contribution or microbes.

Subtypes include 1:erythematotelangiectatic rosacea, 2: papulopustular rosacea, 3: phymatous rosacea, and 4: ocular rosacea.

Telangiectasia may follow malar blush.

Inflammatory papules and skin nodules may occur as well as sebaceous overgrowth.

Rhinophyma sebaceous gland overgrowth on the nose cause significant disfigurement.

Predisposed by vascular hyperreactivity.

Common in patients who blush and in fair skinned individuals, but can be seen in all races.

Caused in large part by sun exposure.

Patients have a genetic predisposition to develop veins and flushing from sun exposure.

Frequently associated with significant psychological distress due to the unpredictability nature of signs and symptoms.

A survey of the National Rosacea Society-90% of respondents had lower self-esteem and self confidence, 88% reported embarrassment, and others had feelings of frustration 76%, anxiety and helplessness 54%, depression 43%, anger 34% and isolation 32%.

High percentage of patients with moderate to severe redness have inhibition of their social lives, including more than 60% avoiding face to face contact, and 39% refusing or cancelling social engagements.

Up to 28% of patients with severe symptoms miss work.

UVA may be a significant contributor to the process.

Patients are more likely to have associated dyslipidemia, hypertension, coronary artery disease, and peripheral arterial occlusive disease.

In a study of women in the US with a diagnosis of rosacea were found to be 1.59 times more likely to have a thyroid cancer and 1.5 times more likely to have basal cell carcinoma than those individuals without rosacea.

Other studies suggest a significant association with allergies, respiratory diseases, GERD, metabolic and urogenital diseases and female hormonal imbalance.

Avoidance of triggers is part of management of the disease.

Mild disease is initially treated with topical metronidazole or oral tetracyclines.

Treatment involves topical or oral medications and laser therapy.

Laser therapy highly effective in treating the venous dilation.

Tetracycline antibiotics are beneficial to decreases inflammatory changes and may impact blood vessels themselves.

Metronidazole topically is useful in the management of the process.

Should undergo sun protection and use moisturizer to help with skin barrier cream.

Moisturizes prevent transdermal water loss and restore the skin barrier to reduce exacerbations.

Sunscreen and other physical blockers such as zinc oxide or take titanium dioxide decrease inflammatory molecules and block production of reactive oxygen species.

Additional agents include brimonidine tartrate 0.5% topical Alpha adrenergic receptor agonist that reduces persistent facial erythema via vasoconstriction for 6-7 hours after application.

Invermectin cream, 1% is an inflammatory papular and pustular rosacea treatment superior to metronidazole.

Other agents affective include: sodium sulfacetamide, azelaic acid, retinoids, topical ivernectin and topical brimonidine.

Studies suggest more than 45% of patients with rosacea have small intestinal bacterial overgrowth (SIBO) compared with 5% of healthy matched controls.

Treating small intestinal bacterial overgrowth (SIBO) in patients with rosacea with the antibiotic rifaximin at 400 mg TID for 10 days cleared rosacea in 78% of the patients in whom SIBO was eradicated.

SIBO might modulate cytokines by increasing tumor necrosis factor–alpha, suppressing interleukin-17, or increasing the T helper cell type 1 pathway gene to drive skin inflammation.

To diagnose small bowel overgrowth a positive lactulose/glucose breath test has been used as a surrogate for standard for diagnosis: jejunal aspirate.

Differential diagnosis includes: acne and SLE.

Acne is seen most commonly in teens while rosacea is likely between the ages of 30 and 60 years.

Also in acne black heads are generally present and papules and pustules on extravacial locations such as the trunk and arms are common.

SLE and rosacea share some clinical manifestations which include facial redness, sensitivity to sunlight, tendency to affect women more than men.

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