ROSACEA & ROSACEA & PERIORAL PERIORAL DERMATITIS DERMATITIS

ESTHER NIMISHA

-Rosacea can be defined as a vascular disorder predominantly affecting the flush area of the face, manifesting with persistent erythema and telangiectasia, punctuated with episodes of inflammation.

DEFINITION:

EPIDEMIOLOGYEPIDEMIOLOGY::

Rosacea affects all races,but is most common in fair skinned individuals.

It occurs in both men and women and onset typically begins after the age 30.

-exact etiology not known-exact etiology not known

-clearly related to-clearly related to vasular hyperactivity; vasular hyperactivity;

1)sunexposure1)sunexposure

2)hot liquid beverages,soups2)hot liquid beverages,soups

3)vasodilator drugs3)vasodilator drugs

4)irritating cosmetics4)irritating cosmetics

5)exercise5)exercise

6)H.pylori6)H.pylori

7)cathelicidin antimicrobial peptide7)cathelicidin antimicrobial peptide

8)demodex folliculorum8)demodex folliculorum

9)infection &resident bacterial flora9)infection &resident bacterial flora

ETIOPATHOGENESIS:

Triggers factors

Associated factors

1)PRE ROSACEA1)PRE ROSACEA

2)VASCULAR STAGE2)VASCULAR STAGE

3) INFLAMMATORY STAGE3) INFLAMMATORY STAGE

4) LATE ROSACEA4) LATE ROSACEA

STAGES OF ROSACEA:

-forehead,nose,chin and -forehead,nose,chin and cheeks are commonly cheeks are commonly involved.involved.

-persistent erythema and -persistent erythema and teleangiectasis remains teleangiectasis remains between the episodes of between the episodes of inflammation.inflammation.

CLINICAL FEATURES:

1)1)PRIMARY SIGNS:PRIMARY SIGNS:

-flushing,non transient erythema, -flushing,non transient erythema,

papules,pustules and telangiectasespapules,pustules and telangiectases

2)SECONDARY SIGNS:2)SECONDARY SIGNS:

-burning,stinging,plaques,dry -burning,stinging,plaques,dry

appearance,edema,ocular appearance,edema,ocular

manifestation,peripheral location and manifestation,peripheral location and

phytomatous changes.phytomatous changes.

CLASSIFICATION:

1) primary: absent1) primary: absent mild mild moderate moderate severe severe

2)secondary: present2)secondary: present absent absent

ROSACEA CAN BE GRADED AS:

GLOBAL ASSESSMENT OF GLOBAL ASSESSMENT OF SUBTYPES:SUBTYPES:

1) ERYTHEMATO-TELANGIECTATIC ROSACEA

2) PAPULOPUSTULAR ROSACEA

3) PHYMATOUS ROSACEA

4) OCULAR ROSACEA

ERYTHEMATO-TELANGIECTATIC ROSACEA

PAPULO-PUSTULAR ROSACEAPAPULOPUSTULAR ROSACEA

PHYMATOUS ROSACEA

OCULAR ROSACEA

Other Rosacea types:Other Rosacea types:

- granulomatous rosacea-steroid rosacea-halogen aggravated rosacea-rosacea conglobata-various phymas( rhinophyma, gnathophyma,otophyma,blepharophyma)

1) RHINOPHYMA1) RHINOPHYMA

2) OCULAR ROSACEA2) OCULAR ROSACEA

3)ROSACEA LYMPHEDEMA3)ROSACEA LYMPHEDEMA

COMPLICATIONS:

1) ETR: 1) ETR: sparse perivascular sparse perivascular

lymphohistiocytic infitrate is accompanied lymphohistiocytic infitrate is accompanied

by dermal edema & ectatic venules & by dermal edema & ectatic venules &

lymphatics.lymphatics.

2) PPR: inflammatory infitrate surrounds hair 2) PPR: inflammatory infitrate surrounds hair

follicle & sebacceous gland.follicle & sebacceous gland.

3) phytomatous: prominent elastosis,fibrosis 3) phytomatous: prominent elastosis,fibrosis

dermal inflammation,sebaceous hyperplasiadermal inflammation,sebaceous hyperplasia

HISTOPATHOLOGY:

1)CUTANEOUS CONDITION: 1)CUTANEOUS CONDITION:

-steroid induced acneiform -steroid induced acneiform

eruptioneruption

-acne vulgaris-acne vulgaris

-perioral dermatitis-perioral dermatitis

-chronic photodamage-chronic photodamage

DIFFERENTIAL DIAGNOSIS:

-Lupus erythematosus-Lupus erythematosus

-dermatomyositis-dermatomyositis

-carcinoid syndrome-carcinoid syndrome

-habers syndrome-habers syndrome

-neurological causes –-neurological causes – brain tumours brain tumours

spinal cord lesions spinal cord lesions

orthostatic orthostatic

hypotensionhypotension

migraine migraine

parkinson disease parkinson disease

2) SYSTEMIC DISEASES:

-vasodilators-vasodilators-calcium channel blockers-calcium channel blockers-morphine-morphine-amyl and butyl nitrite-amyl and butyl nitrite-cholinergic drugs-cholinergic drugs-bromocriptine-bromocriptine-tamoxifen-tamoxifen-systemic steroid-systemic steroid-cyclosporine-cyclosporine

3) MEDICATION INDUCED :

TREATMENT:TREATMENT:ORAL THERAPYORAL THERAPY

1. TETRACYCLINE 250-500 mg q.i.d or b.d

2. DOXYCYCLIN & MINOCYCLINE 50-100 mg bd/od

3. METRONIDAZOLE 200mg b.d

4. ISOTRETINOIN 10-40 mg daily

1.1. METRONIDAZOLE GEL ( 1%)METRONIDAZOLE GEL ( 1%)

2.2. AZELAIC ACID CREAM (20%)AZELAIC ACID CREAM (20%)

3.3. BENZOYL PEROXIDE GEL ( 2.5% ,4% )BENZOYL PEROXIDE GEL ( 2.5% ,4% )

4.4. TACROLIMIUS & TACROLIMIUS &

NICOTINAMIDE(0.1%,0.03% DERIVATIVESNICOTINAMIDE(0.1%,0.03% DERIVATIVES

5. TOPICAL RETINOIDS5. TOPICAL RETINOIDS

TOPICAL THERAPY

Vascular laser & intense pulsed light(IPL) are

useful alternatives to oral rosacea therapies.

Used adjunctively with topical and oral

rosacea regimens

Non-ablative modalities reduce erythema,

papule & pustule counts and appear to

extend the duration of remission

Drawbacks are cost & side effects(transient

erythema, oedema, purpura, burns & rarely

scarring)

-oral isotretinoin: early to moderate -oral isotretinoin: early to moderate

phyma. phyma.

-surgery: advanced phyma-surgery: advanced phyma

-cold scalpel tangential -cold scalpel tangential

excisionexcision

-heated scalpel excision -heated scalpel excision

-electrocautery -electrocautery

-dermaabrasion -dermaabrasion

-laser ablation -laser ablation

-radiofrequency electrosurgery -radiofrequency electrosurgery

TREATMENT OF PHYMA:

-ophthalmologic referral should be -ophthalmologic referral should be

mademade

-sodium sulfacetamide 10% eye -sodium sulfacetamide 10% eye

ointment is effective for control of ointment is effective for control of

blepharitis.blepharitis.

TREATMENT OF OCULAR ROSACEA:

--is characterised by small discrete

papules and pustules in a periorifical

distribution predominantly around the

mouth.

-subset of perioral dermatitis shows

granuloma, when examined

histologically known as granulomatous

peri oral dermatitis.

PERI ORAL DERMATITIS

-It occurs in young women aged 16

and 45 yrs, and sporadically in men.

-granulomatous form of perioral

dermatitis has been reported in

children of prepubertal age.

EPIDEMIOLOGY:

-Exact cause is not known.-Exact cause is not known.

1)use of flourinated topical steroid1)use of flourinated topical steroid

2)hormonal factors2)hormonal factors

3)sunexposure3)sunexposure

4)tobacco4)tobacco

5) pyogenic organisms5) pyogenic organisms

6)demodex folliculorum6)demodex folliculorum

7) cosmetics7) cosmetics

8) fluoride toothpaste8) fluoride toothpaste

ETIOPATHOGENESIS:

-discrete and grouped erythematous -discrete and grouped erythematous

papule,vesicles and pustules.papule,vesicles and pustules.

-unilateral to start with, later -unilateral to start with, later

becomes b/l,around becomes b/l,around

perioral,perinasal, and peri orbital perioral,perinasal, and peri orbital

region.region.

-a distinct 5 mm clear zone at -a distinct 5 mm clear zone at

vermilion border of lip is well vermilion border of lip is well

described.described.

CLINICAL FEATURE:

--granulomatous variant present with granulomatous variant present with

small flesh colored, erythematous or small flesh colored, erythematous or

yellow brown papules some with yellow brown papules some with

confluence.confluence.

-reported to appear on the ear,scalp, -reported to appear on the ear,scalp,

trunk,labia majora & extremities.trunk,labia majora & extremities.

1)1) NON GRANULOMATOUS POD:NON GRANULOMATOUS POD:

--rosacearosacea

-seborrheic dermatitis-seborrheic dermatitis

-allergic contact dermatitis-allergic contact dermatitis

-irritant contact dermatitis-irritant contact dermatitis

-lip licking cheilitis-lip licking cheilitis

-acne vulgaris-acne vulgaris

-gram negative folliculitis-gram negative folliculitis

-D. Folliculorum infestation-D. Folliculorum infestation

-acrodermatitis enteropathica-acrodermatitis enteropathica

DIFFERENTIAL DIAGNOSIS:

-granulomatous rosacea-granulomatous rosacea

-familial juvenile systemic -familial juvenile systemic

granulomatosis(Blau syndrome)granulomatosis(Blau syndrome)

-fungal infection-fungal infection

-lupus miliaris disseminatus faciei-lupus miliaris disseminatus faciei

-benign cephalic histiocytosis-benign cephalic histiocytosis

-sarcoidosis-sarcoidosis

2) GRANULOMATOUS POD:

--consist of slight acanthosis,epidermal consist of slight acanthosis,epidermal

edema,focal perifollicular parakeratosis & edema,focal perifollicular parakeratosis &

spongiosisspongiosis

-scattered perifollicular or perivascular -scattered perifollicular or perivascular

infiltrate consisting of lymphocytes, infiltrate consisting of lymphocytes,

histiocytes and plasma cell in dermis.histiocytes and plasma cell in dermis.

HISTOPATHOLOGY:

TOPICAL:TOPICAL:

1)1) Metronidazole gel 1% b.i.d Metronidazole gel 1% b.i.d

2) Erythromycin or clindamycin 1% 2) Erythromycin or clindamycin 1%

b.i.db.i.d

3) sulfur preparation b.i.d3) sulfur preparation b.i.d

4) Azelaic acid 10%/ 20% cream 4) Azelaic acid 10%/ 20% cream

b.i.db.i.d

TREATMENT:

1) Tetracycline 250-500 mg b.i.d1) Tetracycline 250-500 mg b.i.d

2) Doxycycline 50-100 mg b.i.d2) Doxycycline 50-100 mg b.i.d

3) Minocycline 50-100 mg b.i.d3) Minocycline 50-100 mg b.i.d

4) Erythomycin 400 mg t.i.d4) Erythomycin 400 mg t.i.d

SYSTEMIC :

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