Rosacea and Rhinophyma

oPatientPlus articles are written by UK doctors and are based on research evidence, UK and European Guidelines. They are designed for health professionals to use, so you may find the language more technical than the condition leaflets.

Rosacea is a chronic relapsing disease of the facial skin. It is characterised by recurrent episodes of facial flushing with persistent erythema, telangiectasia, papules and pustules. Ocular rosacea is usually bilateral and causes a foreign-body sensation.

  • A characteristic feature is flushing that may have a number of triggers.
  • It is a chronic acneform disorder of the facial pilosebaceous glands with an increased reactivity of capillaries to heat, causing flushing and eventually telangiectasia. Rhinophyma is an enlarged nose associated with rosacea in men. It is much rarer in women.
  • The aetiology of the disease is unknown but, as well as being a disfiguring condition, the patient suffers from an erroneous public perception that it is related to excessive alcohol consumption.
  • As alcohol is a frequent trigger of flushing it is quite likely that those with the disease drink less than the general population.
  • Medications which can cause a recurrence include amiodarone, topical steroids, nasal steroids and vitamins B6 and B12.
  • Theories about the pathophysiology of the condition include the release of free oxygen radicals, abnormalities of ferritin utilisation in the metabolism of hydrogen peroxide, degeneration of the dermal matrix and infection with antimicrobials.

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  • A study using data from the UK General Practice Research Database reported an overall incidence rate for diagnosed rosacea in the UK as 1.65/1,000 person-years. Rosacea was diagnosed in some 80% of cases after the age of 30 years. Ocular symptoms were recorded in 20.8% of cases at the index date.[2]
  • Rosacea is more common in females and rhinophyma in males.
  • Patients of Celtic origin and southern Italians are more frequently affected.

Symptoms

  • Patients usually complain of the skin condition but direct enquiry may often reveal a long history of flushing back to early teens or before.
  • The symptoms are initially intermittent but progress to a constant flushing with obvious telangiectasia.
  • A few complain of gritty eyes and facial oedema.

Signs

The disease tends to be progressive but that does not mean that everyone will develop all features.

  • The skin is not greasy as in acne and may be rather dry.
  • Erythema and telangiectasia over the forehead and cheeks are variable.
  • Involvement of the neck and upper chest is rare but can occur.
  • Sebaceous glands are prominent.
  • The nose may be enlarged and distorted by rhinophyma.
  • There may be peri-orbital oedema.
ROSACEA -ON FACE
Rosacea on face - note the marked telangiectasia



ROSACEA -ON FACE AND FOREHEAD
Rosacea on face and forehead - note the broad, red nose of rhinophyma



ROSACEA -ON FOREHEAD
Rosacea on forehead - note the acne-like comedones on the red telangiectasia

The American National Rosacea Society has classified the disease into four types:

  • Papulopustular rosacea (PPR) is the classical presentation. Patients are typically middle-aged women with a red central portion of their face that contains small erythematous papules surmounted by pinpoint pustules. They may have flushing. Telangiectasia are often present but may be difficult to distinguish from the erythematous background in which they exist.
  • Phymatous rosacea shows marked skin thickenings and irregular surface nodularities of the nose, chin, forehead, one or both ears and/or the eyelids. There are four histological types of rhinophyma that include glandular, fibrous, fibroangiomatous and actinic.
  • Ocular rosacea may precede the cutaneous form by years but often they develop together. The ocular signs include blepharitis, conjunctivitis, inflammation of the lids and meibomian glands, interpalpebral conjunctival hyperaemia and conjunctival telangiectasia. There may be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation.[3]
  • Erythematotelangiectatic rosacea shows central facial flushing, often with burning or stinging. The redness usually spares around the eyes. They usually have skin with a fine texture that lacks a sebaceous quality typical of other types. The erythematous areas of the face at times appear rough with scale likely due to chronic, low-grade dermatitis. The burning or stinging is exacerbated when topical treatments are applied.

The way these types relate to each other requires further clarification.[4]

Causes of flushing are many and include:

  • Heat or changes in temperature.
  • Alcohol.
  • Caffeine.
  • Spicy foods.
  • Stress or embarrassment.
  • Sun or wind.

The diagnosis is essentially clinical without any confirmatory tests.

  • Bacterial culture of the affected skin may guide therapy and exclude folliculitis.
  • If symptoms persist after 12-16 weeks of treatment, refer to a dermatologist.
  • If there is skin thickening such as rhinophyma, refer to a plastic surgeon.
  • Skin biopsy to exclude other diagnoses, such as cutaneous lupus, is rarely required and is usually performed by a specialist.

Nondrug

  • Reassure patients of the benign nature of the condition and the relative rarity of any complications (including development of rhinophyma).
  • Avoid precipitating or aggravating factors for the trigger factors of flushing.
  • Facial massage may reduce oedema.
  • Sunscreens should be at least factor 15 with UVA and UVB protection.
  • Avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents to be removed, or products containing sodium lauryl sulfate.
  • Judicious use of cosmetics may improve appearance significantly and, in doing so, greatly reduce distress. If the skin is dry use emollients (hypoallergenic and non-comedogenic emollient creams).
  • Avoid topical steroids.

Drugs

  • Mild-to-moderate rosacea should be treated with a topical preparation.
  • Metronidazole is a common first-line option.
  • Azelaic acid 15% gel is an alternative. It may be more effective but can cause sensitivity reactions in some patients.
  • Moderate-to-severe papulopustular rosacea requires oral antibiotics. These are thought to act by virtue of their anti-inflammatory rather than antimicrobial action.
  • Commonly used preparations are tetracycline or oxytetracycline 500 mg bd or erythromycin 500 mg bd.
  • Doxycycline 100 mg can be used as an alternative where oxytetracycline or tetracycline are contra-indicated (eg renal failure) but this is an unlicensed indication,
  • Once-daily modified-released doxycycline is available for facial rosacea.
  • Isotretinoin is occasionally used for refractory cases.
  • Patients with ocular rosacea who have no symptoms and do not have worsening eye disease do not need treatment. However, severe ophthalmic complications must be treated energetically, usually with systemic antibiotics.[3]
  • If the patient is currently using topical corticosteroids on the face, these must be stopped.

Other treatments[1]

  • Laser treatment can obliterate telangiectasia.
  • There is no satisfactory symptomatic treatment for the flushing per se. Current research is looking at the role of alpha-adrenergic receptors and the use of agonists to block their activity.[6]
  • Rhinophyma responds poorly to medical treatment and surgery is usually required. Several options are available including mechanical dermabrasion, carbon dioxide laser peel and surgical shave techniques.[7]

A number of Cochrane reviews have looked at the treatment of rosacea over the years. All have reached the conclusion that large unbiased randomised trials are needed before definitive recommendations can be made. These have yet to take place. The latest review supports the effectiveness of topical metronidazole, azelaic acid and doxycycline (40 mg), in the treatment of moderate-to-severe rosacea, and ciclosporin 0.5% ophthalmic emulsion for ocular rosacea.[8]

Eye involvement[3]

If the eye is involved:

  • Consider an eye lubricant.
  • Pay attention to eye hygiene.
  • Use an oral antibiotic which will also treat skin disease:
    • Oral tetracycline and oxytetracycline are recommended first-line for ocular rosacea, although metronidazole is thought to be equally effective.
    • Oral doxycycline or lymecycline may be preferred if compliance is a problem.
    • Oral erythromycin is an alternative if tetracyclines are contra-indicated or are not tolerated.
    • Metronidazole gel is not licensed for ophthalmic use but one study found it safe and effective for eyelid involvement.
    • Topical steroids have been used to good effect in eyelid inflammation but should be used cautiously and stopped as soon as possible to prevent corneal melting.
    • The use of ciclosporin ophthalmic emulsion has been supported by a number of clinical trials.[8]
    • Isotretinoin is occasionally used in severe eye disease but can cause blepharoconjunctivitis and is best reserved for specialist use in patients who have failed to respond to other agents.

Referral guidance[5]

Routine dermatology referral:
  • Persistent symptoms that are causing psychological or social distress.
  • Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
  • Uncertain diagnosis.
Routine referral to a plastic surgeon:
  • Severe phymatous disease.
  • Prominent rhinophyma.
Routine referral to an ophthalmologist:
  • Ocular symptoms are severe.
  • Ocular symptoms fail to respond to maximal treatment in primary care.
Urgent referral to an ophthalmologist:
  • Suspected keratitis when there is eye pain, blurred vision or sensitivity to light.

Complications are largely psychological distress but eye complications are not uncommon and keratitis occurs in up to 5%, requiring urgent referral to an ophthalmologist.

There may be complications from treatment. Benign intracranial hypertension is a rare but important adverse effect of tetracycline therapy. If the patient develops headache and visual disturbances, stop the tetracycline.

Rosacea has a variable duration and prognosis. It is usually a chronic disease, punctuated by episodes of acute inflammation. There is no cure.

As mentioned above, there is a common misconception associating rhinophyma with excessive alcohol consumption. In William Shakespeare's Henry IV, Part 2, Bardolph has become Sir John Falstaff's corporal as well as his friend. He is described as "an arrant malmsey-nose knave" since his nose is red, supposedly from too much wine. Other traditional terms have included brandy nose and rum nose.

Further reading & references

  • Del Rosso JQ, Gallo RL, Kircik L, et al; Why is rosacea considered to be an inflammatory disorder? The primary role, J Drugs Dermatol. 2012 Jun 1;11(6):694-700.
  • Del Rosso JQ; Advances in understanding and managing rosacea: part 1: connecting the dots J Clin Aesthet Dermatol. 2012 Mar;5(3):16-25.
  1. Kupiec-Banasikowska A et al, Rosacea, Medscape, May 2011
  2. Spoendlin J, Voegel JJ, Jick SS, et al; A Study on the Epidemiology of Rosacea in the UK. Br J Dermatol. 2012 May 5. doi: 10.1111/j.1365-2133.2012.11037.x.
  3. Randleman J et al, Ocular Rosacea, Medscape, Aug 2011
  4. Jansen T; Clinical presentations and classification of rosacea. Ann Dermatol Venereol. 2011 Nov;138 Suppl 3:S192-200.
  5. Rosacea, Prodigy (August 2008)
  6. Del Rosso JQ; Advances in understanding and managing rosacea: part 2: the central role, J Clin Aesthet Dermatol. 2012 Mar;5(3):26-36.
  7. Little SC, Stucker FJ, Compton A, et al; Nuances in the management of rhinophyma. Facial Plast Surg. 2012 Apr;28(2):231-7. Epub 2012 May 6.
  8. van Zuuren EJ, Kramer S, Carter B, et al; Interventions for rosacea. Cochrane Database Syst Rev. 2011 Mar 16;(3):CD003262.
  9. Curnier A, Choudhary S; Rhinophyma: dispelling the myths. Plast Reconstr Surg. 2004 Aug;114(2):351-4.

Disclaimer: This article is for information only and should not be used for the diagnosis or treatment of medical conditions. EMIS has used all reasonable care in compiling the information but make no warranty as to its accuracy. Consult a doctor or other health care professional for diagnosis and treatment of medical conditions. For details see our conditions.

Original Author:
Dr Richard Draper
Current Version:
Peer Reviewer:
Prof Cathy Jackson
Last Checked:
13/06/2012
Document ID:
2739 (v25)
© EMIS

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