Rosacea and Rhinophyma

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.

• It is a common and under-diagnosed condition that is said to affect up to 10% of the population.¹
• It tends to present between age 30 and 50 years although it can strike at any age.
• Rosacea is commoner 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.²
• A few complain of gritty eyes and facial oedema.

Signs

The disease tend 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.

The American National Rosacea Society has classified the disease into 4 types:³

• 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 4 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 hyperemia, and conjunctival telangiectasia. There may be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation.
• Erythemotelangiectatic 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.

Causes of flushing are many and include:

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

• Acne vulgaris especially if it presents early in life.
• Peri-oral dermatitis from use of potent steroids on the face.
• Systemic lupus erythematosus or discoid lupus erythematosus.
• Polymyositis and dermatomyositis.
• Photosensitive eruptions.
• Rhinophyma may resemble lupus pernio from sarcoidosis.
• Especially when flushes start in a woman around 50, hot flushes may suggest the menopause.
• Ophthalmic symptoms may not be recognised as part of the disease although they occur to some extent in over 50%.

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.

Non-drug

• 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 sulphate.
• 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

• Clinical Knowledge Summaries advise that oral tetracyclines are the first line of treatment:
  • Ordinary tetracycline or oxytetracycline are first choice.
  • Doxycycline and lymecycline are less affected by food and cause less gastric intolerance.
  • Minocycline is best avoided because of potential hepatotoxicity.
  • Doxycycline is best in renal impairment but it can aggravate photosensitivity.
  • Clarithromycin may be preferred.
  • Generally, topical treatment is used in mild disease with few lesions and oral treatment is reserved for more severe cases.
  • There is no evidence of further benefit by giving topical and oral treatment simultaneously.
• Review at 6 weeks but at least 3 months of treatment is required and relapse often follows cessation of treatment, requiring further treatment
• Topical retinoids, tretinoin, isotretinoin or benzoyl peroxide do not have good data to support their use and are not licensed for the condition.
• Metronidazole as a topical gel is both safe and effective.⁴ Oral metronidazole is best avoided.
• Azelaic acid 15% gel is an alternative, although it is not licensed for this condition.
• Ophthalmic complications must be treated energetically, usually with systemic antibiotics.
• Isotretinoin is a vitamin A analogue that can be used to treat more serious disease, under the supervision of a dermatologist. In rosacea fulminans it may be preceded by prednisolone at 60 mg a day, reducing to 30 mg daily later.
• The treatment of flushes has been poorly investigated. Nadolol, a nonspecific beta blocker is ineffective.⁵ Clonidine is advocated more often but trials are very few and it may be no better.⁶
• If the patient is currently using topical corticosteroids on the face, they must be stopped.

Antibiotics may be useful at much lower doses than those usually employed to treat infection. These are called anti-inflammatory doses. For example, doxycycline M/R 40 mg daily appears effective and with fewer adverse effects.⁷

Other treatments

• Laser treatment can obliterate telangiectasia.
• Rhinophyma may be treated by mechanical dermabrasion, carbon dioxide laser peel, and surgical shave techniques.

A Cochrane review concluded that the quality of studies evaluating rosacea treatments is generally poor. There is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. There is insufficient evidence concerning the effectiveness of other treatments. Good RCTs looking at these treatments are urgently needed.⁸

A more recent systematic review reached similar conclusions, stating that there is evidence that topical metronidazole and azelaic acid are effective. There is some evidence that oral metronidazole and tetracycline are effective. More well-designed, randomised controlled trials are required to provide better evidence of the efficacy and safety of other rosacea therapies.⁹

Eye involvement

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.
  • Oral doxycycline or lymecycline may be preferred if compliance is a problem.
  • Oral erythromycin is an alternative if tetracyclines are contraindicated or are not tolerated.

Referral guidance

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.