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Rosacea, Perioral Dermatitis, Optimizing Management,Tips and Traps

Rodney Sinclair

Professor of Dermatology

University of Melbourne & Epworth Healthcare

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Predominantly erythematotelangiectatic rosacea affecting the cheeks and nose. Note conjunctival injection

Erythema mainly involving the convex areas of the face in a patient with rosacea.

Inflammatory papulopustular rosacea

Chronic lymphoedema in a patient with a long history of rosacea

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Rhinophyma and other phymas

• The phymas are localized swellings of facial soft tissues due to variable combinations of fibrosis, sebaceous hyperplasia and lymphoedema

• They develop predominantly in males. • The commonest is rhinophyma, a swelling of the

nose which may become grossly distorted in contour

• Other areas which may be affected include the forehead (metophyma)

• chin (gnathophyma) • eyelids (blepharophyma) • ears (otophyma) [2].

forehead (metophyma) chin (gnathophyma)

Eye involvement • Estimates of prevalence vary from 6% to over 30% of patients with rosacea • The pathogenesis is still not well understood. • Symptoms include a sensation of grittiness or irritability of the eyes, often

accompanied by visible reddening of the conjunctiva. • Blepharitis, episcleritis, chalazion and hordeolum are also common. • Rosacea keratitis is a more serious and quite common complication, • The conjunctivitis, keratitis and other complications seem likely to be at

least partly secondary to reduced tear secretion and Meibomian gland dysfunction, resulting in an unstable tear film.

• Ocular rosacea may be seen in isolation or occur before the onset of cutaneous features, especially in children

• The condition may be unilateral or asymmetrical

Pyoderma faciale

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Type 1 Erythematotelangiectatic rosacea • Laser therapy • Fine wire diathermy • IPL

Treatment of rosacea associated erythema with pulsed dye laser

Treatment of rosacea associated erythema with IPL

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Type 2 Papulopustular rosacea Topical therapy • Topical metronidazole • Toical azeleic acid • Sodium sulphacetamide 10% with sulphur 5% No role for topical benyl peroxide

Role of Pimecrolimus, clindamycin unclear Oral tetracycline. Doxycycline, minocycline, ampicillin,

Type 3 Phymomatous rosacea Surgical therapy Ablative laser

Type 4 Occular rosacea Articficial tears Topical steroid Topical cyclosporin emulsion

• 5 day history abrupt worsening • Fever, sore eyes, blurred vision • 3 year history mild papulopustular

rosacea • Treated with prednisolone 30 mg,

isotretinoin 35 mg • Marked improvement within 5 days

• Presented with pruritis, diffuse facial erythema, crusted lesions, • papules and pustules • Responded initially to oral ivermectin and topical permethrin • Required minocycline and metronidazole gel for 32 months

Predominately associated with fluorinated corticosteroids face On occasions, even 1% hydrocortisone may provoke steroid rosacea in children The use of steroid nasal spray may also be responsible A granulomatous eruption described as resembling rosacea developed 9 months into therapy with topical tacrolimus 0.1% ointment

Corticosteroid-induced rosacea Perioral dermatitis

Treatment • The most important measure is to discontinue

the topical corticosteroids. • Other applications, including cosmetics,

should also be stopped. • The patient must be warned that an initial

flare may develop after withdrawal of a topical steroid.

• A 4-week course of oral minocycline is usually all that is required.

• Topical tetracycline, metronidazole cream 1% e 2% are also effective [

• pimecrolimus 1% cream also has been used

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Perioccular dermatitis Granulomatous perioral dermatitis in children

Flushing and flushing syndromes

Flushing and flushing syndromes

Flushing and flushing syndromes

Cause Proposed mediator(s)

Physiological Autonomic

Menopausal Autonomic

Drug-induced Various

Alcohol Acetaldehyde

Chlorpropamide and alcohol Acetaldehyde

Food Autonomic

Scombroid fish poisoning Histamine

Carcinoid syndrome

Serotonin

Prostaglandins

Bradykinin

Histamine

Mastocytosis Histamine

Thyrotoxicosis Thyroxine

Medullary carcinoma of the thyroid Prostaglandins

Calcitonin

Pancreatic tumours Vasoactive intestinal peptide

Insulinoma ?

POEMS syndrome ?

*With ethanol.

5-HT3 receptor antagonists: ondansetron, ramosetron, tropisetron

ACE inhibitors: captopril, enalapril, lisinopril, perindopril, ramipril

β-3 adrenoceptor agonists: fluvoxamine, mirtazapine

Calcium channel blockers: nifedipine, verapamil

Chlorpropamide*

Disulfiram*

Ethanol

Fumaric acid esters

Hydralazine

Metronidazole*

Nicotinic acid

Nitrates: isosorbine mononitrate/dinitrate, glyceryl trinitrate

Phentolamine

Pilocarpine

Prostacyclin

Prostaglandin E

Sildenafil, tadalafil and vardenafil

Venlafaxine

Drugs that cause flushing

Physiologic flushing can be helped by propranalol Menopausal flushing usually improves with oral or transdermal oestrogen replacement therapy. Combined oral contraceptives are effective and even the use of progestagens alone may be beneficial. Non-hormonal approaches to management include the use of clonidine 0.05 mg twice daily or selective serotonin reuptake inhibitors (SSRIs)

Unilateral gustatory flushing

Histamine-evoked ‘geographical’ pattern of flushing due to foregut carcinoid tumour

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Fast Facts

Minor Surgery Second edition

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Contents:

• Operative set-up and equipment

• Local anesthesia • Lesion identification and

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removal • Surgical procedures • Examining your practice

“… it's unique in being able to pack so much relevant information into such a small volume, which makes it highly readable." First Prize winner, Primary Health Care, BMA Book Awards.

Rod Sinclair MBBS FACD MD

Professor of Dermatology, University of Melbourne; Director of Dermatology, Epworth Hospital, Victoria, Australia

Christopher J Price MBBCh MRCGP DipMedEd

Associate Dean, Postgraduate Education for General Practice, Cardiff University, Cardiff, Wales, UK

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Fast Facts

Disorders of the Hair and Scalp Second edition

Rod Sinclair MBBS FACD MD

Professor of Dermatology, University of Melbourne; Director of Dermatology, Epworth Hospital, Victoria, Australia

Andre Burger MB ChB DipEC DipOphth FRCOphth(SA) CESR(UK)

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£15/€18/$25 Buy 3 get 1 FREE

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Contents: • Anatomy and physiology • Diagnosis • Androgenetic alopecia • Diffuse hair loss – telogen effluvium • Alopecia areata • Trichotillosis and traction alopecia • Scarring alopecia • Tinea capitis • Hirsutism and hypertrichosis • Scalp disorders • Special problems in children • Hair transplantation, care and

cosmetics • Useful resources

“It is good value for money and will be a useful addition to any GP or GPSI’s armoury of literature.“ Michelle Ralph, GPSI Cambridge & PCDS Bulletin Editor; Primary Care Dermatology Society Bulletin, Spring 2014

Vicky Jolliffe MA FRCP FRCS(Ed) MRCGP

Senior Lecturer and Honorary Consultant Dermatologist, Barts and The London NHS Trust, London, UK

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