rosacea
ROSACEA
Rosacea is a chronic inflammatory cutaneous disease of the convexities of the central face (cheeks, chin, nose and central forehead) and eyes with periorbital and perioral skin sparing. This condition is attributed to chronic vasodilation.
Remissions and exacerbations are common.
It typically begins after 30 years of age but may occur at any age.  It commonly affects fair-skinned individuals.
The common presenting symptoms are facial flushing, stinging/burning erythema, telangiectasia, edema, papules, pustules, ocular lesions, and hypertrophy of the sebaceous glands of the nose with fibrosis (rhinophyma).
A history of episodic flushing often heralds onset of rosacea.

Rosacea Diagnosis

Diagnosis

  • There are no specific lab tests to confirm diagnosis; hence, the diagnosis is based on patient's history and clinical characteristics

Classification

Phenotype Classification

  • Based on phenotypes which are observable features that result from genetic and/or environmental influences
    • Classification based on phenotype as recommended by the Global Rosacea Consensus (ROSCO) provides a necessary means of assessing and managing rosacea which is consistent with each individual patient's presentation
  • Presence of ≥1 diagnostic or ≥2 major phenotypes (usually in a centrofacial distribution) are required for the diagnosis of rosacea

Diagnostic Phenotypes

  • Persistent centrofacial erythema in a characteristic pattern associated with periodic intensification by potential trigger factors
    • Most common sign of rosacea
    • Personal history, drug history and complete physical examination will help exclude other diagnoses such as lupus erythematosus, seborrheic eczema or steroid-induced rosacea
  • Phymatous changes
    • Most common form is rhinophyma
    • Include glandular hyperplasia, patulous follicles, skin thickening or fibrosis, and bulbous appearance of nose

Major Phenotypes

  • Flushing or transient centrofacial erythema
    • Trigger/exacebating factors cause neurovascular stimulation resulting to flushing which occurs within seconds to minutes
  • Papules and pustules
    • Red, dome-shaped papules with or without accompanying pustules, often occurring in crops and primarily located in the centrofacial area
  • Telangiectasia
    • Cutaneous blood vessels which are enlarged and visible
  • Ocular manifestations
    • Interpalpebral conjunctival injection
    • Lid margin telangiectasia
    • Scleritis and sclerokeratitis
    • Spade-shaped infiltrates in cornea

Secondary or Minor Phenotypes

  • Burning or stinging sensation of the skin
    • Typically occurs on erythematous skin without scales
  • Dry appearance of the skin
    • Central facial skin resemble dry skin appearing rough and scaly
  • Edema
    • May occur during or after prolonged erythema or flushing due to capillary extravasation during inflammation and may persist for days
  • Ocular manifestations
    • Evaporative tear dysfunction
    • Irregularity of the lid margin architecture
    • "Honey crust" and cylindrical collarette accumulation at the base of lashes

Subtype Classification

  • Former standard classification of rosacea grouping the most common presentations into:
    • Erythematotelangiectatic rosacea
    • Inflammatory papulopustular rosacea
    • Phymatous rosacea
    • Ocular rosacea
  • Does not fully cover patient's clinical presentation confounding the assessment of degree of severity

Variant

Granulomatous

  • Noninflammatory
  • Hard, brown, yellow or red cutaneous papules or nodules of similar size
  • May be severe and eventually lead to scarring

Severity Grading Scale

  • No firmly established severity grading scale
  • Severity of each feature/phenotype must be rated independently
    • Physicians give their assessment based on severity of signs and symptoms; duration and extent of disease at the time of examination may also be considered in the evaluation
    • Patient participates in the grading by giving the assessment of his/her condition considering the physical manifestations and its impact on quality of life (psychological, occupational and social effects)
  • Scales used to assess the severity of rosacea phenotypes are:
    • Flushing: Flushing Assessment Tool (FAST) and Global Flushing Severity Score (GFSS)
    • Persistent erythema: Clinician's Erythema Assessment (CEA) and Patient's Self-Assessment (PSA)
    • Papules and pustules: Lesion counts and Investigator's Global Assessment (IGA)
  • Suggested severity scale for papulopustular lesions and facial erythema with or without symptoms
    • Mild: <10 papules/pustules with mild erythema
    • Moderate: 10-19 papules/pustules with moderate erythema
    • Severe: ≥20 papules/pustules with severe erythema
  • Severity scale for ocular manifestations
    • Mild: Mild blepharitis with lid margin telangiectasia
    • Mild-moderate: Blepharoconjunctivitis
    • Moderate-severe: Blepharokeratoconjunctivitis
    • Severe: Sclerokeratitis, anterior uveitis
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