Rosacea By Any Other Name Is Still Facial Redness

Rosacea remains one of the last bastions of dermatologic ignorance. Once considered a variant of acne, this common skin disorder seems fairly well entrenched as a disease sui generis. Although oral and topical antibiotics are effective in treating the papular and pustular varieties of rosacea, evidence demonstrates the lack of an infectious origin.

Rosacea has been indelibly linked with the bulbous nose and "gin blossoms" of comedian and alcohol aficionado W. C. Fields, but the condition actually results from a disparate assortment of stimuli acting in concert on a genetically susceptible host. Additionally, an appropriate constitutional diathesis must exist. Although descriptions suggestive of rosacea harken back to biblical times, modern diagnosis and treatment seem intertwined with the pharmaceutical and advertising industries. Patients in our cosmetically conscious society flock to physicians' offices and demand topical salves in lieu of considering requisite behavior modification. - Ken Landow, MD

Common Variants of Rosacea

The phymas

Rhinophyma, long associated with excessive alcohol consumption, but it also may appear without the typical manifestations of less severe disease. Several forms of rhinophyma are recognized, including glabellar, fibrous, actinic, and fibroangiomatous. Nasal involvement ranges from diffuse hyperplasia of the connective tissue to asymmetric, lobular hyperplasia of the sebaceous glands, which distorts the alae. Large purplish ectatic vessels may be present along with photodamaged skin, a pitted surface, and inflammation. The existence of these morphological entities emphasizes the polymorphous appearance of skin plagued by rosacea and the need to avoid preconceived diagnostic stereotypes. Although rhinophyma, by definition, involves the nose, a variety of phymas affect other areas, including the forehead (metophyma), eyelids (blepharophyma), earlobes (otophyma), and chin or jaw (gnathophyma).

Morbihan's disease

Lymphedema, another complication of rosacea, seems to be considerably underdiagnosed. The current classification system identifies this manifestation as a secondary feature of rosacea. Previously referred to as Morbihan's disease, this hard, nonpitting edema supposedly results from lymphatic obstruction of drainage from the facial skin--primarily the forehead, glabella, eyelids, and nose. Consequences include thickening of the integument and prominence of the follicles. The condition may be quite mild, may mimic the appearance of skin stimulated by an excessive concentration of growth hormone, or may resemble the so-called peau d'orange (skin resembling an orange peel) changes of lymphoma.

Ocular rosacea

Ocular involvement in rosacea remains a contentious issue. Reported prevalence varies greatly: between 3% and well over 75% of female patients older than 45 years who have rosacea ultimately present with a variety of ophthalmologic manifestations. The disease may be so mild as to be easily overlooked except by the trained observer. The initial cutaneous involvement in rosacea typically does not include the ocular tissues. However, in up to 20% of cases, the initial assault targets the skin surrounding the eyes. The meibomian gland dysfunction usually begins as tear instability, which consequently leads to complications of dry, itchy eyes; conjunctivitis; photophobia; eye pain; and grittiness or a foreign body sensation. Telangiectasia of the eyelid margins routinely occurs and tends to parallel the cutaneous flushing rather than the extent of skin eruption. Much less frequently, keratitis with ulceration and vascularization of the cornea develops. The precise mechanism linking the skin to the eye in rosacea remains unknown.

Granulomatous rosacea

Patients with this variant of rosacea exhibit small to mid-sized, relatively noninflammatory granulomatous papules or nodules on the cheeks or near the nostrils, eyes, or mouth. These red, yellow, or brown lesions may be present without the more traditional manifestations of rosacea and may lead to considerable diagnostic uncertainty. The precise categorization of granulomatous rosacea is likely to change as the cause of the disease becomes apparent.

Steroid rosacea

Abuse of topical fluorinated corticosteroids persists in spite of warnings to avoid application of these medicines to the face. Except for treatment of a few well-defined dermatologic disorders, use of these compounds should be discouraged. Profligate reliance on these potent antiinflammatory agents precipitates perioral dermatitis and a condition previously but incorrectly referred to as steroid rosacea.

Diagnosis

Diagnosis of rosacea is rarely difficult. Occasionally, however, differentiating rosacea from seborrheic dermatitis or adult acne may be problematic. Since all of these conditions are common, they may occur simultaneously. Also, a shared genetic tendency may underlie the conditions, prompting their coexistence.

Differential diagnostic considerations include a variety of miscellaneous skin diseases, depending on the stage of rosacea under consideration. For patients in the earliest prodromal states manifesting only intermittent flushing, possible diagnoses include emotional factors (eg, anxiety), use of certain pharmaceutical agents, and fluctuation of not allowed hormones.

Differential diagnostic considerations in rosacea

Acne
Acne conglobata
Bromoderma
Carcinoid syndrome
Dermatomyositis
Dermatophyte infection
Erysipelas
Folliculitis
Frostbite
Gram-negative folliculitis
HIV
Iododerma
Leukemia
Lupus vulgaris
Lymphoma
Perioral dermatitis
Photodermatitis
Polymorphous light eruption
Sarcoidosis
Seborrheic dermatitis
Steroid rosacea (due to use of fluorinated corticosteroids)
Systemic lupus erythematosus

Adapted from Murray AH. Differential diagnosis of a red face. J Cutan Med Surg 1998;2(Suppl 4):S11-5.