Rosacea: Diagnosis and Management

00:00 So the clinical manifestations, classic rosacea looks just like this. It's persistent.

00:06 It's in the middle of the face. It's in sun-exposed areas.

00:09 Hence the sense that maybe ultraviolet light is one of those triggers.

00:12 You see the nose and the medial cheeks.

00:15 So the malar eminences, over time, the stimulation of the blood vessels may actually cause them to undergo proliferation.

00:23 So we'll get telangiectasias, enlarged cutaneous blood vessels.

00:28 And that can give this very profound redness.

00:30 But a persistence will actually see spidery vasculature in that same general area. And again, this is often associated.

00:39 And we can make it more, appear more vascular, coming and going by having exogenous triggers.

00:45 Spicy food, stress, alcohol, sun exposure, etc.

00:49 because the vasomotor component, once the vessels are there, they'll respond, and if they respond, it can become redder.

00:58 Because we're recruiting innate inflammatory cells, there can be a pustular component.

01:05 So you can have papulopustular rosacea.

01:09 And these are eruptive papules and pustules.

01:11 And this is somewhat akin in appearance to acne.

01:16 But we don't have comedones.

01:17 So this is not because we're blocking.

01:20 Remember in acne we block the release of sebum from sebaceous glands along the hair follicle shaft.

01:27 That's not the case here.

01:29 We are recruiting inflammatory cells because of some exogenous stimuli.

01:34 And they're doing their thing.

01:35 They're making proteases, reactive oxygen species, etc. and we are getting then pustules little collections of acute inflammatory cells, neutrophils.

01:46 Ocular rosacea is actually remarkably common in patients who will have rosacea. So they, in many cases, it may even precede the onset of kind of the central facial process.

01:59 Um patients will have conjunctivitis.

02:01 So inflammation of the conjunctiva and blepharitis, which is inflammation of the eyelids.

02:06 And that's seen as you see, in greater than 50% of patients.

02:11 The chronic rosacea is kind of a late manifestation.

02:14 So the more you have it, if you don't treat it the vascular proliferation, the telangiectasias, the kind of ongoing injury and hypertrophy and then scarring gets worse and worse and worse.

02:28 It's a cumulative process.

02:30 So in chronic rosacea you're going to have a very thickened skin with very irregular contours.

02:36 There will be it will feel doughy and more fibrous with hypertrophy of the sebaceous glands. The diagnosis you kind of recognize it when you see it. It's the middle of the face. It's very prominent with vasculature, comes and goes a little bit depending on secondary signals.

02:55 But there are formal diagnostic criteria.

02:58 So if you're a dermatologist, not as a medical student but as a dermatologist, if there are any one of the following.

03:05 So fixed center facial erythema that periodically intensifies and chronic skin changes, you can say, oh, that's rosacea. Or you can have two of the following.

03:15 Recurrent kind of predilection to flushing, papules and pustules, formal telangiectasias and ocular manifestations.

03:24 Do you need to remember this? No. I think it's more important to remember that there are the ocular manifestations and you have the central erythema with telangiectasias.

03:32 How do we manage it? So in general, we try to avoid triggers that are going to cause increased vascular engorgement and the telangiectasias. We may want to also prevent ultraviolet exposure. So sunblock etc.

03:50 gentle skin cleansing to get rid of any microbes that may be driving this, the mites in particular.

03:56 Um moisturizers and avoid irritating topical products and exfoliation, which will actually only make things worse.

04:04 With the erythema. Um, you may want to use actually agonist, alpha two agonists that will cause vasoconstriction.

04:12 That's a good idea. You can take those orally or you can take them as topical agents. Laser therapy can also be used to blast away the telangiectasias, so you may be able to get rid of the underlying vascular proliferation.

04:30 You avoid steroids. Turns out steroids makes it worse.

04:33 And you're thinking, well, gee, this is an inflammatory process. Why is that? Well, in fact, it's thought without being proven yet that the steroids actually allow the mites that may be driving this process to expand. There's less of an inflammatory response to them or less of an immune response to the mites.

04:52 So you avoid steroids.

04:53 You don't give that in this case.

04:55 For the pustules and the papules, you use topical and oral antibiotics to prevent secondary superinfection with bacteria.

05:03 And then for the chronic changes that thickening and induration of the skin and or the proliferation of the vessels that have already occurred. Retinoic acid agents are always good for changing the maturation process and the keratinization of the skin, so that's always good.

05:19 Laser ablation to get rid of some of the vascular changes.

05:23 And you can actually do plastic surgery and remove areas.

05:27 And hopefully with good plastic surgery be able to restore a somewhat normal skin in that area.

05:34 For the ocular therapy you need to use artificial tears topical antibiotics again to prevent superinfection.

05:41 At this point, you've seen and hopefully understood some of what's going on with rosacea. And now when you go home for Christmas break, you can diagnose it in Uncle Fred.

05:51 Thanks.