INTRODUCTION Rosacea is a common chronic condition of unknown etiology characterized by facial flushing, inflammatory papules and pustules, erythema, and telangiectasia. The onset is usually between ages 25 to 50 years, but has been reported in all age groups including children as young as two years. There is a 2:1 predilection for males. The clinical findings result from inflammation of the skin, capillary proliferation, and collagen deposition. Recent studies have shown an increase in the presence of a prostaglandin-like substance and an increase in free fatty acids in the sebaceous glands. Symptoms tend to be worsened by heat, hot or spicy foods, and alcohol. Symptoms may be caused by or worsened by potent topical steroids.
CLINICAL PRESENTATION Skin lesions consisting of variable combinations of patchy erythema, telangiectasia, small papules, pustules, and hypertrophic sebaceous glands occur on the brow, eyelids, and midface. Heat, sunlight and possibly gastrointestinal stimuli may induce physiologic flushing. Capillary proliferation and dilatation may lead to dermal lymphatic stasis and a sterile cellulitis. Common ocular symptoms include burning, redness, itching, foreign body sensation, tearing, dryness, photophobia, and eyelid swelling. Inflammation of the meibomian glands with dilation and plugging of the gland orifices is seen along the lid margins and pressure on the tarsus results in expression of abnormally thick secretions. Greasy scales (scurf) may be present on the eyelashes. With chronic disease there is often loss of lashes and recurrent chalazia. Gland dropout and abnormally low lipid levels result in excessive evaporation of tears and a subsequent dry eye state. An associated conjunctival hyperemia, papillary conjunctivitis, episcleritis and marginal keratitis may occur in up to 5% of cases. A coexisting tear deficiency occurs in over 30% of patients.
HISTOPATHOLOGY The lesions of rosacea are variable. There may be only telangiectatic vessels with a mild to moderate perivascular infiltrate of lymphocytes containing a small number of plasma cells. Papulopustular rosacea lesions have more intense inflammation that is both perivascular and around hair follicles. Active pustular lesions have a superficial folliculitis, while older lesions may have loosely associated granulomas adjacent to follicles. Granulomatous rosacea has "tuberculoid" granulomas with epithelioid cells, multinucleated giant cells of Langhans and foreign-body types, and a substantial rim of lymphocytes and plasma cells. The granulomas may be centered on ruptured hair follicles. The granulomas may have central necrosis ("caseat-ing necrosis") in approximately 10% of cases.
TREATMENT Rosacea is often moderately to poorly responsive to therapy. Treatment usually requires a combination of topical and oral medications, and treatment for weeks to months may be necessary to prevent relapse. All patients should be advised to avoid heat, spicy and hot food and potent topical corticosteroids. Tetracycline 250 mg four times daily is an effective treatment for moderate to severe cutaneous papulo-pustular rosacea. Oral metronidazole 250 mg once or twice daily may also be as effective as oral tetracycline. Benefit begins in three to four weeks and reaches a maximum in six to eight weeks. Pustules and papules respond better than does the erythema. Mild topical corticosteroid creams (hydrocortisone 1%) twice daily may control the erythematous component. Benzoyl peroxide gel 2.5% to 5%, or a topical antibiotic solution once or twice daily may be effective for the treatment of the papulo-pustular component. For resistant cases use of a vitamin A derivative such as isotretinoin may induce a prolonged remission. A topical ocular steroid with or without antibiotic may be necessary for treatment of associated keratitis, and artificial tears are the mainstay for treatment of associated dry eyes. Lid hygiene with a dilute "no tears" shampoo following warm compresses is effective in melting the stagnant lipid secretions. Topical ophthalmic antibiotics applied to the lid margins can in some cases be useful in decreasing the bacterial flora, whose lipases may contribute to the increased free fatty acid production.
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Rosacea and Eczema are two skin conditions that are fairly commonly found throughout the world. Each of them is characterized by different features, and can be both discomfiting as well as result in undesirable appearance features. In a nutshell, theyre problems that many would want to deal with.