> Rosacea

Differential diagnosis

Probably the most frequent disease remembered with acne is rosacea, which has striking similarities with acne and often makes the diagnosis more difficult. Three quick diagnostic facts to differentiate rosacea from acne are age of onset, type of the skin involved and organ system patholgoy. Rosacea is seen between the ages of 30- 50 while acne starts at adolscence. The skin more frequently susceptible to rosacea is fair skin especially in women while acne does not show any skin type preference. Involvement of vascular and lymphatic vessels which could occur following a period of sun exposure, stress and alcohol. Eye symptoms are seen in rosacea . Rosacea is a chronic cutaneous disorder, primarily of the central face. It is often characterized by remission and exacerbation and it encompasses various combinations of such cutaneous signs as flush, erythema, telangiectasias, edema, papules, pustules, ocular lesions, and rhinophyma. Primary features considered as necessary for diagnosis include flushing, erythema, papules, pustules, and telangiectasias. A variety of secondary features are listed that may be absent or present as a single finding or in any combination."

It is common that Rosacea does not present with blackheads that are seen with Acne Vulgaris. Also the age of onset, and the location of redness is a clue. As rosacea is a neurovascular disorder it affects the flushing zone. Rosacea is commonly an adult disease, and is generally restricted to the nose, cheeks, chin and forehead. It can coexist with acne vulgaris.

Some rosacea sufferers have a significant acne component in their symptoms so it can be easily confused with acne vulgaris. The papules and pustules of rosacea tend to be less follicular in origin. Blackheads are not seen with rosacea.

Rosacea will probably have an underlying redness that is related to flushing and thus looks different to acne vulgaris. Acne sufferers normally do not have the accompanying redness.

Manifestations

Rosacea usually begins with flushing, leading to persistent redness. Rosacea is a condition affecting the skin of the face, mostly the area where people blush. Rosacea blood vessels undergo changes in function and become hyper responsive to internal and external stimuli. These changes are ultimately responsible for the progression of all rosacea symptoms. There are a number of symptoms, ranging from mild to more severe.

• Redness, caused by vasodilatation or flushing and looks like a sunburn. Redness may persist and could be seen with dry skin.
  
• Acneform papules. No comedones, blackheads is seen. The lesions are not seen on the back and chest. Persistant vasodilatation and eventual skin irriatation may lead to these lesions.
  
• Telangectasis, damage or enlarged blood vessels .  It is caused by frequent vasodilatation.
  
• Rhinophyma, which is an enlarged, bumpy nose. It is seen in more advance stages and very much emotionaly disturbing.

Treatment

As both conditions are inflammatory, the treatment for rosacea and acne vulgaris can be somewhat similar. However differences in treatment exist and some regimens for acne treatment are too harsh for rosacea affected skin and can severely aggravate the condition.

Rosacea sufferers are cautioned against using common acne treatments such as alpha hydroxy acids (glycolic and lactic acids), topical retinoids, benzoyl peroxide, topical azelaic acid, triclosan, acne peels, chemical peels. Additionally the caution extends to topical exfoliants, toners, astringents and alcohol containing products.

Treatment of rosacea can help control the severity of the disease. Untreated, rosacea can lead to a condition where small blood vessels in the skin of the face become enlarged and look like thin red lines.

Current treatment might include oral antibiotics (similar to those used in acne treatment) and topical metronidazole. One study showed that the use of topical metronidazole alone can help some sufferers to reduce rosacea flare-ups once the rosacea is brought under control.

Experts agree that a gentle cleansing regime is very important. Avoiding chemicals that aggravate the rosacea, but will clean and moisturise the skin is a step in the right direction.

As sun exposure is a strong trigger for many rosacea sufferers, a good non-irritating sunscreen used daily is very important. For those who react badly to chemical sunscreens, a physical sunscreen may be more suitable. Physical sunscreens rely on the reflective properties of the main ingredients (rather than the ability of some chemicals to absorb the sun's energy). The most common physical sunscreens are based on zinc oxide or titatinium dioxide.

The vitamin A derivative isotretinoin (known as Accutane or Roaccutane), has been shown to be effective against severe papopustular rosacea, the same drug effective in treatment of severe acne. It works by inhibiting sebaceous gland function and physically shrinking the glands. It also has potent anti-inflammatory properties, making it ideal to treat resistant rosacea. At low doses, accutane has also been shown to reduce other symptoms such as facial burning and redness. Accutane is a strong drug, and even at the low doses found beneficial to rosacea, should be used under strict supervision of your doctor. Low does accutane may be more suitable than the regular dose, as there are less side effects and lesser chance of aggravating redness

The mixed light pulse laser, Photoderm is showing promise as a treatment for the vascular component of rosacea. It works by targeting facial microvessels that are damaged. This treatment is less effective for acne scar which respond to co2 laser especially when scar depth is not significant.

It is the third generation of topical mineral salt based treatment. The minerals shrink facial vessels as well as reduce papules and pustules.

Clonidine and Minoxidil are two anti hypertensive drugs which could also be used for treatment of vasodilation and flushing.

Topical steroids can worsen all rosacea symptoms by dilating facial blood vessels, thinning the protective skin barrier, and thinning the dermis by breaking down the collagen and elastin support structures

| American Academy of Dermatology | Dermatology Online Journal | Sebaceous Glands | Dermatology Health Guide | Sebaceous follicle Carcinoma | Role of nicotinamide in treatment of acne |

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