Hi everyone welcome back to another lesson. This lesson is on rosacea, so we’re going to talk about some of the potential causes of this condition. We’Re also going to talk about some of the triggers the signs and symptoms, so we’re going to get into some of the specific skin lesions that can occur with rosacea. Then we’re going to talk about how it’s diagnosed and how it’s treated so rosacea is a chronic inflammatory condition involving recurrent episodes of skin lesions on the face we’re going to get into more detail as to these exact skin lesions later on. In this lesson, rosacea is an autoimmune condition, which means that it is the patient’s own immune system that attacks its own cells and tissues to cause a lot of these signs and symptoms.
Now, although this is known to be an autoimmune condition, the pathophysiology is not entirely understood, but we’re going to talk about some of the known path physiology later on in this lesson and rosacea may be associated with other conditions, including inflammatory bowel disease like ulcerative, colitis and Crohn’S disease and cardiovascular diseases and neurologic diseases and rosacea is estimated to affect at least five percent of the general population, which means that it is a relatively common condition and it is more likely to affect certain ethnic groups, particularly those with celtic heritage. Those individuals with celtic heritage have a higher likelihood of having rosacea compared to other populations, and this condition affects individuals between the ages of 30 to 50. Most often now, let’s talk about some of the potential causes of rosacea. So although the causes are not entirely known, it’s believed that genetics are involved. We talked about some of those ethnic groups that are at a higher likelihood of having rosacea, so genetics are likely involved in rosacea now.
Some other potential causes of rosacea include demidex, mites demadex mites. Are these microscopic hair, follicle mites, and it’s been shown that, when looking at the lesions of patients who have rosacea their lesions contain high levels of these demodex mites, so there does seem to be an association between high levels of these demidex mites or these hair. Follicle mites and rosacea and there has been another potential cause that has been noted, and this is an infection with helicobacter, pylori or h pylori. This is a gram, negative bacteria that can cause an infection in the stomach, so there does seem to be an association between an infection with h, pylori and the onset of rosacea as well. There has also been some association with exposure to ultraviolet or uv rays.
This may be more of a trigger and we’re going to talk about triggers of skin lesions later on in this lesson, so this may be more of a trigger of rosacea, not the exact cause, and then certain medications have also been noted to either cause rosacea or Trigger an underlying rosacea, some of these medications include steroids and some blood pressure medications. Now, let’s talk about some of the pathophysiology behind.
Why rosacea occurs so it all has to do with dysregulation of the innate and adaptive immune functioning and vasodilation and dilation of lymphatic vessels. So vasodilation would be dilation of blood vessels, so these are the two main categories of mechanisms and the reason why these may occur why this regulation of innate and adaptive immune functioning may occur includes increased expression or over expression of pole, like receptor 2, which is a Cell receptor involved in innate and adaptive immune functioning, so over expression and over-activation of this receptor seems to be part of the pathophysiology in rosacea and with regards to the vasodilation and dilation of lymphatic vessels, there seems to be an increased release of vasoactive peptides, so increased Release of vasoactive peptides has been noted in patients with rosacea, and patients with rosacea also seem to have higher levels of other particular receptors, including increased or overexpression of transient, receptor potential, vanilloid, 1 or trpv1 receptor and increased expression of trpa1 or transient receptor potential. Anchoring 1 receptor – and there are some other receptors as well, and each of these receptors seems to also be associated with some of the triggers we’re going to talk about later on in this lesson.
So some of these are involved in heat and cold sensation that can cause changes to vasoregulation. So we’re going to talk a bit more about this later on in this lesson as well. So some of these receptors can be involved in why certain things trigger the onset of skin lesions in rosacea. But there also seems to be some interplay with having demodex mites or infestation of demodex mites and an infection with h, pylori, which seem to also increase some of the activation of some of these receptors in release of vasoactive peptides in some patients. So again, not all of the pathophysiology is known, but these are some of the known factors in rosacea.
Now there are several subtypes of rosacea that cause different clinical presentations. One subtype is known as erythematologic. This subtype is more commonly going to be the initial presentation of rosacea. Another one is papulo pustular. This one can appear like acne and often times will occur later on in life, so it can often times be termed.
As adult acne. There is also a subtype known as phymatis subtype and there’s also one that is known as ocular subtype, which affects the eye, so we’re going to talk about all the clinical signs and symptoms of each of these subtypes later on. In this lesson now it’s important to make note of the fact that individuals can have features of different subtypes. They can have some features of multiple subtypes and the subtypes may change over time. They may be more likely to have erythromatogetic subtype and then they may be more likely to have phymatis subtype later on in their life.
Now before we talk about the skin lesions, let’s talk about where they affect the face. Oftentimes, it’s going to affect the forehead, the nose and upper cheeks and the chin. These are going to be common areas where we see a lot of the lesions we’re going to talk about in this lesson and often times are going to be symmetric. So if you see it on one side, if you see it on the patient’s right side, you’re also going to see it on the patient’s left side, so they’re oftentimes going to be symmetric and in these locations now, let’s actually talk about the clinical features of rosacea. So, with regards to the erythomatolyn gectatic subtype, we see telangiectasias telongic pages.
Are these small dilated blood vessels that are often termed as spider veins? So we can see these on the face in those areas we talked about before this is oftentimes going to be more noted in older age. We can also see erythema, which is a reddening of the skin. This can be transient or non-transient, so transient being that it can come and go away, so it’s temporary or it can be non-transient, meaning that it can be permanent, so the patient’s face can become very reddened and oftentimes. This is going to affect younger age groups.
This again is going to be part of the erythemato phalangeatic subtype, and we can also see flushing in some patients, so flushing is going to again be a transient reddening of the face and it’s oftentimes going to occur in younger age groups. Now, with regards to the papulopostular subtype of rosacea that we talked about before this is going to lead to papules so papules are these inflammatory raised skin lesions and we can also see pustules so pustules are also inflammatory, but they are pus filled, so they can oftentimes. Be mistaken for acne and oftentimes be termed as adult acne or acne rosacea, but is not actually the same condition as acne, because there are no comedones. If you want more information on acne, please check out my full lesson on that topic, but suffice to say, with the skin lesions in rosacea the way to distinguish these papules and posturals from actually having acne vulgaris. There are no comedones and often times the patient’s going to have an episode of these clinical features and then they’re going to go into remission and then they’re going to go into another episode.
So there’s often going to be periods where they have an episode of skin lesions that go into remission and then something triggers them to also have another episode. So there’s oftentimes going to be a pattern of episode in remission of these skin lesions. Some other clinical features that can be noted with these skin lesions include burning sensation from the lesions, a tingling sensation from the lesions. A stinging sensation can also be noted and then pruritus, which is an itching sensation, so oftentimes these are going to be some of the other clinical features that can be noted from these skin lesions as well. Let’S talk about the ocular form of this condition, so the ocular form of rosacea actually affects a majority of patients that actually get rosacea so 50 to 75 percent of patients will have eye involvement and oftentimes.
It’S going to be noted with ocular rosacea is that patients have issues with dryness of their eyes, redness of their eyes or tearing. They can often have blurred vision or light sensitivity, and some more specific findings can be blepharitis, which is an inflammation of the eyelids conjunctivitis, which is an inflammation of the conjunctiva of the eyes keratitis, which is an inflammation of the cornea of the eye and iridus, which Is an inflammation of the iris of the eye, so all of these can be noted in patients with rosacea as well and again it can affect 50 to 75 percent of patients who have rosacea, and some patients can have another finding known as a rhinophyma. Rhinophyma is an enlargement of the nose, so this enlargement of the nose is due to hyperplasia of sebaceous glands, so these sebaceous glands become enlarged and lead to an enlargement of the nose, and this can often be due to chronic long-standing untreated rosacea. So if there is long-standing untreated rosacea, it can lead to this rhinophyma and what is noted with rhinophyma is that almost all cases of rhinophyma occur in males. It is very rare in female patients.
So again, this is another clinical presentation of rosacea that can be found and rhinophyma would be under the classification of the phymatis subtype of rosacea. Now, let’s talk about some of the triggering or exacerbating factors, we talked about some of the potential triggers that can cause or increase the likelihood of having skin lesions from rosacea. Some of these include stress, so stress, can trigger rosacea skin lesions. Consumption of caffeine can also trigger the onset of skin lesions. Alcohol can also trigger skin lesions as well, and consumption of hot liquids can trigger or worsen skin lesions in rosacea.
Some other exacerbating factors include eating certain spices, so certain very spicy foods can actually trigger the onset of skin lesions. In rosacea we talked about some of those receptors when we talked about the pathophysiology of rosacea and a lot of them can be triggered by certain spices. So capsaicin in some very spicy foods can actually trigger and activate some of those receptors. Significant temperature changes so going from very hot to very cold that can also trigger skin lesions as well sunlight exposure. We talked about uv light, potentially being a cause, but it’s more likely to be an exacerbating factor and then wind exposure, so wind hitting the face, especially with significant changes in temperature.
This can also exacerbate or trigger skin lesions in rosacea as well. So how do clinicians, diagnose and treat rosacea the diagnosis of rosacea is oftentimes, going to be a clinical diagnosis. So, looking at the history and physical examination and getting some of those triggers we talked about before this is going to be enough to make the diagnosis for clinicians now, with regards to how clinicians treat rosacea oftentimes they’re going to break it down into categories of treatments. So there’s going to be lifestyle treatments, so it’s important to avoid exacerbating and triggering factors we talked about those in the last slide and gentle cleansing with moisturizers can also be helpful for some of those skin lesions and then sun protection so photo protection using sunscreen with At least an spf of 30 can be helpful and the rest of the treatments are going to be more tailored to the specific type of rosacea. So, with regards to ocular rosacea artificial tears can be helpful and metronidazole eye drops can also be helpful with regards to erythema, so that reddening of the skin of the face brimonidine partridge gel, can be helpful in oxymetazoline.
Hydrochloride gel can also be helpful with regards to inflammatory lesions on the face. These include tetracycline and azithromycin, and topical metronidazole, topical zealic, acid and ivermectin cream to treat those demodex mites can also be helpful as well and with regards to issues with flushing in rosacea. Some clinicians may use propanol or curvatolo and laser therapy laser therapy can be helpful for the flushing in rosacea, and clinicians can often treat the phyma or the rhinophyma with doxycycline, isotretinoin and tetracycline, when it is in the inflammatory stage of the rhinophyma. But when it’s in the non-inflammatory stage, when it has become enlarged and permanent, surgical resection may be required, and laser surgery can also be helpful in reducing the rhinophyma. So if you want to learn more about other dermatology conditions, please check out my dermatology playlist and if you haven’t already please like and subscribe for more lessons like this one thanks much watching and hope see you next time.
Read More: rosacea-skincare-and-treatments-that-work-dr-sam-bunting/“>Rosacea: Skincare and Treatments That Work! | Dr Sam Bunting