Answer: C

Rosacea is a chronic, progressive inflammatory disease of the pilosebaceous unit, classically presenting with pustules, papules, or telangiectasias on the face. These paroxysmal flares of lesions are accompanied by underlying erythematous, sensitive skin. Patients often complain of flushing, itching, and burning skin with outbreaks. Rosacea is most common in middle-aged and elderly populations, with higher prevalence in countries with more lighter-skinned individuals.15 Rosacea may appear differently in different races, with papules and pustules more commonly seen in lighter-skinned individuals than in those with darker skin.16

Although the specific pathogenesis of rosacea is unknown, it appears to occur when those with a genetic predisposition are exposed to certain environmental factors.16 Overproduction of antimicrobial peptides, reaction to skin mites, inappropriate cytokine release and B-cell response, overproduction of toll-like receptors, and abnormal vasomotor and nervous response have all been implicated in the pathogenesis of rosacea.15 Although multifactorial in inheritance, twin studies suggest that half of the risk for developing rosacea is genetic, including patterns in MHC class II genes and BPTK3 genes.17 Only in Haber syndrome, where rosacea is one of many classic symptoms, is rosacea directly inherited in an autosomal-dominant manner.15,18


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Triggering factors for rosacea include topical agents, smoking, oral medications, weather or temperature changes, certain foods, and emotional changes.19 The role of Helicobacter pylori in triggering rosacea is still being debated.20 Rosacea due to chronic sun damage as well as long-term topical or oral steroid use has also been observed.

There are several classifications systems for rosacea. One is based on phenotype, with the subtypes of telangiectasias, phyma, transient and persistent erythema, and inflammatory papules or pustules. An older system of classification describes subtypes: I (erythematotelangiectatic rosacea), II (papulopustular rosacea), III (phymatous rosacea), and IV (ocular rosacea).

In subtype I, the central area of the face, especially the nose and cheeks, becomes erythematous and edematous due to chronically dilated capillaries. Differential diagnosis for subtype I includes systemic lupus erythematosus, menopausal hot flashes, dermatomyositis, polycythemia vera, atopic eczema, phototoxic reactions, and pheochromocytoma. Subtype II is classified by inflammatory papules and pustules, and the differential diagnosis often includes papulopustular acne, contact dermatitis, granulomatous rosacea, cutaneous sarcoidosis, and eosinophilic folliculitis. Subtype III involves sebaceous gland hyperplasia, typically on the nose, which results in rhinophyma. The differential diagnosis includes chilblain lupus, angiosarcoma, and eosinophilic granuloma. In subtype IV, there is ocular involvement resulting in symptoms such as eye dryness, irritation, conjunctivitis, and blepharitis. Bacterial, allergic, or viral conjunctivitis should also be considered in the differential diagnosis.15, 20

A thorough clinical examination, history, and medication review are essential for the correct diagnosis of rosacea, especially as it can take several different forms. Features indicative of rosacea include centrofacial erythema, phymatous growths, and papules and pustules, whereas skin thickening, scarring, scaling, or unilateral symptoms would indicate a different pathology. Diagnosis is usually clinical; however, biopsy can be performed to rule out lupus erythematosus and life-threatening angiosarcoma. On biopsy, rosacea will appear as dilated blood vessels in the middle and upper dermis, often with a perivascular or perifollicular lymphocytic infiltrate. Extensive histologic changes are not characteristics of subtype I rosacea, whereas spongiotic changes and intrafollicular neutrophils are seen in subtype II. The histology of subtype III is characterized by cysts, granulomas, and hyperplastic sebaceous glands.15

Although treatment for rosacea is not curative, both topical and oral agents are used to help control symptoms. As there are many factors that contribute to rosacea, no one clear target for treatment has been well established. Topical antibiotics, such as clindamycin, erythromycin, and metronidazole, and topical vitamin A act as anti-inflammatory agents. Other topical agents such as sulfacetamide sulfur and azelaic acid are also routinely prescribed, although they can be more irritating to the skin than topical antibiotics. Topical vitamin C has shown benefit in some studies, suggesting that free-radical damage plays a role in rosacea. Oral tetracycline is often used in combination with topical therapy. If tetracycline use in contraindicated, such as during pregnancy, penicillin, erythromycin, amoxicillin, or ampicillin may be prescribed. Oral isotretinoin, spironolactone, ondansetron, cyclooxygenase-2 inhibitors, and prednisone have also been effective for treating rosacea. Nonmedical treatment — such as photo or laser therapy, sun avoidance, sunscreen use, regular moisturizer use, and avoidance of triggering factors — are important for preventing outbreaks.20

Rosacea can be a disfiguring disorder, and satisfactory results may not be attainable even with multiple treatments. Psychological screening is advised for individuals with rosacea, and appropriate counseling of the disease course can provide a realistic expectation of treatment.20 The patient was advised to avoid the triggers of spicy foods when possible.  She was also prescribed doxycycline 40 mg/d. The patient was also counseled on sun avoidance and sunscreen use. 

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Claire Wiggins, BS, and Michelle Eugene Lee, BA, are medical students at Baylor College of Medicine, and Christopher Rizk, MD, is a dermatologist at Elite Dermatology in Houston, Texas.

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