As the handout Drs. Danby and Margesson have created makes clear, rosacea can be difficult to pin down, largely because of its different forms and its similarity to and overlap with disorders with which it can in fact co-exist. Beyond the “rosy” flushing/blushing that describes its classic form, are these four subtypes with a total of six components: 1. erythematotelangiectatic rosacea — with the two vascular components, telangiectasias and erythema 2. papulopustular rosacea — with two acne-like features, papules and pustules 3. phymatous rosacea — with skin thickening (W.C. Field’s nose is a well known example.) 4. ocular rosacea — with eye irritation
By Any Other Name …
But even subcategories don’t begin to cover rosacea, explains Dr. Danby. “The diagnosis cannot hang on the vascular changes alone, because these features are quite capable of existing by themselves. Therefore, I have begun to diagnose such patients as having ‘‘pseudorosacea.’’ It seems a better fit than other terms bandied about such as ‘‘inconstant vasodilatory and actinic telangiectatic non-rosacea.’’
Patient Expectations
Along with the general confusion among medical specialists, Dr. Danby observes, patients are likely to be frustrated by their doctors’ inability to cure this chronic and often emotionally difficult illness, which can be embarrassing if for no other reason than that its primary symptom, flushing-blushing, is nearly synonymous with social anxiety.
Treatment Targets Symptoms
Dr. Danby describes the complexities of treatment based on the six components of the disorder, some of which may require referrals to an ophthalmologist or laser specialist. Papules and Pustules “Of the six components of rosacea, two — the papules and the pustules — are easily managed in most (but not all) cases by topical metronidazole or sulfur/sulfacetamide products, with or without oral antibiotics; there is diminution of some of the erythema as the inflammation associated with these components lessens.” Erythema and Telangiectasias Yet, he continues, “That leaves us with the need to explain that the two vascular components are manageable only with a vascular laser for the telangiectases or an intense pulsed light (IPL) unit for the background erythema, or both.” This, he notes, may raise suspicion among patients then presented with uninsured light or laser options. Phymatous Rosacea As for that bulbous W.C. Fields nose, rhinophyma, now referred to as ‘‘phymatous rosacea,’’ that will require surgical reduction in one of several ways, usually requiring another referral. Ocular Rosacea “Sixth and last, if the patient responds to careful questioning that an itchy or scratchy or gritty feeling in the eyes is part of the problem, then a diagnosis of ocular rosacea and a referral to an ophthalmologist should be considered,” Drs. Danby and Margesson agree.
When Rosacea is Suspected
Drs. Danby and Margesson also agree that a primary care practitioner noting acne rosacea may offer initial treatment with topicals supplemented as needed with oral cyclines and other anti-inflammatories. However, they maintain, failure to respond should trigger a referral to a dermatologist for consideration of at least seven differential diagnoses, including postadolescent acne, contact dermatitis, drug reaction, seborrheic dermatitis, perioral dermatitis, polymorphous light eruption, and facial psoriasis. “In the absence of the papules and pustules, where only flushing and telangiectasia exist, actinic erythema and/or actinic telangiectasia would be better referring diagnoses,” says Dr. Danby. The dermatologist should be able to confirm the diagnosis, consider the several alternatives, and direct the patient to appropriate care, including sun avoidance techniques and truly broad-spectrum sunscreens. n
As the handout Drs. Danby and Margesson have created makes clear, rosacea can be difficult to pin down, largely because of its different forms and its similarity to and overlap with disorders with which it can in fact co-exist. Beyond the “rosy” flushing/blushing that describes its classic form, are these four subtypes with a total of six components: 1. erythematotelangiectatic rosacea — with the two vascular components, telangiectasias and erythema 2. papulopustular rosacea — with two acne-like features, papules and pustules 3. phymatous rosacea — with skin thickening (W.C. Field’s nose is a well known example.) 4. ocular rosacea — with eye irritation
By Any Other Name …
But even subcategories don’t begin to cover rosacea, explains Dr. Danby. “The diagnosis cannot hang on the vascular changes alone, because these features are quite capable of existing by themselves. Therefore, I have begun to diagnose such patients as having ‘‘pseudorosacea.’’ It seems a better fit than other terms bandied about such as ‘‘inconstant vasodilatory and actinic telangiectatic non-rosacea.’’
Patient Expectations
Along with the general confusion among medical specialists, Dr. Danby observes, patients are likely to be frustrated by their doctors’ inability to cure this chronic and often emotionally difficult illness, which can be embarrassing if for no other reason than that its primary symptom, flushing-blushing, is nearly synonymous with social anxiety.
Treatment Targets Symptoms
Dr. Danby describes the complexities of treatment based on the six components of the disorder, some of which may require referrals to an ophthalmologist or laser specialist. Papules and Pustules “Of the six components of rosacea, two — the papules and the pustules — are easily managed in most (but not all) cases by topical metronidazole or sulfur/sulfacetamide products, with or without oral antibiotics; there is diminution of some of the erythema as the inflammation associated with these components lessens.” Erythema and Telangiectasias Yet, he continues, “That leaves us with the need to explain that the two vascular components are manageable only with a vascular laser for the telangiectases or an intense pulsed light (IPL) unit for the background erythema, or both.” This, he notes, may raise suspicion among patients then presented with uninsured light or laser options. Phymatous Rosacea As for that bulbous W.C. Fields nose, rhinophyma, now referred to as ‘‘phymatous rosacea,’’ that will require surgical reduction in one of several ways, usually requiring another referral. Ocular Rosacea “Sixth and last, if the patient responds to careful questioning that an itchy or scratchy or gritty feeling in the eyes is part of the problem, then a diagnosis of ocular rosacea and a referral to an ophthalmologist should be considered,” Drs. Danby and Margesson agree.
When Rosacea is Suspected
Drs. Danby and Margesson also agree that a primary care practitioner noting acne rosacea may offer initial treatment with topicals supplemented as needed with oral cyclines and other anti-inflammatories. However, they maintain, failure to respond should trigger a referral to a dermatologist for consideration of at least seven differential diagnoses, including postadolescent acne, contact dermatitis, drug reaction, seborrheic dermatitis, perioral dermatitis, polymorphous light eruption, and facial psoriasis. “In the absence of the papules and pustules, where only flushing and telangiectasia exist, actinic erythema and/or actinic telangiectasia would be better referring diagnoses,” says Dr. Danby. The dermatologist should be able to confirm the diagnosis, consider the several alternatives, and direct the patient to appropriate care, including sun avoidance techniques and truly broad-spectrum sunscreens. n
As the handout Drs. Danby and Margesson have created makes clear, rosacea can be difficult to pin down, largely because of its different forms and its similarity to and overlap with disorders with which it can in fact co-exist. Beyond the “rosy” flushing/blushing that describes its classic form, are these four subtypes with a total of six components: 1. erythematotelangiectatic rosacea — with the two vascular components, telangiectasias and erythema 2. papulopustular rosacea — with two acne-like features, papules and pustules 3. phymatous rosacea — with skin thickening (W.C. Field’s nose is a well known example.) 4. ocular rosacea — with eye irritation
By Any Other Name …
But even subcategories don’t begin to cover rosacea, explains Dr. Danby. “The diagnosis cannot hang on the vascular changes alone, because these features are quite capable of existing by themselves. Therefore, I have begun to diagnose such patients as having ‘‘pseudorosacea.’’ It seems a better fit than other terms bandied about such as ‘‘inconstant vasodilatory and actinic telangiectatic non-rosacea.’’
Patient Expectations
Along with the general confusion among medical specialists, Dr. Danby observes, patients are likely to be frustrated by their doctors’ inability to cure this chronic and often emotionally difficult illness, which can be embarrassing if for no other reason than that its primary symptom, flushing-blushing, is nearly synonymous with social anxiety.
Treatment Targets Symptoms
Dr. Danby describes the complexities of treatment based on the six components of the disorder, some of which may require referrals to an ophthalmologist or laser specialist. Papules and Pustules “Of the six components of rosacea, two — the papules and the pustules — are easily managed in most (but not all) cases by topical metronidazole or sulfur/sulfacetamide products, with or without oral antibiotics; there is diminution of some of the erythema as the inflammation associated with these components lessens.” Erythema and Telangiectasias Yet, he continues, “That leaves us with the need to explain that the two vascular components are manageable only with a vascular laser for the telangiectases or an intense pulsed light (IPL) unit for the background erythema, or both.” This, he notes, may raise suspicion among patients then presented with uninsured light or laser options. Phymatous Rosacea As for that bulbous W.C. Fields nose, rhinophyma, now referred to as ‘‘phymatous rosacea,’’ that will require surgical reduction in one of several ways, usually requiring another referral. Ocular Rosacea “Sixth and last, if the patient responds to careful questioning that an itchy or scratchy or gritty feeling in the eyes is part of the problem, then a diagnosis of ocular rosacea and a referral to an ophthalmologist should be considered,” Drs. Danby and Margesson agree.
When Rosacea is Suspected
Drs. Danby and Margesson also agree that a primary care practitioner noting acne rosacea may offer initial treatment with topicals supplemented as needed with oral cyclines and other anti-inflammatories. However, they maintain, failure to respond should trigger a referral to a dermatologist for consideration of at least seven differential diagnoses, including postadolescent acne, contact dermatitis, drug reaction, seborrheic dermatitis, perioral dermatitis, polymorphous light eruption, and facial psoriasis. “In the absence of the papules and pustules, where only flushing and telangiectasia exist, actinic erythema and/or actinic telangiectasia would be better referring diagnoses,” says Dr. Danby. The dermatologist should be able to confirm the diagnosis, consider the several alternatives, and direct the patient to appropriate care, including sun avoidance techniques and truly broad-spectrum sunscreens. n
