Red facial rash with “granitos”

Subtype 3: Phymatous rosacea. The third stage is also called the rhinophymatous stage. It is characterized by deepening shades of erythema and more papules and pustules. In the chronic forms of rosacea, hyperplasia of the sebaceous glands occurs, which forms a thickened confluent plaque of erythema at the tip of the nose known as rhinophyma. This hyperplasia can cause significant disfigurement to the forehead, eyelids, chin, and nose. The nasal disfiguration is seen more commonly in men than women (FIGURE 4).

Subtype 4: Ocular rosacea.The final or fourth stage is an advanced variation of rosacea that is characterized by impressive, severe flushing with persistent telangiectasias, papules, and pustules. At this point, more severe forms of conjunctivitis and blepharitis are more fullblown. The patient may complain of watery eyes, a foreign body sensation, burning, dryness, vision changes, and lid or periocular erythema.³

Diagnosis and treatment

Diagnostic tests

The diagnosis of rosacea is a clinical one. There is no confirmatory laboratory test. Biopsy is warranted only to rule out alternative diagnoses, since histopathological findings are not diagnostic. Scrapings may reveal Demadex folliculorum infection.¹

Treatment: Target the inflammation It is important to reassure patients about the benign nature of the disorder as well as explain that its cause is unknown. It may be useful to direct patients to information, such as web sites like those of the National Rosacea Society (www.rosacea.org). Advise patients to keep a daily diary to identify precipitating factors. These can include hot and humid weather, alcohol, hot beverages, spicy foods, and large hot meals. Suggest daily application of sunscreen, which protects against UVA and UVB rays.

Depending on the severity of the skin rosacea, the first-line treatment is an oral antibiotic (tetracycline or erythromycin) and/or topical metronidazole (0.75%–1.0%) twice daily. These antibiotics target the inflammation because rosacea is not a true infection. There is concern in the medical literature about how long-term use of antibiotics can promote drug resistance. Wolf et al⁴ proposed that once a patient’s lesions have improved after treatment with full-dose antibiotics, the clinician can consider switching to a lower dose and adding a topical agent such as metronidazole for maintenance.⁴ Studies have shown that 1.0% and 0.75% cream are equally effective.

TABLERosacea treatments