The Proposed Inflammatory Pathophysiology of Rosacea: Implications for Treatment

Larry Millikan, MD

Disclosures

Skinmed. 2003;2(1) 

In This Article

Rosacea as a Clinically-Defined Condition

Rosacea is not actually a disease, but rather a chronic dermatologic condition that predominantly affects the convexities of the central aspect of the face.[5,6,7] Facial rosacea is usually delineated into four distinct clinical stages, but there are two consistent characteristics present in all stages of rosacea -- frequent facial flushing (Figure 1) and facial actinic damage, especially solar elastosis (Figure 2).[2,5,8,9,10]

Chronic erythema, flushing, blushing with cyclical crops of pustules, papules. After medication (minocycline and metronidazole), flares are minimized.

Chronic recurring inflammatory lesions of several years' duration, now responding to metronidazole.

The first clinical presentation of facial rosacea involves frequent and intense vasodilatation of superficial facial vasculature. These signs constitute the pre-rosacea stage.[5,6,8,11] In susceptible individuals, this brisk flushing can be easily induced by a number of nonspecific triggers[5,12] ( Table I ).

After years of transient, prolonged blushing or flushing, most patients eventually progress to the vascular stage of rosacea, developing erythema that persists for hours or days.[8] The persistent erythema often masks concurrent development of telangiectases, dilated superficial veins.[2,6,7] Many patients remain stable at the vascular stage of rosacea, never developing the more severe manifestations associated with advanced rosacea.[13]

A subset of patients, however, progress within a few years to the inflammatory stage, which is characterized by a bilateral, symmetrical array of papules and pustules on a background of permanent erythema and telangiectasia.[1,5,7,9,13] The bouts of inflammatory lesions are often sudden and intense, without apparent triggers.[13] If left untreated, the inflammatory state can become constant.[13]

A few patients, mostly men, progress to the ultimate stage of rosacea ( Table II ), easily recognized by distinctive tissue hyperplasia and disfiguring phyma.[2,5] The most common is rhinophyma, a bulbous hypertrophy of the nose.[2,7]

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