Rosacea - External and Internal Eye
See also in: Overview,Cellulitis DDxAlerts and Notices
Synopsis
The etiology of rosacea is incompletely understood but likely involves dysregulation of immune and neurocutaneous mechanisms. Cutaneous vascular changes, ultraviolet (UV) and microbial exposure (ie, Demodex mites, Bacillus oleronius, and Staphylococcus epidermidis), and disruption of the epidermal barrier have all been implicated as playing a role in the pathogenesis in this condition. There have been reports of familial rosacea, so an underlying genetic predisposition has not been ruled out. In fact, rosacea has been found to be associated with single nucleotide polymorphisms in genes coding for major histocompatibility complex (MHC).
Rosacea primarily affects individuals with lighter skin phototypes, namely those of northern European and Celtic descent. In individuals with darker skin colors, rosacea may be underdiagnosed due to difficulty in discerning erythema and telangiectasias. Rosacea has been found to have no sex predilection, in contrast to previous studies noting a female predominance.
According to the American National Rosacea Society, there are 4 main subtypes of the disease: erythematotelangiectatic, papulopustular, phymatous, and ocular rosacea.
- Erythematotelangiectatic rosacea – Presents with persistent erythema of the central portion of the face with intermittent flushing. Telangiectasias are present in most individuals. Patients often mention stinging or burning sensations on the skin. This is the most common subtype.
- Papulopustular rosacea – Presents with variable intensity of central facial erythema with relative sparing of the periocular areas and a variable number of acneiform papules and pustules. Dramatic swelling can result in lymphedematous changes manifesting as solid facial edema or lead to phymatous changes.
- Phymatous rosacea – Chronic inflammation and edema result in marked thickening of the skin with sebaceous hyperplasia, resulting in an enlarged, cobblestoned appearance of affected skin, most commonly on the nose (rhinophyma). Men are more often affected. Less commonly, phymatous rosacea can affect the ears (otophyma), chin (gnatophyma), forehead (metophyma), or eyelids (blepharophyma).
- Ocular rosacea – Symptoms of mild ocular rosacea include gritty sensation, dryness, tearing, and itching of the eyes. Styes occur frequently. More active ocular rosacea can present as blepharitis, lid margin telangiectasia, and conjunctival injection.
Patients can present with characteristics of more than one subtype. More than half of patients with rosacea present with ocular symptoms.
Diagnostic criteria for rosacea were ratified in 2017 by the global ROSacea Consensus (ROSCO) panel and subsequently approved by the American National Rosacea Society. Two features were identified as being independently diagnostic for rosacea: phymatous changes and persistent centrofacial erythema with periodic intensification by potential trigger factors. In their absence, 2 or more major features and some minor features can be used to establish the diagnosis. Major features are flushing / transient centrofacial erythema, telangiectasia, inflammatory papules / pustules, and ocular manifestations. Minor features are burning, stinging, and dry sensation of the face and edema.
Since rosacea manifests on the face, it is important to recognize that this disease can have psychosocial consequences, which may affect quality of life and social and psychological wellbeing.
Codes
ICD10CM:L71.9 – Rosacea, unspecified
SNOMEDCT:
398909004 – Rosacea
Look For
Subscription Required
Diagnostic Pearls
Subscription Required
Differential Diagnosis & Pitfalls
Eye changes:- Chronic blepharitis (allergic, bacterial, viral)
- Hordeolum or chalazion
- Chlamydia
- Dry eye syndrome
- Keratitis (bacterial, herpetic, atopic, sicca)
- Corneal ulceration
- Mucous membrane pemphigoid
- Acne vulgaris
- Perioral dermatitis (periorificial dermatitis)
- Steroid- induced rosacea-like eruptions (eg, from topical steroids) are typically composed of monomorphic inflammatory papules and pustules
- Lupus miliaris disseminatus faciei
- Bromoderma
- Folliculitis
- Sarcoidosis
- Demodex folliculitis
- Menopause, "hot flashes"
- Cellulitis (usually unilateral)
- Erysipelas (usually unilateral)
- Lupus erythematosus
- Seborrheic dermatitis
- Photosensitive or photoallergic drug eruption
Best Tests
Subscription Required
Management Pearls
Subscription Required
Therapy
Subscription Required
Drug Reaction Data
Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.Subscription Required
References
Subscription Required
Last Reviewed:02/15/2022
Last Updated:05/11/2022
Last Updated:05/11/2022
Patient Information for Rosacea - External and Internal Eye
Overview
Rosacea, sometimes called adult acne, is a chronic inflammation of the face of unknown cause and without a permanent cure. Four different types of rosacea have been described:- "Red face" rosacea with face flushing (erythrotelangiectatic rosacea), which can progress to a persistent redness of the nose or central face
- Acne-like bumps and/or pus-filled lesions (papulopustular rosacea), with or without a red face and flushing
- Bumpy, thickened skin of the nose (rhinophyma), with slow enlargement of oil glands and sometimes skin thickening of other areas of the face, usually in men
- Eye problems (ocular rosacea), which may occur before skin changes, in which a burning or gritty feeling may be present, as well as reddening of the eyes and eyelids
Who’s At Risk
Adults aged between 30 and 60 are most often affected by rosacea, and it most commonly affects women. In most people, rosacea comes and goes periodically; in some, it gets worse with time.Rosacea flares can be triggered by increased blood flow to the face, such as from sunlight, hot drinks, spicy foods, alcohol, exercise, hot baths or saunas, temperature extremes, and emotional stress. Prolonged use of cortisone creams on the face can also lead to rosacea.
Signs & Symptoms
- Persistent or recurrent redness of the central face, sometimes with swelling
- In darker skin colors, redness may have a more violet hue, and affected skin may appear darker or dusky brown
- Papules (small, raised bumps) or pustules (small pus-filled bumps) on the face, without blackheads and whiteheads
- A red, bulb-shaped nose
- Small telangiectasia (flat red, purple, or blue blood vessels, also called spider veins) on the central face
- A burning or gritty feeling in the eyes, with or without red eyelids
- Mild – occasional blushing and/or only rare lesions
- Moderate – frequent blushing, persistent face redness, and/or a few lesions almost all the time
- Severe – includes some or all the following:
- Lots of papules and pustules all the time
- Red, uncomfortable eyes all the time
- A large, bulbous nose
- Several telangiectasia on the face
Self-Care Guidelines
Identify and minimize any exposure that triggers episodes of rosacea:- Use a broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or more on your face.
- Avoid your triggers, which may include drinking hot liquids and alcohol, eating spicy foods, and excessive heat exposure.
- Protect your face in cold weather with a scarf or mask.
- Avoid facial products with alcohol or other skin irritants (such as astringents, toners, sorbic acid, menthol, and camphor), and use mild cleansers for the face.
- Green- or yellow-tinted makeup can help hide redness.
- Cool compresses and gel masks may be of some benefit.
- Some over-the-counter products can help to minimize redness, eg, the Aveeno Ultra-Calming range of products and the Eucerin Redness Relief line.
- Eye rosacea can be treated with warm water compresses 2-4 times a day followed by gentle cleaning of the eyelid rims with baby shampoo (eg, Johnson's Baby Shampoo) on a cotton swab. Artificial tears can be used if your eyes feel gritty or uncomfortable.
When to Seek Medical Care
If your rosacea causes changes in your appearance or symptoms that interfere with your daily life, you should seek medical care. If you have severe, persistent flushing, there are other possible causes of flushing requiring laboratory tests; see a medical professional. See an ophthalmologist for persistent or worsening eye symptoms.Treatments
- Topical washes, creams, or lotions with metronidazole (MetroCream), clindamycin (Cleocin T), erythromycin (AkneMycin), prescription-strength sulfur (Liquimat, Sulpho-Lac), sodium sulfacetamide (Sulfacet R), azelaic acid (Azelex, Finacea), or ivermectin (Soolantra).
- If these are only partially helpful, oral antibiotics can be very effective (tetracycline [Sumycin, Actisite], erythromycin, ampicillin [Ampi], or metronidazole [Flagyl]).
- Brimonidine topical gel (Mirvaso) or oxymetazoline cream (Rhofade) can help reduce facial redness.
- Isotretinoin (Amnesteem, Claravis) is used for very severe cases of rosacea and has significant side effects.
- Surgical treatment with lasers or electrocautery can reduce the visibility of blood vessels and the extra nose tissue in rhinophyma.
- Prescription eyedrops and oral antibiotics may be prescribed for rosacea affecting the eyes.
Rosacea - External and Internal Eye
See also in: Overview,Cellulitis DDx