1. ROSACEA By Dan Ladd, D.O. Texas/KCOM Dermatology Residency Program Program Director Bill V. Way, D.O.

2. CC: ITCHY RASH ON FACE “STINGS” “BURNS” ONSET 2 DAYS TOPICAL CREAMS NOT HELPFUL PMX: NONE NO NEW MEDS NO NEW SOAPS OR PERFUMES

3. WHAT IS ROSACEA? VARIABLE DEGRESS OF….. CENTROFACIAL ERYTHEMA TELANGIECTASIAS PAPULES PUSTULES NODULES EDEMATOUS PLAQUES

4. EARLY ROSACEA (STAGE I) “FLUSHER-BLUSHERS” OFTEN < AGE 20 NOSE/CHEEKS RECURRENT EPISODES OF BLUSHING. ERYTHEMA PERSISTS FEW TELANGIECTASIAS

5. STAGE I - TELANGIECTASIAS

6. STAGE I TELANGIECTASIAS BECOME PROGRESSIVELY PROMINENT, FORMING SPRAYS ON THE NOSE, NASOLABIAL FOLDS, CHEEKS AND GLABELLA

7. STAGE II PAPULES & PUSTULES BEGIN, INCREASED ERYTHEMA AND TELANGIECTASIAS

8. STAGE III DENSE ERYTHEMA PAPULES, PUSTULES, NODULES. TELANGIECTASIAS SEVERE, DIFFUSE VARIABLE PLAQUE-LIKE EDEMA

11. ROSACEA VS. ACNE ADULTS PAPULES PUSTULES NO COMEDONES ERYTHEMA TELANGIECTASIAS TEENS PAPULES PUSTULES COMEDONES NO ERYTHEMA NO TELANGIECTASIAS

12. WHAT CAUSES ROSACEA? “VIRTUALLY NOTHING IS KNOWN ABOUT CAUSATION……….THE INFLUENCE OF HEREDITY IS MOOT, AS IS ALMOST EVERYTHING THAT HAS BEEN WRITTEN ABOUT ETIOLOGY” --A. Kligman Vasomotor lability? Hypertension? Demodex mite infestation? Solar damage? Heat? Caffiene? Lymphatic obstruction? Emotional stress?

13. Found within follicular infundibula & sebaceous ducts…

14. Commensal organisms….

15. NOT Pathogenic organisms….

16. TRIGGERS HOT LIQUID BEVERAGES, SOUPS ALCOHOL / CAFFEINE SPICY FOODS SUN EXPOSURE IRRITATING COSMETICS/OTC HEAT – EXERCISE IN COOL AREAS.

17. COMPLICATIONS COMPLICATIONS: RHINOPHYMA – DISFIGURING, NOSE OPHTHALMIC ROSACEA LESS COMMON VARIANTS: GRANULOMATOUS, STEROID, GRAM- NEGATIVE, CONGLOBATA, FULMINANS

18. RHINOPHYMA - EARLY

19. RHINOPHYMA MODERATE

20. SEVERE

22. RHINOPHYMA OCCURS EXCLUSIVELY IN MEN. PROGRESSIVE INCREASE IN CONNECTIVE TISSUE, SEBACEOUS GLAND HYPERPLASIA, ECTATIC VEINS AND CHRONIC DEEP INFLAMMATION. MAY OCCUE WITH STAGE III ROSACEA, BUT SURPRISINGLY, PATIENTS WITH RHINOPHYMA MAY ONLY HAVE MILD ROSACEA.

23. Treatment – Cosmetic Repair

24. OCULAR ROSACEA

26. COMMON, MAY BE FIRST SIGN OF ROSACEA VARIABLE PRESENTATION

27. OCULAR ROSACEA BLEPHARITIS CONJUNCTIVITIS PAIN, PHOTOPHOBIA IRITIS, IRIDOCYLITIS, KERATITIS MAY NEED OPHTHALMOLOGY CONS KERATITIS MAY LEAD TO BLINDNESS

28. TREATMENT - MILD SUNSCREENS TOPICAL SULFACETAMIDE/SULFUR TOPICAL METRONIDAZOLE ORAL TETRACYCLINE, DOXYCYCLINE, MINOCYCLINE

29. Topicals- Sulfacetamide/Sulfur Klaron 10% Lotion Rosula Lotion (with Urea) Sulfacet R Rosanil Cleanser Ovace Cleanser Plexion Cleanser, Suspension and SCT

30. Topical Metronidazoles Noritate 1% cream, Once a Day Metrocream 0.75% BID Metrolotion 0.75% BID Metrogel 0.75% BID

31. Tetracyclines Tetracycline 250-500mg QD or BID Very cheap, but must take 1 hour before or 2 hours after meals, less compliance Doxycycline 50-75-100mg QD or BID Generic, Doryx Pellets, Adoxa. Minocycline 50-75-100mg QD or BID Generic, Vectrin, Dynacin, Minocin

32. Tetracyclines Not for children due to teeth discoloration, may cause hyperpigmetation at sites of trauma in adults, stop medication if worsening headache occurs (pseudotumor cerebri) Photosensitivity reactions rare if patients on sunscreens

33. TREATMENT – SEVERE ORAL METRONIDAZOLE CLONIDINE 0.1mg QD or BID FOR FLUSHING HELPS PREDNISONE TAPER ISOTRETINOIN (ACCUTANE)

34. A SIMPLE REGIMEN FOR THE VAST MAJORITY OF ROSACEA PATIENTS WASH FACE GENTLY WITH CETAPHIL DAILY FACIAL CLEANSER APPLY KLARON LOTION QAM APPLY SUNSCREEN WASH FACE AGAIN AT NIGHT APPLY NORITATE CREAM QHS

35. A GOOD START…. KLARON LOTION, 4oz., apply qAM to face NORITATE CREAM, 30g, apply qHS to face

39. EXPECTATIONS TELL THEM TO EXPECT IMPROVEMENT IN 4-6 WEEKS TELL THEM TO CONTINUE REGIMEN UNTIL NEXT VISIT MAY GIVE ORAL TETRACYCLINES FOR FLARES INFORM THEM THERE IS NO CURE FOR ROSACEA!!!!!!!!!!!!!!!!!!!!

40. QUESTIONS