CAM Exam #4

• chronic inflammatory cutaneous disorder that affects the central face
• progressive with intermittent periods of exacerbation and remission

small, dilated blood vessels on skin

reddening of skin as a result of vasodilation

swelling, mass, or hypertrophy of tissue

small, superficial, palpable lesion elevated on skin surface

superficial, elevated lesions that contains pus beneath epidermis

• increased prevalence among Northern Eurpoean descents
• more common in females
• males are more common to have skin disfiguration
• 30-50 yoa

• genetic - relatives or of Northern European descent
• fair skinned

• multifactorial:  inflammation
• pro-inflammatory substances & degradative enzymes released from inflammatory cells in facial dermis leads to angiogenesis & dermal destruction
• up regulate cytokines
• Microvascular:  abnormality of dermis surrounding vessels
• Sun damage
• Others:  bacteria (H. pyloir & Demodex folliculorum), neurologic, hormones

Trigger → recruitment and activation of infammatory cells and other immune cells in facial skin → release inflammatory mediators (histamine & PG) → release degradative enzymes → damage to CT supporting blood vessels → angiogenesis → multiple blood vessels in the face

• topical cosmetics/skin products
• weather
• emotions
• exercise
• beverages
• tobacco
• caffeine
• hormonal changes
• medications (nitroglycerin, BB, nitrates, topical steriods, niacin, amiodarone)

• Primary features:  one or more of transient erythema (flushing), nontransient erythema, papules, pustules, telangiectasia
• Secondary features:  burning/stinging, plaques, dry appearance, facial edema, phymatous changes, ocular manifestations

• 1. Erythematotelangiectatic (Vascular)
• 2. Papulopustular
• 3. Phymatous
• 4. Ocular

• identify & avoid triggers
• reduces/alleviate inflammatory lesions & erythema
• decrease flares
• prevent progression
• obtain remission & prevent exacerbations
• keep skin in good condition
• improve QOL

• most common type
• flushing & persistent central facial erythema
• telangiectasias common
• central face edema, stinging, burning, roughness, or scaling

• First Line:  avoid triggers
• Second Line:  phototherapy OR vascular laser therapy OR topical metronidazole and/or sodium sulfacetamide sulfur in AM (for pts w/ minimal barrier dysfunction) OR isotretinoin

• persistent central facial erythema w/ transient papules and/or pustules
• burning and stinging
• may occur concommitantly w/ vascular rosacea
• resembles acne vulgaris except comedones (white/black heads) are absent

First Line:  metronidazole/azelaic acid

• tetracylines - mainstay of oral therapy
• macrolides

• metronidazole
• isotretinoin (Not first line due to SE & birth defects) - tx refractory disease & has a delayed effect

• vascular laser therapy
• phototherapy

• long-term tx necessary (at least 12 wks) - gradual improvement takes weeks
• relapse often occurs w/i weeks of d/c systemic tx
• topical tx can maintain remission - 6 wks is recommended

• least common subtype overall
• men > women
• thickening skin, nodules, hypertrophy, and hyperplasia of sabaceous glands and CT
• rhinophyma = nose rosacea
• may have telangectasias
• observed concomitantly/after subtype 1 or 2
• social stigma of "alcoholic"

• Antibiotics play limited role
• Isotretinoin - beneficial for early dz; delay progression; decrease hypertrophy & sebaceous glands
• Other for advanced dz:  electrosurgical sculpting & laser therapy

• dx w/ one of the following:  watery/bloodshot eyes, foreign body sensation, burning/stinging, dryness, itching, sensitivity to light, blurred vision, telangectasias of eye or eyelid, or periocular erythema
• blepharitis, conjunctivitis, or irregularity of eyelid margins
• vision changes are rare
• frequently dx w/ cutaneous signs of rosacea

• Broad spectrum ATB:  azithromycin, polymyxin B/trimethoprim, erythromycin, bacitracin
• Topical steroid solution:  rimexolone, loteprednol, fluorometholone (short course for systemic tx) ~2-3 wks to avoid cataracts

• tetracyclines - only one shown to tx ocular rosacea
• macrolides - good in kids
• metronidazole
• istretinoin (severe dz)

• usually 6-12 wks
• gradual tapering of dose after improvement achieved
• relapse after d/c common

• referall to opthalmologist recommended
• eyelid hygeine - clean eyelids with warm water BID; hot compress 5-10 min QD
• artificial tears

• ATB
• metallic taste, N/V/D
• Disulfiram rx - avoid alcohol
• take w/ food to avoid GI upset

• ADR - dyslipidemia, increased liver fxn tests
• iPLEDGE program - part of REMS program
• only prescribed for 30 days

• FDA approved for rosacea
• apply BID on affected areas on face
• wait to dry before placing cosmetics to face
• ADR - burning, stinging, tinging, pruritis

• ADR - photosensitivity, hepatotoxicity
• CI - 2nd & 3rd trimester and kids < 8 years

• ADR - GI upset, dizziness, HA, taste disturbances (metallic taste)
• DI - erythromycin

• avoid potential triggers
• stress mgmt techniques
• use moisturizer to protect against wind and cold
• coping with humidity/overheating due to exercise - chew on ice chips or use cool, moistened towel; immediately rinse off salt/Cl water; avoid being outside/exercising during hottest time of the day (10 am-2 pm)