An update on the management of rosacea and its complications

By Dr Daron Seukeran / 01 Feb 2015

Aesthetics Conference and Exhibition speaker and presenter Dr Daron Suekeran outlines methods for treating rosacea

Rosacea is a chronic inflammatory disorder of the skin primarily affecting the central face (cheeks, chin, nose and central forehead). The primary symptoms are often flushing with transient erythema, fixed erythema, papules and pustules and telangiectasia. Secondary symptoms may be a burning or stinging sensation, ocular manifestations and rhinophymatous changes.1 

Rosacea more commonly affects patients with fair skin, particularly those of Celtic or Northern European origin. It is rare in patients of less than 30 years of age, and is generally thought to be more common in women, especially in the age group 36-50 years.2 Rosacea can often be a socially stigmatising disease, since facial flushing and skin changes can be mistakenly attributed to alcohol abuse. Patients with rosacea experience more stress than healthy individuals and the embarrassment and lower esteem caused by rosacea can result in social and professional isolation, which may often be underestimated by physicians.3

The precise aetiology of rosacea remains largely unknown. Numerous theories have been proposed including age, immunity, vascular changes, reactive oxygen species (ROS), ultraviolet radiation and microbes. Many factors seem to trigger or lead to a flare of rosacea symptoms and these triggers vary from patient to patient. The common factors tend to be sun exposure, hot environments, alcohol consumption, spicy foods and caffeine, emotion and stress.4 Since the aetiology of rosacea is poorly understood, treatment targets the disease symptoms rather than the underlying cause. 

Red facial appearance caused by rosacea 

Types of rosacea

Rosacea is often classified as erythematotelangiectatic, papulopustular, rhinophymatous and ocular.1 Erythematotelangiectatic rosacea consists predominantly of telangiectasia, which are small dilated blood vessels on the face associated with flushing – central facial erythema. This is the most common form of rosacea affecting roughly 70% of patients with the condition.1 Patients often report a long history of a flushing response to a variety of stimuli. Often, patients get a characteristic sparing of the peri-ocular region also. 

The second type is papulopustular rosacea. These patients often have central facial erythema with transient papules and pustules in a central facial distribution. This type of rosacea accounts for just over 20% of patients,1 and this is the sub-type that most closely resembles acne vulgaris without comedones.

Rhinophymatous change is where the patient experiences a thickening of the skin, particularly over the anterior aspect of the nose. This is a combination of fibrosis, sebaceous hyperplasia
and lymphoedema. This affects just over 3% of male patients and about 1% of female patients.5 The last type, ocular rosacea, is when rosacea affects the eyes, causing a burning or stinging sensation.1

Treatment

The aim of treatment is to alleviate the signs and symptoms such as reddening of the skin, flushing and irritation, and to reduce papules and pustules. In terms of the papulopustular component, this has often been treated with topical agents such as Metronidazole or Azelaic acid, often combined with an oral antibiotic such as a tetracycline or erythromycin. The drugs are often taken for at least four months. Although topical and oral treatments are effective for inflammatory lesions, they have limited effect on diffuse facial erythema and telangiectasia.6

Since the aetiology of rosacea is poorly understood, treatment targets the disease symptoms rather than the underlying cause 

It is advised to use sun protection, protective sunscreens if sunshine is a precipitating factor and to avoid other trigger factors through lifestyle changes. Medical treatments for flushing have proven di cult. Betablockers and other drugs such as clonidine have been used to try and reduce flushing find these often lead to a partial response and I have not found them to be effective in most patients. 

A new topical treatment, brimonidine tartrate, to treat facial erythema has been developed. This is a highly selective alpha-2 adrenergic receptor agonist with potent vaso-constrictor activity. The alpha-2 adrenergic receptor is found in vascular smooth muscle and induces vasoconstriction in the peripheral blood vessels.7 This targets areas of persistent facial erythema. It normally is applied to the affected areas of the face and usually has an effect within 30 minutes of its first application. This can last for up to twelve hours,8 and can be very helpful in reducing erythema, but is not a cure for rosacea symptoms. 

The most frequent related adverse effect included worsening of erythema and flushing, pruritis and skin irritation in one third of patients, though no serious adverse effects were observed.8 Patients may still induce flushing by exposing themselves to factors which they would normally avoid.8 In recent years, however, the use of lasers has led to significant advances in the treatment of rosacea.

Laser treatment of rosacea

Vascular lasers and intense pulsed light systems are capable of reducing both erythema and telangiectasia.9 The aim is to reduce the superficial vasculature which leads to a reduction in redness as well as the secondary symptoms of flushing, and the burning or stinging sensations.10 The pulsed dye laser was first successfully used by Tan et al in 1989 for the treatment of port wine stains.

Purpura caused by laser treatment 

The pulsed dye laser emits a pulsed beam of a yellow light at 595nm. This is absorbed by oxidised haemoglobin in superficial blood vessels. It’s important to note that, the brief pulse duration can cause vascular rupture which leads to purpura.9 This was one of the limitations of the pulsed dye laser treatment. 

Now, however, one can use increased pulsed durations which I have found can reduce purpura and avoid the need for “down time”, making this treatment much more acceptable. 

Other lasers such as the Potassiunm Titanyl Phosphate laser (KTP) are useful particularly for linear telangiectasia on the nose and rarely lead to any bruising.11 The Neodymium:Yttrium- Aluminium- Garnet (Nd:Yag) laser 1064nm can also be used for erythetemato-temngiectatic rosacea particularly for larger calibre vessels.12 

Individuals treated this way can become asymptomatic. It cannot be considered a cure in that the underlying aetiology has not been addressed and the individual may get an exacerbation of rosacea in the future, but from my experience I have found it does lead to long periods of remission. 

Treatment of rhinophyma using lasers 

Simply removing the erythema can lead to a significant improvement psychologically, particularly in terms of the perception that a red face is associated with alcohol consumption. This effect is highly desirable as a red face can be a source of personal embarrassment, emotional distress, and social isolation.13 

Shim et al demonstrated that erythemato-telangiectatic rosacea impairs quality of life as measured by the DLQI (disability life quality index). The authors have also shown that laser treatment significantly produced a reduction in DLQI score and reinforced the effectiveness of PDL in the treatment of rosacea and the disease impact on the psychosocial aspect of rosacea.14

Ablative Lasers:

The use of the CO2 laser ablation has led to a significant improvement in the treatment of rhinopehyma. During the 1980s and 90s, continuous wave carbon dioxide lasers were used for laser resurfacing the skin, which meant removing the skin layer by layer with a view to allowing the growth of new smoother, more evenly toned skin.

To reduce the thermal damage that occurred in the skin tissue pulsed CO2 (10600nm) laser systems were developed. These removed layers of skin in a more controlled manner.

Simply removing the erythema can lead to a significant improvement psychologically 

The whole epidermis and a variable thickness of dermis is ablated. Ablative lasers can be used for incisional surgery and have the advantage of non-contact with the skin, haemostasis, reducing post-operative pain, and the sealing of lymphatic channels.

The goal of surgical management of rhinophyma is to debulk the hypertrophied tissue and leave an adequate glandular reserve to allow reepithelialisation with a relatively low risk of scarring.

CO2 continuous wave laser ablation allows for precise ablation of the hyperplastic tissue, and haemostasis during the procedure allows visualisation of the treated areas and greater control over contouring.15 Reepithelialistion often takes about two weeks. 

Rhinophymas have also been treated with fractionated ablative CO2 lasers, which has achieved good results in early to moderate cases of rhinophyma using relatively aggressive parameters.16 This still retains the benefits of a fractionated treatment such as faster healing times and fewer adverse events.16

In summary, laser technology continues to improve and has led to a significant improvement in our ability to treat the erythema, telangiectasia, flushing and secondary symptoms of rosacea as well as the complications of rhinophyma. 

References

  1. Wilkin J, et al., ‘Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea’, J Am Acad Dermatol, 46(4) (2002), pp. 584–7.
  2. Powell FC, ‘Clinical Pratice. Rosacea’, NEJM, 352 (2005), pp. 793-803.
  3. Belivosky C, Ilhe F, Pernet AM, ‘Equale study: impact of rosacea on quality of life on affected patients’, J Am Acad Dermatol, 56 (2007).
  4. National Rosacea Society, ‘Rosacea Triggers Survey’, (National Rosacea Society) http://www.rosacea.org/patients/materials/triggersgraph.php
  5. Kyriakis KP, et al., ‘Epidemiologic aspects of rosacea’, J Am Acad Dermatol, 53 (2005), pp. 918–9. 
  6. Van Zuuren EJ, Kramer S, Carter B et al. (2011) Interventions for rosacea. Cochrane Database Syst Rev 3:CD003262.
  7. Tong LX1, Moore AY, ‘Brimonidine tartrate for the treatment of facial flushing and erythema in rosacea’, Expert Rev Clin Pharmacol, 7(5) (2014), pp. 567-77.
  8. Fowler J Jr et al, ‘Efficacy and Safety of once daily topical Brimonidine Tartrtate gel 0.5% for the treatment fo moderate to severe facial erythema of rosacea: Results of two randomized doulble blind , vehicle –ccontrolled pivotal studies’, J Drugs Dermatol, 12(6) (2013), pp. 650-656. 
  9. Neuhaus IM, Zane LT, Tope WD., ‘Comparative e cacy of nonpurpuragenic pulsed dye laser and intense pulsed light for erythematotelangiectatic rosacea’, Dermatol Surg, 35 (2009), pp. 920–928. 
  10. Clark SM, Lanigan SW, Marks R., ‘Laser treatment of erythema and telangiectasia associated with rosacea’, Lasers Med Sci., 17 (2002), pp. 26–33.
  11. Becher GL et al., ‘Treatment of super cal vascular lesions with KTP 532nm laser: experience with 647 patients’, Lasers Med Sci, 29(1) (2014), pp. 267-71.
  12. Salem S Aetal., ‘Neodymium-yittrium aluminum garnet laser laser versus pulsed dye laser in erthemt-telangiectatic roseacea: comparison of clinical efficacy and effect on cutaneeous substance (P) expression’, J Cosmet Dermatol, 12(3) (2013), pp. 187-94.
  13. Menezes N, Moreira A, Mota G, Baptista A., ‘Quality of life an drosacea: pulsed dye laser impact’, J Cosmet Laser Ther, 11 (2009), pp. 139–141.
  14. Shim TN, Abdullah A, ‘The effect of pulsed dye laser on the dermatology life quality index in erythematotelangiectatic rosacea patients: an assessment’, J Clin Aesthet Dermatol, 6(4) (2013), pp. 30-2. 
  15. Moreira A et al, ‘Surgical treatment of rhinophyma using carbon dioxide (CO2) laser and pulsed dye laser(PDL)’, J Cosmet Lase Ther, 12(2) (2010), pp. 73-76.
  16. Serowka KL1, Saedi N, Dover JS, Zachary CB, ‘Fractionated ablative carbon dioxide laser for the treatment of rhinophyma’, Lasers Surg Med, 46(1) (2014), pp. 8-12. 

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