Rosacea
6
http://ino.sagepub.com/ for general practice InnovAiT: Education and inspiration http://ino.sagepub.com/content/6/7/442 The online version of this article can be found at: DOI: 10.1177/1755738012467183 2013 6: 442 InnovAiT Alison Elsey Rosacea Published by: http://www.sagepublications.com On behalf of: Royal College of General Practitioners can be found at: InnovAiT: Education and inspiration for general practice Additional services and information for http://ino.sagepub.com/cgi/alerts Email Alerts: http://ino.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: What is This? - Jul 12, 2013 Version of Record >> at Scientific library of Moscow State University on January 29, 2014 ino.sagepub.com Downloaded from at Scientific library of Moscow State University on January 29, 2014 ino.sagepub.com Downloaded from
Transcript of Rosacea
http://ino.sagepub.com/for general practice
InnovAiT: Education and inspiration
http://ino.sagepub.com/content/6/7/442The online version of this article can be found at:
DOI: 10.1177/1755738012467183
2013 6: 442InnovAiTAlison ElseyRosacea
Published by:
http://www.sagepublications.com
On behalf of:
Royal College of General Practitioners
can be found at:InnovAiT: Education and inspiration for general practiceAdditional services and information for
http://ino.sagepub.com/cgi/alertsEmail Alerts:
http://ino.sagepub.com/subscriptionsSubscriptions:
http://www.sagepub.com/journalsReprints.navReprints:
http://www.sagepub.com/journalsPermissions.navPermissions:
What is This?
- Jul 12, 2013Version of Record >>
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
Rosacea
Rosacea is a chronic relapsing condition that affects the facial skin. Facialflushing is the predominant feature but erythema, papules, pustules andtelangiectasia often develop. Swelling of the soft tissues of the nose may
occur, this is known as rhinophyma. The eyes can also be affected causing asensation of a foreign body. The cause of rosacea is unknown. It usually affectsthose with fair skin, blue eyes and those of Celtic origin. It is more common inwomen; though rhinophyma occurs more frequently in men. The condition usu-ally manifests in the 30–40 age group and 30% of patients report a family history.General practice has a key role to play in managing rosacea effectively.
The GP curriculum and rosacea
The curriculum highlights that skin problems affect a quarter of the population and most problems are managed inprimary care. Clinical example 3.21: Care of people with skin problems requires GPs to be able to:. Manage primary contact with patients who have a skin problem. Work with patients to empower them to take responsibility for managing their skin problems. Promote skin wellbeing by applying health promotion and disease prevention strategies appropriately. Coordinate care with other primary care health professionals, dermatologists and other appropriate specialists,
leading to effective and appropriate acute and chronic disease management. Appreciate the importance of the social and psychological impact of skin problems on the patient’s quality of life. Identify the patient’s health beliefs regarding skin problems and either reinforce, modify or challenge these
beliefs as appropriate. Recognise how disfigurement and cosmetic skin changes fundamentally affect patients’ confidence, mood and
interpersonal relationships
Pathogenesis...........................................................There are different theories regarding the aetiology ofrosacea. It is thought that overactive facial capillariesand an overactive innate immune response promoteinflammation. It is possible, though not proven, that thehair follicle mite, Dermodex folliculorum, is responsiblesince they are observed in greater numbers in patientswho have a flare of rosacea. Rosacea has also beenobserved more commonly in those who haveHelicobacter pylori infection.
There are no diagnostic histopathological features forfacial rosacea. Specimens from affected and non-affectedareas of the same patient show a similar granulomatousappearance. Papulopustular lesions show more pro-nounced granulomatous inflammation. A biopsy israrely performed but may help to exclude other diag-noses (Box 1).
Clinical features...........................................................Rosacea can be divided into four clinical subtypes,depending on the predominant clinical features. Each..
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.
Box 1. Differential diagnoses of rosaceaincludes:
. Lupus erythematous: patients have light sensitiv-ity, erythema and scarring with no pustules
. Seborrhoeic dermatitis: scalp dandruff and facialeczema with no pustules
. Perioral dermatitis: pustules around the mouthand chin, with premenstrual exacerbation
. Acne vulgaris: patients have comedomes and thecondition improves with sunlight unlike rosacea,which is made worse
! The Author(s) 2013. Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav442
......................
InnovAiT, 6(7), 442–446 DOI: 10.1177/1755738012467183
.........................................................................................................................................................................................................
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
of these subtypes can then be graded into 1 (mild), 2(moderate) or 3 (severe).
Subtype 1. ErythematelangiectaticPatients with erythematelangiectatic rosacea have facialerythema with flushing, often with little provocation.Patients may also experience skin sensitivity and havetelangiectasia. With this subtype patients can haveocular rosacea and rhinophyma (Figure 1).
Subtype 2. PapulopustularPatients with papulopustular rosacea have a persistentfacial erythema with erythematous papules and smallpustules similar to acne vulgaris. Typically the lesionsare monomorphic, and occur predominantly on thecheeks. It was this subtype of rosacea that was referredto as acne rosacea (Figure 2). Again this subtype mayinvolve the eyes and nose.
Subtype 3. PhymatousIn the phymatous subtype the skin of the nose, chin,forehead, ears and eyelids may be thickened and nodu-lar. When it affects the nose it is known as rhinophyma.Patients know and fear this condition, calling it a ‘whiskynose’ (Figure 3). Rhinophyma is more common in menand may occur alone, or with subtype 1 or 2.
Subtype 4. OcularOcular rosacea affects up to 50% of patients. They reportgritty eye symptoms. There is erythema and telangiecta-sia of the eye lid margin. Patients may get recurrentchalazia or hordeola, which can be painful.Conjunctivitis occurs more frequently, as can keratitis.Keratitis presents with a red painful eye with blurredvision, though fortunately this is rare.
Other: steroid rosaceaSteroid rosacea is caused by the side effects of pro-longed topical steroids, which results in telangiectasiaand sometimes papules and pustules. This is not a typeof rosacea but creates a rosacea-like clinical picture. Thesteroids should be stopped.
Psychological features...........................................................It is important to ask open questions about how rosaceais affecting a patient’s life. Patients may report feeling lowin mood, lacking enjoyment in their lives and other symp-toms consistent with depression. They can develop socialphobia and anxiety. Patients may volunteer variations onthe following:
‘I avoid relationships because I feel embarrassed to tellthem about my rosacea. Sometimes I stay inside when inthe past I would go out and see my friends. Last week I
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
...
Figure 2. Papulopustular and ocular rosacea of moderateseverity.From: Powell, F.C. Rosacea. New England Journal of Medicine(2005) 352(8), 793–803. Reproduced with permission of theNew England Journal of Medicine.
Figure 3. Advanced rhinophyma.From: Powell, F.C. Rosacea. New England Journal of Medicine(2005) 352(8), 793–803. Reproduced with permission of theNew England Journal of Medicine.
Figure 1. Erythematotelangiectatic rosacea.From: Powell, F.C. Rosacea. New England Journal of Medicine(2005) 352(8), 793–803. Reproduced with permission of theNew England Journal of Medicine.
443......................
InnovAiT............................................................................................................................................................................................................
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
called in sick because I did not want to give a presenta-tion at work because I thought people would just belooking at my face’.
Treatment...........................................................Rosacea is a chronic condition, and patients should beadvised that total cure may not be possible. However,significant symptom modification and improvement tothe clinical signs can be achieved.
Lifestyle modificationEarly diagnosis means that patients can avoid triggersand stop rosacea from progressing. Reassure early pre-senters of the benign nature of the disease and the rarityof rhinophyma, which only affects 4% of rosacea patients.Patients should receive advice and leaflets highlightingcommon triggers such as alcohol, spicy foods, emotionalstress and sun exposure (Box 2). Advise patients to applya daily sunscreen with UVA and UVB protection. Ensurethe patient is not taking any medication that causes vaso-dilatation and in not using topical steroids.
Topical therapiesTopical therapies are most useful to reduce relapse fol-lowing a course of oral therapy. They can also be usedfor mild rosacea. In moderate to severe rosacea topicaltreatments are often used in addition to other therapies
and are continued when these are withdrawn. Topicaltherapies are probably most effective in patients whohave papules and pustules. They are less useful for ery-thema and telangiectasia.
Topical metronidazole 0.75% which is available as acream or gel has been shown to be efficacious. This
should be used once to twice daily for 8–12 weeks. Itshould be avoided in pregnancy. Azelaic acid is anotheroption. It has the advantage that it can be used in preg-nancy and may have some action against the develop-
ment of erythema but can cause skin dryness andincreased sensitivity as side effects.
Other topical alternatives that are not as widely used inrosacea include topical erythromycin or clindamycin.These also exert the same antibacterial and anti-inflam-matory effects as metronidazole and azelaic acid and aresafe to use in pregnancy.
Oral therapiesOral antibiotics are the mainstay of treatment for moder-ate to severe rosacea. It is thought that they work byexerting an anti-inflammatory rather than antimicrobialeffect. Tetracycline, oxytetracycline and low-dose doxy-cycline are all licensed for this purpose. It is recom-mended that these antibiotics are taken on an emptystomach and that the course is an average of 3–6months. Tetracycline antibiotics deposit in growingteeth and bone and for this reason cannot be used inpregnancy or in breast-feeding women. The alternative iserythromycin. Side effects are uncommon with nauseaand vomiting being the most frequent. Doxycyline mayalso cause photosensitivity and it should be re-iterated tothese patients that sun exposure should be avoided.
A course of antibiotics will significantly improve symp-toms in one-third of patients. A second course of anti-biotics will improve the symptoms in another third, whilstthe remainder may need longer courses, although this isnot usually for longer than 2 years. Because of the dur-ation of treatment it is worth considering that patientcompliance can be a problem and tailoring the treatmentplan accordingly. In severe cases of rosacea, isotretinoinmay be considered although it is currently unlicensed forthis indication. Clonidine has not been shown to improvefacial flushing and is not recommended.
Treatment of specific featuresTelangiectasia can be treated with laser or light therapy.A popular treatment option is intense pulsed light (IPL)therapy. The IPL machine emits short bursts of white lightgenerating heat which destroys the capillary. There arevarious lasers available such as the argon or the pulsed-dye laser. These treatments are not usually availablethrough the NHS. Unfortunately, the results may notbe longstanding and several treatments may be required.
In ocular rosacea, eyelid hygiene may be beneficial alongwith the use of hot compresses and eyelid massage.Artificial tears can also help. Ocular rosacea alsoresponds well to oral antibiotics. An ophthalmologistshould be involved early if there are uncontrolled symp-toms or if there is diagnostic doubt or suspected keratitis(5% of patients).
Patients with rhinophyma should be advised to keep theirnose clean. Antibiotics should be used at the first sign ofany infection to the inflamed tissue. Topical steroids,used cautiously, may help prevent scar formation. Moresevere cases will require surgical intervention, and some-times skin grafting although this is rare. Rhinophyma..
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.Box 2. Factors that may exacerbate rosacea.
. Food and drink: alcohol, hot beverages, spicyfoods, large hot meals
. Environmental: sun exposure, cold or harsh wind,hot or humid weather
. Products: perfumed creams/sunscreen, scentedproducts containing hydralcoholic extracts,toners or moisturisers containing glycolic acid,exfoliating preparations
. Medications: vasodilators such as calcium channelblockers, nitrates, topical steroids and opioids
. Other: emotional stress, strenuous exercise
444......................
..............................................................................................................................................................................................................................
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
responds well to electrosurgery. The overgrown tissue isshaved off and then left to heal by secondary intention.This generally produces a good cosmetic result. Otheroptions include cryotherapy or argon/carbon dioxidelasers that destroy the excess sebaceous tissue.
Psychosocial therapies...........................................................In the initial consultation, enquiry into a patient’s healthbeliefs should be made. It is helpful to know what eachindividual’s concerns are, and what they expect fromtreatment, especially since total cure is not usually pos-sible. It may help to highlight that some famous peoplesuffer from rosacea and are still very popular and suc-cessful. They include Bill Clinton and beauties CameronDiaz and Renee Zellweger.
Support resources for patients with rosacea are listed inBox 3. In certain situations counselling or more formalcognitive behavioural therapy will help.
Camouflage make up can be provided and may helppatients reduce social embarrassment. The charity‘Changing Faces’ provides this free of charge throughGP referral. Rosacea can trigger depression and conse-quently social isolation. Medication can be used toimprove symptoms, such as a selective serotonin reup-take inhibitor).
Follow-up...........................................................Patients should be reviewed at 12 weeks after initial diag-nosis and treatment has been instigated. In patients whoare using both an oral and topical therapy with noimprovement, a specialist referral should be made.Referral should also be considered in those with psycho-logical distress. In those who are responding well to treat-ment it is advisable to continue therapy for 3–6 monthsuntil stepping down or instigating a ’drug holiday’.
Conclusion...........................................................Rosacea is a chronic relapsing disorder with four mainclinical subtypes. The symptoms can rarely be cured butcan often be managed. The most effective therapy isusually oral antibiotics. There will often need to be life-style changes and psychological management.
References and further information
. Aroni, K., Tsagroni, E., Lazaris, A. C., Patsouris, E.,& Agapitos, E. (2004). Rosacea a clinicopathologi-cal approach. Dermatology, 209(3), 177–182. doi:10.1159/000079886
. Ashton, R., & Leppard, B. (2004). DifferentialDiagnosis in Dermatology. Oxford: RadcliffePublishing Ltd
. British National Formulary 2010. London: BJMGroup and Pharmaceutical Press
. Butterwick, K. J., Butterwick, L. S., & Han, A.(2006). Laser and light therapies for acne rosacea.Journal of Drugs in Dermatology, 5(1), 35–39
. Buxton, P. (2003). ABC Dermatology. London:Wiley-Blackwell
. Clinical Knowledge Summaries. (2008). Rosacea.Retrieved from cks.nhs.uk/rosacea/management/scenario_rosacea
. DermNetNZ. (2012). Rosacea. Retrieved fromhttp://dermnetnz.org/acne/rosacea.html
. Gupta, A. K., & Gover, M. D. (2007). Azelaic acid(15% gel) in the treatment of acne rosacea.International Journal of Dermatology, 46(5),533–538. doi: 10.1111/j.1365-4632.2005.02769.x
. Karim Ali, M., & Streitmann, M. J. (1997). Excisionof rhinophyma with the carbon dioxide laser: a ten-year experience. Annuals of Otology, Rhinologyand Laryngology, 106(11), 952–955
. Jansen., T., & Plewig, G. (1998). Clinical and histo-logical variants of rhinophyma, including nonsurgi-cal treatment modalities. Facial Plastic Surgery,14(4), 241–253. doi: 10.1055/s-2008-1064456
. Patient UK. (2009). Rosacea and Rhinophyma.Retrieved from www.patient.co.uk/doctor/Rosacea-and-Rhinophyma.htm
. Powell, F. C. (2005). Rosacea. New EnglandJournal of Medicine, 352(8), 793–803. doi:10.1056/NEJMcp042829
. RCGP. Clinical example 3.21: Care of people withskin problems. Retrieved from www.rcgp-curricu-lum.org.uk/pdf/RCGP-Curriculum-3.21-Skin-Problems.pdf
. Rebora, A., Drago, F., & Parodi, A. (1995). MayHelicobacter pylori be important for dermatolo-gists? Dermatology, 191(1), 6–8. doi: 10.1111/j.1365-4362.1996.tb03012.x
. Rosacea Support Group. www.rosacea.org/index.php
. Thiboutot, D., Thieroff-Ekerdt, R., & Graupe, K.(2003). Efficacy and safety of azelaic acid (15%)gel as a new treatment for papulopustular rosacea:..
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
.
Box 3. Contact details for support groups forpatients with rosacea.
. Changing Faces: website: www.changingfaces.org.uk. Address: Changing Faces, The SquireCentre, 33-37 University Street, London, WC1E6JN. Telephone: 0845 4500 275 or 0207 391 9270
. The National Rosacea Society: onlineresource: www.rosacea.org
. International Rosacea Foundation: onlineresource: www.internationalrosaceafoundation.org
445......................
InnovAiT............................................................................................................................................................................................................
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
results from two vehicle- controlled, randomizedphase 3 studies. Journal of the American
Academy of Dermatolgy, 48, 836–845.doi:10.1067/mjd.2003.308
. Wilkin, J. K. (1983). Effect of subdepressor cloni-dine on flushing reactions in rosacea. Change inmalar thermal circulation index during provokedflushing reactions. Archive of Dermatology,
119(3), 211–214. doi: 10.1001/archderm.1983.01650270029012
. Wilkin, J. K. (1994). Rosacea. Pathophysiology andtreatment. Archives of Dermatology, 130,359–362. doi: 10.1001/archderm.1984.01690030091015
. Wolf Jr, J. E., & Del Rosso, J. Q. (2007). TheCLEAR trial: results of a large community-basedstudy of metronidazole gel in rosacea. Cutis,79(1), 73–80
Dr Alison ElseyGeneral practice, ST3 KingstonEmail: [email protected]
DOI: 10.1177/1755738013491857
............................................................................................................................................................
AKT question relating to movementdisorders
Extended Matching Question
Complete the answers to the following questions which
relate to movement disorders, by selecting the SINGLEMOST appropriate diagnosis from the list.
Each option may be used once, more than once ornot at all. Select ONE option only.
A. Alcohol dependence syndromeB. Cerebellopontine angle tumourC. Essential tremorD. Gilles de la Tourette syndromeE. HemiballismusF. Huntington’s diseaseG. MyoclonusH. Parkinson’s diseaseI. Tardive dyskinesiaJ. Wilson’s disease
Question 1
You see a 66-year-old man with schizophrenia for hisannual mental health review. On examination you observeinvoluntary repetitive movements of his lower face.
Question 2
This condition demonstrates an autosomal pattern ofinheritance.
Question 3
A 19-year-old woman complains of occasional suddenjerking movements during sleep.
Question 4
A 21-year-old woman presents with a 6-month history ofworsening hand tremor. Her mother is concerned thatshe has become very withdrawn recently. On examin-ation she has nystagmus and an ataxic gait.
Question 5
A 44-year-old woman complains of tinnitus and deafnessover the last 4 months. On examination she has a tremorin her right hand, which is worse with movement.
Answer DOI: 10.1177/1755738013493546
Dr Michael NandakumarGP, Fairfields Practice, Nottingham
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
....
..
446......................
..............................................................................................................................................................................................................................
at Scientific library of Moscow State University on January 29, 2014ino.sagepub.comDownloaded from
