Pharmacy & Therapeutics - January 2009 - (Page 39) CONTINUING EDUCATION CREDIT granulomatous rosacea is manifested as firm, skin-colored papules. This type of rosacea is more prevalent in AfricanAmericans and in Afro-Caribbeans than in persons of lighter skin. This form of rosacea usually presents as yellowish-brown nodules and papules in the malar, perioral, and periocular regions. FACE syndrome (facial Afro-Caribbean childhood eruption) is now considered a variant of granulomatous rosacea and is characterized by grouped papules in perinasal and perioral locations. The histological picture is similar to that of granulomatous rosacea.3 Several skin conditions resemble rosacea and should be Table 1 Triggers of Rosacea Ingested/Iatrogenic Foods and drinks Cheese (except cottage) Chocolate Spicy food Soy sauce Vanilla Dairy products Liver Beverages Red wine Hot drinks Alcohol (beer, bourbon, gin, vodka) Drugs Niacin Nitroglycerin Tobacco Topical agents Topical corticosteroids Retinoids Cosmetics (sometimes) Acetones Alcohol Environmental Temperature Sauna heat Overheating Sun lamp Humidity Hot baths Weather Sun Heat Strong wind Cold Emotion Anger Stress Rage Embarrassment Activity Exercise Menopause Caffeine withdrawal Chronic cough Straining Table 2 Major Subtypes of Rosacea Subtype Erythematotelangiectatic Characteristics • Flushing lasts more than10 minutes • Burning or stinging associated with flushing • Persistent erythema of the central aspects of the face • Telangiectasias Papulopustular • Small, dome-shaped erythematous papules • Tiny surmounting pustules on the central aspects of the face • Solid facial erythema and edema • Phymatous changes Phymatous • Thickening of skin with irregular surface contours • Affects nose, chin, forehead, eyes, or eyelids • • • • • Burning, stinging, and itching of eyes Sensitivity to light Foreign body sensations Blepharitis Conjunctivitis Data from Rohrich RJ, Griffin JR, Adams WP Jr. Plast Reconstr Surg 2002;110(3):860-869; quiz, 870;1 and Scheinfeld NS. Rosacea. Skinmed 2006;5:191–194.2 Ocular45,46 For a diagnosis of rosacea, one or more of the following primary features concentrated on the convex areas of the face is required: flushing (transient erythema), nontransient erythema, papules and pustules, and telangiectasia. Secondary features include burning or stinging, edema, plaques, a dry appearance, ocular manifestations, peripheral locations, and phymatous changes. The relative abundance of other associated findings often dictates the subtype of disease (Table 2) and treatment. Some clinicians still use staging for determining appropriate treatment of rosacea. Stages range from frequent flushing in pre-rosacea to rhinophyma, hyperplasia, and other inflammatory changes seen in Stage 3 (Table 3). Data from references 10, 13, 31, 45, and 46. Table 3 Stages of Rosacea Stage Pre-rosacea Stage 1 Symptoms and Signs Frequent flushing Irritation caused by topical preparations Transient facial erythema that becomes more persistent Slight telangiectasias Increased skin sensitivity Persistent, spreading erythema Edema, papules, pustules Enlarged pores Ocular changes Large inflammatory nodules and furuncles Tissue hyperplasia, fibroplasias Rhinophyma Variants of Rosacea and Differential Diagnosis Two variants of rosacea are not captured in the four major subtypes presented in Table 2. Rosacea fulminans, which manifests with multiple erythematous papules, pustules, nodules, and purulent discharging cysts, is a severe manifestation of rosacea. On rare occasions, this form can be associated with Crohn’s disease, ulcerative colitis, colon cancer recurrence, and pregnancy.11 It can be treated with prednisone 0.5 to 1 mg/kg, followed by oral isotretinoin (Accutane, Roche). Histologically, granulomatous rosacea can resemble sarcoid or cutaneous tuberculosis. Particularly in people of color, Stage 2 Stage 3 Data from 5, 9, 10, 35, and 40. Vol. 34 No. 1 • January 2009 • P&T® 39
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