Rosacea - Central and Eastern Sydney PHN

Rosacea - Central and Eastern Sydney PHN

Rosacea: Diagnosis and
Management
Dr Michelle Hunt MBBS, MM, FACD, FACMS
Inner Sydney Dermatology 2014
Inner Sydney Dermatology
n
n
n
General dermatology
Skin cancer management
Cosmetic dermatology:
n
n
n
n
n
Muscle relaxing injections
Hyperhidrosis therapy
Chemical peels
Dermal ‘Fillers’
Lasers
n
n
n
n
n
Vbeam® Perfecta laser
Q-switched Nd-Yag laser
Fraxel® Re:store Dual laser
Emerge® laser
Coolsculpting
M Hunt IWSML August 2014
What is Rosacea?
n
n
n
Chronic disorder affecting mainly the
convex central face
Polymorphic
Characterised by:
Frequent flushing
n Persistent erythema and telangiectases
n Episodes inflammation: papules, pustules,
swelling
n
M Hunt IWSML August 2014
Rosacea: who is affected?
n
More common in
Fair skinned individuals
n Young-middle aged adults (30-50 yrs)
n Women (although more severe in men)
n
n
Genetic predisposition also a factor
M Hunt IWSML August 2014
Rosacea: what causes it?
n
n
n
n
Exact cause(s) uncertain
Damage to dermal connective tissue à
dysfunction unsupported vasculature
Roles of Helicobacter pylori
Role of Demodex mite
M Hunt IWSML August 2014
Rosacea: what causes it?
n
Chronic inflammation
n
Production pro-inflammatory cytokines
Aberrant cathelicidin expression
n Elevated Kallikrein 5 proteolytic activity
n Altered toll-like receptor 2 expression
n
n
Vascular/neurovascular changes
Localised vasodilatation
n Angiogenesis (cathelicidin LL-37)
n Tissue fibrosis
n
n
Altered innate immune response
M Hunt IWSML August 2014
Rosacea: common triggers
n
n
n
n
n
n
Sun exposure
Emotional influences: stress,
embarrassment, anger
Extremes of temperature and weather
Exercise: intensive workouts
Drinks: hot drinks, alcohol
Foods: spicy or large hot meals
M Hunt IWSML August 2014
Rosacea: clinical features
n
n
n
n
n
Episodic flushing (usually no increased
sweating)
Erythema, burning sensation
Telangiectases
Follicular and non follicular papules and
pustules (without comedones)
Oedema, fibrosis, glandular hyperplasia
(phymas)
M Hunt IWSML August 2014
Rosacea: clinical features
n
Other potential signs and symptoms:
Eye irritation
n Burning and stinging
n Dry appearance
n Plaques
n Facial swelling
n Extrafacial signs: neck, chest, scalp, ears
n
M Hunt IWSML August 2014
Rosacea: histopathology
n
n
n
n
n
Dilated superficial blood vessels
Dilated lymphatic channels
Solar elastosis
Inflammation (ranging from mild
perivascular/periofollicular lymphohistiocytic
infiltrate to granulomatous)
Demodex folliculorum (51%)
M Hunt IWSML August 2014
4 Rosacea subtypes
n
n
n
n
Erythrotelangiectatic Rosacea
Papulopustular rosacea
Phymatous rosacea
Ocular rosacea
M Hunt IWSML August 2014
Rosacea: clinical progression
n
n
n
Early/ erythrotelangiectatic rosacea
n Episodic flushing
n Mild telangiectases
n Transient oedema
Progressive (papulopustular rosacea)
n Papules, Pustules
n Sustained oedema
n Extensive telangiectases
Late
n Induration
n Phymas eg. rhinophyma
M Hunt IWSML August 2014
Rosacea: complications
n
Eye involvement
Occurs in > 50% pts
n Pathogenesis not well understood ?reduced
tear secretion, meibomian gland dysfunction
n Grittiness, irritation, dry eyes, conjunctival
erythema, blepharitis, episcleritis, chalazion,
keratitis
n
M Hunt IWSML August 2014
Rosacea: complications
n
Chronic lymphoedema
Face (especially upper face: Morbihans’s
Disease), ears
n Histology: lymphoedema, inflammatory cell
infiltrate
n
M Hunt IWSML August 2014
Phymas
n
Localised swelling of facial soft tissues
due to variable combinations of:
Lymphoedema
n Fibrosis
n Sebaceous hyperplasia
n
M Hunt IWSML August 2014
Phymas
n
n
n
n
n
Rhinophyma (nose)
Metophyma (forehead)
Gnathophyma (chin)
Blepharophyma (eyelids)
Otophyma (ears)
M Hunt IWSML August 2014
Rosacea: differential Dx
n
n
n
n
n
n
n
Acne vulgaris
Perioral dermatitis
Seborrhoeic dermatitis
Tinea faceii
Lupus erythematosis
Nasal sarcoidosis (lupus pernio)
Carcinoid (severe flushing)
M Hunt IWSML August 2014
Rosacea: treatment options
n
General measures
Avoid irritants and triggers
n Sun protection
n Cosmetic camouflage
n
M Hunt IWSML August 2014
Rosacea: treatment options
n
Topical:
Metronidazole 0.75% - 1 % gel/cream
n Azelaic acid 15-20%
n Erythromycin, clindamycin
n Retinoic acid 0.025%
n Sodium Sulphacetamide 10% - 4% sulphur
n Anti Demodex eg. Ivermectin 1%, Permethrin 5%
n Calcineurin inhibitors (tacrolimus 0.1%,
pimecrolimus 1%)
n Bromonidine tartrate gel 0.33%
n
M Hunt IWSML August 2014
Rosacea: treatment options
n
Systemic:
n
Antibiotics
Doxycycline
n Minomycin
n Metronidazle
n
n
Isotretinoin 10-60 mg /day
M Hunt IWSML August 2014
Flushing: treatment options
n
Beta blockers
Clonidine 50 ug bd
n Propranalol 40 mg bd
n
M Hunt IWSML August 2014
ETR: treatment options
n
Vascular laser
Pulsed dye laser
n Long pulsed Nd-Yag laser
n
n
IPL
M Hunt IWSML August 2014
Lymphoedema: treatment options
n
n
n
n
Antibiotics (reduce inflammatory component)
Low dose isotretinoin (0.1-0.2 mg/kg/day over
2-4/12)
Prednisone
Facial massage
M Hunt IWSML August 2014
Rhynophyma: treatment options
n
n
n
n
n
Oral isotretinoin
Surgical paring
Electrosurgery
Ablative lasers
Fractionated lasers
M Hunt IWSML August 2014
Ocular rosacea: treatment
options
n
n
n
n
General eye care
Liquid paraffin ointment
Doxycycline (100 mg/d)
Avoid retinoids
M Hunt IWSML August 2014
Rosacea: what’s new?
n
n
n
Botanicals
Nicotinamide
Mirvaso® (bromonidine tartrate 0.33%)
M Hunt IWSML August 2014
Rosaliac AR Intense
n
3 active ingredients:
Ambophenol: vegetable extract rich in
polyphenols, reduces size of blood
vessels and strengthens walls
n Neurosensine: dipeptide, soothing,
reduces appearance of redness
n Thermal Spring Water: anti-irritant
n
n
Free of preservatives, parabens,
alcohol, fragrance, colorant
M Hunt IWSML August 2014
Redness Relief CalmPlex™
n
n
n
Inhibits PGE
Prevention vasodilatation
Prevention UV induced inflammation
M Hunt IWSML August 2014
Redness Relief CalmPlex™
n
CalmPlex TM-4-Ethoxybenzaldehye
n
n
Niacinamide
n
n
Suppresses release PGE2 (key mediator of
inflammation)
Improves barrier function, reduces sebum
production
Squalene and Jojoba oil
Improves barrier function, moisturisation
n Controls release inflammatory cytokines
n
M Hunt IWSML August 2014
Brimonidine tartrate (Mirvaso®)
n
n
n
n
n
n
Highly selective alpha-adrenergic receptor
agonist
Induces peripheral vasoconstriction
Aug 2013 FDA approved for Rx facial
erythema rosacea
0.33% once daily application (small pea
sized amount to each of 5 facial areas)
30g tube
Available Sept 1
M Hunt IWSML August 2014
Brimonidine tartrate (Mirvaso®)
n
n
n
n
n
n
Rapid onset within 30 min
Peak effects lasting over 4-6 hours
Gradual return of erythema towards
baseline over 12hours
Safe for long term use
S/E mild and short-lived (skin irritation,
itching, burning, flushing)
< 5% rebound
M Hunt IWSML August 2014