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pathogenesis: unknown
| • | the basic abnormality seems to be a microcirculatory disturbance |
| • | migraine headaches more common in rosacea patients (suggesting possibility of a more generalized vascular pathogenesis) |
| • | it is not primarily a disease of sebaceous follicles, and in contrast to acne vulgaris comedones are absent |
clinical:
| • | may extend over the entire face and also the scalp (itchy follicular pustules of the scalp are typical) |
| • | ophthalmic rosacea: the most frequent eye sign, which may never progress, is chronically inflamed margins of the eyelids with scales and crusts |
| • | gram (-) rosacea: analogous to gram (-) folliculitis which sometimes develops on top of acne vulgaris after long term antibiotic administration; organisms are the same (Klebsiella, proteus, pseudomonas, acinetobacter, proteus) |
ddx:
| • | episodic facial flushing ddx – carcinoid syndrome (24hr urine for 5-hydroxyindoleacetic acid) |
| • | erythrotelangiectatic rosacea ddx – carcinoid, LE, corticosteroid-induced rosacea-like syndrome, Habers syndrome, Dowling-Degos disease, photodermatosis |
| • | acneiform rosacea ddx – acne, bromoderma/iododerma, pustular folliculitis, perioral dermatitis, seborrheic dermatitis |
| • | granulomatous rosacea ddx – acne conglobata, amyloidosis, sarcoidosis, lupus vulgaris |
| • | "refractory rosacea" - consider demodex folliculitis, gram negative folliculitis, pityrosporum folliculitis |
Treatment:
| • | minocycline 100mg PO QD X 1 week takes care of most flares (then maintain with topicals and refills for future flares) |
| • | tetracycline or erythromycin 500mg PO BID (can take erythromycin with food) |
| • | alternative antibiotics: Azithromycin 250mg TIW (M, W, Fri) |
| • | OR azithromycin 500 qday then 250qday |
| • | second line - Flagyl 500mg po BID x 2weeks (per Dr. Blyumin) or 200mg PO BID x 6 weeks (Lebwohl textbook) |
| • | azeleic acid gel or cream |
| • | Noritate (metronidazole 1%) – problem: cream base is so thick that people find it unpleasant to apply |
| • | (Norm Levine) – isotretinoin 10mg/day |
| • | (Joseph Bikowski) - 81mg enteric-coated aspirin / day (for flushing) |
| • | Soolantra cream (topical ivermectin 1%) |
Clenia vs. Plexion vs. Sulfacet-R etc... (= sodium sulfacetamide 10%, sulfur 5%):
| • | good choice for multiple facial conditions in one patient (acne, seb derm, rosacea) |
| • | and the sulfur treats demodex |
Make-up for rosacea patients:
| • | Physician's formula (at CVS) mineral make-up line |
| • | Bare Minerals Line (at Sephora) |
Granulomatous rosacea
| • | non-caseating epithelioid cell granulomas histologically |
Variants (i.e. other granulomatous papular facial diseases):
| • | Granulomatous Perioral Dermatitis In Children |
| • | FACE syndrome probably synonymous with granulomatous perioral dermatitis in children |
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