Rosacea

Rosacea is one of the most common skin diseases that a practicing dermatologist has to face. The history of the study of rosacea is long and ornate. The main symptoms of the disease are known from ancient times and have not been practically pathomorphosed, but there is still no generally accepted definition of this disease.

Abroad, the clinical definition of rosacea as a disease manifested by persistent erythema of the central part of the face, especially prominent surfaces, with well-marked enlarged skin vessels, often accompanied by the appearance of papular and papulopustular eruptions, and the possible development of pineal deformities of the stepping parts of the face.

[1], [2], [3]

Causes

Rosacea is most often defined as an angioneurosis of a predominantly venous link in the vascular plexus of the dermis, based on the most widely accepted hypothesis of the pathogenesis of the disease.

The disease often develops in female, second-fourth decade of life, having a genetically determined predisposition to transient reddening of the facial skin, less often the neck and the so-called decollete zone.

Since the pathological changes in the skin of rosacea patients are localized mainly on the face, the cosmetic significance of the disease and the emergence of secondary psychosomatic problems of patients with rosacea have led to very active participation of the community in the study of this disease. As a result, national societies for the study of rosacea were formed in developed countries, representing highly influential commissions of professionals, monitoring periodicals on the problem, including, among other things, financial support for research in this field. Being a kind of information centers, these societies regularly publish modern generalized views of experts on classification, pathogenesis and treatment methods. Often these views do not correspond to the historically formed ones.

[4], [5], [6], [7], [8]

Pathogenesis

The pathogenesis of rosacea is still unclear. There are many theories, but none of them pretend to be the dominant role, because it is not fully proven. Some of these theories are based on the results of systematic studies on the relationship of rosacea development with various initiating factors and disorders, others on the results of individual observations.

The main etiopathogenic mechanisms considered vasodilatation vascular plexus dermis due to the implementation of the innate characteristics of the hypothalamic-pituitary vasomotor activity as one of the mechanisms of brain thermoregulation under conditions of temperature increase (as a result of physical or psycho-emotional factors), and the associated blood flow in the basin of the carotid arteries.

The effect of ultraviolet irradiation, which, in the opinion of many researchers, leads to the early onset of telangiectasias, has not been fully explained, and its role in the pathogenesis of rosacea continues to be debated. The combination of paretic dilated vessels and prolonged UVD leads to dystrophic changes in the intercellular matrix of the dermis and partial disorganization of the fibrous structures of the connective tissue due to the accumulation of metabolites and proinflammatory mediators. This mechanism is considered one of the main in the development of hypertrophic rosacea.

The colonization of the digestive system of one of the subpopulations of Helicobacter rulory producing cytotoxic substances that stimulate the release of vasoactive substances such as histamine, leukotrienes, prostaglandins, tumor necrosis factor and some other cytokines is considered one of the major causes of erythematous-teleangiektaticheskoy rosacea.

Excessive consumption of alcohol, spicy food and spices for today is considered only a factor that strengthens the manifestations of the disease, but has no etiological significance. As well as the role of Demodex folliculorurn, which is a typical commensal, at this stage it is recognized as a factor of exacerbation of the skin process mainly in the papular-pustular type of rosacea.

[9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]

Symptoms

The clinical picture of erythematous-telangiectatic rosacea is characterized by the appearance of erythema, initially transitory, amplified by tides, and then becoming resistant, mainly on the cheeks and lateral surfaces of the nose. The color of erythema can range from bright pink to cyanotic red, depending on the duration of the disease. Against the backdrop of such erythema, patients develop telangiectasia of various diameters, scant or moderate exfoliation and swelling of the skin. Most patients complain of burning sensations and tingling in the erythema area.

Manifestations of the disease are intensified by exposure to low and high temperatures, alcohol, spicy food and psycho-emotional stress. For patients with this type of rosacea is characterized by increased sensitivity of the skin to external drugs and UV. Even indifferent creams and sunscreens can cause an increase in inflammatory manifestations. In the history of most of the patients suffering from this type of rosacea, there is no transferred vulgar acne.

Forms

The issues of rosacea classification to the present time remain the subject of discussions. Historically, it is believed that the disease is characterized by a staged current. However, the classification of the expert committee of the American National Society for the Study of Rosacea from 2002 points to the existence of four main types of rosacea (erythematous-telangiectatic type, papular-pustular type, fimatose and ocular types, corresponding to the hypertrophic stage and ophthalmicosis in the domestic classification). There is also questioning the transformation of one type to another, except for cases of development of rhinophyma in patients with papulopustular type of rosacea.

Papulopustular rosacea is characterized by a similar clinical picture, but with this type of rosacea there is no such number of complaints of sensation from the side of erythema, as in the erythematous-telangiectatic type. Patients are mostly concerned about papular rashes. They are characterized by bright red coloration and perifollicular arrangement. Individual papules can be crowned with a small round pustule, but such papulopustular elements are few. Peeling is usually absent. It is possible to form persistent edema at the site of common erythema, which is more common in men.

Fimatose, or hypertrophic, type of rosacea is characterized by a significant thickening of the tissue and uneven tuberosity of the skin surface. The appearance of such changes on the skin of the nose is called rhinophyma, metaphimic - if the skin of the forehead is affected; gnatofima - this is a pineal change in the chin, otophima - the auricles (it is also monolateral); much less often the process captures the eyelids - blepharophyma. There are 4 histopathological variants of pineal formations: glandular, fibrotic, fibroangiomatous and actinic.

The ocular type, or ophthalmosporus, is clinically predominantly represented by a combination of blepharitis and conjunctivitis. Recurrent cholazion and meibomitis often accompany the clinical picture. Often there are conjunctival telangiectasias. Complaints of patients are non-specific, burning, itching, photophobia, and foreign body sensation are often noted. Ophthalmosporus can be complicated by keratitis, scleritis and iritis, but in practice such changes are rare. In rare cases, the development of eye symptoms outstrips cutaneous symptoms.

There are special forms of the disease: lupoid, steroid, conglobate, fulminant, gram-negative rosacea, rosacea with solid persistent edema (Morbigan's disease), etc.

In particular, lupoid rosacea (rosacea lupoides, granulomatous rosacea, Lewandowski tuberculoid) is characterized by the formation of granuloma by the type of foreign bodies. At a diascopy the yellowish-brownish color of papules is noticeable. A decisive role in diagnosis is played by the histological examination of the characteristic element.

[20], [21]

Diagnostics

The diagnosis, according to the American committee on the study of rosacea, is based on anamnestic data, indicating, in the first place, about the existing at least 3 months of persistent erythema of the central part of the face. Complaints of burning and tingling in the area of such erythema, on dry skin and the appearance of telangiectasias, on the appearance of papules against a background of stagnant erythema, hypertrophy of the protruding parts of the face and the detection of eye lesions allow us to determine the type of rosacea.

[22], [23], [24], [25]

Differential diagnosis

In terms of differential diagnosis, it is necessary first and foremost to exclude true polycythemia, connective tissue diseases, carcinoid and mastocytosis. In addition, it is necessary to differentiate rosacea from peri-peripheral or steroid dermatitis and contact dermatitis, including photodermatitis. Laboratory diagnostics is mainly done by eliminating other diseases, since there are still no specific tests for rosacea verification.

[26], [27], [28], [29], [30], [31], [32]

Treatment

To date, the problem of treatment is much better than the pathogenesis and etiology of rosacea. Therapeutic tactics depend to a large extent on the clinical type of the disease. However, the success of treating rosacea is based on the joint efforts of the doctor and the patient to identify provoking factors that are strictly individual. Most often they include meteorological factors: exposure to solar radiation, high and low temperatures, wind and related abrasive effects; alimentary: the use of hot and carbonated beverages, alcohol, spicy foods and excess food; neuroendocrine: emotional effects, climacteric syndrome and other endocrinopathies, accompanied by increased blood circulation in the pool of carotid arteries; iatrogenic, including both systemic drugs, erythema-causing individuals (for example, nicotinic acid preparations, amiodarone) and external preparations, including cosmetic preparations and detergents, which have irritating effect (waterproof cosmetics and toning preparations, the removal of which requires the use of solvents , as well as detergents containing soap). The exclusion or reduction of these factors significantly influences the course of the disease and reduces the costs of medical therapy.

The basis of therapeutic measures is to ensure adequate daily skin care. First of all, it includes sunscreen preparations. They should be selected taking into account the increased sensitivity of the skin of patients with rosacea. The least irritating effects are indifferent preparations (titanium dioxide, zinc oxide) blocking ultraviolet irradiation of the skin due to their physical properties. Preparations containing chemical ultraviolet filters that can be recommended for patients with rosacea should not contain sodium lauryl sulfate, menthol and camphor, and, on the contrary, should contain silicones (dimethicone, cyclomethicone) that significantly reduce the irritant effect of sunscreens and ensure their water resistance and low comedogenicity.

The basis for recommendations for daily skin care is the regular use of light in consistency, dyed green, obesity preparations for daily use. It is desirable to apply them in a thin layer 2 times a day and as a makeup base, which is preferably present in the form of a powder or agitated mixture. It must be remembered that the restoration of barrier functions is a very important component of rosacea therapy, which is characterized by increased sensitivity of the skin.

Currently, it is believed that external treatment is preferred for all types of rosacea, except for hypertrophic, in which the most effective are surgical treatment and systemic synthetic retinoids. Numerous comparative studies conducted in independent centers in compliance with the principles of evidence-based medicine demonstrated the absence of statistically reliable data on the superior effectiveness of systemic treatment. For example, it has been shown that the effectiveness of systemic administration of tetracycline antibiotics does not depend on the dose and frequency of administration of the drugs, and, apparently, is not related to their antimicrobial effect. The same applies to systemic applications of metronidazole, although it can serve as an alternative to tetracycline antibiotics in cases where the latter are contraindicated. Unsustainable were the assumptions about the effectiveness of metronidazole against Demodex spp., Which survive in conditions of high concentrations of metronidazole. These drugs, however, continue to be widely used, but their use is not authorized by organizations such as the Federal Office for Food and Drug Administration (FDA) of the United States. With lupoid rosacea, systemic tetracyclines are prescribed, there are indications of the efficacy of phtivazide.

The most effective is the combined use of external azelaic acid preparations with external preparations of metronidazole or clindamycin. There are numerous publications on the efficacy of tacrolimus or pimecrolimus. They retain their actual sulfur-containing preparations and benzoyl peroxide, although a side effect of these drugs is noted. At initial manifestations of the fimatose type of rosacea, monotherapy with isotretinoin in usual doses turned out to be the most effective. Whereas in the treatment of the formed rhinophyma, one can not do without the methods of plastic surgery, which are often combined with various thermal effects. In connection with this, modern photo and laser therapy deserve special attention. Sources of incoherent intense light radiation (IPL), diode, KTP, alexandrite and, most modern, long-pulse neodymium lasers based on alumium yttrium garnet (Nd; YAG lasers) are used. Laser treatment appears to be more effective and less expensive both with respect to telangiectasias (selective photothermolysis) and with respect to collagen reorganization due to thermal stimulation of fibroblasts, although it is often better to use IPL sources. In the treatment of hypertrophic type of rosacea, laser dermabrasion has recently taken one of the leading positions in sitting its safety.

As a physiotherapeutic treatment, the method of microcurrent therapy is widely used. Its effectiveness is mainly associated with the redistribution of fluid in the tissues of the face and restoration of lymphatic drainage. It was also noted that microcurrents effectively contribute to the restoration of the damaged skin barrier and prevent dissociation of the saprophyte microflora.