I. Introduction
- Rosacea Stages - First through fourth stage
- Rosacea Severity - Pre-rosacea through severe rosacea
II. Pre-rosaceao
- Brief description
- General description
III. Mild rosaceao
- Brief description
- General description
IV. Moderate rosaceao
- Brief description
- General description
V. Severe Rosaceao
- Brief description
- General description
VI. Classification
system for rosacea subtypeso
- Subtype
1: Erythematotelangiectatic rosacea - Color photo of rosacea
patient
-
Subtype 2: Papulopustular rosacea - Color photo of rosacea patient
-
Subtype 3: Phymatous rosacea - Color photo of rosacea patient
-
Subtype 4: Ocular rosacea - Color photo of rosacea patient
- Subtype
5: Neuropathic rosacea - Detailed description
VII. References
I. Introduction
Rosacea is a progressive
disorder that usually advances in stages if left untreated. There
are four basic stages to rosacea:
| Rosacea
Stages |
Rosacea Severity |
|
First stage |
Pre-rosacea |
Second stage |
Mild rosacea |
|
Third stage |
Moderate rosacea |
Fourth stage |
Severe rosacea |
II. Pre-Rosacea
Brief Description:
In general, people who are prone to frequent bouts of facial flushing
and blushing are placed into this category. (1) At this
stage, facial redness from the flush is very transient and immediately
disappears after the instigating trigger is over. For example, a
transient flush to a warm environment, exercise, facial cleansing,
overheating, or embarrassing situation, can all be categorized as
pre-rosacea flushes.
General Discussion:
Although this stage is usually quite innocent in nature, pre-rosacea
flushing is the first cardinal sign of rosacea. (2-5)
In the pre-rosacea stage, most sufferers experience a basic functional
change in the reactivity of facial blood vessels - i.e., rosacea
blood vessels dilate to more stimuli, open up wider, and stay open
for longer periods of time than do normal facial blood vessels.
This basic difference is responsible for the frequent facial flushing.
At this early stage, there are usually no signs of physical damage
to the blood vessel wall.
III. Mild Rosacea
Brief Description:
The mild stage of rosacea begins when the facial redness induced
by flushing persists for an abnormal length of time after the instigating
trigger is over -- usually a half-an-hour or more after the trigger
is over. (1, 6) During this stage, many rosacea sufferers
also report that their facial skin has a healthy-looking glow to
it. (7)
General Discussion:
Individuals who experience frequent bouts of pre-rosacea flushing
are especially susceptible to progressing into mild rosacea (the
first "true" form of rosacea). In mild rosacea, facial
blood vessels tend to become even more reactive - dilating more
easily than in pre-rosacea. This subtle change results in greater
blood flow into the superficial layers of the facial skin. Facial
blood vessels also remain open for exaggerated periods of time,
resulting in facial redness that persists for an extended period
of time after the initial trigger is over. In mild rosacea, there
may also be minor structural damage to facial blood vessels, but
this is not an important factor..... At least not yet.
IV. Moderate
Rosacea
Brief Description:
The moderate stage of rosacea begins when the facial redness persists
for days or weeks - often times becoming semi-permanent in the central
areas of the face such as the nose and cheeks. This results in a
generalized 'sunburned' or 'windburned' look. In facial areas where
chronic flushing or redness is intense, swelling and burning sensations
may also occur. A significant number of patients also report outbreaks
of inflammatory papules (tiny red bumps), and pustules (tiny red
bumps with pus) during this stage. In most cases there are prominent
areas of telangiectasia that are located in facial areas where flushing
is the worst.
General Discussion:
As facial flushing becomes more frequent and intense, blood vessels
become dysfunctional and often incur significant structural damage.
(6, 8-10) These vascular changes result in long-lasting
facial redness, broken blood vessels, swelling, and inflammatory
papules. At this stage, facial blood vessels may exhibit several
different levels of structural damage:
- Mild damage: Blood vessels that have mild
damage can still function normally. This damage can be fixed by
the blood vessel's internal repair mechanisms.
- Moderate damage: Blood vessels that have received
moderate damage are usually 'sick', and function much differently
than normal blood vessels. This structural damage is much harder
to repair, and in some cases, cannot be fully fixed.
- Severe damage: Blood vessels that have incurred
severe damage are permanently dilated (telangiectasia). These
blood vessels cannot fix themselves. These vessels serve as open
tunnels for large volumes of blood flow.
V. Severe Rosacea
Brief Description:
A small portion of sufferers progress to the final stage of rosacea
which is characterized by intense bouts of facial flushing, severe
inflammation, swelling, facial pain, and debilitating burning sensations.
On top of the inflammation can emerge crops of inflammatory papules
and pustules. At this stage, some patients may also develop rhinophyma
(rino-fi-ma), a bulbous enlargement of the nose.
General Discussion:
After months, years, or decades of uncontrolled flushing and inflammation,
permanent changes take place in the facial skin and blood vessels.
Major changes include: (1) Widespread damage to facial blood vessels,
(2) Extreme hyper-reactivity of the remaining blood vessels, (3)
Significant leakage from damaged blood vessel walls, and (4) Adverse
changes to facial skin.
VI. Classification
System for Rosacea Subtypes
The Rosacea Society Medical
Committee has recently developed a "Rosacea Classification
System" to help diagnose rosacea subtypes. While there
is a trend for rosacea sufferers to proceed through the stages listed
above, it is helpful to understand that based on genetics some rosacea
sufferers are more susceptible to develop certain symptoms; therefore
it was necessary to develop a rosacea classification system. This
system helps rosacea sufferers better understand their symptoms
and find the proper treatments. Below is a summary of each subtype
adapted from the Journal of the American Academy of Dermatology.
2002; 46:584-587.
| Rosacea
Subtypes |
Rosacea
Symptoms |
|
Erythematotelangiectactic Rosacea |
Facial Redness |
Papulopustular Rosacea |
Papules & Pustules |
|
Phymatous Rosacea |
Facial Skin Growth/Thickening |
Ocular Rosacea |
Eye Symptoms |
| Neuropathic Rosacea |
Facial Burning/Stinging Sensations |
Subtype 1: Erythematotelangiectatic
Rosacea
Erythematotelangiectatic
rosacea is mainly characterized by flushing and persistent central
facial redness. The appearance of telangiectasia is common but not
essential for a diagnosis of this subtype. Central facial edema,
stinging and burning sensations, and roughness may also occur. A
history of flushing alone is common among patients presenting with
erythematotelangiectatic rosacea.
Printed
with Permission
Subtype 2: Papulopustular
Rosacea
Papulopustular rosacea
is characterized by persistent central facial redness with transient
papules or pustules. The papulopustular subtype resembles acne vulgaris,
except that comedones are absent. Burning and stinging sensations
may be reported by patients with papulopustular rosacea.
This subtype is often
reported in combination with subtype 1, including the presence of
telangiectasia. The telangiectasia may be obscured by persistent
redness, papules, or pustules.
Printed
with Permission -- http://www.dermnetnz.org/
Subtype 3: Phymatous
Rosacea
Phymatous rosacea includes
thickening of the nose skin, irregular surface nodularities, and
enlargement. Rhinophyma is the most common presentation, but phymatous
rosacea may occur in other locations, including the chin, forehead,
cheeks, and ears.
Printed
with Permission
Subtype 4: Ocular Rosacea
The diagnosis of ocular
rosacea should be considered when a patient's eyes have one or more
of the following signs and symptoms: watery or bloodshot appearance,
foreign body sensation, burning or stinging, dryness, itching, light
sensitivity, blurred vision, telangiectasia of the conjunctiva and
lid margin. Blepharitis, conjunctivitis, and irregularity of the
eyelid margins also may occur.
Printed
with Permission
Subtype 5: Neuropathic
Rosacea
This classification system
has proven helpful to many general dermatologists. However, a gaping
hole has been left in the system setup. This system has excluded
one of the most important rosacea subtypes. It's important that
all dermatologists become aware that a new clinical subtype has
recently been identified. Though not officially recognized yet,
Neuropathic Rosacea (Subtype 5) is believed to be the most debilitating
form of the disorder.
Hallmarks of Neuropathic
Rosacea include bouts of centrofacial burning and pain sensations
following exposure to triggers. Such bouts usually last longer than
30 minutes. More serious cases can become semi-permanent if dermal
inflammation or various inflammatory cytokines damage or permanently
activate sensory nociceptors. In severe cases, underlying facial
inflammation may trigger these sensory nociceptors in the absence
of external triggers. It must be stressed that this subtype can
cause physical disability comparable to diabetic neuropathy and
other painful peripheral neuropathies.
Rosacea sufferers with
Neuropathic Rosacea are best treated by a collaborative effort between
dermatologists, neurologists with peripheral nerve treatment training
and pain specialists.
VII. References
-
Marks, R., R.J. Beard, M.L. Clark, M. Kwok,
and W.B. Robertson. Gastrointestinal observations in rosacea.
Lancet 1: 739-743, 1967.
-
Lowe, N.J., K.L. Behr, R. Fitzpatrick, M. Goldman,
and J. Ruiz-Esparza. Flash lamp pumped dye laser for rosacea-associated
telangiectasia and erythema. J Dermatol Surg Oncol 17:
522-525, 1991.
-
Wiemer, D.R. Rhinophyma. Clin Plast Surg
14: 357-365, 1987.
-
Elliott, R.A.J., L.E. Ruf, and J.G. Hoehn.
Rhinophyma and its treatment. Clin Plast Surg 7: 277-288,
1980.
-
Thiboutot, D.M., P.C. Donshik, D.M. Hoss, and
W.H. Ehlers. Acne and Rosacea: Inflammatory and papulosquamous
disorders of the skin and eye. Am Fam Physician 50: 1691-1692,
1994.
-
Greaves, M.W. "Flushing, flushing syndromes,
rosacea and perioral dermatitis". In: Textbook of Dermatology,
edited by R.H. Champion, J.L. Burton, and et al. Malden: Blackwell
Science, 1998, p. 2099-2112.
-
National Rosacea Society. "Rosacea Review".
Summer. 1997. Drake,L.
-
Ellis, C.N. and M.A. Stawiski. "The treatment
of perioral dermatitis, acne rosacea, and seborrheic dermatitis".
Med Clin North Am 66: 819-830, 1982.
-
Flarer, F. "The causes of inflammatory
erythema". J Invest Dermatol 201-209, 1954.
-
Anonymous. Rosacea--a chronic disease of the
skin which, if not treated, can cause permanent damage. Sante
Que 3: 17-18, 1992.
-
Neumann, E. and A. Frithz. Capillaropathy and
capillaroneogenesis in the pathogenesis of rosacea. Int J
Dermatol 37: 263-266, 1998.
-
Pierard, G.E., C. Pierard-Franchimont, and C.M.
Lapiere. Proliferation and hyperplasia of vascular endothelium
in human skin. Am J Dermatopathol 7: 477-488, 1985.
-
Wilkin, J.K. Rosacea. Pathophysiology and treatment.
Arch Dermatol 130: 359-362, 1994.
-
Rebora, A. Rosacea. J Invest Dermatol
88: 56s-60s, 1987.
-
Marks, R. Histogenesis of the inflammatory component
of rosacea. Proc R Soc Med 66: 742-745, 1973.
-
Ramelet, A.A. and G. Perroulaz. Rosacea: histopathologic
study of 75 cases. Ann Dermatol Venereol 115: 801-806,
1988.
-
Pochi, P.E. "Acne Rosacea". Clin
Dermatol 2: 1-7, 1987.
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