ROSACEA & PERIORAL

DERMATITIS

ESTHER NIMISHA
DEFINITION:

-Rosacea can be defined

as a vascular disorder
predominantly affecting
the flush area of the
face, manifesting with
persistent erythema and
telangiectasia,
punctuated with
episodes of
inflammation.
EPIDEMIOLOGY:

 Rosacea affects all races,but is most

common in fair skinned individuals.

 It occurs in both men and women and

onset typically begins after the age 30.
 ETIOPATHOGENESIS:
-exact etiology not known

-clearly related to vasular hyperactivity;

1)sunexposure

2)hot liquid beverages,soups

Triggers factors
3)vasodilator drugs

4)irritating cosmetics

5)exercise

6)H.pylori

7)cathelicidin antimicrobial peptide

Associated factors
8)demodex folliculorum

9)infection &resident bacterial flora

STAGES OF ROSACEA:

1)PRE ROSACEA

2)VASCULAR STAGE

3) INFLAMMATORY STAGE

4) LATE ROSACEA
CLINICAL FEATURES:
-forehead,nose,chin and cheeks
are commonly involved.

-persistent erythema and

teleangiectasis remains between
the episodes of inflammation.
CLASSIFICATION:
1)PRIMARY SIGNS:
-flushing,non transient erythema,
papules,pustules and telangiectases

2)SECONDARY SIGNS:
-burning,stinging,plaques,dry
appearance,edema,ocular
manifestation,peripheral location and
phytomatous changes.
ROSACEA CAN BE GRADED AS:
1) primary: absent
mild
moderate
severe

2)secondary: present
absent
GLOBAL ASSESSMENT OF SUBTYPES:

1) ERYTHEMATO-TELANGIECTATIC ROSACEA

2) PAPULOPUSTULAR ROSACEA

3) PHYMATOUS ROSACEA

4) OCULAR ROSACEA
ERYTHEMATO-TELANGIECTATIC ROSACEA
PAPULOPUSTULAR ROSACEA
PAPULO-PUSTULAR ROSACEA
PHYMATOUS ROSACEA
OCULAR ROSACEA
Other Rosacea types:
- granulomatous rosacea
-steroid rosacea
-halogen aggravated rosacea
-rosacea conglobata
-various phymas( rhinophyma,
gnathophyma,otophyma,blepharophyma)
 COMPLICATIONS:

1) RHINOPHYMA

2) OCULAR ROSACEA

3)ROSACEA LYMPHEDEMA
 HISTOPATHOLOGY:
1) ETR: sparse perivascular lymphohistiocytic

infitrate is accompanied by dermal edema &

ectatic venules & lymphatics.

2) PPR: inflammatory infitrate surrounds hair

follicle & sebacceous gland.

3) phytomatous: prominent elastosis,fibrosis

dermal inflammation,sebaceous hyperplasia

 DIFFERENTIAL DIAGNOSIS:

1)CUTANEOUS CONDITION:

-steroid induced acneiform eruption

-acne vulgaris

-perioral dermatitis

-chronic photodamage
 2) SYSTEMIC DISEASES:
-Lupus erythematosus
-dermatomyositis
-carcinoid syndrome
-habers syndrome
-neurological causes – brain tumours
spinal cord lesions

orthostatic hypotension

migraine

parkinson disease
 3) MEDICATION INDUCED :

-vasodilators
-calcium channel blockers
-morphine
-amyl and butyl nitrite
-cholinergic drugs
-bromocriptine
-tamoxifen
-systemic steroid
-cyclosporine
TREATMENT:
ORAL THERAPY

1. TETRACYCLINE 250-500 mg q.i.d or b.d

2. DOXYCYCLIN & MINOCYCLINE 50-100 mg

bd/od

3. METRONIDAZOLE 200mg b.d

TOPICAL THERAPY

1. METRONIDAZOLE GEL ( 1%)

2. AZELAIC ACID CREAM (20%)

3. BENZOYL PEROXIDE GEL ( 2.5% ,4% )

4. TACROLIMIUS & NICOTINAMIDE(0.1%,0.03%

DERIVATIVES

5. TOPICAL RETINOIDS
 Vascular laser & intense pulsed light(IPL) are
useful alternatives to oral rosacea therapies.

 Used adjunctively with topical and oral rosacea

regimens

 Non-ablative modalities reduce erythema, papule

& pustule counts and appear to extend the
duration of remission

 Drawbacks are cost & side effects(transient

erythema, oedema, purpura, burns & rarely
scarring)
TREATMENT OF PHYMA:
-oral isotretinoin: early to moderate
phyma.
-surgery: advanced phyma
-cold scalpel tangential excision
-heated scalpel excision
-electrocautery
-dermaabrasion
-laser ablation
-radiofrequency electrosurgery
TREATMENT OF OCULAR ROSACEA:

-ophthalmologic referral should be

made

-sodium sulfacetamide 10% eye

ointment is effective for control of
blepharitis.
 PERI ORAL DERMATITIS

-is characterised by small discrete papules

and pustules in a periorifical distribution
predominantly around the mouth.

-subset of perioral dermatitis shows

granuloma, when examined histologically
known as granulomatous peri oral
dermatitis.
 EPIDEMIOLOGY:

-It occurs in young women aged 16 and

45 yrs, and sporadically in men.

-granulomatous form of perioral

dermatitis has been reported in children
of prepubertal age.
ETIOPATHOGENESIS:
-Exact cause is not known.
1)use of flourinated topical steroid
2)hormonal factors
3)sunexposure
4)tobacco
5) pyogenic organisms
6)demodex folliculorum
7) cosmetics
8) fluoride toothpaste
 CLINICAL FEATURE:
-discrete and grouped erythematous
papule,vesicles and pustules.

-unilateral to start with, later becomes

b/l,around perioral,perinasal, and peri
orbital region.

-a distinct 5 mm clear zone at vermilion

border of lip is well described.
-granulomatous variant present with
small flesh colored, erythematous or
yellow brown papules some with
confluence.

-reported to appear on the ear,scalp,

trunk,labia majora & extremities.
 DIFFERENTIAL DIAGNOSIS:
1) NON GRANULOMATOUS POD:
-rosacea
-seborrheic dermatitis
-allergic contact dermatitis
-irritant contact dermatitis
-lip licking cheilitis
-acne vulgaris
-gram negative folliculitis
-D. Folliculorum infestation
-acrodermatitis enteropathica
2) GRANULOMATOUS POD:

-granulomatous rosacea
-familial juvenile systemic
granulomatosis(Blau syndrome)
-fungal infection
-lupus miliaris disseminatus faciei
-benign cephalic histiocytosis
-sarcoidosis
 HISTOPATHOLOGY:

-consist of slight acanthosis,epidermal

edema,focal perifollicular parakeratosis &
spongiosis

-scattered perifollicular or perivascular

infiltrate consisting of lymphocytes, histiocytes
and plasma cell in dermis.
 TREATMENT:

TOPICAL:

1) Metronidazole gel 1% b.i.d

2) Erythromycin or clindamycin 1% b.i.d

3) sulfur preparation b.i.d

4) Azelaic acid 10%/ 20% cream b.i.d

 SYSTEMIC :

1) Tetracycline 250-500 mg b.i.d

2) Doxycycline 50-100 mg b.i.d

3) Minocycline 50-100 mg b.i.d

4) Erythomycin 400 mg t.i.d

THANK YOU