Although dentists lack the necessary training to definitively diagnose rosacea, they are in a strategic position to recognize this condition early on and refer patients to a physician for confirmation of the diagnosis and treatment.

	SUBTYPES OF ROSACEA AND CLINICAL PRESENTATION

TOP ABSTRACT SUBTYPES OF ROSACEA AND... WHO IS LIKELY TO... NONROSACEA CONDITIONS THAT HAVE... HOW IS ROSACEA TREATED? WHAT SHOULD DENTISTS TELL... CONCLUSION REFERENCES

 
Rosacea is classically defined as a chronic dermatologic condition that predominantly affects the face.^1,3 Rosacea usually is divided into four clinical subtypes^2,4–6 (Box 1). Sometimes referred to as the prerosacea subtype, the first subtype of rosacea is distinguished by episodes of intense flushing (Figure 1).³ A number of environmental triggers can induce this flushing (Box 2, page 605). After years of such episodic flushing, most patients progress to subtype 2, developing persistent facial redness (erythema), dilated blood vessels (telangiectasia) and inflammatory lesions (papules and pustules) (Figure 2, page 605).^4,5 The telangiectasia frequently occurs in the area of the nose. Rosacea may stabilize at subtype 2 or progress to subtype 3, which is characterized by thickening skin and irregular surfaces^4,5 (Figure 3, page 605). Some patients with subtype 3 rosacea develop rhinophyma (so-called W.C. Fields nose), easily recognized by excessive tissue growth.^4,5,7

View larger version (127K): [in this window] [in a new window]   Figure 1. Subtype 1: Prerosacea. Typical appearance of a transient episode of intense prolonged flushing. (Photo reprinted with permission of Galderma SA, Lausanne, Switzerland. All rights reserved.)

View larger version (112K): [in this window] [in a new window]   Figure 2. Subtype 2: Papulopustular rosacea. Note the bilateral erythema with sprays of telangiectases across the cheeks and inflammatory lesions. (Photo reprinted with permission of Galderma SA, Lausanne, Switzerland. All rights reserved.)

View larger version (108K): [in this window] [in a new window]   Figure 3. Subtype 3: Phymatous rosacea. Papules and edema on a background of permanent erythema, enlarged pores, irregular surface nodules and rhinophyma. (Photo reprinted with permission of Galderma SA, Lausanne, Switzerland. All rights reserved.)

Ophthalmic rosacea, subtype 4, typically is manifested by watery or bloodshot eyes.⁵ Estimates of the prevalence of ophthalmic rosacea in all patients with rosacea range from 3 to 58 percent.^1,2,5,7 Approximately 20 percent of patients with ophthalmic rosacea develop ocular symptoms before facial symptoms.² The most common symptom of ophthalmic rosacea is inflamed margins of the eyelids, with or without pain. Patients also experience aversion to light (that is, photophobia).^1,6,8

	WHO IS LIKELY TO DEVELOP ROSACEA?

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Rosacea usually occurs in adults with fair skin, especially those of Northern and eastern European heritage.^1,2,4 People of English or Scottish descent are especially at risk; rosacea sometimes is referred to as the curse of the Celts.^2,8

Several authors have reported the mean age at onset to be between 30 and 50 years, but prerosacea can begin in the teenage years or early 20s in patients with a family history of rosacea.^1,2,4 The prevalence of rosacea is approximately 13 million Americans, or roughly one in every 20 individuals.^2,7 Obviously, the fraction of affected people is much higher among adults of European descent.

Rosacea rarely is reported in African-Americans, Koreans or other people with highly pigmented skin.^2,9 This may be owing to the fact that these people are less likely to exhibit obvious signs of blushing or flushing. Also, these people are less prone to photoaging, which is a pathophysiological feature of later-subtype rosacea.^1,8,9 Ophthalmic rosacea may be more prevalent in African-Americans than in whites.⁹

Women are more likely than men to develop rosacea, with a prevalence ratio of 3:1.^1,7 On the other hand, most patients who exhibit rhinophyma are men.^1,7

	NONROSACEA CONDITIONS THAT HAVE A SIMILAR PRESENTATION

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For the most part, rosacea has precise clinical features that are readily recognized.⁶ While a few conditions and diseases have similar cutaneous manifestations, most can be distinguished easily from rosacea.

Acne vulgaris. Rosacea sometimes is mistaken for acne vulgaris. Like rosacea, acne vulgaris is associated with inflammatory lesions, but the age at acne onset—10 to 25 years old—is much younger than the age at onset for rosacea.² Unlike rosacea, the inflammatory lesions associated with acne vulgaris often coexist with blackhead and whitehead lesions (that is, comedones). Furthermore, the lesions of acne vulgaris are not confined primarily to the central face.^2,7 Finally, flushing, persistent facial redness and dilated blood vessels rarely are seen with acne.^7,8

Systemic lupus erythematosus. As with rosacea, a cardinal feature of systemic lupus erythematosus is symmetrical erythema on the cheeks (butterfly rash).^5,8 Systemic lupus erythematosus can be distinguished from rosacea by the absence of inflammatory lesions and the presence of scales, pigmentary changes (skin blotches) and scarring.^2,5,7

Steroid-induced dermatitis. Steroid-induced dermatitis, or iatrosacea, is another cutaneous condition that can be mistaken for rosacea.¹⁰ After using topical corticosteroids (especially the more potent fluorinated types) on the face for just a few weeks, patients can develop a dermatitis. This skin inflammation resembles the progressive changes that occur after years of having had rosacea.^5,6,10 In addition to a history of topical corticosteroid use, the presence of comedones and skin atrophy or thinning, as well as a wider pattern of distribution of skin lesions and other stigmata, can differentiate steroid-induced dermatitis from rosacea.¹ Unfortunately, withdrawing the steroid treatment inevitably results in a transient exacerbation of symptoms.^1,5

Perioral dermatitis. Some clinicians consider perioral dermatitis, which is prevalent in women, to be a variant of rosacea.² Symmetrical lesions on a background of facial redness are common features of perioral dermatitis.⁸ However, flushing and telangiectasia are not characteristic of perioral dermatitis.² Furthermore, the lesions seen with perioral dermatitis are smaller than rosacea lesions, and are confined to the lower one-third of the face.^2,5,6 Perioral dermatitis usually occurs in people who are slightly younger than those who have rosacea.⁵

Cutaneous sarcoidosis. Cutaneous sarcoidosis is characterized by inflammatory lesions and telangiectasia on the face.² A skin biopsy is required to make a definitive diagnosis.²

Dentists should reassure patients that there are things they can do to control their condition.

Seborrhea dermatitis. Differentiating rosacea from seborrhea dermatitis can be difficult, in part because these conditions often coexist.^2,7,8 Millikan² estimated that a majority of patients with rosacea who are in their 50s and 60s also have seborrhea dermatitis. Differentiating features of seborrhea dermatitis are the presence of eczema-like yellow, greasy scales.^5,7 Unlike rosacea lesions, seborrhea dermatitis lesions are found in the eyebrows, in the area around the nose, on the scalp and around the ears.^2,5,7,8

	HOW IS ROSACEA TREATED?

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There is no cure for rosacea, but there are treatments that can control symptoms and halt the disease progression.²

Inflammatory lesions respond well to oral antibiotics, especially tetracycline.^{1,2,7,8,11–13} Compliance with prolonged oral antibiotic treatment regimens is limited by concerns about gastrointestinal distress, vaginitis, photosensitivity and the potential for the development of bacterial resistance.^2,6,11,14 Unfortunately, topical tetracyclines are not as effective in controlling rosacea.^1,8,14

Topical metronidazole, developed in response to these concerns, is the mainstay of rosacea therapy.¹⁵ Topical metronidazole demonstrates anti-inflammatory and antioxidant actions.^1,6,11 Topical metronidazole has demonstrated significant efficacy in reducing inflammatory lesions and erythema.^7,12,14,16 These benefits continue with the long-term maintenance therapy usually warranted for patients with this disorder.^15,16

The first available formulation of topical metronidazole was an aqueous gel (metronidazole topical gel, MetroGel Topical Gel, 0.75 percent [Galderma Laboratories, L.P., Fort Worth, Texas]). Although the aqueous gel is well-tolerated, metronidazole lotion (MetroLotion Topical Lotion, 0.75 percent, Galderma Laboratories) and metronidazole topical cream formulations (MetroCream Topical Cream, 0.75 percent, Galderma Laboratories and Noritate Cream, 1 percent, Dermik Laboratories, Berwyn, Pa.) were developed for patients with rosacea who have unusually sensitive skin. All formulations of topical metronidazole are well-tolerated.^{7,11,12,14,16}

In a head-to-head comparison, once-daily application of MetroCream, 0.75 percent, or Noritate, 1 percent, achieved comparable reduction of erythema and inflammatory lesions despite the difference in metronidazole concentration by weight.¹⁷ Dahl and colleagues¹⁷ cited a study that found that more metronidazole from the Metro-Cream formulation appeared to penetrate the skin than that from the Noritate formulation.

Therefore, the recommended first-line treatment for rosacea is to start with a regimen of an oral antibiotic plus topical metronidazole, tapering the oral antibiotic dosage once patients experience symptom remission.^2,3,7 To maintain remissions, clinicians should continue topical metronidazole therapy for an indefinite period.^2,7

Low-dose oral isotretinoin is used occasionally as second-line treatment for severe or recalcitrant rosacea.^1,7,8 However, isotretinoin has significant side effects.^1,7 Other interventions for the more severe subtypes of rosacea include surgery and laser therapy.^7,8,18

	WHAT SHOULD DENTISTS TELL PATIENTS WHO HAVE ROSACEA?

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Dentists should reassure patients that there are things they can do to control their condition. The first is to seek appropriate medical treatment from a dermatologist for patients with facial rosacea and from an ophthalmologist for those with ocular symptoms. Also, patients should be encouraged to modify their behavior (for example, reducing excessive sun exposure) whenever possible to avoid triggers that initiate a rosacea flare-up. A personal diary can be helpful to identify the triggers to which one is specifically susceptible (Box 2).²

Patients with rosacea should use a broad-spectrum sunscreen to prevent further sun damage.⁷ Women with persistent erythema may benefit from a make-up base with a green tint, which neutralizes the red.¹⁵ Helping patients with rosacea improve their facial appearance may be one of the dentist’s most dramatic procedures for improving the esthetics of smiles.

	CONCLUSION

TOP ABSTRACT SUBTYPES OF ROSACEA AND... WHO IS LIKELY TO... NONROSACEA CONDITIONS THAT HAVE... HOW IS ROSACEA TREATED? WHAT SHOULD DENTISTS TELL... CONCLUSION REFERENCES

 
Rosacea is a common dermatologic disorder seen in adults. Fortunately, effective treatments, such as topical metronizadole formulations and oral antibiotics, are available. Recognizing rosacea in dental patients and referring them to a physician for diagnosis and treatment is a health care service that dentists should perform in their quest to provide more comprehensive health care for patients.

View larger version (121K): [in this window] [in a new window]   Dr. Fuchs is in private practice, 5113 Lees-burg Pike, Suite 811, Falls Church, Va. 22041, e-mail "steven.fuchs{at}msdn.com". Address reprint requests to Dr. Fuchs.