Update of Rosacea. Case 1. Case 2 8/15/2017

Transcription

1 Update of Rosacea Dr Samantha Eisman Dermatologist Sinclair Dermatology MBChB MRCP(UK) FCDerm(SA) FACD Case 1 Your 55 year old cousin calls and asks advise about her red face. What is your differential diagnosis list 5 options Case 2 A 17 year old presents with these lesions. What is the diagnosis? What features help make the diagnosis? 1

2 Case 3 45 year old woman C/O 1 year flushing when eats spicy food or drinks red wine Metronidazole burns Azelaic acid too drying Doxy and minocycline 8 weeks each Uses thick make up to conceal Many cosmetics sting/ burn What is the diagnosis- be specific? How would you manage this lady? ( discuss prevention and active Rx) Case 4 68 year old lady Red face No ETOH Good skin care Tried many topicals Tried Doxy Tried Laser What is the diagnosis? When would you refer? What are management options? Case 5 45 year old women 6 months ago presented with rash adjacent to right nasal alar Went to pharmacy- 1% Hydrocortisone ointment Went to GP- potent topical corticosteroid for 1 week Rash persists What is the diagnosis? How can this be prevented? How can you treat? 2

3 Case 6 18 year old girl Rash on face- asymptomatic Clinical finding rash arms and thighs Father has similar rash on arms What is diagnosis? Management options? Case 7 62 year old Dryness and erythema Eyebrow and nasolabial Tried antifungal creams Tried emollients Diagnosis? Management? Case 8 22 year old girls Joint aches and facial rash Likely diagnosis? 3

4 Painting 15 th century Nasal involvement Case 9 Diagnosis? Treatment options? Case year old ladies Lesions around the nose Cosmetic concern Cough otherwise healthy Case 11 Rash on neck and face Itchy No response to 1% HC Diagnosis and treatment? 4

5 Rosacea- definition Chronic skin disorder of vascular origin Skin of central face (convexities) Woman Skin type I and II Prevalence 0,5%-22% 1,78 Million in Australia Low self esteem Pathogenesis Increased vascularity Inflammation Around vessels ROSACEA Clinical Signs Increased vascularity Inflammation Around vessels Flush/ erythema/ Dilated capillaries ROSACEA Disrupts barrier/ papules/ pustules 5

6 Pathogenesis genetic Increased vascularity Inflammation Around vessels ROSACEA Pathogenesis genetic Environmental Dietary trigger Drugs/Disease Increased vascularity Inflammation Around vessels ROSACEA Pathogenesis genetic Environmental Dietary trigger Drugs/Disease infection Increased vascularity Inflammation Around vessels ROSACEA 6

7 Pathogenesis genetic Environmental Dietary trigger Drugs/Disease infection Increased vascularity Dysregulation innate immunity -increase toll-like R-2 -increase cathelicidin -Increase kallikrein 5 -increase MMP Inflammation Around vessels ROSACEA Diagnostic Criteria Primary Features- one or more in central face Flushing Non transient erythema Papules and pustules (no comedones) Telangiectasia Diagnostic Criteria Secondary Features- one/more may be present Burning/ stinging/dryness/scaling Red plaques/phymatous changes/oedema Eyes signs Peripheral location 7

8 Subtypes 1. Erythematotelangiectatic (12%) 2. Papulopustular (69%) 3. Phymatous (3,7%) 4. Ocular (6-50%) 5. Variants 1. Erythematotelangiectatic (ETT) Flushing Persistent central facial erythema (spare periocular) Burning and stinging Irritation from topical substances Minimal inflammatory lesions/scale 2. Papulopustular Redness central face Telangiectasia Spare periocular skin Papules and pustules (transient) Oedema may be present Flushing (mild) 8

9 3. Phymatous Sebaceous hyperplasia Skin thickens Irregular surfaces and nodularities/ prominent pores Nose/chin/forehead/eyelids rhynophyma gnatophyma metophyma 4. Ocular/ Eye involvement May precede skin signs 50-70% patients Unilateral or asymmetrical Decrease tear secretion and Meibomian gland dysfunction 20% present eyes first/ 50% present skin first injection 4. Ocular/ Eye involvement More than 1 Burning/ blurred vision/ stinging/ itching/ light sensitivity/ FB/watery/ bloodshot/ dryness/telangiectasia conjunctiva or lid/ lid and periocular erythema Conjunctivitis Blepharitis Stye (chalazion) Meibomian gland inflammation Rosacea keratitis (5%)- corneal involvement 9

10 5. Variants Granulomatous Chronic Lymphoedema Steroid induced Rosacea fulminans granulomatous lymphoedema Steroid induced Rosacea fulminans Treatment of Rosacea Avoid trigger Skin care Disease specific Maintenance Treatment Avoid trigger Skin care Disease specific Maintenance 10

11 Treatment- avoid trigger Heat (exercise/ bath/ food/ clothes/ heating home) Exertion Emotions (anger/ embarrassment/ stress) Weather (wind/ heat) Food (pepper/ coffee/ tea/ citrus/ tomato/choc) Topical products (cosmetics/ toners/anti-wrinkle/acne/fragrance) Drugs (vasodilators/ steroids/ tamoxifen/ erectile dysfunction/ metformin/ nicotinic acid) Treatment Avoid trigger Skin care Disease specific Maintenance Treatment- Skin care Soap Free washes Simple emollients (apply after medicated products) Sun protection (UVA and UVB)- at least SPF 30 Cosmetics 11

12 Treatment Avoid trigger Skin care Disease specific Maintenance Pathogenesis Increased vascularity Inflammation Around vessels ROSACEA Treatment of inflammatory component- Papulopustular (papules/ pustules/ phymatous) Topical Antibiotics Anti-inflammatory Systemic (extensive or non- responsive) Antibiotics (off-label use) Isotretinoin (off-label) ivermectin Laser/ Surgery 12

13 Topical antibiotics Metronidazole 0,5%/ 1%/0,75% / cream/gel/ointment/ lotion Erythromycin gel Clindamycin lotion Topical anti-inflammatory Azelaic acid gel 15%/ 20% lotion/ cream/ foam Benzoyl peroxide/ +/- clindamycin or erythromycin Retinoids (adapalene cream/gel and tretinoin cream/gel) Calcineurin inhibitors (pimecrolimus and tacrolimus) Sulphacetamide 10%/ sulphur 5% lotion/ cream Ivermectin 1% cream / permethrin 5% cream Systemic treatment First line antibiotics Doxycycline/ minocycline mg daily Second line antibiotics Erythromycin 250mg-500mg BD/QDS or 400mg BD Clarithromycin 250mg-500mg BD/QDS Azithromycin 250mg 3weekly/ 1000mg 45 days then 500mg 45 days) Amoxycillin Bactrim Metronidazole 200mg BD 6 weeks Isotretinoin- low dose/ longterm Ivermectin 13

14 Pathogenesis Increased vascularity Inflammation Around vessels ROSACEA Treatment of Vascular Component- Erythematotelangiectatic Redness/ telangiectasia/ flushing Topical vasoconstrictors Systemic Laser Surgery Topical vasoconstrictors Brimonidine 0,5% gel Oxymetazoline 0.05% solution (nasal) - 14

15 Systemic treatment for flushing B blockers Clonidine Aspirin Naloxone Ondansetron SSRIs Contraceptive pill Amitriptyline Botox Laser/Surgery Telangiectasia/ persisting erythema AND symptoms Short wavelength Lasers (superficial vessels and persistent erythema) Pulsed dye laser/ long pulsed dye laser Long-pulse KTP laser IPL Diathermy Treatment Eyes Artificial tears Eyelid hygiene Warm compress and massage Cyclosporine 2% drops/ 0,05% emulsion Metronidazole eye drops (compounded)!0% sulphacetamide eye drops Azithromycin 1,5% drops Azithromycin and other oral antibiotics Ophthalmology review 15

16 Cochrane review 2015 High quality evidence Topical azelaic acid/ ivermectin/ brimonidine Doxy/ isotretinoin Moderate quality evidence Topical metronidazole Oral tetracyclines Low quality evidence Low dose minocycline (45mg) IPL AND laser Cyclosporine ophthalmic emulsion Future Treatments Topical serine protease inhibitors/? Cathelicidin blockers Topical mast cell stabilisers (cromolyn sodium) Nitric oxide inhibitors ( vasoconstrictors) Take home Non contagious inflammation of skin of face Cause unknown but many new theories (therapeutic targets) No cure but options for control Avoid triggers and good skin care Variety of topicals/ medications and laser- subtype Non responders/ eye disease referral Online support groups 16