06-May-15. Rosacea, Perioral Dermatitis, Optimizing Management,Tips and Traps

Transcription

1 Rosacea, Perioral Dermatitis, Optimizing Management,Tips and Traps Rodney Sinclair Professor of Dermatology University of Melbourne & Epworth Healthcare 1

2 Predominantly erythematotelangiectatic rosacea affecting the cheeks and nose. Note conjunctival injection Erythema mainly involving the convex areas of the face in a patient with rosacea. Inflammatory papulopustular rosacea Chronic lymphoedema in a patient with a long history of rosacea 2

3 Rhinophyma and other phymas The phymas are localized swellings of facial soft tissues due to variable combinations of fibrosis, sebaceous hyperplasia and lymphoedema They develop predominantly in males. The commonest is rhinophyma, a swelling of the nose which may become grossly distorted in contour Other areas which may be affected include the forehead (metophyma) chin (gnathophyma) eyelids (blepharophyma) ears (otophyma) [2]. forehead (metophyma) chin (gnathophyma) Eye involvement Estimates of prevalence vary from 6% to over 30% of patients with rosacea The pathogenesis is still not well understood. Symptoms include a sensation of grittiness or irritability of the eyes, often accompanied by visible reddening of the conjunctiva. Blepharitis, episcleritis, chalazion and hordeolum are also common. Rosacea keratitis is a more serious and quite common complication, The conjunctivitis, keratitis and other complications seem likely to be at least partly secondary to reduced tear secretion and Meibomian gland dysfunction, resulting in an unstable tear film. Ocular rosacea may be seen in isolation or occur before the onset of cutaneous features, especially in children The condition may be unilateral or asymmetrical Pyoderma faciale 3

4 Type 1 Erythematotelangiectatic rosacea Laser therapy Fine wire diathermy IPL Treatment of rosacea associated erythema with pulsed dye laser Treatment of rosacea associated erythema with IPL 4

5 Type 2 Papulopustular rosacea Topical therapy Topical metronidazole Toical azeleic acid Sodium sulphacetamide 10% with sulphur 5% No role for topical benyl peroxide Role of Pimecrolimus, clindamycin unclear Oral tetracycline. Doxycycline, minocycline, ampicillin, Type 3 Phymomatous rosacea Surgical therapy Ablative laser Type 4 Occular rosacea Articficial tears Topical steroid Topical cyclosporin emulsion 5 day history abrupt worsening Fever, sore eyes, blurred vision 3 year history mild papulopustular rosacea Treated with prednisolone 30 mg, isotretinoin 35 mg Marked improvement within 5 days Presented with pruritis, diffuse facial erythema, crusted lesions, papules and pustules Responded initially to oral ivermectin and topical permethrin Required minocycline and metronidazole gel for 32 months Corticosteroid-induced rosacea Predominately associated with fluorinated corticosteroids face On occasions, even 1% hydrocortisone may provoke steroid rosacea in children The use of steroid nasal spray may also be responsible A granulomatous eruption described as resembling rosacea developed 9 months into therapy with topical tacrolimus 0.1% ointment Perioral dermatitis Treatment The most important measure is to discontinue the topical corticosteroids. Other applications, including cosmetics, should also be stopped. The patient must be warned that an initial flare may develop after withdrawal of a topical steroid. A 4-week course of oral minocycline is usually all that is required. Topical tetracycline, metronidazole cream 1% e 2% are also effective [ pimecrolimus 1% cream also has been used 5

6 Perioccular dermatitis Granulomatous perioral dermatitis in children Flushing and flushing syndromes Flushing and flushing syndromes Flushing and flushing syndromes Cause Proposed mediator(s) Physiological Autonomic Menopausal Autonomic Drug-induced Various Alcohol Acetaldehyde Chlorpropamide and alcohol Acetaldehyde Food Autonomic Scombroid fish poisoning Histamine Serotonin Prostaglandins Carcinoid syndrome Bradykinin Histamine Mastocytosis Histamine Thyrotoxicosis Thyroxine Prostaglandins Medullary carcinoma of the thyroid Calcitonin Pancreatic tumours Vasoactive intestinal peptide Insulinoma? POEMS syndrome? Drugs that cause flushing *With ethanol. 5-HT3 receptor antagonists: ondansetron, ramosetron, tropisetron ACE inhibitors: captopril, enalapril, lisinopril, perindopril, ramipril β-3 adrenoceptor agonists: fluvoxamine, mirtazapine Calcium channel blockers: nifedipine, verapamil Chlorpropamide* Disulfiram* Ethanol Fumaric acid esters Hydralazine Metronidazole* Nicotinic acid Nitrates: isosorbine mononitrate/dinitrate, glyceryl trinitrate Phentolamine Pilocarpine Prostacyclin Prostaglandin E Sildenafil, tadalafil and vardenafil Venlafaxine Physiologic flushing can be helped by propranalol Menopausal flushing usually improves with oral or transdermal oestrogen replacement therapy. Combined oral contraceptives are effective and even the use of progestagens alone may be beneficial. Non-hormonal approaches to management include the use of clonidine 0.05 mg twice daily or selective serotonin reuptake inhibitors (SSRIs) Unilateral gustatory flushing Histamine-evoked geographical pattern of flushing due to foregut carcinoid tumour 6

7 Fast Facts Minor Surgery Second edition Rod Sinclair MBBS FACD MD Professor of Dermatology, University of Melbourne; Director of Dermatology, Epworth Hospital, Victoria, Australia Christopher J Price MBBCh MRCGP DipMedEd Associate Dean, Postgraduate Education for General Practice, Cardiff University, Cardiff, Wales, UK 15/ 18/$25 Buy 3 get 1 FREE Available from: Contents: Operative set-up and equipment Local anesthesia Lesion identification and management Treatment planning Avoiding complications Suturing techniques and removal Surgical procedures Examining your practice it's unique in being able to pack so much relevant information into such a small volume, which makes it highly readable." First Prize winner, Primary Health Care, BMA Book Awards. Fast Facts Disorders of the Hair and Scalp Second edition Rod Sinclair MBBS FACD MD Professor of Dermatology, University of Melbourne; Director of Dermatology, Epworth Hospital, Victoria, Australia Vicky Jolliffe MA FRCP FRCS(Ed) MRCGP Senior Lecturer and Honorary Consultant Dermatologist, Barts and The London NHS Trust, London, UK 15/ 18/$25 Buy 3 get 1 FREE Available from: Contents: Anatomy and physiology Diagnosis Androgenetic alopecia Diffuse hair loss telogen effluvium Alopecia areata Trichotillosis and traction alopecia Scarring alopecia Tinea capitis Hirsutism and hypertrichosis Scalp disorders Special problems in children Hair transplantation, care and cosmetics Useful resources It is good value for money and will be a useful addition to any GP or GPSI s armoury of literature. Michelle Ralph, GPSI Cambridge & PCDS Bulletin Editor; Primary Care Dermatology Society Bulletin, Spring 2014 Receive 20% off your order with discount code WHU20 Receive 20% off your order with discount code WHU20 7