Rosacea

00:02 With the rosacea, you have a myriad of presentations.

00:06 You may have what’s known as your rhinophyma.

00:10 And if you take a look at the nose here, and if you take a look at it on closer examination, you’ll notice that there is absolutely no comedone.

00:18 And on top of that, there’s erythema in the background of telangiectasia.

00:23 How is rosacea being triggered? You’re looking for spices, maybe alcohol or maybe stress.

00:29 So, every so often with my medical students, obviously, a lot of stress in our particular profession.

00:36 No doubt.

00:38 And so therefore, many of these students end up having rosacea, and you can tell by looking at the nose, it becomes reddened, but they’re not alcoholics.

00:47 So therefore, there has been a stereotype where we find a bulbous nose or rhinophyma, in which the patient is embarrassed that people may think that he or she is an alcoholic.

00:59 Not always the case, keep that in mind.

01:03 Demographics: When do you find rosacea? Adulthood.

01:07 More often of those of Northern European descent, and women are affected much more so than men.

01:14 And if it is men, then as I showed you a picture earlier, it’s the rhinophyma that you’re paying attention to.

01:21 You know what rhino- means, rhinoplasty so on and so forth.

01:25 It’s the nose undergoing erythematous telangiectasia type of changes.

01:31 Acne rosacea is the full name.

01:34 I have abbreviated it for you for convenience sake as rosacea.

01:39 Keep in mind that this is going to be a differential for acne vulgaris.

01:43 As we travel through our course in dermatology, you’re going to have this long list of differentials in which you will be able to clearly rule things in or rule things out.

01:55 And man, let me tell you, that is such a good feeling.

01:59 Etiology: poorly understood.

02:02 But we know that there is going to be involvement of your blood vessels, vasoactivity.

02:07 Flushing or blushers is what they’re called “because of the erythema.” And there is a particular mite that you probably want to memorize.

02:18 In current day practice, you still have possibly the involvement of a particular mite called demodex having been implicated in some research and theory that you want to keep in mind, please.

02:31 Acne rosacea.

02:33 Morphology: Well, here, you find your papules and pustules, usually on the central aspect of the face.

02:39 Also, keep it as a differential, something like your SLE that we’ll talk about soon enough with malar rash, and this is not that.

02:47 It’s not a malar rash.

02:48 You must have telangiectasia, please.

02:51 You must have.

02:52 And they will give this to you in a clinical vignette.

02:55 Telangiectasia, which obviously means your little blood vessels that are undergoing inflammation.

03:00 And with that type of dilation that’s taking place, there is every possibility that you’re going to find these areas of erythema.

03:07 The triggers: sunlight/wind, spicy food, hot temperatures, and caffeine, and perhaps, alcohol.

03:15 Look for the triggers, please, in the history of your patient, either on your wards or on the boards.

03:23 Management: Here, possibly metronidazole.

03:27 Mechanism of action poorly understood.

03:30 Other topical agents, we have something called azelaic acid.

03:35 Tetracycline derivatives, only those with anti-inflammatory properties.

03:39 And cosmetic procedures, maybe something like your rhinophymectomy and laser treatment.

03:45 Why? Because you’re trying to take care of the telangiectasia.

03:47 Cosmetically speaking, I showed you that nose to begin with.

03:51 And so therefore, cosmetically, you try to treat this so that, or manage it so that you’re able to restore some of the self-esteem in your patient psychologically.

04:00 Please make sure that you’re familiar with the steps of management of rosacea and the triggers.

04:07 Differential diagnosis, quickly here.

04:10 By acne, we mean acne vulgaris.

04:12 Once again, you know about your patient, andrenarche, puberty age, comedones are huge feature.

04:18 Next once again, here we have another differential diagnosis, perioral or periocular dermatitis.

04:25 Occurs in specific areas as noted here.

04:28 Monomorphic in its appearance.

04:29 And so you don’t have these areas of, I showed you a picture of rhinophyma where you might have areas of erythema.

04:37 A little bit darker, maybe a little bit lighter, or even acne vulgaris.

04:40 But here, it’s monomorphic and inflammatory papules without comedones.

04:47 Other differentials: well, I showed you that picture of the nose.

04:50 And as I told you earlier, malar rash, it could be confused with systemic lupus.

04:56 But with lupus, it’s an abrupt onset with greater confluence in these triggers that we talked about.

05:01 Rosacea are not so present at all, actually.

05:05 And spares -- huge here -- nasolabial fold.

05:13 So with SLE.

05:14 and that malar rash, it spares the nasolabial fold, photodistribution.

05:20 That’s huge.

05:22 I’ll talk about this over and over again so that it becomes part of your, what’s known as, I like to call it your reflexive consciousness.

05:29 Another differential: well, in a baby, we call this cradle cap, and you’ll see why.

05:36 This is seborrheic, and I’m going to repeat this, reinforce it, reinforce it, reinforce it, and I’m going to shove this down your throat, I’m sorry.

05:43 I usually don’t like doing that but I need to here.

05:45 There’s a condition that we’ll talk about later called seborrheic keratosis.

05:50 That is not our topic here.

05:51 As a differential for rosacea, we have seborrheic dermatitis.

05:56 Is that clear? So, when the time is right, we’ll walk through seborrheic dermatitis, seborrheic keratosis, and you’ve heard of another condition called actinic keratosis.

06:08 All of this is coming, I’m just introducing one thing at a time.

06:12 We have seborrheic dermatitis as being a differential.

06:15 So, how can you rule it in or rule it out? Often, intensely pruritic.

06:18 What does that mean? Itch, itch, itch.

06:20 Greasy, yellow scale.

06:24 Prominent involvement of the nasolabial folds, the glabella and the hairline are areas that you want to pay attention to, seborrheic dermatitis.

06:32 And we will expand upon this further and I’ll show you pictures, not to worry.