History
Patients are likely to have a background of facial flushing, often dating to childhood or the early teens. In adult life, flushing may be increasingly precipitated by hot drinks, heat, emotion, and other causes of rapid body temperature changes. Some patients report flushing with alcohol, which is not specific.
The symptoms are usually intermittent but can progressively lead to permanently flushed skin. The latter may be described as high color and is associated with the development of permanent telangiectasia. Additionally, a few individuals report a gritty quality of the eyes and facial edema.
Physical Examination
The disease consists of a spectrum of symptoms and signs, with most patients failing to develop every stage of disease. Variable erythema and telangiectasia are seen over the cheeks and the forehead. Inflammatory papules and pustules may be predominantly observed over the nose, the forehead, and the cheeks. Extrafacial involvement uncommonly occurs over the neck and the upper part of the chest. Prominence of sebaceous glands may be noted, with the development of thickened and disfigured noses (rhinophyma) in extreme cases. Unlike acne, patients generally do not report greasiness of the skin; instead, they may experience drying and peeling. The absence of comedones is another helpful distinguishing feature. Ocular lymphedema may be prominent but is uncommon. The condition generally does not produce scarring.
Rhinophyma may occur as an isolated entity, without other symptoms or signs of rosacea. Rhinophyma can be disfiguring and therefore distressing for patients. Some authorities consider rhinophyma to represent a different disease process, although phymatous rosacea is considered one of the four subtypes of rosacea. [17]
Lymphedema may be marked periorbitally, and, on occasion, it is the presenting symptom.
Symptoms of ocular rosacea may be accompanied by conjunctival injection, and, rarely, chalazion and episcleritis may occur.
Rosacea fulminans (pyoderma faciale) is fortunately a rare complication and is characterized by the development of nodules and abscesses with sinus tract formation accompanied by systemic signs. Patients often have low-grade fever, elevated ESR, and possibly elevated white blood cell count.
Both seborrhea and seborrheic dermatitis/blepharitis are not uncommonly observed in patients with rosacea. The reasons for these associations are not well understood.
A rare granulomatous variant of rosacea (acne agminata/lupus miliaris disseminatus faciei) can manifest with inflammatory erythematous or flesh-colored papules distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. The lesions tend to be discrete, and surrounding erythema is not a marked feature but may be present. These patients often do not have a history of flushing. This pattern of rosacea is sometimes associated with scarring and may be resistant to conventional treatment.
See Practice Essentials for details on the 2016 global rosacea consensus that one diagnostic or two major phenotypes are required for the diagnosis of rosacea.
Complications
Rosacea keratitis and keratoconjunctivitis sicca are recognized complications. Rosacea fulminans is a rare complication. Scarring generally does not occur.
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Histopathology of rosacea. Perifollicular chronic inflammation and vascular ectasia. Courtesy of Dirk Elston, MD.
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Mild papules and erythema. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2367).
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Moderate papules and early pustules. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2369).
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Severe erythema, papules, and pustules. Courtesy of DermNet New Zealand (https://www.dermnetnz.org/imagedetail/2371).
