Flushing and Papule in Middle-Aged Woman Obstetrics and gynecology Vol. 105, No.2, Feb R2 서 영 진

CASE  42-year-old woman no gynecologic complaints, no medical illness does not smoke, takes no medications menstruations : regular considering beginning oral contraceptive method  The review of systems hot flushes: facial redness (burning, stinging) pimples on her chin acne and wrinkle

 Examination slightly sunburned under the eye & over the cheeks: dry, minimal flaking on her chin & around her nose: 8~10 small red solid papules normal female hair pattern no evidence of androgenization  Management avoiding direct sun exposure, wearing sunscreen 3 rd generation oral contraceptive pill

▶ 1 year later remains healthy but still her facial skin problem now generally red and irritated pimples on most days eyes: irritated and watery most of the time use skin care products, but no effect diffuse erythema (nose,medial cheeks,forehead,chin) acne-like lesion around the nose (not chest & back)  refers her to a dermatologist

HISTORY AND EXAMINATION  History facial flushing, redness pimples, burning sensation negative for joint acnes, pruritus, other complaints  Examination dense network of prominent telangiectasias over the nasal bridge, forehead, central cheeks scattered inflammatory papules and pustules over the nose and medial cheeks no comedone chest, back, upper extremities: non specific

 rosacea

QUESTIONS AND COMMENTARY  What causes rosacea? - abnormalities of the small vessels sun damage to the surrounding connective tissue abnormal inflammatory response → fluids leak out into the dermis - hot drinks, spicy foods, alcoholic beverages →exacerbate the vasoinflammatory response - Demodex folliculorum (in sebaceous follicle)

 How common is rosacea? - reliable data are lacking - the 3 rd or 4 th decade fair-skinned people of Celtic or northern European - average of 1.1 million annual outpatients in U.S.A from 1990 to 1997

 What is the differential diagnosis for rosacea and what distinguishes it from other skin conditions? - younger age group - comedonal lesion with or without associated inflammatory papules and pustules - chest and back (not rosacea) - facial erythema, but secondary response of papules - telangiectatic component ↓ (< rosacea)

- typically, erythema and scaling of the nasolabial folds, eyebrows, scalp, postauricular folds, ear canal and involve the central chest, axillae, groin - flushing, inflammatory papules and pustules is not characteristics of seborrheic dermatitis

- because rosacea affects the central face and can be exacerbated by sun exposure, it may be mistaken for the malar rash of SLE → but malar rash lacks papules or pustules - other finding: follicular plugging, atrophy, scarring, and adherent scale - ANA is not specific, so blood studies are nor helpful in differential diagnosis

- papules and vesicles appear in groups and smaller than rosacea - telangiectasia ↓ (<rosacea) - no flushing and blushing - resemble rosacea, but invariably pruritic - geometric shape and pattern follows the size and shape of the external causal agents

 How is rosacea diagnosed? - the presence of one or more primary features (with or without secondary features) indicates rosacea ▪ Primary features flushing (transient erythema) nontransient erythema papules and pustules telangiectasia

▪ Secondary features burning or stinging plaque formation dry or scaly appearance edema ocular manifestations peripheral location phymatous change →laboratory marker, biopsy are not helpful !!!

▪ vascular rosacea - flushing and persistent central facial erythema with or without telangiectasia ▪ papulopustular rosacea - persistent central facial erythema with occasional central facial papules or pustules

▪ phymatous rosacea - thickened skin, irregular surface nodularities of nose, chin, forehead, cheeks, ears ▪ ocular rosacea - burning, stinging, dryness, ocular photosensitivity, blurry vision, telangiectasia of sclera, periobital edema

 What are the risk factors? - no specific risk factors - commonly, northern European ethnicity - alcoholic beverages

 What happens if rosacea remains untreated? - rosacea : remissions and exacerbations - various combination various subtype (independently or evolution) - mild~moderate~severe form - psychological affects: disabling, quality of life ↓ - untreated rosacea: chronic inflammatory change (erythema, edema, phymatous)

 How is rosacea initially treated? - long-term treatment to suppress inflammation - should be tailored to the specific variant of rosacea - avoiding factors : sun, alcohol, hot beverages, certain foods, irritating cosmetics - regular use of sunscreen is important

 Topical therapy - mild erythema, limited number of papules & pustules : topical metronidazole clindamycin azelaic acid sodium sulfacetamide sufur lotion - response is not immediate

 Oral therapy - more extensive papules or pustules mild edematous change : oral tetracycline (+ topical treatment) - if improved : discontinue oral treatment continue topical treatment

- more severe, refractory, persistent cases : 13-cis-retinoic acid (isotretinoin) therapy - adverse effects : dry skin, mocosae and eye pruritus, dermatitis, myalgia liver enzyme↑, cholesterol ↑ → indicated only for treatment-resistant rosacea - risk of teratogenicity

- active  -blocking hypotensive drug (clonidine) low dose  -blocker (nadolol) - adverse effects : orthostatic hypotension xerostomia

- prominent telangiectasias associated with rosacea : laser or intense pulsed light treatments - topical steroid : initially decrease → but prolonged use : telangiectasia exacerbate flushing, etrythema

 When should the primary care provider refer to a dermatology specialist? - if the diagnosis is in doubt or if patients fail to respond to first-line therapy → referral to a dermatologist