Symptoms of rosacea: diagnostic stages

According to the recommendations for the management of dermatosis (Rosacea medical management guidelines (AARS, 2008)), the diagnosis of rosacea is established when the following criteria are found:

Primary symptoms of rosacea

• Transient erythema
• Persistent erythema for at least 3 months
• Papules/pustules
• Telangiectasia
• Localization of rashes in the central part of the face

Secondary symptoms of rosacea

• Burning and tingling
• Infiltration
• Dryness
• Edema
• Eye damage
• Damage to surrounding areas
• Phymatous changes

First of all, you need to pay attention to patients with bright pink hyperemia in the central part of the face. Often it is transient and disappears “before our eyes,” especially if the conversation with the doctor takes place in a calm and sincere atmosphere. Patients note that such hot flashes always accompany emotional stress, drinking hot drinks, alcohol, spicy food, and occur during physical activity, during periods of very hot or too cold weather, after a hot bath and shower. Persistent erythema is accompanied by a persistent increase in facial skin temperature (you can feel this by touching your palm), a feeling of heat (Bamford JT, Gessert CE, Renier CM. Measurement of the severity of rosacea. J Am Acad Dermatol. 2004 Nov. 51(5):697 -703; Crawford GH, James WD. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. 51(3):327-41; Rosacea subtypes: a treatment algorithm. Cutis. 2004 Sep. 74(3 Suppl):21-7, 32-4). Such patients have thin sensitive skin. Erythematous areas become rougher over time, peeling appears, and the clinical picture resembles chronic dermatitis.

To make a diagnosis of rosacea, it is important that such redness has bothered the patient for at least 3 months. There may also be bright pink papules, pustules, and telangiectasias on the skin of the face. Among the secondary signs, you should pay attention to the patient's complaints (skin burning and tingling), especially after exposure to trigger factors. Less typical, but long-term rosacea is characterized by swelling, plaque formation, dry skin surface, eye damage and thickening of the skin in the nose, chin, forehead, ears and even eyelids.

Not all tidal erythema should be considered "prerosacea." Redness of the facial skin, including centrofacial, can occur with the following diseases:

• Carcinoid syndrome
• Polycythemia
• Pheochromocytoma
• Mastocytosis
• Menopause
• Taking certain medications (diltiazem, niacin, levodopa, bromocriptine)

In these cases, a survey of organs and systems will immediately reveal multiple disorders, and often patients know about their general disease, but do not associate facial skin lesions with it.

Not all persistent erythema, telangiectasias and infiltration are rosacea. Rosacea can mimic:

• Diffuse connective tissue diseases (dermatomyositis, lupus erythematosus)
• Infections (erysipelas, tinea faciei)
• Dermatitis (seborrheic dermatitis, perioral dermatitis)
• Adult acne
• Other dermatoses

The presence of these signs in combination with rashes atypical for rosacea (atrophy, follicular hyperkeratosis, vesicles, complaints of intense itching, pain in the area of the rash) should alert you in terms of differential diagnosis with a number of infectious and autoimmune diseases. Conduct a targeted survey to clarify this pathology. Do not hesitate to refer suspicious patients to related specialists (rheumatologist, internist, infectious disease specialist).

It is also necessary to differentiate rosacea from rosacea-like dermatoses of the facial skin: periorificial dermatitis, steroid dermatitis and contact dermatitis, including photodermatitis, seborrheic dermatitis, Acne vulgaris. This can only be done by an experienced dermatologist, since the clinical picture in some cases may not be typical and not much different from rosacea. Additional tests may be needed: microscopic examination for fungi, blood tests for autoantibodies and LE cells.

Not every thickening of the nose is rhinophyma. Fima can be a manifestation of other pathological conditions:

• Sarcoidosis
• Lymphoma
• Skin tumors

Such conditions end in tissue disintegration and ulceration, so the presence of a tissue defect or hemorrhagic crusts should be alarming. There may be changes in the clinical blood test, and medical history may suggest repeated treatment for sarcoidosis or lymphoma.

There are known factors that aggravate rosacea and cause exacerbation of dermatosis. Thus, a reliable association of rosacea and Demodex infestations is known [Elston, DM (2010) Demodex mites: facts and controversies. Clinics in Dermatology, 28 (5), p.pp.502-4]. Infection with Demodex spp. is a risk factor for rosacea, and the degree of infection plays a more important role than the frequency of its detection [Forton, F., Germaux, M.-A., Brasseur, T., Liever, A. De, Laporte, M., Mathys, C. ., Sass, U., Stene, J.-J., Thibaut, S., Tytgat, M. & Seys, B. (2005) Demodicosis and rosacea: epidemiology and significance in daily dermatologic practice. Journal of the American Academy of Dermatology, 52(1), pp.74-87]. Therefore, microscopic examination of skin flakes and eyelashes must be carried out in all patients with an established diagnosis of rosacea.

• Bacillus oleronius, a bacterium found in the intestinal tract of Demodex, can cause inflammation, stimulate rosacea, and is sensitive to antimicrobial therapy [Li, J., O'Reilly, N., Sheha, Hosam, Katz, R., Raju, Vadrevu K. Kavanagh, Kevin & Tseng, Scheffer CG (2010) Correlation between ocular Demodex infestation and serum immunoreactivity to Bacillus proteins in patients with Facial rosacea. Ophthalmology, 117(5), p.pp.870-877.e1.]
• Demodex can carry some pathogens, such as Staphylococcus albus and Microsporon canis, and transmit infection from one follicle to another [Lacey, Noreen, Ní Raghallaigh, S. & Powell, Frank C (2011) Demodex mites-commensals, parasites or mutualistic organisms? Dermatology, 222(2), p.pp.12830.; Wolf, R., Ophir, J., Avigad, J., Lengy, J. & Krakowski, A. (1988) The hair follicle mites (Demodex spp.). Could they be vectors of pathogenic microorganisms? Acta dermatovenereologica, 68 (6), pp.535-537.]
• Propionibacterium acnes may be a trigger factor for rosacea [Goldgar C. 2009 et all. Treatment Options for Acne Rosacea Am Fam Physician. 2009 Sep 1;80(5):461-468]. The presence of Propionibacterium acnes and Bacillus oleronius in patients with rosacea is difficult to confirm, since routine culture testing does not involve the identification of these microorganisms. A cultural study on standard bacterial media will reveal the presence of secondary pustular flora - staphylococci, streptococci, etc. In this case, an antibiotic is included in the treatment complex according to the results of the antibiogram. If there is no pathogenic bacterial flora, they are limited to a course of doxycycline to suppress the activity of Bacillus oleronius and Propionibacterium acnes.