Rosacea Subtypes

The primary and secondary rosacea features often occur together. The most common patterns or groupings of signs are provisionally designated as specific subtypes of rosacea are described here. Each subtype includes the fewest signs sufficient to make a diagnosis of the subtype (though not necessarily limited to these), and patients may have characteristics of more than one rosacea subtype at the same time.

Subtype 1: Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea is mainly characterized by flushing and persistent central facial erythema. The appearance of telangiectases is common but not essential for a diagnosis of this subtype. Central facial edema, stinging and burning sensations, and roughness or scaling may also be reported. A history of flushing alone is common among patients presenting with erythematotelangiectatic rosacea.

Subtype 2: Papulopustular rosacea
Papulopustular rosacea is characterized by persistent central facial erythema with transient papules or pustules or both in a central facial distribution. However, papules and pustules also may occur periorificially (that is, they may occur in the perioral, perinasal, or periocular areas). The papulopustular subtype resembles acne vulgaris, except that comedones are absent. Rosacea and acne may occur concomitantly, and such patients may have comedones as well as the papules and pustules of rosacea. Burning and stinging sensations may be reported by patients with papulopustular rosacea. This subtype has often been seen after or in combination with subtype 1, including the presence of telangiectases. The telangiectases may be obscured by persistent erythema, papules, or pustules, and tend to become more visible after successful treatment of these masking components.

Subtype 3: Phymatous rosacea
Phymatous rosacea includes thickening skin, irregular surface nodularities, and enlargement. Rhinophyma is the most common presentation, but phymatous rosacea may occur in other locations, including the chin, forehead, cheeks, and ears. Patients with this subtype also may have patulous, expressive follicles in the phymatous area, and telangiectases may be present. This subtype has frequently been observed after or in combination with subtypes 1 or 2, including persistent erythema, telangiectases, papules, and pustules. In the case of rhinophyma, these additional stigmata may be especially pronounced in the nasal area.

Subtype 4: Ocular rosacea
The diagnosis of ocular rosacea should be considered when a patient's eyes have one or more of the following signs and symptoms: watery or bloodshot appearance (interpalpebral conjunctival hyperemia), foreign body sensation, burning or stinging, dryness, itching, light sensitivity, blurred vision, telangiectases of the conjunctiva and lid margin, or lid and periocular erythema. Blepharitis, conjunctivitis, and irregularity of the eyelid margins also may occur. Meibomian gland dysfunction presenting as chalazion or chronic staphylococcal infection as manifested by hordeolum (stye) are common signs of rosacea-related ocular disease.

Some patients may have decreased visual acuity caused by corneal complications (punctate keratitis, corneal infiltrates/ulcers, or marginal keratitis).Treatment of cutaneous rosacea alone may be inadequate in terms of lessening the risk of vision loss resulting from ocular rosacea, and an ophthalmologic approach may be needed.

Ocular rosacea is most frequently diagnosed when cutaneous signs and symptoms of rosacea are also present. However, skin signs and symptoms are not prerequisite to the diagnosis, and limited studies suggest that ocular signs and symptoms may occur before cutaneous manifestations in up to 20% of patients with ocular rosacea. Approximately half of these patients experience skin lesions first, and a minority have both manifestations simultaneously.

The Diagnosis of Rosacea

Rosacea typically affects the convexities of the central face. The presence of one or more of the following signs with a central face distribution is indicative of rosacea. These signs are commonly transient, and each may occur independently. Many patients may present with more than one of these diagnostic features.
Flushing (transient erythema).
A history of frequent blushing or flushing is common.
Nontransient erythema.
Persistent redness of the facial skin is the most common sign of rosacea.
Papules and pustules.
Dome-shaped red papules with or without accompanying pustules, often in crops, are typical. Nodules may also occur. Although patients with concomitant acne may exhibit comedones, comedones should be considered part of an acne process unrelated to rosacea.
Telangiectasia.
Telangiectases are common but not necessary for a rosacea diagnosis.

The following signs and symptoms often appear with one or more of the primary features of rosacea, but in some patients can occur independently.
Burning or stinging.
Burning or stinging sensations with or without scaling or dermatitis may occur, especially on malar skin.
Plaque.
Elevated red plaques without epidermal changes in the surrounding skin may occur.
Dry appearance.
Central facial skin may be rough and scaling so as to resemble dry skin and suggest an eczematous dermatitis, and may often include the coexistence of seborrheic dermatitis. This “dryness” may be associated with burning or stinging sensations, and may be caused by irritation rather than the disease process.
Edema.
Edema may accompany or follow prolonged facial erythema or flushing. Sometimes soft edema may last for days or be aggravated by inflammatory changes. Solid facial edema (persisting hard, nonpitting edema) can occur with rosacea, usually as a sequel of the papulopustular type, and also independently of redness, papules and pustules, or phymatous changes.
Ocular manifestations.
Ocular manifestations are common, and range from symptoms of burning or itching to signs of conjunctival hyperemia and lid inflammation. Styes, chalazia, and corneal damage may occur in many patients with rosacea in addition to cutaneous stigmata. The severity of ocular manifestations may not be proportional to those of the skin.
Peripheral location.
Rosacea has been reported to occur in other locations, but the frequency and occurrence of this are ill-defined. Rosacea in peripheral locations may or may not be accompanied by facial manifestations.
Phymatous changes.
These can include patulous follicles, skin thickening or fibrosis, and a bulbous appearance. Rhinophyma is the most common form, but other phymas may occur.

Rosacea Sun Care

Because sun exposure was cited as the most common rosacea trigger by 81 percent of patients responding to a National Rosacea Society survey, it may be important to remember a few things over the summer when sunlight is at its height. Here are some tips for protecting yourself from the sun:
Avoid the sun as much as possible. Limit the amount of time spent in direct sunlight, especially between the hours of 10 a.m. and 4 p.m., when sun is the strongest.
Protect your face. Use a sunscreen year round, but especially in the summer. Make sure it has an SPF of 15 or higher and is effective against both UVA and UVB rays.
Apply sunscreen at least 30 minutes before going outdoors. Apply it liberally and periodically throughout the time spent in the sun.
Try a pediatric sunscreen. If you have sensitive skin, a pediatric formulation or a hypoallergenic sunscreen may minimize irritation.
Wear a hat. Make sure the hat has a wide brim or visor. You'll have added protection and may even make a fashion statement.
Stay cool. Seek the shade as much as possible and remember to stay hydrated by taking along a water bottle. Chewing on ice chips also helps, especially with flushing.
Don't take a vacation from medical therapy. Be sure to continue your normal cleansing routine as well as the medical therapy prescribed by your doctor.