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COSMETIC DERMATOLOGY: PRINCIPLES AND PRACTICE
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Differential Diagnosis
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Facial erythema and flushing are seen in many dermatologic and systemic disorders A clinical history and physical examination are very important aspects of the patient evaluation The Baumann Skin Type Indicator (BSTI) can help determine patients at risk for developing rosacea by asking them historical questions about facial flushing (see 9) Laboratory tests may be needed to rule out systemic diseases, such as collagen vascular disorders, if these are suspected Table 16-3 lists the differential diagnosis of rosacea26
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FIGURE 16-2 Papulopustular rosacea exhibits one of the following: interpalpebral conjunctival hyperemia, burning or stinging of the eyes, photosensitivity, telangiectasias of the lid margin, or conjunctiva, and erythema around the eyes 22 Patients may also present with clinical pictures of conjunctivitis, blepharitis, inflamed meibomian glands (or tarsal glands), or chalazion24,25 Notably, the symptoms of ocular rosacea may precede the cutaneous signs, although most patients have some cutaneous manifestation of this condition Interestingly, children who have styes are more likely to develop rosacea as adults
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TREATMENT
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The first step in the treatment of rosacea is to determine the subtype All subtypes share one common feature inflammation Therefore, anti-inflammatory supplements and skin care products can help this condition (see
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TABLE 16-3 Differential Diagnosis of Rosacea Benign cutaneous ushing Allergic contact dermatitis Lupus erythematosus Dermatomyositis Mixed connective tissue disease Carcinoid syndrome Pheochromocytoma Medullary carcinoma of the thyroid Pancreatic cell tumor (VIPoma) Mastocytosis Photosensitivity from medications Climacterium/postmenopausal
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FIGURE 16-3 Phymatous rosacea Thickened, irregular skin on the nose This individual exhibits the papulopustular form of rosacea as well
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TABLE 16-5 Rosacea Treatment Modalities Topical treatments Antibiotics Metronidazole Clindamycin Erythromycin Anti-in ammatories Azelaic acid Feverfew Green tea Licochalcone Licorice extract Immunomodulators Pimecrolimus Tacrolimus Sulfur products Sulfur Sodium sulfacetamide Oral antibiotics Tetracyclines (Tetracycline, doxycycline, minocycline) Macrolides (Erythromycin, azithromycin, clarithromycin) Metronidazole Ampicillin Trimethoprim/sulfamethoxazole Other oral treatments Isotretinoin Aspirin Beta-blockers Selective serotonin reuptake inhibitors (SSRIs) Clonidine Hormones (oral contraceptives) Laser and light treatments Intense, pulsed-light therapy Vascular lasers (Pulsed dye laser, Dornier 940 nm, KTP laser) Carbon dioxide resurfacing laser Other treatments (for phymatous subtype) Hot loop electrocoagulation Dermabrasion
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CHAPTER 16 ROSACEA (TYPE 2 SENSITIVE SKIN)
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FIGURE 16-4 Ocular rosacea is characterized by bilateral erythema of the conjunctiva and/or eyelids 35) Sunscreen and sun avoidance are very important aspects of controlling symptoms Often, because of the facial sensitivity of these patients, selecting the right sunscreen may be challenging Physical blockers (eg, zinc oxide and titanium dioxide) are usually tolerated the best by rosacea patients Green-tinted moisturizers/sunscreens can conceal facial erythema and are therefore favored by many patients with rosacea Avoidance of aggravating factors also plays an important role in treating this anxiety-producing condition (Table 16-4) Based on the severity of symptoms, several topical and oral antibiotics may be used Although antibiotic therapy controls the inflammatory component of rosacea, and may prevent its exacerbation, antibiotics do not improve the telangiectatic lesions on the face In recent years, light and laser treatments have been widely and successfully used for this purpose In a study of 60 patients affected with rosacea who were treated with intense pulsed light (IPL), there was a mean clearance of almost 78% of the telangiectasias In this study, the mean number of treatments was about four and the wavelength, pulse duration, and energy were adjusted according to patients skin color27 Pulsed dye laser (PDL) is another alternative It is reasonable to consider an initial treatment plan with IPL and later, treat the resistant telangiectatic areas with PDL Vascular laser treatments will be discussed in detail in 24 Table 16-5 summarizes different treatment modalities for rosacea28
TABLE 16-4 Rosacea Aggravating Factors Food Hot temperature beverages Spicy food Chocolate Dairy products Vanilla Soy sauce Environmental factors Heat UV light Cold Humidity Chemicals Alcoholic beverages Medications Physical exertions Stress Chronic cough Heavy exercise
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