NAME:JUDITH EMAH

MATRICULE:HS22HN200
COURSE:MEDICO SURGICAL

ROSACEA

SUMMARY
Rosacea is a common inflammatory skin disorder that can seriously impair quality of life.
Treatment starts with general measures which include gentle skin cleansing, photoprotection
and avoidance of exacerbating factors such as changes in temperature, ultraviolet light, stress,
alcohol and some foods.
For patients with the erythematotelangiectatic form, specific topical treatments include
metronidazole, azelaic acid, and brimonidine as monotherapy or in combination. Laser therapies
may also be beneficial.
For the papulopustular form, consider a combination of topical therapies and oral antibiotics.
Antibiotics are primarily used for their anti-inflammatory effects.
For severe or refractory forms, referral to a dermatologist should be considered. Additional
treatment options may include oral isotretinoin, laser therapies or surgery.
Patients should be checked after the first 6-8 weeks of treatment to assess effectiveness and
potential adverse effects.

INTRODUCTION
Rosacea is a common chronic relapsing inflammatory skin condition which mostly affects the
central face, with women being more affected than men.! The pathophysiology is not completely
understood, but dysregulation of the immune system, as well as changes in the nervous and the
vascular system have been identified. Microbes that are part of the normal skin flora, and
specifically in the pilo-sebaceous unit - including Demodex mites and Staphylococcus
epidermidis - may also play a role as triggers of rosacea. 23
Symptoms are initially transient. This is followed by persistent erythema due to repeated
vasodilation, then telangiectasia and skin inflammation in the form of papules, pustules,
lymphoedema and fibrosis. 24
Rosacea can seriously affect a patient's quality of life.
This should prompt clinicians to diagnose it early and start treatment.

DEFINITION
Rosacea is a chronic skin condition that primarily affects the face, causing redness, flushing, and
sometimes the development of small, pus-filled bumps or visible blood vessels. It typically
begins after the age of 30 and tends to affect fair-skinned individuals.OR Rosacea is a common
long-term skin condition that mainly affects the face. It can be controlled to some degree with
long-term treatment. Sometimes the changes in physical appearance can have a significant
psychological impact.
You should see your GP if you have persistent symptoms that could be caused by Rosacea. While
the exact cause of rosacea is unknown, it is believed to involve a combination of genetic and
environmental factors.

SYMPTOMS OF ROSACEA
The symptoms of rosacea can vary from person to person but commonly include:
. Facial redness: Persistent redness on the central part of the face, including the cheeks,
nose, forehead, and chin.
. Flushing: Frequent episodes of flushing or blushing, often triggered by certain factors
like spicy foods, alcohol, or temperature changes.
. Bumps and pimples: Small, pus-filled bumps or acne-like breakouts may develop. These
bumps may come and go, and they can be accompanied by stinging or burning sensations.
. Visible blood vessels: Over time, small blood vessels may become visible on the skin,
particularly on the nose and cheeks.
. Eye problems: In some cases, rosacea can affect the eyes, causing symptoms like
dryness, irritation, redness, and in more severe cases, blurry vision or sensitivity to light.

DIAGNOSIS
Steroid-induced acneiform eruption
The diagnosis of rosacea is usually made on history
Folliculitis
and clinical features. If it is not clear, differential diagnoses must be considered and ruled out

Differential diagnoses of rosacea

Common
Acne vulgaris
Seborrhoeic dermatitis
Tinea faciei
Periorificial dermatitis
Contact dermatitis (irritant or allergic)
Steroid-induced acneiform eruption
Folliculitis
Uncommon
Lupus erythematosus
Dermatomyositis
Drug reaction, e.g. isoniazid
Sarcoidosis
Demodicosis

CLASSIFICATION OF ROSACEA
Rosacea can be classified into four subtypes: erythematotelangiectatic, papulopustular,
phymatous
and ocular.
1) Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea is characterised by flushing and persistent central facial
erythema.
Redness may also involve the peripheral face, ears, neck and upper chest, but periocular skin is
typically spared. Telangiectases are also common, but are not required for the diagnosis
2)Papulopustular rosacea
Papulopustular rosacea subtype includes patients who develop papules or pustules in a central
facial distribution. In severe cases, these episodes of inflammation can lead to chronic facial
oedema
3) Phymatous rosacea
Phymatous rosacea is characterised by thickened skin with enlarged pores and irregular surface
nodularities.
These changes are most commonly found on the nose (rhinophyma), but can occur on the ears,
chin and forehead. This subtype is more common in men than women
4)Ocular rosacea
Ocular rosacea is characterised by a watery or bloodshot appearance of the eyes, foreign body
sensation, burning or stinging. Blepharitis, conjunctivitis, dryness, itching, light sensitivity,
blurred vision and telangiectasia of the conjunctiva or eyelids also occur. Chalazia and styes are
more common in ocular rosacea than other forms. Because there is no specific test, the
diagnosis relies on the physician's.
ADDITIONAL TEST
If the diagnosis cannot be made clinically, other tests may be necessary. These include skin
swabs and scrapings for microbiology studies primarily to exclude staphylococcal infection. An
antinuclear antibody test can be useful if photosensitivity is prominent. A skin biopsy is useful
when other diagnoses such as lupus or chronic folliculitis are being considered.'

APPROACH TO PATIENTS WITH ROSACEA

Educating the patient about rosacea as a chronic relapsing skin condition which can be
controlled but does not have a traditional 'cure' is important.
Warning them that flare-ups can occur even when treated properly is also useful and plays a key
role in the patient's expectations and the role of therapy.
General measures
The treatment plan will be adapted to the subtype of rosacea and then realistic expectations are
set and potential adverse effects discussed. This enables the patient to participate in the choice
of therapy appropriate for them and consider the balance between the disease and the
treatment.'
Skin care
Sun avoidance and photoprotection are an important part of management.° Reducing skin
irritability is also key. Skin care should include a gentle facial cleanser and a moisturiser or
barrier repair product, as this can adjunctively improve therapeutic outcomes and reduce skin
irritation in patients undergoing medical therapy. Cosmetic products, especially those with a
green tinge, may help to cover erythema and may improve the patient's self-perception."
Avoiding triggers
Avoiding triggers such as extreme temperatures (hot or cold), ultraviolet radiation exposure,
spicy foods, hot or alcoholic beverages, wind, exercise and stress, should be recommended to all
patients.
Hormonal replacement therapy can be used for menopausal flushing.!"
It is important to ask the patient what medicines they are taking as some over-the-counter or
prescription drugs may worsen rosacea or trigger flushing episodes. These include calcium
channel blockers, sildenafil, nitrates, nicotinic acid and some vitamin B-related medications

SPECIFIC TREATMENT
Treatment can be optimised according to the dominant features.915 Topical therapies are
recommended for at least six weeks to effectively review the response. 5* Topical
corticosteroids should be avoided.
Treatment for flushing and erythema may involve oral drugs with vasoconstriction properties
including adrenergic antagonists including mirtazapine (alpha blocker), propranolol (beta
blocker) or carvedilol (both alpha and beta blocker).These are used at low doses to avoid
adverse effects such as hypotension, somnolence, fatigue and bronchospasm. They should be
prescribed under specialist supervision, and careful monitoring is required.
Clonidine is an oral alpha, agonist that has been used for flushing. However, topical alpha,
agonists are preferred because they target the skin and carry less risk of systemic adverse
effects. Brimonidine is a topical alpha, agonist which can reduce erythema for up to 12 hours
through direct cutaneous vasoconstriction. Brimonidine 0.33% gel is very useful for some people
when not used on a daily basis.5.9 Post-treatment rebound erythema may occur, and in general
telangiectases will not clear.
-Erythematotelangiectatic rosacea
Topical treatments for this form of rosacea include metronidazole, azelaic acid and brimonidine.
They can be used alone or in combination. Metronidazole works as an anti-inflammatory drug by
altering neutrophil chemotaxis and inactivating reactive oxygen species.
Metronidazole 0.75% has been shown to reduce erythema, papules and pustules in multiple trials
of patients with moderate to severe rosacea. It is usually well tolerated with minor local adverse
effects such as skin irritation.?15
Topical azelaic acid is an over-the-counter preparation which has anti-inflammatory, anti-
keratinising and antibacterial effects. A 15% gel and 20% lotion are available and can be applied
once or twice daily.
Adverse effects may include skin irritation, but azelaic acid is usually well tolerated and can be
used for long
Laser therapy, including vascular lasers or intense pulse light, may help to reduce refractory
background erythema and clinically significant telangiectases, but will not reduce the frequency
of flushing episodes.
Different laser therapies that target the vessels have been used such as 595 nm pulsed dye
laser, Nd:YAG and other vascular lasers, or intense pulsed light therapy.
These should be administered by an experienced and trained laser therapist and the number of
sessions and length of treatment varies for each individual.
-Papulopustular rosacea
Combining topical treatments with oral antibiotics may be needed for papulopustular rosacea.
Topical treatments include metronidazole, azelaic acid, ivermectin and dapsone.
Ivermectin (1% cream) is useful for mild to moderate rosacea. It has an anti-inflammatory effect
as well as having an effect on Demodex mites, which may activate the local immune response to
produce the pustules. It is applied once daily for up to four months, and the course may be
repeated if needed.
Topical dapsone is a sulfone antibacterial with anti-inflammatory actions. It was recently
approved for acne in Australia, but in the USA it is approved for rosacea. Dapsone 7.5% gel is
applied once daily for up to 12 weeks. It should be avoided in those with known glucose-6-
phosphate dehydrogenase deficiency!8
Oral antibiotics used in papulopustular rosacea include minocycline, doxycycline, erythromycin,
clarithromycin and clindamycin. Their effectiveness at sub-antimicrobial doses is mostly due to
their anti-inflammatory properties rather than a direct antimicrobial mechanism.
Although bacteria may contribute to this form of rosacea, evidence for this is scant.'
Doxycycline 40 mg per day is commonly given in the USA as a sub-antimicrobial dose. The risk
of resistance at this dose is less than with higher doses.
Photosensitivity is the main adverse effect, and sun avoidance or sunscreens may be required,
especially during the summer months. Minocycline is probably a more effective agent but the
increased risk of pigmentation, liver disorders and lupus-like syndrome limits its long-term use.
The goal of oral therapy is to improve the rosacea to a point where control is achieved by topical
therapies.
Treatment duration varies from four weeks to supress flares to many months for long-term
disease suppression. With lower doses, adverse effects like headache, photosensitivity,
diarrhoea and mucosal candidiasis are relatively uncommon. The antibiotics should be taken with
food.
Erythromycin and clarithromycin are generally used in patients who are intolerant or have
refractory disease to tetracyclines (e.g. doxycycline, minocycline). Topical or oral erythromycin is
sometimes used in pregnant women with papulopustular rosacea.
Oral isotretinoin is usually reserved for patients who are intolerant to oral or systemic therapies.
Its effect is thought to be secondary to the downregulation of the local cutaneous immunity,
although an alteration in the lipid environment of the skin cannot be excluded.
Low-dose isotretinoin (10 mg daily) may be effective and have less adverse effects. The
teratogenicity and adverse effects of isotretinoin requires routine clinical and laboratory
monitoring for safety. Referral to a dermatologist is therefore recommended.9.19
Phymatous rosacea
Oral isotretinoin is also used in phymatous rosacea as
The hypertrophied tissue in patients with phymatous rosacea can be reshaped and contoured
with ablative lasers including carbon dioxide or electrosurgery devices.
Treatment is aimed at debulking the excess tissue and then sculpting the disfigured area. Lasers
produce less bleeding when compared to traditional surgery. Patients may be referred to a
dermatologist or plastic surgeon for these therapies. Traditional surgery involving scalpel and
loop electrosurgical excision are also used to debulk and sculpt the nose, but experience in this
is required as precision may be more difficult compared to laser treatments.
-Ocular rosacea
Lid care and artificial tears are used for ocular rosacea, as are oral tetracyclines. Ciclosporin
drops are reserved for moderate to severe cases and are prescribed by a consultant
ophthalmologist.
Patient monitoring
If there is an important clinical improvement in the first six weeks, the patient may need to stay
on therapy for at least six months. Patients receiving oral antibiotics for six months with stable or
improving rosacea should have the dose tapered as tolerated.
If the response is inadequate, therapy is completed for another six weeks and compliance should
be assessed.
Consider the differential diagnosis at this stage. If the diagnosis of rosacea remains, alternative
regimens of oral antibiotics or switching of topical treatment may be considered. If this is not
successful, consider oral isotretinoin or laser/light therapies.

PATIENTS MONITORING
If there is an important clinical improvement in the first six weeks, the patient may need to stay
on therapy for at least six months. Patients receiving oral antibiotics for six months with stable or
improving rosacea should have the dose tapered as tolerated.
If the response is inadequate, therapy is completed for another six weeks and compliance should
be assessed.
Consider the differential diagnosis at this stage. If the diagnosis of rosacea remains, alternative
regimens of oral antibiotics or switching of topical treatment may be considered. If this is not
successful, consider oral isotretinoin or laser/light therapies.
Conclusion
Rosacea can be a challenging condition to treat. Tailoring

NURSING CARE PLAN

Creating a nursing care plan for rosacea involves a holistic approach that addresses both the
physical symptoms and the emotional impact of the condition. Let's outline a sample nursing
care plan with a focus on assessment, interventions, and patient education.
A-Nursing Diagnosis
1. Risk for Impaired Skin Integrity related to the presence of papules, pustules, and erythema
secondary to rosacea.
2. Disturbed Body Image related to altered facial appearance and skin changes secondary to
rosacea.

B-Nursing Interventions
1. Risk for Impaired Skin Integrity

C-Assessment:
- Assess the patient's skin regularly for signs of irritation, inflammation, and infection.
- Document the location, type, and severity of skin lesions or redness.
- Evaluate the patient's skin care routine, including the use of skincare products and
environmental exposure.

D-Interventions:
- Educate the patient on gentle skincare practices, including the use of mild, non-abrasive
cleansers and moisturizers. Emphasize the importance of avoiding harsh chemical products and
abrasive facial treatments.
- Implement measures to protect the skin from environmental triggers, such as sun exposure and
extreme temperatures. Advise the use of broad-spectrum sunscreen and protective clothing.
- Collaborate with the healthcare team to monitor and manage the patient's topical and systemic
treatments, ensuring adherence and assessing for potential side effects.
- Encourage the patient to report any changes in skin condition promptly.
2. Disturbed Body Image

E-Assessment:
- Evaluate the patient's emotional response to the physical changes associated with rosacea,
including feelings of embarrassment, self-consciousness, and impact on self-esteem.
- Assess the patient's social interactions and psychological well-being in the context of their
rosacea symptoms.

F-Interventions:
- Provide emotional support and a non-judgmental environment for the patient to express their
concerns and feelings related to their appearance and the impact of rosacea on their self-image.
- Offer information and resources about rosacea support groups, counseling services, or mental
health professionals who can provide further support and guidance.
- Foster open communication and encourage the patient to voice their concerns about body
image and self-esteem. Emphasize the importance of self-care and self-acceptance.

G-Patient Education
Skincare Education:
- Educate the patient about gentle skincare practices, emphasizing the use of mild cleansers,
hypoallergenic skincare products, and the avoidance of harsh exfoliants or astringents.
- Emphasize the importance of sun protection and maintaining a consistent skincare routine to
minimize potential triggers for rosacea flare-ups.

Trigger Management:
- Discuss common triggers for rosacea flare-ups, such as spicy foods, alcohol, extreme
temperatures, and stress, and provide guidance on identifying and minimizing these triggers in
daily life.

Emotional Support:
- Provide resources and information about support groups, online forums, and educational
materials related to rosacea, encouraging the patient to seek emotional support and connect
with others facing similar challenges.

H- Evaluation and Follow-Up

Continuously assess the patient's skin condition and emotional well-being to monitor the
effectiveness of the nursing care plan. Encourage open communication and adjust the plan as
needed based on the patient's progress, concerns, and evolving needs.

Remember, the nursing care plan for rosacea should prioritize a supportive and empowering
approach that addresses both the physical and emotional aspects of the condition. Tailoring the
plan to the individual patient's needs and providing ongoing education and support can
significantly impact their overall management of rosacea.

If you have further questions or need more details on any specific aspect of the care plan, feel
free to ask!

CONCLUSION
Rosacea can be a challenging condition to treat. Tailoring therapies to the type of rosacea is an
important part of management.
Information about possible triggers of flushing can allow the patient to decide which are
important for them. One goal should be to reduce treatment from oral to topical when possible,
advise on physical therapies including laser treatment if appropriate, and to be able to explain
both physical and medical management of rosacea.
Asking about ocular rosacea should be considered to ensure eye health is maintained where
possible. For those with severe disease or with refractory cutaneous or ocular. If you suspect you
have rosacea or are experiencing persistent facial redness, it's best to consult with a
dermatologist or healthcare professional who can provide an accurate diagnosis and recommend
appropriate treatment options tailored to your specific needs.