Rosacea

Rosacea is a persistent eruption occurring on the forehead and cheeks. It is more common in women than men. There is erythema with prominent blood vessels. Pustules, papules, and oedema occur. Rhinophyma, with thickened erythematous skin of the nose and enlarged follicles, is a variant. Conjunctivitis and blepharitis may be associated. It is usually made worse by sunlight. Rosacea should be distinguished from: Acne, in which there are blackheads, a wider distribution, and improvement with sunlight. Acne, however, may coexist with rosaceahence the older term acne rosacea. Seborrhoeic eczema, in which there are no pustules and eczematous changes are present. Lupus erythematosus, which shows light sensitivity, erythema, and scarring but no pustules. Perioral dermatitis, which occurs in women with pustules and erythema around the mouth and on the chin. There is usually a premenstrual exacerbation. Treatment is with oral tetracyclines.

Treatment
The treatment of rosacea is with long term courses of oxytetracycline, which may need to be repeated. Topical treatment along the lines of that for acne is also helpful. Topical steroids should not be used as they have minimal effect and cause a severe rebound erythema, which is difficult to clear. Avoiding hot and spicy foods may help. Recent reports indicate that synthetic retinoids are also effective.

Rosacea adalah letusan terus-menerus terjadi di dahi dan pipi. Hal ini lebih sering terjadi pada wanita dibandingkan pria. A da eritema dengan pembuluh darah yang menonjol. Pustula, papula, dan edema terjadi. Rhinophyma, dengan kulit meneb al eritematosa hidung dan folikel membesar, adalah varian. Konjungtivitis dan blepharitis dapat dikaitkan. Hal ini biasanya diperparah oleh sinar matahari. Rosacea harus dibedakan dari: Jerawat, di mana ada komedo, distribusi yang lebih luas, d an perbaikan dengan sinar matahari. Jerawat, bagaimanapun, mungkin hidup berdampingan dengan rosacea-maka istilah y ang lebih tua "rosacea jerawat". eksim seboroik, di mana tidak ada pustula dan perubahan eksematosa hadir. Lupus erit ematosus, yang menunjukkan sensitivitas cahaya, eritema, dan jaringan parut tetapi tidak ada pustula. perioral dermatitis , yang terjadi pada wanita dengan pustula dan eritema di sekitar mulut dan dagu. Biasanya ada eksaserbasi pramenstruasi. Pengobatan dengan tetrasiklin oral. Pengobatan pengobatan rosacea adalah dengan program jangka panjang oxytetracycli ne, yang mungkin perlu diulang. Pengobatan topikal sepanjang garis bahwa untuk jerawat juga membantu. Steroid topikal sebaiknya tidak digunakan karena mereka memiliki efek minimal dan menyebabkan eritema rebound yang parah, yang suli t untuk membersihkan. Menghindari makanan panas dan pedas dapat membantu. Laporan terbaru menunjukkan bahwa re tinoid sintetik juga efektif.

EPIDEMIOLOGY Occurrence Common, affecting approximately 10% of fair-skinned people. Age of Onset 30 to 50 years; peak incidence between 40 and 50 years. Sex Females predominantly, but rhinophyma occurs mostly in males. Race Celtic persons (skin phototypes I and II) but also southern Mediterraneans; less frequent or rare in pigmented persons (skin phototypes V and VI, i.e., brown and black) EPIDEMIOLOGI Kejadian umum, mempengaruhi sekitar 10% dari orang-orang berkulit putih. Umur dari Onset 30 sampai 50 tahun; insidensi puncak antara 40 dan 50 tahun. Wanita Sex dominan, tetapi rhinophyma kebanyakan terjadi pada laki-laki . Ras orang Celtic (kulit phototypes I dan II), tetapi juga Mediterraneans selatan; kurang sering atau jarang terjadi di berpig men orang (kulit phototypes V dan VI, yaitu, coklat dan hitam) STAGING (PLEWIG AND KLIGMAN CLASSIFICATION) The rosacea diathesis : episodic erythema, flushing and blushing Stage I: Persistent erythema with telangiectases Stage II: Persistent erythema, telangiectases, papules, tiny pustules. Stage III: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent solid edema of the central part of the face Note: progression from one stage to another does not always occur. Rosacea may start with stage II or III and stages may overlap. Pementasan (Plewig and Kligman KLASIFIKASI) The rosacea diatesis: eritema episodik, "flushing dan merona" Tahap I: erite ma persisten dengan telangiectasia Tahap II: eritema Persistent, telangiectasia, papula, pustula kecil. Tahap III: eritema Per sistent mendalam, telangiectases padat, papula, pustula, nodul; jarang gigih "solid" edema dari bagian tengah wajah Catata n: perkembangan dari satu tahap ke tahap lainnya tidak selalu terjadi. Rosacea mungkin mulai dengan stadium II atau III da n tahap mungkin tumpang tindih. CLINICAL MANIFESTATION Usually a history of episodic reddening of the6 face (flushing) with increases in skin temperature in response to heat stimuli in the mouth (hot liquids); spicy foods; alcohol,. Exposure to sunrosacea is often associated with solar elastosisand heat (such as chefs working near a hot stove) may cause exacerbations. Acne may have preceded the onset of rosacea by years; nevertheless, rosacea may and usually does arise de novo without any preceding history of acne or seborrhea. Duration of Lesions Days, weeks, months. Skin Symptoms Concern about cosmetic facial appearance; patients are often perceived as being alcoholicwhich, of course, is not true. Skin Lesions Early Pathognomonic flushing red face (Fig. 1-6); tiny papules and papulopustules (23 mm), pustule often small (1 mm) and on the apex of the papule (Figs. 1-7 and 1-8). No comedones . Late Red facies and dusky-red papules and nodules (Figs. 1-6 to 1-9) Scattered, discrete

lesions. Telangiectases. Marked sebaceous hyperplasia and lymphedema in chronic rosacea, causing disfigurement of the nose, forehead, eyelids, ears, and chin. Manifestasi klinis Biasanya riwayat kemerahan episodik dari 6 wajah (flushing) dengan peningkatan suhu kulit sebagai resp on terhadap rangsangan panas di mulut (cairan panas); makanan pedas; alkohol,. Paparan sinar matahari rosacea sering dik aitkan dengan solar elastosis-dan panas (seperti koki yang bekerja di dekat kompor panas) dapat menyebabkan eksaserbasi . Jerawat mungkin telah mendahului timbulnya rosacea dengan tahun; Namun demikian, rosacea mungkin dan biasanya tid ak timbul de novo tanpa ada riwayat sebelumnya dari jerawat atau seborrhea. Durasi Lesi Hari, minggu, bulan. Gejala kulit Kepedulian tentang penampilan wajah kosmetik; pasien sering dianggap sebagai beralkohol-yang, tentu saja, tidak benar. L esi kulit Awal patognomonik pembilasan-"wajah merah" (Gambar 1-6); papula kecil dan papulopustules (2-3 mm), pustule s ering kecil ( 1 mm) dan pada puncak dari papul (Gambar 1-7 dan 1-8). Tidak ada komedo. Akhir facies Merah dan papula k ehitaman-merah dan nodul (Gambar 1-6 untuk 1-9) Tersebar, lesi diskrit. Telangiectasia. Ditandai hiperplasia sebaceous da n lymphedema di rosacea kronis, menyebabkan cacat dari hidung, dahi, kelopak mata, telinga, dan dagu. Distribution Characteristic is the symmetric localization on the face (Fig. 1-7). Rarely, neck, chest (V-shaped area), back, and scalp. Special Lesions Rhinophyma (enlarged nose), metophyma (enlarged cushion-like swelling of the forehead), blepharophyma (swelling of the eyelids), otophyma (cauliflower-like swelling of the earlobes), and gnathophyma (swelling of the chin) result from marked sebaceous gland hyperplasia (Fig. 1-11) and fibrosis. Upon palpation: soft, rubber-like. Eye Involvement Red eyes as a result of chronic blepharitis, conjunctivitis, and episcleritis. Rosacea keratitis, albeit rare, is a serious problem because corneal ulcers may develop. Karakteristik Distribusi adalah lokalisasi simetris pada wajah (Gambar 1-7). Jarang, leher, dada (daerah berbentuk V), pungg ung, dan kulit kepala. Khusus Lesi rhinophyma (hidung membesar), metophyma (diperbesar pembengkakan bantal-seperti dahi), blepharophyma (pembengkakan pada kelopak mata), otophyma (kembang kol seperti pembengkakan pada telinga), dan gnathophyma (pembengkakan dagu) hasil dari ditandai hiperplasia kelenjar sebasea (Gambar 1-11) dan fibrosis. Setela h palpasi: lunak, seperti karet. Keterlibatan Eye "Red" mata sebagai akibat dari blepharitis kronis, konjungtivitis, dan episkle ritis. Rosacea keratitis, meskipun jarang, adalah masalah serius karena ulkus kornea dapat berkembang. LABORATORY EXAMINATIONS Bacterial Culture Rule out S. aureus infection. Scrapings may reveal massive concurrent Demodex folliculorum infestation. LABORATORIUM PEMERIKSAAN bakteri Budaya Rule out infeksi S. aureus. Kerokan dapat mengungkapkan besar bersamaa n Demodex folliculorum kutu.

Dermatopathology Nonspecific perifollicular and pericapillary inflammation with occasional foci of tuberculoid granulomatous areas; dilated capillaries. Foci of neutrophils high and within the follicle. Later stages : diffuse hypertrophy of the connective tissue, sebaceous gland hyperplasia, epithelioid granuloma without caseation, and foreign-body giant cells. Rhinophyma Very marked lobular sebaceous hyperplasia ( glandular type ) and/or marked increase in connective tissue ( fibrous type ) with large ectatic

veins ( fibroangiomatous type ). Dermatopatologi perifollicular nonspesifik dan peradangan pericapillary dengan fokus sesekali "tuberkuloid" daerah granul omatosa; dilatasi kapiler. Fokus neutrofil tinggi dan dalam folikel. Kemudian tahap: difus hipertrofi jaringan ikat, hiperplasia kelenjar sebaceous, granuloma epithelioid tanpa kaseasi, dan sel-sel raksasa benda asing. Rhinophyma Sangat ditandai hip erplasia lobular sebaceous (kelenjar jenis) dan / atau ditandai peningkatan jaringan ikat (tipe fibrous) dengan urat ectatic b esar (tipe fibroangiomatous).

DIFFERENTIAL DIAGNOSIS Facial Papules/Pustules Acne (in rosacea there are no comedones), perioral dermatitis,8 S. aureus folliculitis, gram-negative folliculitis, D. folliculorum infestation. Facial Flushing/Erythema Seborrheic dermatitis, prolonged use of topical glucocorticoids, systemic lupus erythematosus; dermatomy ositis. COURSE Prolonged Recurrences are common. After a few years, the disease may disappear spontaneously; usually it is for life time. Men and very rarely women may develop rhinophyma. MANAGEMENT Prevention Marked reduction or elimination of alcohol may be helpful in some patients. Topical Metronidazole gel or cream , 0.75%, twice daily Metronidazole cream , 1%, once daily Sodium sulfacetamide, sulfur lotions 10% and 5% Topical antibiotics (e.g., erythromycin gel) are less effective. Systemic Oral antibiotics are more effective than topical treatment. Minocycline or doxycycline , 50100 mg twice daily, first-line antibiotics; very effective (doxycycline is a phototoxic drug and its use limits exposure to sunlight in summer). Tetracycline , 11.5 g/d in divided doses until clear; then gradually reduce to once-daily doses of 250500 mg, most effective is oral metronidazole 500 mg BID. A dose of 50 mg minocycline or doxycycline or 250500 g tetracycline is given as maintenance. Oral Isotretinoin For individuals with severe disease (especially stage III) not responding to antibiotics and topical treatments. A low-dose regimen of 0.10.5 mg/kg body weight per day is effective in most patients, but occasionally 1 mg/kg may be required. Ivermectin 12 mg PO in case of massive demodex infestation. Rhinophyma and Telangiectasia Treated by surgery or laser surgery with excellent cosmetic results. Website http://www.aad.org/pamphlets/ rosacea.html DIAGNOSIs Papula Facial / Pustules Jerawat (dalam rosacea tidak ada komedo), dermatitis perioral, 8 S. aureus folikulitis, gr am negatif folikulitis, D. folliculorum kutu. Facial Flushing / Eritema Seborrheic dermatitis, penggunaan jangka panjang gluk okortikoid topikal, lupus eritematosus sistemik; dermatomy ositis. Rekurensi KURSUS berkepanjangan yang umum. Setelah

beberapa tahun, penyakit ini dapat menghilang secara spontan; biasanya itu adalah untuk waktu hidup. Pria dan wanita sa ngat jarang dapat mengembangkan rhinophyma. Pencegahan MANAJEMEN pengurangan Ditandai atau penghapusan alkoh ol mungkin dapat membantu dalam beberapa pasien. Topical Metronidazole gel atau krim, 0,75%, krim Metronidazol dua k ali sehari, 1%, sekali sehari Sodium sulfacetamide, lotion sulfur 10% dan 5% antibiotik topikal (misalnya eritromisin gel) kur ang efektif. Antibiotik oral sistemik lebih efektif daripada pengobatan topikal. Minocycline atau doxycycline, 50-100 mg dua kali sehari, antibiotik lini pertama; sangat efektif (doksisiklin adalah obat fototoksik dan batas penggunaannya paparan sin ar matahari di musim panas). Tetrasiklin, 1-1,5 g / d dalam dosis terbagi sampai jelas; kemudian secara bertahap menguran gi dosis sekali sehari 250-500 mg, yang paling efektif adalah metronidazol 500 mg BID lisan. Dosis 50 mg minocycline atau d oxycycline atau 250-500 g tetrasiklin diberikan sebagai pemeliharaan. Isotretinoin Oral Bagi individu dengan penyakit yang parah (terutama stadium III) tidak menanggapi a

Rosacea is a congestive blushing andflushing reaction of the central areas ofthe face. It is usually associated with anacneiform component (papules,pustules, and oily skin). It usuallyoccurs in mi ddle-aged and older people.The cheeks, nose, and chin, on theentire face, may have a rosy hue. Burning or stinging often accompaniesepisodes of flushing. It is much morecommon than lupus erythematosus, with which it is often confused. Rosaceais distinguished from acne by age, the p resence of the vascular component, andthe absence of comedones.

Rosacea adalah memerah dan pembilasan reaksi kongestif dari daerah pusat ofthe wajah. Hal ini biasanya berhubungan dengan komponen acneiform (papula, pustula, dan kulit berminyak). Bia sanya terjadi pada usia paruh baya dan lebih tua people.The pipi, hidung, dan dagu, pada seluru h wajah, mungkin memiliki hue.Burning kemerahan atau menyengat sering menyertai episode p embilasan. Ini jauh morecommon daripada lupus erythematosus, dengan yang sering bingung. R osacea Apakah dibedakan dari jerawat dengan usia, kehadiran komponen vaskular, andthe adan ya komedo.

A common pustular eruption with flushing and telangiectasias on the butterfly area of the face may occur in adults especially in the 40- to 60-year-old age group (Fig. 13-10). Presentation and Characteristics Primary Lesions Diffuse redness, papules, pustules, and, later, dilated venules, mainly of the nose, cheeks, and forehead, are seen. Secondary Lesions Severe, longstanding cases eventuate into the bulbous, greasy, hypertrophic nose characteristic of rhinophyma. Course The pustules are recurrent and difficult to heal. Rosacea keratitis of the eye may occur. Rosacea is rare in children, but there is a risk of significant eye disease in this population. Sebuah letusan pustular umum dengan pembilasan dan telangiectasias di daerah kupu-kupu dari wajah dapat t erjadi pada orang dewasa terutama di 40 - untuk kelompok usia 60 tahun (Gambar 13-10). Penyajian dan Karak teristik Primer Lesi difus kemerahan, papula, pustula, dan, kemudian, venula melebar, terutama dari hidung, pi pi, dan dahi, terlihat. Lesi sekunder parah, kasus lama terwujud menjadi bulat, berminyak, karakteristik hidung hipertrofik dari rhinophyma. Kursus pustula yang berulang dan sulit untuk menyembuhkan. Rosacea keratitis mata dapat terjadi. Rosacea jarang terjadi pada anak-anak, tapi ada risiko penyakit mata yang signifikan pada p opulasi ini. Penyebab
Causes

Several factors influence the disease: 1. Heredity (oily skin) 2. Excess ingestion of alcoholic beverages, hot drinks, and spicy foods 3. Demodex mites (may be causative) 4. Increased exercise 5. Increased exposure to hot or cold environment 6. Topical or systemic corticosteroids Excess sun exposure and emotional stress can aggravate some cases of rosacea. Differential Diagnosis Systemic lupus erythematosus: No papules or pustules; positive antinuclear antibody (ANA) blood test (see Chapter 37). Boils: Usually only one large lesion; can be recurrent but may occur sporadically; an early case of rosacea may look like small boils. Bacterial culture shows Staphylococcus aureus or group A _-hemolytic streptococci. Responds to anti-Staphylococcus antibiotics

(see Chapter 20). Iodide or bromide drug eruption: Clinically similar, but drug eruption usually is more widespread; history positive for drug (see Chapter 8). Seborrheic dermatitis: Pustules uncommon; red and scaly; also in scalp. Rosacea-like tuberculid of Lewandowsky: Mimics small papular rosacea clinically and tuberculids histologically, rare; biopsy helpful. Flushing: Carcinoid pheochromocytoma, mastocytosis, medullary thyroid carcinoma, climacterium in menopausal women and some medications (especially nicotinic acid). Penyebab Beberapa faktor yang mempengaruhi penyakit:..... 1 Keturunan (kulit berminyak) 2 konsumsi Kelebih an minuman beralkohol, minuman panas, dan makanan pedas 3 tungau Demodex (mungkin penyebab) 4 latiha n Peningkatan 5 Peningkatan paparan lingkungan yang panas atau dingin 6. topikal atau sistemik kortikosteroi d paparan sinar matahari berlebih dan stres emosional dapat memperburuk beberapa kasus rosacea. Diferensi al Diagnosis Lupus eritematosus sistemik: Tidak ada papula atau pustula; antinuclear antibody test positif (A NA) darah (lihat Bab 37). Bisul: Biasanya hanya satu lesi besar; bisa berulang tetapi mungkin terjadi secara sp oradis; kasus awal rosacea mungkin terlihat seperti bisul kecil. Kultur bakteri Staphylococcus aureus menunjuk kan atau streptokokus grup A _-hemolitik. Merespon anti-Staphylococcus antibiotik (lihat Bab 20). iodida ata u erupsi bromida obat: klinis serupa, tetapi erupsi obat biasanya lebih luas; sejarah positif untuk obat (lihat Ba b 8). Dermatitis seboroik: Pustules jarang; merah dan bersisik; juga di kulit kepala. tuberculid Rosacea-sepe rti Lewandowsky: meniru kecil rosacea papular klinis dan histologis tuberkulid, langka; Biopsi membantu. Flu shing: pheochromocytoma karsinoid, mastositosis, karsinoma tiroid meduler, klimakterium pada wanita meno pause dan beberapa obat (khususnya asam nikotinat). Treatment Case Example: A 44-year-old man presents with redness and pustules on the butterfly area of the face. 1. Prescribe avoidance of these foods: chocolate, nuts, cheese, cola drinks, iodized salt, seafood, alcohol, spices, and very hot drinks. 2. Metronidazole gel (MetroGel, Metrocream, Metrolotion, or Noritate cream). Sig: Apply thin coat b.i.d. Response to therapy is slow, taking 4 to 6 weeks to benefit. 3. Sulfur, ppt. 6% Resorcinol 4% Colored alcoholic shake lotion q.s. 60.0 Sig: Apply to face h.s. Similar proprietary lotions are Sulfacet-R lotion Rosac cream (contains a sunscreen), Rosula (contains urea to decrease irritation), sodium sulfacetamide topical preparations, Plexion topical preparations, Novacet lotion, and Avar Green (contains green tint to hide redness). 4. Tetracycline, 250-mg capsules. Sig: Take 1 capsule q.i.d. for 3 days, then 1 capsule b.i.d. for weeks, as necessary for benefit. Other antibiotics that can be used, as for acne, include doxycycline, minocycline, and erythromycin. 5. Therapy for Helicobacter pylori in the same treatment regimens as for peptic ulcer disease has been tried with some benefit in severe cases. 6. Azeleic acid (Azelex and Finacea) in thin coat b.i.d.

7. Crotamiton (Eurax) lotion in thin coat b.i.d. 8. Subantimicrobial doses of antibiotics (i.e., Oracea [40-mg doxycycline] one each day with food) may be safer (less vaginal yeast infections, less superinfections, less upset stomach, and less photosensitivity) and still be effective. 9. Oral zinc sulfate 100 mg three times a day is safe and has shown benefit according to some authors. 10. Other remedies used include topical tretinoin (may worsen redness), topical tacrolimus, oral sulfate (100 mg b.i.d.), and oral Nicomide (combination of vitamins and minerals). 11. Sun protection may be helpful.

Pengobatan Contoh Kasus: Seorang pria 44-tahun menyajikan dengan kemerahan dan pustula pada daerah ku pu-kupu dari wajah. . 1 Resep menghindari makanan ini: cokelat, kacang, keju, minuman cola, garam beryodiu m, makanan laut, alkohol, rempah-rempah, dan minuman yang sangat panas. 2. Metronidazole gel (MetroGel, Metrocream, Metrolotion, atau krim Noritate). Sig: Oleskan lapisan tipis b.i.d. Respon terhadap terapi lambat, mengambil 4 sampai 6 minggu untuk mendapatkan keuntungan. Sulfur 3., Ppt. 6% Resorsinol 4% berwarna alk ohol qs goyang lotion 60.0 Sig: Oleskan pada wajah h.s. Lotion proprietary serupa Sulfacet-R lotion Rosac crea m (mengandung tabir surya), Rosula (mengandung urea untuk mengurangi iritasi), natrium sulfacetamide persi apan topikal, Plexion persiapan topikal, Novacet lotion, dan Avar Hijau (mengandung warna hijau untuk menye mbunyikan kemerahan). 4. Tetrasiklin, kapsul 250 mg. Sig: Ambil 1 kapsul q.i.d. selama 3 hari, kemudian 1 kaps ul b.i.d. selama berminggu-minggu, yang diperlukan untuk keuntungan. Antibiotik lain yang dapat digunakan, s eperti untuk jerawat, termasuk doxycycline, minocycline, dan eritromisin. 5. Terapi untuk Helicobacter pylori d alam rejimen pengobatan sama seperti untuk penyakit ulkus peptikum telah dicoba dengan beberapa manfaat pada kasus yang berat. 6. Azelat acid (Azelex dan Finacea) dalam upaya lapisan tipis 7. Crotamiton (Eurax) lotio n di lapisan tipis b.i.d. 8. Dosis Subantimicrobial antibiotik (yaitu, Oracea [doxycycline 40-mg] masing-ma

Rosacea (acne rosacea) is a fairly common disorder of adults, involving primarily the convexities of the central face (cheeks, chin, nose, and central forehead).13051311 Rosacea may occur in other locations but the frequency and occurrence of this are ill-defined.1311,1312 Rarely, children are affected.1313 It exists in five clinical forms,1311,1314 although cases with overlapping features are common: 1. an erythematous, telangiectatic type, accounting for 70% of cases1315 2. a papulopustular type 3. a granulomatous type (see p. 175) 4. a hyperplastic glandular type (phymatous rosacea) which results in irregular, bulbous enlargement of the nose, the condition known as rhinophyma1316 5. ocular disease. Most cases are characterized by persistent erythema, recurrent episodes of flushing, edema, papules, and pustules. Later, telangiectasia, a burning sensation, and fibrosis occur.1317 Central facial erythema from actinic damage should not be confused with rosacea. 1318 Ocular manifestations range from burning or itching to signs of conjunctival hyperemia, lid edema, rarely severe,1319 and inflammation.1311 Ocular involvement is sometimes quite severe in children.1320 Rosacea in adults is more common in individuals who as children had an eyelid stye.1321 It has been estimated by the National Rosacea Society in the United States that 14 million Americans have the disease.1321 Rosacea has an equal sex incidence but the median age of presentation in males is about a decade later (59 years) compared to females (48 years).1315 It has occurred in one of monozygotic twins.1322 Severe rosacea developed for the first time in an elderly male coincident with the diagnosis of a recurrence of his colon cancer. 1323 Although the great majority of phymatous lesions occur on the nose (rhinophyma), they may also occur at other sites. Lesions involving lateral to the nasolabial fold,1324 the chin (gnathophyma),1325,1326 and the ear (otophyma) have been reported.1327 Rhinophyma has been reported in an adolescent male.1328 Rosacea is a difficult entity to classify, not only because its pathogenesis is poorly understood but also because of the broad spectrum

of histopathological changes found.1329 Rosacea has been variously regarded as a folliculitis, a sebaceous gland disorder, a response to overabundant demodex mites, and a functional disorder of superficial dermal blood vessels associated with prominent flushing.1330,1331 The last of these possibilities is currently the most favored, although some of the evidence supporting it is somewhat circumstantial.1309,1332,1333 Vasodilator drugs may also exacerbate rosacea.1334 Although there is enhanced skin blood flow in papulopustular rosacea, the increase is not significant in the erythemato-telangiectatic variant.1335 Neoangiogenesis occurs in this latter variant.1336 Lymphatics are increased in lesional skin from an early stage, even in the absence of edema. 1337 Demodex mites may be increased secondary to these vascular changes.1338,1339 Demodex mites have been regarded as a cofactor rather than the cause of rosacea,1340 even though rosacea-like eruptions can be seen in response to heavy local infestations by Demodex folliculorum (rosacealike demodicidosis see p. 653).1302,1341 Recently, antigenic proteins from a bacterium, Bacillus oleronius, isolated from D. folliculorum in a patient with papulopustular rosacea, were found to have the potential to stimulate an inflammatory response in rosacea patients.1342 Rosacealike eruptions may also occur following the topical application of potent fluorinated steroids,13431345 the use of a halogenated steroid nasal spray,1346 and the application of pimecrolimus.1347 A florid papulopustular eruption with a spiny filiform hyperkeratosis has developed during therapy with the multikinase inhibitor sorafenib. 1348 Acne rosacea has been reported in patients with HIV infection.1349 There has been considerable interest in the role of Helicobacter pylori in the etiology of rosacea;13501354 however, controlled trials offer no support for this association.13551357 It is likely that the treatment used for H. pylori is beneficial for rosacea.13581363 A rosacea-like eruption has also occurred with Candida albicans infection.1364 Perioral dermatitis (see p. 176) is possibly a related entity.13651370 It is characterized by burning, non-itchy, perioral erythema and papules usually associated with severe discomfort.1371,1372 It has been regarded by some as a subtype of rosacea in atopic patients.1373 It may follow corticosteroid therapy.1374 Periocular dermatitis is considered to have a similar pathomechanism to perioral dermatitis.1375 Sometimes rosacea will present with periorbital edema.1376 This feature should not be confused with periocular dermatitis. Griffiths has drawn attention toa group of patients with lesions resemblin g what has been called perioral dermatitis which he calls the MARSH syndrome, combining as it does melasma, acne, rosacea, seborrheic eczema, and hirsutism.1377
Rosacea (jerawat rosacea) adalah gangguan yang cukup umum orang dewasa, yang melibatkan terutama Convexities wajah pusat (pipi, dagu, hidung, dan dahi pusat) ,1305-1311 Rosace a dapat terjadi di lokasi lain tetapi frekuensi dan terjadinya ini sakit-defined.1311, 1312 Jarang, anak-anak affected.1313 Itu ada dalam lima bentuk klinis, 1311,1314 meskipun kasus den gan fitur tumpang tindih yang umum:.. 1 sebuah eritematosa, jenis telangiectatic, akuntansi untuk 70% dari cases1315 2 papulopustular a ketik 3. tipe granulomatosa (lihat hal. 175) 4. ti pe hiperplastik kelenjar (rosacea phymatous) yang mengakibatkan tidak teratur, pembesaran bulat hidung, kondisi yang dikenal sebagai penyakit mata rhinophyma1316 5.. Kebanyakan kasus yang ditandai dengan eritema persisten, episode berulang flushing, edema, papula, dan pustula. Kemudian, telangiectasia, sensasi terbakar, dan fibrosis occur.1317 eritema wajah Central dari kerusakan actinic tidak harus bingung dengan manifestasi okular rosacea.1318 berkisar dari pembakaran atau gatal tanda-tanda hiperemi konjungtiva, edema tutup, jarang parah, 1319 dan peradangan. 1311 Keterlibatan okuler kadang-kadang cukup parah pada children.1320 Rosacea pada orang dewasa lebih sering terjadi pada individu yang sebagai anakanak memiliki kelopak mata stye.1321 Telah diperkirakan oleh National Rosacea Society di Amerika Serikat yang '14 juta orang Amerika memiliki penyakit ' 0,1321 Rosacea memiliki keja dian seks yang sama tetapi usia rata-rata presentasi paRosacea (jerawat rosacea) adalah gangguan yang cukup umum orang dewasa, yang melibatkan terutama Convexities wajah pusat (pipi, dagu, hidung, dan dahi pusat) ,1305-1311 Rosacea dapat terjadi di lokasi lain tetapi frekuensi dan terjadinya ini sakit-defined.1311, 1312 Jarang, anak-anak affected.1313 Itu ada d alam lima bentuk klinis, 1311,1314 meskipun kasus dengan fitur tumpang tindih yang umum:.. 1 sebuah eritematosa, jenis telangiectatic, akuntansi untuk 70% dari cases1315 2 papulop ustular a ketik 3. tipe granulomatosa (lihat hal. 175) 4. tipe hiperplastik kelenjar (rosacea phymatous) yang mengakibatkan tidak teratur, pembesaran bulat hidung, kondisi yang dikenal s ebagai penyakit mata rhinophyma1316 5.. Kebanyakan kasus yang ditandai dengan eritema persisten, episode berulang flushing, edema, papula, dan pustula. Kemudian, telangiectasia, sensasi terbakar, dan fibrosis occur.1317 eritema wajah Central dari kerusakan actinic tidak harus bingung dengan manifestasi okular rosacea.1318 berkisar dari pembakaran atau gatal t anda-tanda hiperemi konjungtiva, edema tutup, jarang parah, 1319 dan peradangan. 1311 Keterlibatan okuler kadang-kadang cukup parah pada children.1320 Rosacea pada orang dew asa lebih sering terjadi pada individu yang sebagai anak-anak memiliki kelopak mata stye.1321 Telah diperkirakan oleh National Rosacea Society di Amerika Serikat yang '14 juta orang A merika memiliki penyakit ' 0,1321 Rosacea memiliki kejadian seks yang sama tetapi usia rata-rata presentasi pa

Treatment of rosacea
Attempts have been made to establish a global Rosacea Severity Index so that treatment outcomes can be standardized and compared. 13781380 In this regard, clinicians tend to focus on erythema, while patients

focus on papules and pustules. Topical metronidazole is well tolerated and efficacious for moderate to severe papulopustular rosacea.1317 Maintenance therapy is usually continued to avoid recurrences on cessation of the drug.1381 Trials have shown that topical azelaic acid is as effective as, or even better than, metronidazole.13821384 Antibiotics have also been used.1342 Azithromycin is at least as effective as a once daily, anti-inflammatory dose (40 mg) of minocycline.13851387 Pimecrolimus 1% cream is an effective and well-tolerated treatment for steroid-induced rosacea1388 and perioral dermatitis,1371,1389 even though tacrolimus and pimecrolimus may themselves produce a rosaceiform eruption.1347,1390 Nevertheless a randomized, double-blind study found that pimecrolimus was no more effective than treatment with the vehicle cream.1391 This has been confirmed in another trial.1392 Erythema and flushing have been controlled with oxymetazoline.1393 Laser can be used to treat persistent telangiectasia.1384 Intense pulsed light also reduces erythema and telangiectasia, and this is sustained for at least 6 months.1394 Soap and rubbing with a cloth have been suggested as a means of reducing demodex mites.1302 Photodynamic therapy was promising in one small case series.1381 Isotretinoin is beneficial for mild to moderate rhinophyma but late stages require surgery.1395
Pengobatan Upaya rosacea telah dilakukan untuk membangun global Rosacea Indeks Keparahan sehingga hasil pengobatan dapat distandarisasi dan compared.1378-1380 Dalam hal ini, dokter cenderung berfokus pada eritema, sementara pasien fokus pada papula dan pustula. Metronidazol topikal ditoleransi dengan baik dan berkhasiat untuk moderat untuk terapi M aintenance rosacea.1317 papulopustular parah biasanya dilanjutkan untuk menghindari rekurensi pada penghentian Ujian drug.1381 telah menunjukkan bahwa asam azelaic topikal sa ma efektifnya dengan, atau bahkan lebih baik daripada, metronidazole.1382 -1384 Antibiotik juga telah used.1342 Azitromisin setidaknya sama efektif sebagai sekali sehari, dosis anti-in flamasi (40 mg) dari minocycline.1385-1387 Pimecrolimus 1% cream adalah pengobatan yang efektif dan ditoleransi dengan baik untuk steroid-induced rosacea1388 dan dermatitis peri oral, 1371,1389 meskipun tacrolimus dan pimecrolimus dapat sendiri menghasilkan eruption.1347 rosaceiform, 1390 Namun demikian, studi double-blind acak menemukan bahwa pim ecrolimus tidak lebih efektif dibandingkan pengobatan dengan cream.1391 kendaraan ini telah dikonfirmasi di trial.1392 lain Eritema dan pembilasan telah dikendalikan dengan oxymet azoline.1393 Laser dapat digunakan untuk mengobati telangiectasia.1384 persisten cahaya berdenyut intens juga mengurangi eritema dan telangiectasia, dan ini dipertahankan selama minimal 6 months.1394 Sabun dan menggosok dengan kain telah diusulkan sebagai cara untu

Histopathology1396
Rosacea is characterized by a combination of several histopathological features. Sometimes the histopathological changes are non-diagnostic. 1397 In the erythematous-telangiectatic group there is telangiectasia, sometimes prominent, of superficial dermal vessels (Fig. 15.25). There is a perivascular infiltrate of lymphocytes, usually mild to moderate in intensity. A small number of plasma cells are usually present and are an important clue to the diagnosis. Inconstant features include mild dermal edema, solar elastosis, and mild perifolliculitis. The papulopustular lesions have a more pronounced inflammatory cell infiltrate which is both perivascular and peripilar, involving the superficial and mid dermis. The infiltrate may include a few neutrophils as well as lymphocytes and plasma cells. Active pustular lesions show a superficial folliculitis while in older lesions a granulomatous perifolliculitis is often present. Keratotic follicular plugging, but not comedones, may be present. Demodex mites are present in 2050% of cases. The granulomatous form1398 is usually characterized by a tuberculoid reaction, often in the vicinity of damaged hair follicles (see p. 175). Necrosis, resembling caseation, was present in 11% of patients in one series (Fig. 15.26).1399 Sebaceous gland hypertrophy and scattered follicular plugging are present in most cases of rhinophyma (Fig. 15.27).1400 In the less common fibrous variant of rhinophyma, there is telangiectasia, diffuse dermal fibrosis with abundant mucin, a virtual absence of pilosebaceous structures, and an increase in factor XIIIa-positive cells in the dermis.1401,1402 Telangiectasia of superficial dermal vessels is also quite common, a feature which is not present in senile sebaceous gland hyperplasia. Demodex mites may be present in the pilosebaceous follicles. Inconstant

features include solar elastosis, dilatation of follicles, focal folliculitis, and perifolliculitis. Sometimes, finger-like acanthotic downgrowths extend from the epidermis and follicular walls.1400 The infiltrate of lymphocytes and plasma cells around superficial vessels varies from sparse to moderately heavy in intensity. Direct immunofluorescence has demonstrated the presence of immunoglobulins and complement in the region of the dermoepidermal junction in some cases.1403,1404 Immunoperoxidase stains show increased expression of vascular endothelial growth factor (VEGF), CD31, and the lymphatic marker D2-40.1337 Matrix metalloproteinase-9 (MMP-9) is increased in patients with ro sacea and D. folliculorum mites, raising the possibility of a pathogenetic link

Histopathology1396 Rosacea ditandai dengan kombinasi dari beberapa fitur histopatologi. Kadang-k adang perubahan histopatologi yang non-diagnostik. 1397 Pada kelompok eritematosa-telangiectati c ada telangiectasia, kadang-kadang menonjol, pembuluh dermal dangkal (Gambar 15.25). Ada infiltr at perivaskular dari limfosit, biasanya ringan sampai sedang. Sejumlah kecil sel plasma biasanya hadi r dan merupakan petunjuk penting untuk diagnosis. Fitur kekal termasuk edema ringan dermal, elast osis surya, dan perifolliculitis ringan. Lesi papulopustular memiliki infiltrasi sel radang lebih jelas yang baik perivaskular dan peripilar, melibatkan dermis superfisial dan pertengahan. Infiltrasi dapat menc akup beberapa neutrofil serta limfosit dan sel plasma. Aktif lesi pustular menunjukkan folikulitis dan gkal sedangkan pada lesi yang lebih tua yang perifolliculitis granulomatosa sering hadir. Follicular plu gging keratotik, tetapi tidak komedo, mungkin ada. Tungau demodex yang hadir dalam 20-50% kasus . The form1398 granulomatosa biasanya ditandai oleh reaksi tuberkuloid, sering di sekitar folikel ram but yang rusak (lihat hal. 175). Necrosis, menyerupai kaseasi, hadir di 11% dari pasien dalam satu ser i (Gambar 15.26) 0,1399 sebasea hipertrofi kelenjar dan tersebar follicular plugging yang hadir dalam sebagian besar kasus rhinophyma (Gambar 15.27) 0,1400 Pada varian berserat kurang umum rhinop hyma, ada telangiektasia, fibrosis dermal menyebar dengan musin berlimpah, tidak adanya virtual st ruktur