CAM Exam #4

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Author:
DrJBlack
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215511
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CAM Exam #4
Updated:
2013-04-24 19:32:09
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rosacea
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rosacea
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  1. What is rosacea?
    • chronic inflammatory cutaneous disorder that affects the central face
    • progressive with intermittent periods of exacerbation and remission
  2. Define telangiectasia
    small, dilated blood vessels on skin
  3. Define erythema
    reddening of skin as a result of vasodilation
  4. Define phyma
    swelling, mass, or hypertrophy of tissue
  5. Define papules
    small, superficial, palpable lesion elevated on skin surface
  6. Define pustules
    superficial, elevated lesions that contains pus beneath epidermis
  7. Rosacea epidemiology
    • increased prevalence among Northern Eurpoean descents
    • more common in females
    • males are more common to have skin disfiguration
    • 30-50 yoa
  8. Rosacea risk factors
    • genetic - relatives or of Northern European descent
    • fair skinned
  9. Rosacea Pathophysiology
    • multifactorial:  inflammation
    • pro-inflammatory substances & degradative enzymes released from inflammatory cells in facial dermis leads to angiogenesis & dermal destruction
    • up regulate cytokines
    • Microvascular:  abnormality of dermis surrounding vessels
    • Sun damage
    • Others:  bacteria (H. pyloir & Demodex folliculorum), neurologic, hormones
  10. Rosacea Step by Step Pathophysiology
    Trigger → recruitment and activation of infammatory cells and other immune cells in facial skin → release inflammatory mediators (histamine & PG) → release degradative enzymes → damage to CT supporting blood vessels → angiogenesis → multiple blood vessels in the face
  11. Triggers of Rosacea
    • topical cosmetics/skin products
    • weather
    • emotions
    • exercise
    • beverages
    • tobacco
    • caffeine
    • hormonal changes
    • medications (nitroglycerin, BB, nitrates, topical steriods, niacin, amiodarone)
  12. Rosacea Dx Criteria
    • Primary features:  one or more of transient erythema (flushing), nontransient erythema, papules, pustules, telangiectasia
    • Secondary features:  burning/stinging, plaques, dry appearance, facial edema, phymatous changes, ocular manifestations
  13. Subtypes of Rosacea
    • 1. Erythematotelangiectatic (Vascular)
    • 2. Papulopustular
    • 3. Phymatous
    • 4. Ocular
  14. Rosacea Tx Goals
    • identify & avoid triggers
    • reduces/alleviate inflammatory lesions & erythema
    • decrease flares
    • prevent progression
    • obtain remission & prevent exacerbations
    • keep skin in good condition
    • improve QOL
  15. Subtype 1:  Erythematotelangiectatic Rosacea (ETR) - Presentation
    • most common type
    • flushing & persistent central facial erythema
    • telangiectasias common
    • central face edema, stinging, burning, roughness, or scaling
  16. Subtype 1:  Erythematotelangiectatic Rosacea (ETR) - Tx
    • First Line:  avoid triggers
    • Second Line:  phototherapy OR vascular laser therapy OR topical metronidazole and/or sodium sulfacetamide sulfur in AM (for pts w/ minimal barrier dysfunction) OR isotretinoin
  17. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Presentation
    • persistent central facial erythema w/ transient papules and/or pustules
    • burning and stinging
    • may occur concommitantly w/ vascular rosacea
    • resembles acne vulgaris except comedones (white/black heads) are absent
  18. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Mild-Mod Dz
    First Line:  metronidazole/azelaic acid
  19. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Mod-Severe Dz
    • tetracylines - mainstay of oral therapy
    • macrolides
  20. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Systemic Therapy
    • metronidazole
    • isotretinoin (Not first line due to SE & birth defects) - tx refractory disease & has a delayed effect
  21. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Other Tx
    • vascular laser therapy
    • phototherapy
  22. Subtype 2:  Papulopustular (Inflammatory) Rosacea - Tx Duration
    • long-term tx necessary (at least 12 wks) - gradual improvement takes weeks
    • relapse often occurs w/i weeks of d/c systemic tx
    • topical tx can maintain remission - 6 wks is recommended
  23. Subtype 3:  Phymatous Rosacea - Presentation
    • least common subtype overall
    • men > women
    • thickening skin, nodules, hypertrophy, and hyperplasia of sabaceous glands and CT
    • rhinophyma = nose rosacea
    • may have telangectasias
    • observed concomitantly/after subtype 1 or 2
    • social stigma of "alcoholic"
  24. Subtype 3:  Phymatous Rosacea - Systemic Tx
    • Antibiotics play limited role
    • Isotretinoin - beneficial for early dz; delay progression; decrease hypertrophy & sebaceous glands
    • Other for advanced dz:  electrosurgical sculpting & laser therapy
  25. Subtype 4:  Ocular Rosacea - Presentation
    • dx w/ one of the following:  watery/bloodshot eyes, foreign body sensation, burning/stinging, dryness, itching, sensitivity to light, blurred vision, telangectasias of eye or eyelid, or periocular erythema
    • blepharitis, conjunctivitis, or irregularity of eyelid margins
    • vision changes are rare
    • frequently dx w/ cutaneous signs of rosacea
  26. Subtype 4:  Ocular Rosacea - Mild Dz Topical Therapy
    • Broad spectrum ATB:  azithromycin, polymyxin B/trimethoprim, erythromycin, bacitracin
    • Topical steroid solution:  rimexolone, loteprednol, fluorometholone (short course for systemic tx) ~2-3 wks to avoid cataracts
  27. Subtype 4:  Ocular Rosacea - Mod-Severe Dz Tx
    • tetracyclines - only one shown to tx ocular rosacea
    • macrolides - good in kids
    • metronidazole
    • istretinoin (severe dz)
  28. Subtype 4:  Ocular Rosacea - Tx Duration
    • usually 6-12 wks
    • gradual tapering of dose after improvement achieved
    • relapse after d/c common
  29. Subtype 4:  Ocular Rosacea - Adjuvant Tx
    • referall to opthalmologist recommended
    • eyelid hygeine - clean eyelids with warm water BID; hot compress 5-10 min QD
    • artificial tears
  30. Metronidazole (Flagyl)
    • ATB
    • metallic taste, N/V/D
    • Disulfiram rx - avoid alcohol
    • take w/ food to avoid GI upset
  31. Isotretinoin (Acutane)
    • ADR - dyslipidemia, increased liver fxn tests
    • iPLEDGE program - part of REMS program
    • only prescribed for 30 days
  32. Azelaic acid (Finacea)
    • FDA approved for rosacea
    • apply BID on affected areas on face
    • wait to dry before placing cosmetics to face
    • ADR - burning, stinging, tinging, pruritis
  33. Tetracyclines
    • ADR - photosensitivity, hepatotoxicity
    • CI - 2nd & 3rd trimester and kids < 8 years
  34. Macorlides
    • ADR - GI upset, dizziness, HA, taste disturbances (metallic taste)
    • DI - erythromycin
  35. Coping with common Triggers of Rosacea
    • avoid potential triggers
    • stress mgmt techniques
    • use moisturizer to protect against wind and cold
    • coping with humidity/overheating due to exercise - chew on ice chips or use cool, moistened towel; immediately rinse off salt/Cl water; avoid being outside/exercising during hottest time of the day (10 am-2 pm)

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