Connecting the Dots Between Pathophysiological Mechanisms and Common Clinical Features of Rosacea with Emphasis on Vascular Changes and Facial Erythema

Rosacea is a common inflammatory facial dermatoses affecting primarily adults with fair skin, although all skin types may be affected. The diagnostic term “rosacea” reflects a spectrum of clinical features with the more common presentations characterized by increased blood flow and vasodilation during disease flares, which accentuate central facial erythema. Inflammatory lesions, usually papules and/or pustules are present in some cases. Variations in magnitude of the associated features of rosacea are noted clinically. Over time, other clinical features emerge or may be further accentuated, such as diffuse facial erythema and telangiectasias, as fixed changes in cutaneous vasculature occur. These later findings account for persistent diffuse facial erythema usually accentuated centrally on the inner cheeks, chin, nose, and/or medial forehead. Some patients may also develop phymatous changes and/or have concurrent ocular rosacea. Augmented innate immune response to certain triggers (often exogenous) and neurovascular/neuroimmune dysregulation appear to be involved early in the pathophysiological sequence of cutaneous rosacea and appear to signal other downstream inflammatory or physiochemical cascades that contribute to the pathogenesis of the disorder. In this article, Part 1 of a two-part series, emphasis is placed upon the correlation of clinical features and underlying pathophysiological changes in the more common presentations of rosacea encountered by the clinician. The importance of this information is that some of these pathogenic mechanisms are modulated by available therapies, and others remain as targets for the development of new therapeutic agents or modalities. (J Clin Aesthet Dermatol. 2012;5(3):16–25.) DISCLOSURE: Dr. Del Rosso is a consultant, speaker, and/or researcher for Coria/Valeant, Allergan, Galderma, Graceway, Intendis, Medicis, Onset Dermatologics, Obagi Medical Products, Ortho Dermatologics, PharmaDerm/Nycomed, Promius, Ranbaxy, Stiefel/GSK, TriaBeauty, Triax, Unilever, and Warner-Chilcott. ADDRESS CORRESPONDENCE TO: James Q. Del Rosso, DO; E-mail: [email protected] Advances in Understanding and Managing Rosacea: Part 1 Connecting the Dots Between Pathophysiological Mechanisms and Common Clinical Features of Rosacea with Emphasis on Vascular Changes and Facial Erythema JAMES Q. DEL ROSSO, DO, FAOCD Dermatology Residency Program Director, Valley Hospital Medical Center, Las Vegas, Nevada; Clinical Professor (Dermatology), Touro University College of Osteopathic Medicine, Henderson, Nevada; Dermatology and Cutaneous Surgery, Las Vegas Skin & Cancer Clinics, Las Vegas, Nevada, and Henderson, Nevada “Rosacea is an odd disorder which seems to defy understanding and the aim is...to see whether we can identify any central unifying theme that can explain the pathogenesis and/or major signs of the disease.” “... it is quite possible (some might say ‘quite likely’) that what we understand by the term ‘rosacea’ is in fact a collection of several disease entities all manifesting the same set of physical signs—a final common pathway— but at least we should all agree on these physical signs.” The preceding statements were published as recently as 2007 by Dr. Ronald Marks, a dermatologist who has dedicated much of his career to the subject of rosacea. Together, they clearly emphasize our limited ability over many years to scientifically and rationally classify the clinical presentations of the common facial disorder that we term “rosacea.” These statements also reflect our relative lack of knowledge and understanding of the underlying pathophysiological mechanisms that correlate with the clinical features we encounter in individual cases, and how DelRosso_Rosacea_Part1.qxp 3/7/12 1:23 PM Page 16