Edema with rosacea

Rosacea (rosacea, acne rosacea, rosaceus, acne rosacea, acne pink) is a noninfectious, chronic inflammatory disease of the skin of the face, affecting people mostly of mature age.

The etiology of this disease is not fully understood.

  • progredient current,
  • frequent redness,
  • persistent erythema, with episodes of inflammation,
  • telangiectasia,
  • the appearance of papules, pustules and, rarely, knots.

In more severe cases many years later, disfiguring hypertrophy may develop, especially in the area of ​​the nose - rhinophyma.

The disease begins on the third or fourthdecade of life and reaches a heyday between the 40th and 50th year. Women often suffer (60%), although hyperplasia of connective tissue and sebaceous glands leading to rhinophyma is observed exclusively in men.

Rosacea occurs in all races, butpredominantly in fair-skinned and very rarely in blacks (Negroes of Africa and America). Epidemiological studies in North America show that rosacea suffer from 5% to 7% of the population. In the Scandinavian countries this figure reaches 10%, and in Germany it is estimated at 7%. The English call rosacea "tides of the Celts". Individuals of Irish origin are more likely to have more severe forms of the disease.

The causes of rosacea, pathogenesis.

The cause of rosacea is still unknown,although there are many theories about the origin of the disease. In the pathogenesis of rosacea, the leading role is played by vascular disorders, pathology of the gastrointestinal tract, dysfunction of the endocrine system, psychosomatic and immune disorders, and a number of endocrine factors. Genetic predisposition to rosacea is not established.

Exogenous factors of development of rosacea

A number of elementary factors (alcohol, hotdrinks and spices) stimulate the mucous membrane of the stomach and due to the reflex action causes the expansion of the blood vessels of the face. It is believed that excessive consumption of meat is the reason for the formation of rhinophyma. However, rosacea develops in vegetarians, which casts doubt on this assumption. There is no reliable relationship between the reaction of blood tides and food intake with a high content of sodium glutamate, used as flavor additives in meat products (syndrome of Chinese restaurants). The abuse of coffee, tea or cola, according to some scientists, is associated with the pathogenesis of rosacea, but careful studies have shown that the flow of blood to the skin of the face causes water with a temperature above 60 ° C, and not actually coffee [J. K. Wilkin, 1979]. Nevertheless, the authors in the recommendations for a diet of patients with rosacea still instructed to exclude foods that provoke erythema from food, such as alcohol, hot drinks, spicy dishes and citrus fruits.

One of the factors contributing to the development ofrosacea, is the increased content of porphyrins in the secretion of the sebaceous glands of the facial skin, which in combination with a number of other causes causes photodynamic damage to the structural elements of the skin.

Presence of pustular elements, as well asthe effectiveness of antibacterial drugs in rosacea allowed to suggest the infectious nature of the disease. However, with repeated bacteriological studies, the etiological role of bacteria has not been proven - the content of pustules is sterile in most cases. Gram-negative microorganisms indicate only the severity of the disease (gram-negative rosacea).

One of the most common causes of rosacea is the presence of ticks of the genus Demodex folllculorum. Detection for histological examinationmites in individual infiltrates, as well as the effectiveness of acaricides (hexachlorocyclohexane, crotamiton, benzyl benzoate), metronidazole and sulfur in rosacea confirm this assumption. At the same time, the localization of the effusive elements of rosacea is mainly not associated with the follicular apparatus, but Demodex folllculorum is not found in all patients. Demodex folllculorum - a physiological representative of skin microflora,the population of follicles increases significantly with age. External application of sulfur in rosacea leads to clinical improvement, but not to histopathological reduction of tick mites. Most authors associate the emergence of the extrafacial form of rosacea with infection Demodex folllculorum. In some patients, even specific antibodies to demodex are found.

Genetic factors of rosacea development

No acceptable evidence of genetica predisposition to rosacea is not yet found, although sometimes in the family there is more than one case of the development of this disease. In addition to skin color and family history, predisposition in people of some nationalities can act as a risk factor in the occurrence of rosacea. Surveys of 2,052 people suffering from acne, conducted by the National Society of Rosacea in the United States, have shown that its development can be linked to heredity. About 40% of those surveyed indicated the presence in their family of members suffering from rosacea. More than 60% had light skin, 33% had at least one parent of Irish descent, and 26% had English. About 15% noted that their mothers were of Scandinavian origin and 12% had fathers. The remaining ethnic groups from rosacea among those surveyed included those from Scotland, Poland, Lithuania and the Balkan countries.

The relationship between genetic polymorphismreceptor gene of vitamin D with a lightning-fast form of rosacea [T. Jansen, G. Messer, 1997]. This form of rosacea is rare and is characterized by the sudden appearance of inflammatory knots and fused dried sines on the face, affecting exclusively young women. This is obviously due to the fact that violations of hormonal regulation may be involved in the development of rosacea. With the lightning-fast form of rosacea, the prevalence of VDR of the first allele was found, confirming the predisposition to this inflammatory disease at the level of hormonal control.

The role of diseases of the gastrointestinal tract in the development of rosacea

According to some scientists, disruption of activityThe gastrointestinal tract does not play a leading role in the pathogenesis of rosacea. In 50-90% of patients with rosacea, clinical and histological signs of gastritis were identified, and in 33% - pathological changes in the jejunal mucosa. Based on the results of the study of gastric juice, the pathogenetic significance is given more often to the hypo- or anacidic state, more rarely to the hyperacid state. The association of rosacea with chronic inflammatory diseases of the stomach and intestines has been reported.

Attention is paid to increased populationgastrointestinal tract of rosacea patients with spiralformed Helycobacter pylori bacteria, which are known as the etiologic factor of chronic active gastritis of type B. Numerous studies have established a correlation between rosacea and hepatopathy or cholecystopathy. However, a number of researchers do not notice a significant difference in the frequency of the above changes with respect to the control group. While Powell F. C. et al. [1992] found in 19 of 20 patients with rosacea antibodies to H. pylori, in another group the results were not so impressive.

Schneider, M.A., et al. [1992] found antibodies to H. pylori in only 49% of rosacea patients, but there was no difference with the control group. This figure is only slightly higher than the prevalence of antibodies to H. pylori in the United States, which is 45%. In the clinical study [A. E. Rebora et al. 2000], 31 patients with rosacea at the age of 28 to 11 years were examined, and the presence of H. pylori was histologically confirmed in 84% of cases. We performed Helicobacter pylori infection in 18 of 20 patients with fibro-esophagi-gastro-duodenoscopy with targeted gastro biopsy and H. pylori determination with urease test and histological examination of biopsy specimens from antrum and fundus stomach. P.Adaskevich, 2001].

Although based on the currently availablethe relationship between rosacea and H. pylori-induced gastrointestinal diseases can not be completely ruled out, the data are more controversial than in cases of chronic urticaria.

The role of the pathology of the endocrine system in the development of rosacea

Some researchers regard the existence ofdiabetes mellitus and a 15% decrease in lipase secretion as evidence of the pathogenetic significance of metabolic disorders in patients with rosacea. Ovarian and pituitary insufficiency, thyroid diseases and other hormonal disorders are not considered as single causes of rosacea, as this disease affects both men and women of different age groups. The effect of adrenal insufficiency on the formation of rosacea on the basis of a positive effect on the adrenal hormones was noted.

The role of psycho-vegetative disorders in the development of rosacea

Mental factors for a long time were consideredthe primary cause of rosacea, but targeted psychological studies have not statistically confirmed the alleged relationship between rosacea and mental factors. They rather pointed to the effect of a disfiguring cosmetic defect on the psyche of the patient. A psychological screening using the SMOL test revealed emotional and vegetative instability in rosacea patients with a tendency to suppress the behavioral response of emotional stress [M. V. Cherkasova, Yu. V. Sergeev, 1995]. Neurologic disorders were observed with unilateral rosacea, which appeared after trauma or defeat of the so-called vegetative face mask.

The role of vascular pathology in the development of rosacea

Clinical and experimental studiesshow that disturbances in the regulation of cerebral influence on the blood vessels of the facial skin play a special role in the pathogenesis of rosacea. As a result, a slowdown in the redistribution of blood flow and venous stasis in the outflow area of ​​venae facialis sive angularis, corresponding to the most frequent topography of rosacea. In the area of ​​the outflow of the facial vein, the conjunctiva is also included, which explains the frequent involvement of the eyes in this disease.

Based on morphological and laboratoryresearch is established [E. I. Ryzhkova, 1976] that at the heart of the pathogenesis of the disease lies an angioneurosis with a primary lesion of the vessels of the face as one of the manifestations of vegetovascular dystonia.

It is assumed that the blood and lymphaticthe vessels are not primarily involved in the inflammatory process, and the dilatation of the vessels appears to be mediated indirectly and is caused by actinic elastosis. In patients with rosacea, normal reactions to adrenaline, norepinephrine, acetylcholine and histamine are noted.

Role of vasoactive peptides in the development of rosacea

Vasoactive peptides of the gastrointestinal tract(VIP, pentagastrin) is attributed to the ability to cause hot flashes. The alcohol-induced reactions of tides are associated with its insufficient enzymatic destruction, especially among people of Eastern nationalities. As a cause of the reaction of the tides in patients with rosacea, there was also an increase in the content of a number of mediator substances, such as endorphins, bradykinin and substance R. Activation of the kallikrein-kinin system and enhancement of kininogenesis were established in many patients with rosacea [O. V.Snitsarenko, 1988; 1989]. The vasoactive direction of the action of kinins, their ability to change the tone of the vessels in extremely small concentrations and to increase the permeability of the capillaries cause the vascular changes characteristic of rosacea. The predominant localization of their on the face, apparently, is due to the increased sensitivity of the bradykinin receptors located here. This is a confirmation of the theory of vasoactive bradykinin as an "effector" of rosacea.

The role of immune system disorders in the development of rosacea

Rosacea patients have a reliablean increase in the level of immunoglobulins of all three classes: A, M, G. However, there was no correlation between the level of immunoglobulins and the duration and stage of the disease. With the help of the immunofluorescence reaction on the basement membranes, immunoglobulin deposits are sometimes found, and more rarely the complement of the C3 fraction. A number of authors in the study of cellular immunity revealed a significant increase in the absolute number of "total" and "active" rosette-forming cells and a decrease in the number of T suppressors.

The interaction of rosacea with other diseases

In patients carcinoid syndrome, characterized by frequent hot flashes, develops rosacea with numerous telangiectasias, and sometimes rhinophymus-like hyperplasia. When mastocytosis one can also observe a spectrum of changes typical for rosacea. Light forms of rosacea occur in women often over the age of 35, when it increases benign hormonal reaction tides. There is a clear association of rosacea with migraine, which is now regarded as a pathological vasomotor reaction. Often rosacea is associated with diseases seborrheic nature, diseases of the follicles and sebaceous glands. The importance of seborrhea as an element of the pathogenesis of rosacea is maintained due to the predominant localization of the disease in seborrheic sites and the effectiveness of isotretinoin and antiandrogens.

Factors provoking rosacea: sun, stress, heat, alcohol, spicy and salty foods, exercise, hot tub, cold, coffee or tea, cosmetics. The influence of these factors on the disease is different in each individual case.

Thus, rosacea is aa disease with poly-factors of provoking factors and a diverse clinical picture. The main role in the pathogenesis of rosacea belongs to the pathological reaction of the vessels, which develops under the influence of vasoactive peptides, antibodies, circulating immune complexes and other endogenous irrigants.

Rosacea is a disease witha characteristic combination of skin stigma. If you take a typological model of rosacea, then in its epicenter are patients with erythema, telangiectasia, facial edema, papules, pustules, ocular foci and rhinophyma. Most patients, of course, have fewer symptoms than a complete set of these symptoms. Far from the center, on the periphery, there are so few signs and they are so vague that identification of rosacea becomes more and more difficult. Thus, rosacea is well defined in the center, but not on the periphery. Typically, rosacea can be considered a type of reaction, a phenotype that is provoked by various causes in individuals prone to rosacea. Identification and classification of these causes suggests the dominance of the physiological mechanism in the occurrence of rosacea.

Modern and relevant is the classification of rosacea proposed by J. K. Wilkin [1994], taking into account the etiological and pathogenetic factors. There are 4 stages in this classification: prerozacea, vascular rosacea, inflammatory rosacea, and later rosacea.

Stages of rosacea (J. K. Wilkin, 1994)

Rosacea is basically a skin and vascular disease.

In the initial stage of rosacea There is an erythema, the intensity of which graduallyincreases and there is a correlation between the severity of ophthalmic rosacea and the tendency to severe reddening. Intravenous administration of xanthinal nicotinate causes the expansion of small conjunctival vessels, with collateral vessels becoming especially noticeable.

Patients with severe reddening have alla variety of signs, including ophthalmological telangiectasia of the face and pronounced hypertrophy of connective tissue. Rapidly progressing rosacea develops in patients with severe erythema. Poorly expressed rosacea often occurs in women after 35 years, when the frequency of "hot flashes" and redness increases. Redness (flush of blood to the face) is unchanged and the earliest of the visible symptoms of rosacea. Repeated relapsing redness in people prone to rosacea may be considered a pre-stripe.

The second stage of rosacea is vascular (vascular). Early vascular rosacea consists of a simpleerythema (or cyanosis on cold days). This erythema reflects the increased number of erythrocytes in the slightly inflamed superficial vasculature. Local irritants, such as certain topical preparations, air irritants, wind, extreme temperatures, lead directly to the accumulation of extravascular fluid in the surface layer of the dermis. Redness reactions, whether caused by menopause, swelling, vasodilator therapy, mastocytosis, ethanol, or intolerance to food, represent an increase in blood flow in the superficial dermis. This leads to an increase in extracellular fluid, which is collected faster than it can be removed by the lymphatic system. If the skin's lymphatic vessels are severely damaged, inflammatory edema may occur.

Chronic progressive damagelymphatic vessels is clinically almost not manifested due to a weak degree of cellulite and actinic changes. The earliest component of vascular rosacea - erythema - is often a reaction to local or systemic antibiotics. In particularly severe cases, the reaction can be complete, causing depression in the patient due to the phenomenon of post-erythema telangiectasia (PERT - posterythema-disclosed telangiectasia). Teleangiectasia was present all the time, it was simply masked by erythema.

Rosacea reacts to therapy in the form of a massage,confirming the theory that redness leads to swelling, which then leads to other symptoms. Signs of rosacea are typically found in those areas of the face that are located above the relatively inactive musculature, where the edema caused by redness tends to be stable. Extrafacial rosacea occurs in extrafacial areas of redness. Rhinophymus is explained by the fact that chronic skin edema often results in hypertrophy of connective tissue and fibroplasia, which is a manifestation of factor XIII.

Elastin network, which surrounds the lymphatic system in the skin, performs two important functions.

  • First, it is the binding that makes the lymphaticthe endothelium is sensitive to the volume of liquids near the lymphatic vessels, so that any increase in this volume causes a greater tension of anchor filaments.
  • Secondly, the elastic network provides a low resistance to passage through the interstitium, along which the macromolecules move to the lymphatic vessels.

Degeneration of elastin due to actinic action and is probably the common cause of a lymphatic defect in rosacea.

Further, as rosacea progresses,the continuing activity of the protease during inflammation releases the cytoskeleton from its attachment to the cell membrane. Neutrophils can degrade the rapid degradation of various extracellular matrix molecules, especially elastin, in the inflamed stage of the disease. Neutrophil elastase also destroys type IV collagen in the extracellular matrix, on which the integrity of the capillary wall depends. Thus, sterile surface dermal cellulitis in rosacea leads to the separation of elastin from the lymphatic vessels.

With the loss of superficial lymphaticmicrovascular function, the accumulation of any extravascular fluid (which can occur with redness) will tend to persist for a long time. Dysfunction of lymph leads to a stable inflammatory response in skin cellulite. In fact, with the onset of dysfunction of lymph, any factor capable of causing protein exudation will give self-sustained long-lasting inflammation. These proteins, which can not be cleared of interstitium due to lymph dysfunction, are denatured and become an inflammatory factor. The accumulation of plasma proteins also can play an important role in fibroplasia, which underlies the development of rhinophyma. Chronic sterile dermal cellulite also leads to an increase in the microvascular capacity, which then rises sharply from the effects of vasodilator stimuli leading to subjective observation that reddening occurs more frequently in patients with rosacea.

Teleangiectasia is a later phase of rosacea. One of the key causal factors isweakening of the mechanical integrity of the upper dermal connective tissue, which contributes to the passive expansion of the vessels. Perivascular inflammatory cell infiltrate and an enlarged endothelial index underlie the damage to the cell wall, which contributes to the pathology of rosacea. The expansion of both small dermal blood vessels, and lymphatic, is clearly expressed in rosacea. The destruction of these vessels by a laser leads to a decrease in inflammatory foci.

Angiogenesis can also contribute totelangiectasia with rosacea. Angiogenesis depends on the presence of a space in which endothelial cells can grow. So the edema of the stratum corneum, which can occur after severe redness, reduces the compactness of the corneum, contributing to its vascularization. Ocular rosacea is mainly vascular and correlates with the degree of redness. Because lymph dysfunction can give a prolonged inflammatory response in sterile cellulite in rosacea, various symptoms can contribute to angiogenesis. The protease can release the angiogenesis factors stored in the extracellular matrix, macrophages can be attracted and activated to release angiogenesis factors, and endothelial factors can be released from inhibitory control.

  • prerosacea corresponds to temporary reactions of skin reddening (transient erythema and hyperemia);
  • vascular rosacea is characterized by persistent erythema and telangiectasia;
  • inflammatory rosacea accompanied by papules and pustules;
  • later rosacea corresponds to rhinophyma.

Currently, there is no generally recognized classification of rosacea. According to the clinical-morphological classification [E. I. Ryzhkova, 1976] distinguish four stages of the disease:

  1. erythematous,
  2. Papular,
  3. pustuleznuyu,
  4. infiltrative-productive.

A peculiar variant of pustular rosacea is the cystic form.

The most successful is the subdivision of the disease into the classical staged current, taking into account the diverse clinical options [PlewigG. Kligman A. M. 1993].

  1. Episodic erythema: diathesis rosacea.
  2. Rosacea I degree: persistent moderate erythema and rare telangiectasias.
  3. Rosacea II degree: persistent erythema, numerous telangiectasias, papules, pustules of Rosacea III degree: persistent deep erythema, abundant telangiectasia, inflammatory nodules and plaques.
  • Persistent facial swelling
  • Ophthalmorozate with blepharitis, conjunctivitis, iritis, iridocyclitis, hypopionitis, keratitis
  • Lupoid or granulomatous rosacea
  • Steroid Rosacea
  • Gram-negative rosacea
  • Conglomerate rosacea
  • Lightning Rosacea
  • Halogen-related rosacea
  • Fima with rosacea:
    • rhinophyma,
    • gnathofima,
    • metofima,
    • otofim,
    • blepharophyma

German and American dermatologists currently allocate during the rosacea three consecutive stages:

  1. erythematous-telangiectatic,
  2. papulo-pustulose,
  3. pustularly-knotty.

The beginning of rosacea is characterized by a lush tidalerythema, the cause of which can be numerous nonspecific stimulating factors: mechanical skin irritation, insolation, temperature fluctuations; the use of hot drinks, spicy food, alcohol. Initially, the duration of erythema varies from a few minutes to several hours, accompanied by a sensation of heat or heat and then completely disappears, but soon under the influence of provoking factors appears again.

Localization is often limited to the skin of the nose and lips. In this state of relapse and remission, the process can continue for many months and years. Later on the site of hyperemia appears moderate infiltration, telangiectasia. Erythema becomes more intense, with a cyanotic shade, often changes to the surrounding nose of the cheeks, on the forehead and chin. At a histological study, only the enlarged blood and lymphatic vessels predominate at this stage.

Later on the background of a diffuse thickening of the affectedskin appear isolated or grouped inflammatory pink-red papules, often covered with delicate scales. Papules are capable of persistence for many days or weeks. The largest elements are infiltrated at the base. Further, most of the nodules undergo suppuration, forming papulopustules and pustules with sterile contents. Pustulization is formed due to cell-mediated immunity with the diffusion of a large number of neutrophilic granulocytes in response to the presence Demodex folliculorum. The lesion spreads from the centrofacial area to the skin of the forehead, behind-the-ear regions, the front surface of the neck and even the pre-intestinal region.

Histologically, perivascularlymphohistiocyte infiltrates in the epidermis mainly in the area of ​​follicles of the sebaceous glands. In the presence of pustules in the histological picture, spongios of the follicular funnel, atrophic changes in the follicular apparatus, as well as the destruction of collagen fibers are observed.

In the future, due to chronicprogressing course, the pathological process leads to the formation of inflammatory nodes, infiltrates and tumor-like growths due to progressive hyperplasia of connective tissue and sebaceous glands and persistent vasodilation. These changes affect primarily the nose and cheeks, less often the chin, forehead and ears, creating a pronounced disfiguring appearance.

Some authors consider this stage of the disease as an independent form - rhinophymus. Rinofima occurs almost exclusively inmen. The shape of the nose becomes asymmetric, with numerous large telangiectasies on the background of congestive-cyanotic erythema. Functional activity of the sebaceous glands sharply increased. When pressing from the mouth of the follicles, a whitish pasty secret is released.

Similar changes occur in places of other localization:

  • thickening of the skin on the chin - gnathofima,
  • Pillow-shaped thickening in the area of ​​the nadiprese and forehead - metaphim,
  • growths on the ear lobes - otofim,
  • The thickening of the eyelids due to hyperplasia of the sebaceous glands - blepharophyma.

Rinofima is considered as the most severe form of rosacea, which does not develop in all patients. This is confirmed by detailed pathomorphological studies [E. I. Ryzhkova, 1976].

Classification of rosacea by severity

Some researchers [G. Plewig, 1997] rosacea is divided into three degrees of severity, which usually correspond to the stages of the disease:

Rosacea I. Persistent erythema and telangiectasia. With the development of erythema,several hours to several days (congestive erythema). In this case, telangiectasias are added, which are located mainly on the skin of the nose, cheeks, forehead, and are an appreciable cosmetic defect.

Rosacea II. Papules, papulopustules and pustules. In the central part of the face are often foundisolated or grouped hemispherical, inflammatory, hyperemic papules with fine-lamellar ecdysis, which can be for several days or weeks. There may also be papulopustules, pustules, and mild edema. Pustules have a normal bacterial flora or are sterile. Comedones do not develop. The resolution of inflammatory eruptions does not lead to scarring. Subsequently, rosacea can capture not only the central part of the face, but also the forehead area at the border of hair growth, lateral neck areas, retro-aureicular region and the pre-intestinal region. Skin in these zones is characterized by increased blood circulation and thickened.

Rosacea III.Inflammatory nodes and plaques. With further development of the process, rosacea canaccompanied by inflammatory nodes that capture large areas, as well as infiltrates with a tendency to inflammation and diffuse tissue hyperplasia, that is, the formation of tubercles or "fim." This applies especially to the cheeks and nose (rhinophyma), less often the chin (gnatofima), the forehead (metaphim), or the ears (otohim). Skin in patients with large pores, inflamed thickened, edematous ("orange peel"), and there are inflammatory infiltrates, an increase in connective tissue, hyperplasia of the sebaceous glands, an increase in the volume of the skin. There may be thickening the size of the little finger. On this basis the rhinophyma can develop.

In rosacea, in some patients,permanent hyperplasia of the connective tissue, hyperplasia of the sebaceous glands and vascular ectasia, a pineal, tuberous nose appears. In addition to the pineal nose, there are also typical changes in rosacea. However, the pineal nose can also form without the symptoms of rosacea.

Rinofima is a disease of men. With his glandular form The nose is cone-shapedly enlarged, and the follicles of the sebaceousGlands deeply retracted and strongly dilated. Often an irregular tumor-like formation on the nose is very pronounced and the shape of the nose becomes asymmetric. Sometimes there are multiple wormlike thickenings. Secretion of the sebaceous glands is sharply increased (seborrhea of ​​the nose area). When pressed from the deeply retracted estuaries of the sebaceous glands, a white paste-like secret from the follicular filaments is formed, which consists of horn cells, fat, bacteria and demodex mites. The color of the facial skin is from pronounced yellow to stagnant red. At the heart of this process is mainly diffuse hyperplasia of the connective tissue, vasodilation, hyperplasia of the follicles of the sebaceous glands. This hyperplasia does not spontaneously disappear and can not be treated with antibiotics.

When fibrous form Rhinophyma on the foreground is diffuse hyperplasia of connective tissue, as well as significant actinic elastosis, vascular hyperplasia and hyperplasia of the follicles of the sebaceous glands.

When fibroangiomatous form rhinophyma nose color from copper-red toDark red and its size is greatly increased. Constantly appear pustules. Here, with histological examination, fibrosis, vasodilation and inflammatory changes come to the fore. Hyperplasia of the sebaceous glands with this form is not so strong. Fibroangiomatous rhinophyma is more common with other manifestations of rosacea.

And one more option - actinic rhinophyma - in which the main component of rhinophymais actinic elastosis. In the formation of rhinophyma, the role of congenital vascular changes in the facial skin can play a role. The cases of transformation of the congenital vascular nevus, localized in the central part of the face, into the rhinophymus are described.

Differential diagnosis of rhinophyma conducted with:

Ophthalmorosacea (ocular rosacea). Every third patient has rosaceaeye damage in the form of blepharitis, conjunctivitis, iritis, iridocyclitis, hypopionitis, or keratitis. Complications of eye diseases are not related to the severity of rosacea and may for several years outstrip skin lesions. Typical for ophthalmicosis is cyclically leaking dry keratoconjunctivitis, which is characterized by a sensation of foreign particles in the eyes and photophobia. Unfavorable for the prognosis is rosacea-keratitis, which in extreme cases can lead to loss of vision due to corneal opacity. In case of eye damage in patients with rosacea, consultation of an ophthalmologist is recommended.

Persistent edema. In rare cases, rosacea flows under a picture of a persistent, indistinct, slight edema of the face that appears on the forehead, in the area of ​​the nadir or cheeks.

Special clinical forms of rosacea

Steroid-induced (steroid) rosacea develops in patients for a long timeusing corticosteroid ointments, especially fluoridated, about this or that dermatosis. As a result, the phenomenon of "steroid skin" with light subatrophy and extensive dark red erythema appears on the surface of which there are telangiectasias and papulo-pustular elements. After the abolition of local corticosteroids, as a rule, there is a temporary aggravation.

When lupoid, or granulomatous, rosacea against the background of erythema, localized mainlyaround the eyes and mouth, densely distributed disseminated brownish-red papules or small knots, with the diascopy of which sometimes reveal yellow-brown spots. Adhering to each other, the papules form an uneven, bumpy surface. A similar clinical picture is identical to Lupus miliaris disseminatus faciei (rosace-like tuberculosis of Lewandowski). According to the polymerase chain reaction in patients with lupoid rosacea, no tubercle bacilli were detected in the granulomas. The question of the identity or difference between lupoid rosacea and rosace-like tuberculosis of Levandovsky remains a debatable topic.

Conglomerate rosacea (rosacea conglobata) develops on the site alreadyexisting rosacea and is characterized by the formation of large globular abscessed nodes and induced fistulas. This aggravation often occurs after taking drugs, which include halogens (iodine, bromine).

Lightning Rosacea (rosacea fulminans) is observed practicallyOnly in young women is the most difficult variant of conglobata rosacea. In the foreign literature this form is described as Pyoderma faciale [G. Plewig et al. 1992; T. Jansen et al. 1993]. The disease begins acutely, the rashes are localized exclusively in the face area, there are no signs of seborrhea. The causes of the lightning-fast rosacea are unknown. The influence of psychoemotional factors, hormonal disorders, pregnancy is supposed. Lightning Rosacea begins suddenly. The general condition suffers insignificantly. However, there may be nervous and mental reactions in the form of depressions and dysphoria, which are caused by the suddenness and severity of the disease.

The primary localization of the rash is the forehead,cheeks, chin. A pronounced edema and erythema of cyanotic red color, papules and pustules, nodes of hemispherical and spherical forms are formed. Inflammatory nodes quickly merge into powerful conglomerates, there is a fluctuation, sinuses and fistulas are formed. Hyperthermia is noted in palpation. Lightning rosacea can be accompanied by the formation of blisters [N. N. Potekaev, 1999].

Histologically, massive clusters are notedneutrophils and eosinophils. Then non-specific reactions are formed, characterized by the presence of lymphohistiocyte infiltrates, epithelioid granules with single cells of foreign bodies, collagen fibers destroyed. When bacteriological study of the contents of pustules and fluctuating nodes is usually detected Staphylococcusepldermidis.

Gram-negative form of rosacea characterized by the formation of numerousfolliculitis. When examining the contents of pustules, gram-negative bacteria are found. Gramnegative folliculitis is a complication of prolonged, irrational therapy of rosacea with antibiotics, mainly tetracycline. There are two types of the gram-negative form of rosacea. The most common 1 type, which is caused by various bacteria Enterobacteriaceae, as well as Pseudomonas aeruginosa, and clinically manifested by small pustuleznymi elements. When 2 type, caused by Proteusmirabilis, edematous papules and nodes are observed.

Rosacea-lymphoidema (solid persistent facial edema, chronic persistent erythema and facial edema, morbigan's disease, morbus Morbihan) - rare, not always diagnose