What are the other Names for this Condition? (Also known as/Synonyms)

• Rosacea, Subtype 2
• Subtype 2 Rosacea

What is Papulopustular Rosacea? (Definition/Background Information)

• Rosacea is a common, benign, and chronic skin disorder that manifests as reddish skin with papules and pustules on the face, especially near the eyes, nose, and mouth. It occurs due to inflammation of the sebaceous glands and pilosebaceous follicles
• Papulopustular Rosacea is a subtype of Rosacea. There are 4 subtypes of rosacea:
  • Subtype 1 Erythematotelangiectatic Rosacea
  • Subtype 2 Papulopustular Rosacea
  • Subtype 3 Phymatous Rosacea
  • Subtype 4 Ocular Rosacea
• Rosacea is more common in women; 75% of the cases are observed in women. The onset of Papulopustular Rosacea may occur during young adulthood; a peak incidence is seen during middle-age
• The cause of Papulopustular Rosacea is generally unknown, but it may be presaged by the presence of acne during adolescence. The condition can also be aggravated by a variety of factors, most importantly by alcohol consumption
• There may be persistent papules and pustules on the face. Sometimes, the skin papules come and go over time (transient papules and pustules). It may resemble the common acne in many individuals
• Papulopustular Rosacea can lead to dry and thickened skin. Since it is a longstanding condition with exacerbation and remission of symptoms over a long period, it can result in severe emotional stress and trauma in some individuals
• Currently, no treatment measures are available for Papulopustular Rosacea that can ensure its cure. However, a lack of treatment can make the condition much worse. A symptomatic management of the condition and avoidance of the aggravating factors is generally practiced
• The prognosis for Papulopustular Rosacea is good with suitable treatment; however, the skin condition can recur. In some, the condition may be difficult to treat, since it may respond variably to treatment

Who gets Papulopustular Rosacea? (Age and Sex Distribution)

• Papulopustular Rosacea is a common skin condition that may affect individuals of any age. However, it is generally seen in adults in the 25-70 years’ age range (commonly onset at age 30 years). A peak incidence is seen around 45 years
• Even though both males and females are affected, it is much more common in females
• Individuals of all racial and ethnic background may be affected. It is more common in fair-skinned individuals than dark-skinned individuals
• Worldwide, no geographical localization has been reported for this skin condition; nevertheless, it is more frequent among  northern Europeans

What are the Risk Factors for Papulopustular Rosacea? (Predisposing Factors)

The following risk factors have been identified for Papulopustular Rosacea:

• Acne during adolescence
• Fair-skinned Caucasians (Europeans, Americans) have a greater risk over Africans and Asians (who are generally darker-skinned)

Factors that increase the severity of the skin findings may include:

• Increased alcohol consumption
• Sun exposure without adequate cover or sun protection
• Exposure to heat such as while working in the kitchen or a factory
• Spicy foods
• Consumption of hot fluids (the condition may become worse around the mouth)
• Emotional stress can also cause flare-ups

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Papulopustular Rosacea? (Etiology)

• Presently, the cause of Papulopustular Rosacea is unknown
• Some studies show that small intestinal bacterial organisms (SIBO) are associated with the condition
• However, rosacea is not an infectious condition that can spread from one individual to another through contact
• Papulopustular Rosacea can occur either after or at the same time with type 1 erythematotelangiectatic rosacea, which causes redness and a presence of prominent blood vessels of affected skin in the facial area

Note: Even though demodex mites (Demodex folliculorum) are frequently present in the skin lesions, there is no evidence that demodex mites cause Papulopustular Rosacea. The human demodex mites are normal resident organisms that are present on the facial sebaceous glands.

What are the Signs and Symptoms of Papulopustular Rosacea?

Papulopustular Rosacea leads to chronic inflammation of the facial sweat glands and hair follicles. The symptoms get better and worse over time. A majority of the individuals have mild signs and symptoms. There are 3 stages of Papulopustular Rosacea progression:

• Stage 1:
  • Redness of the affected skin and
  • Telangiectatic presence of small blood vessels
• Stage 2:
  • Redness of the affected skin,
  • Telangiectatic presence of small blood vessels, and
  • The presence of tiny pustules and papules
• Stage 3:
  • Redness of the affected skin,
  • Telangiectatic presence of small blood vessels,
  • The presence of tiny pustules and papules,
  • The presence of nodules and thickening of skin

It is important to note that the signs and symptoms do not always progress sequentially from stage 1 to stage 3. Sometimes, individuals may have stage 2 to stage 3 as presenting symptoms. In some individuals, various parts of the affected skin may have various stages of the condition.

There are 4 subtypes of rosacea based on the pattern/collection of common signs and symptoms. These include:

• Erythematotelangiectatic rosacea: Vascular form, concerning the blood vessels. There are dilated blood vessels with persistent redness around the face
• Papulopustular Rosacea: It is an inflammatory form, like acne. The papules and pustules occur around the face. These are either persistent or transient (they come and go over time)
• Phymatous rosacea: Growth of excess tissue causing thickening of the skin and lobular overgrowth of the nose. The chin, cheeks, lips, and ears can show similar changes
• Ocular rosacea: Affecting, particularly the eyes and eyelids, causing redness, watering of the eye, itching and blurred vision. The skin around the eye is red and thickened. There may be frequent eye infections

In general, the signs and symptoms of Papulopustular Rosacea may include the following:

• Flushing of face (redness, like blushing) is a very common indicative sign, if it is present with type 1 erythematotelangiectatic rosacea
• The condition can be present symmetrically on both sides of the face
• Formation of multiple papules and pustules on the face (the condition appears like acne)
  • A papule is an area of abnormal skin tissue that is less than 1 cm around. Usually a papule has distinct borders, and it can appear in a variety of shapes
  • A pustule indicates a small bump on the skin that is filled with fluid or pus
• Over a prolonged period, it can result in dry and thick skin
• Papulopustular Rosacea commonly affects the head and neck region; particularly the face, around the eyes, nose, chin, mouth, and forehead. The face may feel a burning and stinging sensation
• Sometimes, even the scalp and chest are affected
• There may be thickened skin on the nose, cheek, and forehead with prominent scaling over time

Depending on where the concentration of skin lesions is observed, rosacea in general is termed the following:

• Rhinophyma, which mainly affects the nose
• Metophyma, which mainly affects the forehead
• Blepharophyma, which mainly affects the eyelids; also, the individual may have conjunctivitis, corneal ulceration, and rosacea keratitis
• Otophyma, which mainly affects the earlobes
• Gnathophyma, which mainly affects the chin

Papulopustular Rosacea can be associated with significant eye signs and symptoms. It is researched that nearly or over 50% of rosacea cases affect the eye (termed ocular rosacea). When the eyes are affected, it can cause conjunctivitis-like symptoms including:

• Itching and redness of the eye
• Eye pain and inflammation
• Gritty feeling of sand-like particles inside the eye
• Continuous discharge of water from the eyes
• Blurred vision
• Sensitivity to light

How is Papulopustular Rosacea Diagnosed?

There is no single test available to definitively diagnose Papulopustular Rosacea. A diagnosis may involve the following tests and procedures:

• A thorough medical history and physical examination
• Dermoscopy: It is a diagnostic tool where a dermatologist examines the skin using a special magnified lens
• Wood’s lamp examination: In this procedure, the healthcare provider examines the skin using ultraviolet light. It is performed to examine the change in skin pigmentation
• Bacterial culture to rule out any bacterial infection
• Blood test may be performed to find the cause of rosacea outbreaks
• Skin biopsy: A skin biopsy is performed and sent to a laboratory for a pathological examination. The pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist may arrive at a diagnosis. On examination of the biopsy sample, the presence of Demodex folliculorum organisms (mites) may be observed

A differential diagnosis for Papulopustular Rosacea may be undertaken to eliminate the following conditions:

• Acne vulgaris
• Perioral dermatitis
• Bacterial infection
• Lupus (systemic lupus erythematosus)
• Seborrheic dermatitis
• Dermatomyositis

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Papulopustular Rosacea?

Papulopustular Rosacea is a chronic and longstanding skin condition. It can result in the following complications:

• Secondary bacterial or fungal infections due to ulceration and bleeding of the lesions
• Scarring of the healed skin lesions
• The presence of skin infections and scarred skin on the face can cause self-image issues (cosmetic concerns), emotional and psychological stress
• Severe stress from chronic Papulopustular Rosacea can lead to depression
• The skin condition may inadvertently get aggravated by a host of common factors, which include anxiety, certain foods, drinks containing caffeine, and heavy exercising
• Recurrence of the condition, even after the signs and symptoms have completely disappeared

How is Papulopustular Rosacea Treated?

Currently, there is no established cure for Papulopustular Rosacea. The treatment depends upon the severity of the signs and symptoms. The treatment provided is to mostly reduce severity of the symptoms, which may involve the following measures:

• Topical creams and antibiotics
• Oral medications such as antibiotics
• In severe cases of resistance to topicals and standard antibiotic treatments, isotretinoin can be used
• Using laser surgery for cosmetic issues
• Protect skin from sun, use sunscreens, wide-brimmed hats, protective clothing, etc.
• Follow-up care with regular screening and checkups are important

Note: Topical applications and oral medications containing steroids are known to make the condition worse.

How can Papulopustular Rosacea be Prevented?

Currently, there are no known methods available to prevent Papulopustular Rosacea occurrence. However, controlling the following factors may help prevent it from getting worse (i.e., prevent flare ups):

• Reducing or eliminating alcohol consumption is the most important preventative factor
• Exercise
• Stress and anxiety: Learn stress-reduction techniques. Talking to one’s healthcare provider about suitable options or seeking qualified counseling may be helpful
• Avoid caffeinated drinks
• Avoid use of topical or oral steroids, nasal steroid sprays
• Avoid foods containing high levels of histamines, such as pickled foods, canned foods, certain cheese varieties, smoked meat, shellfish, beans and pulses, including certain nuts (cashew, almonds)
• Avoidance of spicy foods and hot liquids
• Cosmetic procedures, such as chemical peels and microdermabrasion can make rosacea flare. These procedures are often used to treat wrinkles and acne
• Avoid prolonged and chronic exposure to the sun
• Avoid excessive sunbathing, use of tanning beds, sun lamps, and chemical agents which accelerate tanning
• Avoid exposure to excess heat, such as in a home or industrial setting

Note: Keeping a journal as to what triggers the condition may help identify issues and possibly help in prevent severe forms of Papulopustular Rosacea in the future.

What is the Prognosis of Papulopustular Rosacea? (Outcomes/Resolutions)

• The prognosis for Papulopustular Rosacea is good with appropriate treatment. The condition can be longstanding and cause emotional stress and depression in the affected individual
• The condition can also recur, even after complete resolution following treatment. Many researchers believe that it is a lifelong disease
• In some cases, the signs and symptoms disappear even without treatment
• In some cases, Papulopustular Rosacea does not respond to many treatment measures. This can worsen the prognosis

Additional and Relevant Useful Information for Papulopustular Rosacea:

• Even though alcohol makes the condition worse; not all individuals with severe forms of the disorder are known to consume alcohol
• Cleaning the skin too hard with strong chemicals or soaps may aggravate the skin condition. Care must be taken avoid strong soaps and chemicals that could potentially worsen the condition
• The presence of dirt on the body is not a causative factor for the condition. However, it helps to be clean and hygienic, which may help the condition from getting worse