Derm: Rosacea: Free MSRA Podcast

🎧 MSRA Deep Dive: Rosacea – High-Yield Revision Essentials
A focused, exam-oriented breakdown of rosacea: features, subtypes, triggers, management, and complications – perfect for your MSRA prep.

🧠 Core Learning Points

📌 Definition
• Chronic inflammatory skin condition
• Affects the central face – redness, flushing, visible vessels, papules, pustules
• May include eye involvement or rhinophyma

📌 Subtypes & 2016 Classification
• Papulopustular – spots + redness
• Erythematotelangiectatic – flushing + telangiectasia
• Phymatous – skin thickening (e.g. rhinophyma)
• Ocular rosacea – dry, gritty, irritated eyes
• Uses ARSCO criteria: diagnostic, major & secondary features

📌 Causes & Triggers
• Multifactorial: genetics, immune dysfunction, Demodex mites
• Triggers include:
– UV exposure ☀️
– Stress 😥
– Alcohol 🍷
– Spicy food 🌶️
– Temperature extremes 🔥❄️
– Caffeine, vasodilator meds
🧠 Mnemonic: SHAUVES – Stress, Heat, Alcohol, UV, Vasodilators, Exercise, Spices

📌 Risk Factors
• Fair-skinned women aged 30–60
• Family history
• High UV exposure
• Triggering lifestyle habits

📌 Pathophysiology
• Chronic cutaneous inflammation + vasodilation
• Immune dysregulation → redness, bumps, sensitivity
• Trigger exposure → flare-up cycle

📌 Differentials
• Acne vulgaris – but rosacea skin is dry/sensitive
• Seborrhoeic dermatitis
• SLE (malar rash)
• Perioral/contact dermatitis
🧠 Dry skin + central facial redness = think rosacea

📌 Epidemiology & Diagnosis
• ~10% in UK (underdiagnosed)
• Diagnosis is clinical – ≥3 months of symptoms
• Consider biopsy/bloods if unclear or atypical features

📌 Clinical Features
• Persistent central redness, flushing, telangiectasia
• Papules/pustules, nodules, dry/burning/stinging skin
• Ocular signs – blepharitis, keratitis
• Severe swelling: Morbihan disease
• Nasal thickening: Rhinophyma

📌 Management (NICE/CKS aligned)

🧴 Lifestyle
• Avoid triggers (heat, alcohol, sun)
• Gentle skincare
• Daily SPF – oil-free sunscreen
🚫 Avoid topical steroids on the face

💊 Topical treatments
• Metronidazole, azelaic acid, ivermectin
• Brimonidine/oxymetazoline – reduce flushing

💊 Oral treatments
• Tetracyclines – doxycycline (anti-inflammatory dose)
• Low-dose isotretinoin – severe cases
• Consider clonidine/carvedilol for flushing

👁️ Ocular rosacea
• Lid hygiene, artificial tears, oral tetracyclines
• Avoid retinoids/steroids

💡 Other treatments
• Laser/IPL – telangiectasia
• Referral – derm (severe/rhinophyma), ophthal (ocular)
• Surgery/laser – for advanced phymatous cases

📌 Prognosis & Complications
• Chronic, relapsing – flares + remissions
• Trigger avoidance & early treatment key
• Complications:
– Ocular damage (if untreated)
– Rhinophyma (physical disfigurement)
– Psychosocial impact – anxiety, distress, low self-esteem

📎 More Free M

Episode Transcript

(00:00):
Welcome back to the Deep Dive. Today we're tackling something
you'll definitely see a lot and it's super high yield.
If you're prepping for exams like the MSRA, we've got some
revision notes here all focused on rosacea.
Our plan? Basically pull out the absolute
key things you need to know fromthese sources, give you a really
focused overview. Exactly.
Rosacea, yeah. It's more than just, you know, a

(00:21):
bit of redness. It's chronic.
It has specific features, specific ways to manage it that
you really need to get your headaround.
So yeah, we'll walk through the essentials from these sources.
Cut through the fluff. Get straight to the core facts.
OK, so rosacea. Let's unpack it point by point
based on what we've got here. First off, the definition, what
is rosacea? Fundamentally, the sources

(00:42):
consistently call it a chronic inflammatory skin condition,
mostly affecting the face. Yeah, and that chronic
inflammatory bit is crucial. It's not just blushing that goes
away. The key features to look for
based on this material are that persistent redness, the flushing
episodes, those tiny visible blood vessels.
Talenticacious. Talentic Tasius.
Exactly. Yeah, and often papules and

(01:04):
pustules, bumps and spots. It's a long term thing.
And it doesn't always look the same, does it?
The sources mention different subtypes.
That seems pretty important for figuring things out.
Absolutely critical. So you've got the papular
posterior type, that's redness with the papules and pustules.
Then Arrington, the total angiotactic bit of a mouthful.
That's mainly the flushing, the persistent central redness and

(01:26):
those visible vessels. They think femadas less common,
but you need to know it. That's where the skin thickens
up, gets nodular. Think rhinophyma.
Rhinophyma, the classic nose changes.
Precisely, though that's usuallyan advanced stage.
And don't forget ocular rosacea.It affects the eyes, dryness,
itching, gritty feeling, blurredvision, sometimes even inflamed

(01:46):
eyelids, Blepharitis or the cornea keratitis.
Oh, and there's a granulomatous type mention too.
Less common. Wow, OK.
Lots of possibilities. The sources also bring up an
updated classification from 2016.
Why does that matter for revision?
Well, it helps structure how youassess clinically.
It's linked to these are scope panel criteria sometimes
mentioned instead of just subtypes.
It looks for diagnostic featureslike persistent redness in the

(02:09):
centre of the face or those feminist changes.
If you see those, that is rosacea, then you have major
features, flushing spots, vessels, eye signs and secondary
ones like burning, stinging, swelling, dryness.
The point is diagnosis isn't random.
It's about spotting these patterns, these phenotypes.
Got it. So pattern recognition.

(02:30):
OK, we know what it is, how it looks.
But why does it happen? The sources say the exact cause
is, well, murky, multifactorial.Right, no single smoking gun.
It seems to be a mix. Genetics definitely play a role.
You often see it run in families, yeah.
Then there are issues with the skin's immune response being a
bit off, and the blood vessels themselves seem overreactive.
And yes, Demodex mites get a mention.

(02:51):
Demodex mites those tiny things on our skin.
Yep. Everyone has them, but maybe in
rosacea they trigger an immune response, contributing to the
inflammation. It's part of that complex
picture. Beyond the biology, there's a
whole list of triggers, things that make it flare up.
Yeah, this sounds super practical for patient advice.
Oh. Totally.
This is high yield for you and for patients.

(03:12):
The list includes things like age, being photosensitive, UV
exposure, so sun, smoking, big temperature swings, spicy foods,
alcohol, stress, even heavy exercise and some medications.
So knowing these is gold dust for managing it.
Definitely, and specifically forflushing the sources narrow it
down. Heat, sudden temperature
changes, alcohol, caffeine, spicy food, stress, sun, wind,

(03:35):
and vasodilator meds. Knowing that list helps you ask
the right questions. OK, it leads us nicely to risk
factors. Who's more likely to actually
get rosacea? Key things to look for.
Fair skin is a big one, especially if there's a family
history. It's more common in women,
typically showing up between 30 and 50.
Lots of sun exposure is another risk factor, which ties back to
the UV trigger. And yet those triggers again,

(03:58):
regularly consuming hot drinks, spicy foods, alcohol.
They're listed as risk factors too.
Right, so fair skinned woman, maybe 40s complaining of
flushing rosacea should be high on your list.
Exactly helps you build that differential diagnosis list.
Let's go a bit deeper. The pathophysiology.
How does it actually work? OK, so the core problem is this
chronic inflammation in the skin.

(04:19):
The blood vessels dilate way toomuch abnormal vasodilation and
the skin's immune system isn't functioning quite right.
Think of it like the skin's thermostatin defence system
being overly sensitive. So when those triggers hit sun,
stress, spice, whatever, they kick off this immune response in
the skin that releases inflammatory chemicals which

(04:40):
then make the blood vessels widen dramatically.
It becomes this cycle trigger immune response, inflammation,
vasodilation, leading to the redness and bumps you see.
It's that chronic loop. OK, explains why avoiding
triggers is so fundamental now. Facial redness.
It isn't always rosacea, is it? What else should be on our
minds? The differentials.
Absolutely critical. You got to rule out other

(05:01):
things. Acne vulgaris is a big one,
especially if there are papules and pustules.
Also seborrheic dermatitis, Lupus, particularly the facial
rash, the butterfly rash, contact dermatitis and perioral
dermatitis. And there's a useful clue to
tell it apart from acne. Yes, a really helpful point.
Rosacea skin usually isn't greasy like typical acne.
It might actually feel quite dryor sensitive.

(05:22):
That's a key differentiator. So imagine a case the patient
has facial spots, redness but reports dry skin that steers you
away from classic acne, maybe towards rosacea or possibly
seborrheic dermatitis. Good tip.
What about how common it is epidemiology, especially in the
UK? It's pretty common.
The sources suggest around one in 10 people in the UK might

(05:43):
have it. It's much more frequent in fair
skinned individuals, particularly those with Celtic
or Northern European backgrounds.
And like we said, about three times more common in women
typically hitting that 30 to 60 age bracket.
Oh. And an important diagnostic
point from the sources that persistent central facial
redness needs to have been therefor at least three months.
Three months duration. OK, so let's paint a picture.

(06:05):
What are the actual clinical features?
What does it look and feel like?Well, the main thing is that
persistent redness on the face combined with the flushing
episodes and those visible telangiectasius.
But patients often report more the papules, pustules, sometimes
deeper lumps called inflammatorynodules.
They might feel burning or stinging skin dryness.
Of course, the eye symptoms we mentioned ocular rosacea.

(06:27):
And it tends to evolve, right? It doesn't just appear fully
formed. Usually, yeah, might start
subtly, maybe just occasional flushing triggered by certain
things. Then over time that can become
more constant redness, the little vessels become more
obvious. Some people also mentioned that
gritty feeling in their eyes, oreven some facial swelling,
edoema. Other things you might see
prominent oil glands that nasal enlargement, rhinophyma.

(06:49):
In advanced cases, something swelling around the eyes,
periorbital edoema. The sources summarise the key
things to look for central face involvement, the flushing,
persistent redness with spots, bumps, telangiectasia, sensitive
skin, sometimes dry scaling skincalled rosacea dermatitis and
that rare severe swelling more behind disease.
More behind disease, right? The severe edoema and triggers

(07:11):
make all this worse. You mentioned blepharitis, again
with the eye stuff. Shows how linked it all is.
Exactly. And it's progressive, but the
severity is hugely variable. Some people just have mild
flushing, others get really significant changes.
OK. So with all these signs, what
tests do we actually need? Investigations.
This is a key point for exams. Diagnosis is overwhelmingly

(07:32):
clinical based on history and what you see.
No specific lab test confirms rosacea itself.
Now you might do tests, but usually it's to rule out other
conditions if the picture isn't clear.
Maybe a skin biopsy if you're really unsure.
Hatch tests for allergies. Blood tests if you suspect
lupus. But most times, history
examination, identifying triggers, that's enough.

(07:53):
So biopsies are only for uncertainty.
Pretty much, yeah, not routine and thinking about those ARSCO
criteria, diagnostic major, secondary features, that is your
structured assessment. It's clinical reasoning.
Right then the crucial bit management.
How do we treat it? Thinking about guidelines like
NICE CKS or general NHS approaches.
OK, the goals are simple. Control the symptoms, calm down

(08:16):
the inflammation and stop it getting worse.
And the first step isn't necessarily medication.
Absolutely not. Lifestyle advice is paramount.
Identifying and avoiding personal triggers is #1 whether
it's spicy food, alcohol, heat stress, using gentle water based
cosmetics. A huge don't is using topical
steroids on the face. Big no no can make it worse and

(08:37):
daily high factor. Ideally oil free sunscreen non
negotiable because of the UV link.
OK, essential baseline advice then.
What about treatments? For mild stuff, topicals are
first line. Metronidazole cream or gel is
common for the papules and pustules.
Azelaic acid is another good option if flushing is the main
issue. Topical bromonidine or

(08:58):
oxymetasoline can temporarily shrink the blood vessels and
reduce redness, and topical iiformectin is particularly good
for the papulopuscular type. May be linked to those Demodex
mics. What if it's more severe or
topicals aren't enough? Then you step up to oral
antibiotics, usually tetracyclines like doxycycline
or Minocycline. They work mainly for their
anti-inflammatory effect here. For really tough cases other

(09:20):
oral meds might be tried and lowdose.
Oral isotretamoin is an option for severe resistant rosacea but
comes with significant side effects and strict prescribing
rules. For really bad flushing, things
like Clonidine or carvedilol might be considered.
Other anti inflammatories like oral diclofenac or toppable
calcerin inhibitors, tacrolimus,pymacrolimus are also sometimes

(09:43):
used. And managing ocular rosacea
specifically. Yeah, that needs dedicated
attention. Lid hygiene is key.
Gentle cleaning, warm compresses, lots of artificial
tears for dryness. Systemic tetracyclines often
help here too. For the inflammation, definitely
avoid retinoids which can worsendry eye and stop any facial
topical steroids. Are there other non medication
treatments available? Yes, lasers or IPL are good for

(10:06):
the cholangitacious, the visiblevessels.
Cosmetic camouflage can help hide redness and referrals
important to dermatology, ophthalmology, maybe plastics if
needed for severe cases, diagnostic uncertainty or things
like rhinophyma or bad eye symptoms.
And for those physical procedures, vascular lasers,
IPL, diathermy, sclerotherapy, cautery for telangiectasia for

(10:29):
the spots maybe radiofrequency or laser and rhinophyma usually
needs referral for things like laser reshaping, surgical
excision or electric cautery. Right, a whole toolkit depending
on the specific problem. What's the general outlook?
Prognosis. Generally it's decent with good
management and trigger avoidance.
But, and this is a big but, it is chronic.
People will have flares and remissions.

(10:50):
It waxes and wanes treatment, control symptoms, prevents
complications. Getting onto it early and
sticking with the plan makes a big difference.
But progression can happen and relapse is pretty common.
Definitely relapse is expected and why rare severe forms exist
and rhinophyma is that classic example of progression.
The positive note is that treatments for rhinophyma

(11:10):
usually work well and patients are often happy with the results
despite how it looked before. Lastly, complications.
What are the potential impacts beyond the skin itself?
This is really important. The impact on quality of life
can be huge. The visible nature, the
unpredictability it causes real emotional distress, social
anxiety, low self esteem. The ocular side can lead to

(11:31):
chronic irritation and if severepotentially vision problems.
And rhinophine is obviously a major physical complication if
it develops. Yeah, that really highlights why
good management and support are so vital.
It's not just cause asthmatic. OK, so that was a pretty deep
dive into rosacea. Guided by those revision
sources, we've covered the definition, the types, causes,

(11:51):
risks, the mechanisms, differentials, how common it is,
what it looks like, investigations, a whole range of
management options, and the prognosis and complications.
Yeah. Hopefully that pulls out the
really high yield stuff for you,whether it's for MSRA Prep or
just seeing patients. Key things to remember It's
chronic triggers are crucial andmanagement needs tailoring to

(12:11):
this specific presentation, the phenotype.
And maybe something to think about, given how much this
effects people's lives, maybe the most powerful thing you can
do is really partner with them to nail down their specific
triggers. Could that be even more
impactful than the prescription pad sometimes?
Just a thought. Absolutely.
So this deep dive was about extracting those revision

(12:32):
essentials for you. And if you're looking for more
resources. For more free MSRI revision
resources, you can always visit freesra.com.
And for the full Premium Revision Toolkit, check out Pass
Them sra.com. That's us for this deep dive.
Keep exploring, keep learning.