Neurogenic Rosacea Treatment: A Literature Review

June 2023 | Volume 22 | Issue 6 | 566 | Copyright © June 2023


Published online May 23, 2023

doi:10.36849/JDD.7181  

Mirjana G. Ivanic BAa, Aislyn Oulee BSb, Alexandra Norden BAc, Sogol S. Javadi BSd, Michael H. Gold MDe, Jashin J. Wu MDf

aMeharry Medical College School of Medicine, Nashville, TN
bUniversity of California Riverside School of Medicine, Riverside, CA
cHofstra University Zucker School of Medicine, Hempstead, NY
dDavid Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
eGold Skin Care Center, Tennessee Clinical Research Center, Nashville, TN
fDepartment of Dermatology, University of Miami Miller School of Medicine, Miami, FL

Abstract
Rosacea is a chronic skin disorder involving central facial erythema secondary to vascular instability and cutaneous inflammation. Rosacea is divided into different subtypes based on the morphology of the rash — erythematotelangiectatic, papulopustular, phymatous, and ocular rosacea. A less-known subtype called neurogenic rosacea has been proposed to categorize patients suffering from rosacea with erythematous flushing and burning sensation that is refractory to traditional treatment. There is minimal data on this subgroup of rosacea patients and its potential treatment options. This review aims to explore current medical literature to define characteristics of neurogenic rosacea and its management. We performed a systematic search of PubMed database and identified 6 articles meeting inclusion criteria with a total of 37 patients with suspected neurogenic rosacea. Combination treatments with topicals (eg, metronidazole, brimonidine), as well as oral medications including vascular (eg, beta blockers), psychiatric (eg, diazepam, duloxetine), neurologic (eg, pregabalin, sumatriptan), and antibiotic agents (eg, rifaximin), were often cited to have better outcomes, but this finding was highly variable between patients. There were isolated reports of effective management with onabotulinumtoxinA intradermal injections and endoscopic thoracic sympathectomy treatment. Current literature supports selecting agents aimed at treating the major symptom pattern (eg, erythema, telangiectasias, burning sensation).


Neurogenic rosacea treatment: a literature review.
Ivanic MG, Oulee A, Norden A, et al. J Drugs Dermatol. 2023;22(6):566-571. doi:10.36849/JDD.7181
 

INTRODUCTION

Rosacea is a chronic inflammatory cutaneous vascular disorder involving the central nervous system that presents various signs and symptoms, including central facial erythema, flushing, edema, papulopustular lesions, and telangiectasias.1 It affects approximately 16 million people in the United States, with individuals with fair sun-sensitive skin (skin phototypes I and II) being at the greatest risk for developing this condition2; however, it is also underdiagnosed in patients with skin of color because of clinicians' poor ability to detect erythema in darker skin individuals.3 Although the pathogenesis of rosacea is unknown, it is hypothesized to be multifactorial, involving both genetic and environmental factors that result in the dysfunction of both nervous and vascular elements.4 It has been speculated that the vasodilation, increase in cutaneous blood flow, and thermal hypersensitivity seen in individuals with rosacea may be explained by stimulation of transient receptor potential (TRP) receptors and release of neuropeptides in response to chemical, mechanical, and thermal stimuli.1

Rosacea has been traditionally divided into 4 subtypes – "classic type" erythematotelangiectatic (ETR), papulopustular (PPR), phymatous, and ocular rosacea5 although patients can present with overlapping phenotypes. ETR is characterized by flushing episodes persisting for greater than 10 minutes, and it is frequently associated with burning and stinging. PPR involves central facial redness with small papules topped with pustules. Phymatous rosacea describes skin thickening and irregular surface nodularities, often involving the nose (rhinophyma), chin (gnathophyma), and forehead (metophyma).5 Ocular rosacea includes eye erythema, pruritus, burning, and photophobia.6 

Neurogenic rosacea is a recently proposed new subtype that describes rosacea patients who have prominent and debilitating neurologic and neuropsychiatric symptoms.5  There is no professional consensus on the definition for neurogenic rosacea and it has yet to be further elucidated. The common denominator for patients with neurogenic rosacea is the experience of neuronal rosacea symptoms (eg, burning and 
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