Off-site rosacea: Presentation on scalp, back, chest less frequent; occurs more often in men

Key Points

"Rosacea of the back and chest are less frequently diagnosed than facial rosacea," he says.

It is more common in men in those areas than it is in women. For the most part, the men who complain of rosacea of the scalp are bald or have very thin hair on top.

Presentation

Symptoms include an itchy, burning and tingling feeling. Patients often think breakouts are caused by acne.

"Rosacea on the back and chest is sometimes an incidental finding. Rosacea on the chest and back is more common in men, and they commonly think it is just a little bit of acne.

"The décolletage of chest gets burned red and brown over time from sun exposure, and if male patients have a little bit of rosacea, they think it is sun damage," Dr. Werschler says.

Rosacea can be seen on the chest and backs in women, too. Of the four major subtypes of rosacea, different variations occur on different parts of the body. For example, on the upper forehead/scalp, blushing and flushing are commonly seen, he says. Pimples may appear on the chest.

"We approach management globally - targeting the worst area first," he says. "If the worst area is the scalp and we think that will require topical and oral therapy, that is what we do."

1-2-3 punch

The same products can be used to treat rosacea of the chest, back and scalp as are used to manage rosacea on the face.

According to Dr. Werschler, the 1-2-3 approach to rosacea management is effective. Step 1 is education on the disease state.

"The patient learns what the triggers are - spicy foods, fruit and veggies, sun exposure, alcohol - and can practice avoidance therapy," Dr. Werschler tells Dermatology Times.

Step 2 includes topical therapy. "The most common topical is metronidazole, which can be used on the scalp if the patient is bald, and these products also can be used on the chest and back.

"The second most common category is the sulfur and sodium sulfacetamide products, which are helpful as an anti-inflammatory," he says.

These products can be used anywhere on the body, and they tend to not stain clothing, which is a consideration for the chest and back.

"The sulfurs also come in washes and soaps. If there is some hair in the area, you could use one of the cleansers to wash the scalp, and that works well, too. Antiseborrheic shampoos can also be used," Dr. Werschler says.

Step 3 is oral therapy. "Today we usually use Oracea (doxycycline, Galderma). There are still a lot of tetracycline and minocycline products used, and they all work very well, but we try to use Oracea, because the low-dose, 24-hour timed-release pill of doxycycline never goes above that level which affects bacteria, so it is truly an anti-inflammatory product," he says.

In addition, for patients who exhibit blushing and flushing of the chest, face and scalp, Dr. Werschler uses non-sedating antihistamines, such as Zyrtec (Pfizer), which works well in some cases.

Other treatments

Lasers - most commonly, the pulsed-dye category - are typically used for the redness and dilated veins of rosacea.

"They are very effective for treating redness, and that includes the scalp," Dr. Werschler says.

"For example, one patient came in saying that everyone says he has sunburn on his scalp and he was tired of hearing that. We used the pulsed-dye therapy on his bald frontal scalp, and in a couple of treatments, the redness went away and he was satisfied," he says.

Current treatments for rosacea that occurs off the face are similar to those used for facial rosacea. These usually are effective and provide the patient with relief of symptoms, he says.

If the patient has rosacea of the face, the dermatologist can ask questions regarding the chest, back and scalp and also look for signs as well, Dr. Werschler says.

Disclosure: Dr. Werschler is a consultant, investigator and speaker for Galderma.