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Ruling out Photosensitivity diseases from Rosacea

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"When a patient presents with a rash on sun-exposed areas, a thorough history must be taken that includes exposure to sunlight, use of medication, and prior personal and family history of manifestations of dermatologic disease.  The dermatologic examination further delineates the photosensitive dermatosis. Correctly diagnosing the specific condition associated with a photosensitive rash makes it possible to provide adequate treatment and, depending on the diagnosis, avoid future outbreaks. Clinicians must be aware of the spectrum of photosensitivity diseases because these conditions are common and can be associated with systemic diseases, although they are rarely life-threatening."

Photosensitivity diseases: a review of sun-exposed skin rashes, by Young Moon; Danielle Brown; Maura Holcomb, MD
June 08, 2017, Clinical Advisor

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Here is a partial list of photosensitivity diseases to rule out with rosacea: 

Photosensitivity refers to various symptoms, diseases and conditions (photodermatoses) caused or exacerbated by exposure to sunlight. It is classified into the following groups: Primary photodermatoses: Polymorphic light eruption. Juvenile spring eruption. Actinic folliculitis. Actinic prurigo. Solar urticaria. Chronic actinic/photosensitivity dermatitis. Hydroa vacciniforme (associated with Epstein-Barr virus). Exogenous photodermatoses: Drug-induced photosensitivity: common photosensitising drugs are thiazides, tetracyclines, non-steroidal anti-inflammatory drugs (NSAIDs), phenothiazines, voriconazole, quinine, vemurafenib. Photocontact dermatitis: due to phototoxic chemicals such as psoralens in plants, vegetables, fruit; fragrances in cosmetics; sunscreen chemicals; dyes and disinfectants. Pseudoporphyria: induced by drugs and/or renal insufficiency. Photoexacerbated dermatoses: Lupus erythematosus. Dermatomyositis. Darier disease. Rosacea. Pemphigus vulgaris. Pemphigus foliaceus. Atopic dermatitis. Psoriasis. Metabolic photodermatoses (rare): Porphyria cutanea tarda. Erythropoietic protoporphyria. Variegate porphyria. Erythropoietic porphyria (Gunther disease). Genetic photodermatoses (very rare): Xeroderma pigmentosum. Bloom syndrome. Rothmund Thomson syndrome. Cockayne syndrome.

Oakley A, James W.
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2017-.
2017 Feb 7., Copyright © 2017, StatPearls Publishing LLC.

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Telangiectatic Photoaging 

"Telangiectatic photoaging is characterized by less transient and nontransient erythema, a more lateral distribution of erythema and telangiectasia, less neurogenic mast cell activation, and less MMP-mediated matrix remodeling than ETR. These data demonstrate that TP is a distinct clinical entity from ETR that can be distinguished on the basis of clinical, histologic, and gene expression findings."

JAMA Dermatol. 2015;151(8):825-836. doi:10.1001/jamadermatol.2014.4728
Clinical, Histologic, and Molecular Analysis of Differences Between Erythematotelangiectatic Rosacea and Telangiectatic Photoaging
Yolanda R. Helfrich, MD; Lisa E. Maier, MD; Yilei Cui, PhD; et al

JAMA Dermatol. 2015 Aug;151(8):825-36. doi: 10.1001/jamadermatol.2014.4728.
Clinical, Histologic, and Molecular Analysis of Differences Between Erythematotelangiectatic Rosacea and Telangiectatic Photoaging.
Helfrich YR, Maier LE, Cui Y, Fisher GJ, Chubb H, Fligiel S, Sachs D, Varani J, Voorhees J.

JK Wilkin has a comment on the above article published in JAMA and another in the NEJM

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"In this case report, we detail the response of a 37-year-old Caucasian man with an overlap of erythematotelangiectatic rosacea and telangiectatic photoaging to brimonidine tartrate gel. With the application of brimonidine only on half of his face, skin analysis images, clinician's and patient's assessment showed that there was significant improvement in the erythema. This case has lent insight into how brimonidine can be used to assess the extent of photoaging by eliminating the erythema of rosacea to some degree. We propose that it can be used as a non-invasive test to differentiate between the two conditions, sparing patients from skin biopsies and molecular analysis."

Australas J Dermatol. 2017 Feb;58(1):63-64. doi: 10.1111/ajd.12430. Epub 2016 Jan 13.
Rosacea or photodamaged skin? Use of brimonidine gel in differentiating erythema in the two conditions.
Oon HH, Lim ZV.

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