La rosacée

Zitouni Imounachen 14/02/2024 307

IntroductionLa rosacée est une dermatose inflammatoire chronique qui affecte la partie centrale et convexe du visage : les joues, le nez, le front ainsi que les yeux. Les lésions cutanées comprennent un érythème facial persistant, des papules, des pustules, des télangiectasies, des flushs avec atteinte oculaire et dans les formes sévères un rhinophyma. Son évolution

Introduction
La rosacée est une dermatose inflammatoire chronique qui affecte la partie centrale et convexe du visage : les joues, le nez, le front ainsi que les yeux. Les lésions cutanées comprennent un érythème facial persistant, des papules, des pustules, des télangiectasies, des flushs avec atteinte oculaire et dans les formes sévères un rhinophyma. Son évolution est caractérisée par des rémissions et des exacerbations. La rosacée retentit de façon importante sur le psychisme et sur la qualité de vie.
La rosacée survient fréquemment après l’âge de 30 ans, avec un pic à 50 ans, mais elle peut apparaître à tout âge. Sa prévalence varie de 1 à 20 % selon les séries. Dans une étude récente, elle a été estimée à 5,5 % chez les adultes.
Elle prédomine chez les femmes, mais les formes les plus sévères (rhinophyma) sont l’apanage des hommes. Dans des études plus récentes, la prévalence calculée était comparable pour les deux sexes.

Les différentes formes de rosacée
La forme vasculaire ou couperose
C’ est, de loin, la forme la plus fréquente.
La rougeur ou érythrose est l’ élément le plus caractéristique de la rosacée et, c’ est en tout cas, le motif de consultation le plus courant. Cette sensation de visage rouge est particulière car l’ atteinte se concentre principalement au centre du visage en épargnant le pourtour des yeux et celui de la bouche.
En revanche, les joues, le nez, le milieu du front et le menton sont concernés.
Au microscope, on s’ aperçoit que la peau est très œdémateuse, que les cellules de l’ épiderme sont disjointes et que les vaisseaux du derme sont irréguliers et dilatés.
Dans cette forme, la rougeur est accompagnée d’ une sensibilité exacerbée de la peau qui rend difficile l’ application de cosmétiques. Cette intolérance concerne même parfois le savon et l’ eau. Cette sensibilité de la peau correspond à un nombre élevé de terminaisons nerveuses dans la partie profonde la peau et à la présence d’ une substance appelée « substance P » présente localement et dans le sang. Cette molécule sécrétée par les cellules nerveuses est responsable d’ une inflammation locale. Après traitement par le laser, le nombre des terminaisons nerveuses diminue de façon importante.
La coloration de la peau peut être associée au développement de petits vaisseaux très fins, très rouges et parfois même violacés définissant la couperose. Ils sont visibles juste sous la surface de la peau, il s’agit de télangiectasies. Cette forme s’ accompagne fréquemment de manifestations à type de bouffées de chaleur (flushes) qui surviennent dans des circonstances très évocatrices telles que lors de l’ ingestion d’ aliments chauds ou épicés ou de la prise d’ alcool. Le visage et parfois le cou deviennent très rouges avec une désagréable impression de chaleur.
Un œdème (gonflement) du centre du visage est parfois visible. La peau peut avoir un aspect sec avec desquamations.
Autre signe fréquemment associé (chez un malade sur trois), les brûlures oculaires avec une sensation permanente de grain de sable dans l’ œil appelé rosacée oculaire.

La rosacée oculaire
30 à 50% des rosacées s’ accompagnent d’ une atteinte oculaire. Elle peut précéder de plusieurs années la forme cutanée de la rosacée. Elle serait due au dysfonctionnement des glandes de Meibomius qui contribuent à la lubrification des yeux : ce sont des petites glandes présentes le long des paupières et qui secrètent une substance huileuse).
La rosacée oculaire se présente sous forme de conjonctivite, blépharite, kératite, chalazions, télangiectasies des paupières, hyperhémie conjonctivale (œil rouge), irrégularités visibles du bord des paupières.
Les symptômes très inconfortables sont : sécheresse avec sensation de corps étranger ou de sable dans les yeux, brûlures, vision trouble, hypersensibilité à la lumière (photophobie).
Un avis médical spécialisé ophtalmologue est nécessaire.

La forme papulo-pustuleuse
Sur ce fond de rougeur du visage, peuvent apparaître des papules mais surtout des pustules, qui ressemblent à des lésions d’ acné.
Les papules sont des élévations de la peau, rouges, fermes et parfois douloureuses qui mesurent de un à quatre millimètres. Elles sont entourées d’ une auréole inflammatoire et peuvent apparaître spontanément sur fond de rougeur du centre du visage. Elles expriment parfois l’ invasion de la glande sébacée par un parasite, présent habituellement dans le follicule et appelé Demodex Folliculorum.
A ce stade, l’ atteinte du follicule pilo-sébacée est superficielle, mais elle peut évoluer vers le stade de pustule.
Les pustules ont une taille souvent inférieure à celle des papules, elles peuvent se développer en dehors de tout contexte infectieux. Ces éruptions évoluent par poussées qui s’ améliorent le plus souvent spontanément : la rougeur persiste, mais les lésions pustuleuses et papuleuses régressent. Si ce n’ est pas le cas, les traitements peuvent aider efficacement au retour à la normale.
Au début peu nombreuses, le nombre des papules et pustules s’ aggrave habituellement progressivement au cours des poussées ultérieures. Les poussées au début espacées se rapprochent au fils des mois ou années.

La forme hypertrophique
C’ est la forme la plus rare qui concerne moins de 5% des patients souffrant de rosacée avec une très grande prédominance masculine. Classiquement, elle se traduit par :

  • un aspect rouge et soufflé de la pointe du nez ; qui peut avoir un effet très négatif sur le moral et l’ image corporelle.
  • un épaississement de la peau et une dilatation des orifices des glandes sébacées de cette région du visage.
  • des protubérances charnues très disgracieuses.
    C’ est ce qu’ on appelle le rhinophyma : cette forme, plus que les autres, a des répercussions psychologiques importantes.
    Le préjudice esthétique est tel que le rhinophyma est considéré comme une complication majeure de la rosacée. L’ épaississement cutané est parfois également associé à des papulo-pustules et peut s’ étendre au reste du visage.

La forme compliquée rare à type de pyoderma facial ou rosacée fulminans
Cette forme exceptionnelle débute chez les femmes de 30 à 40 ans parfois au cours de la grossesse, de la maladie de Crohn, ou d’ un traitement par interferon alfa. Les pustules sont très nombreuses et douloureuses et les lésions peuvent être nodulaires et défigurantes. Une hyperséborrhée associée est parfois possible (peau grasse).

Les causes de la rosacée
Les mécanismes de survenue de la rosacée sont, aujourd’hui encore, assez mystérieux et l’ on ne connaît pas la cause de cette maladie.
Parmi les certitudes des scientifiques :

  • Une origine vasculaire de la maladie : une anomalie de « shunts » avec « hyperéactivité » des vaisseaux du visage. Les vaisseaux sanguins seraient porteurs d’ une anomalie de fonctionnement. Dans le cas de la rosacée, il existe parfois un dysfonctionnement de ces veines qui se traduit par une stagnation du sang dans les vaisseaux de la face, entraînant en cascade la dilatation des vaisseaux, l’ œdème et l’ altération de l’ endothélium, fine membrane qui recouvre l’ intérieur des veines du visage.
  • La Prédisposition génétique : l’ anomalie se rencontre surtout chez les sujets de type nordique à peau claire, yeux clairs et cheveux clairs.
  • Le rôle du Demodex Folliculorum, et de certaines bactéries retrouvées en grand nombre sur le visage des patients atteints. Le Demodex est retrouvé également dans la dermite péri-orale et post corticoïdes, ainsi que dans les blépharites (atteinte des paupières en bordure des cils). Il agit comme un agent pro-inflammatoire (favorise l’ inflammation) dans la rosacée.

Diagnostic
Le diagnostic de la rosacée repose sur l’aspect caractéristique; il n’existe pas de tests diagnostiques spécifiques. L’âge d’apparition et l’absence de comédons permettent de distinguer l’acné de la rosacée.
Le diagnostic différentiel de rosacée se posera avec l’acné vulgaire, le lupus érythémateux disséminé, la sarcoïdose, les photodermatites et les éruptions médicamenteuses (iodures et bromures en particulier), les granulomes cutanés et la dermite périorale.
Traitement
Le traitement initial de la rosacée implique l’évitement des facteurs déclenchant (notamment par l’utilisation d’un écran solaire). Les antibiotiques et/ou l’acide azélaïque peuvent être utilisés en cas de maladie inflammatoire. L’objectif du traitement est de contrôler les symptômes et non de les guérir.

Le métronidazole en crème (à 1%), lotion (à 0,75%), ou gel (à 0,75%) et l’acide azélaïque en crème à 20%, appliqués 2 fois/jour sont tout aussi efficaces; le peroxyde de benzoyle à 2,5% sous toute forme (gel lotion, crème) appliqué 1 ou 2 fois/jour, peut être utilisé pour améliorer le contrôle.
Des alternatives moins efficaces comprennent la lotion de sulfacétamide de sodium à 10%/soufre à 5%; la solution, gel ou lotion de clindamycine à 1%; et la solution d’érythromycine à 2%, tous appliqués 2 fois/jour.
L’ivermectine topique crème à 1% est également efficace dans le traitement des lésions inflammatoires de la rosacée.

Les antibiotiques oraux sont indiqués en cas de papules ou pustules multiples et de rosacée oculaire; les options sont la doxycycline 50 à 100 mg 2 fois/jour, la tétracycline 250 à 500 mg 2 fois/jour, la minocycline 50 à 100 mg 2 fois/jour, l’érythromycine 250 à 500 mg 2 fois/jour, et 250 mg d’azithromycine 1 fois/jour ou divers régimes posologiques alternés ou différés. La dose doit être réduite à la plus petite dose qui contrôle les symptômes, une fois une réponse obtenue.

Un érythème persistant ou un flush peuvent être traités par un gel à 0,33% à la brimonidine, un alpha-2-agoniste sélectif adrénergique appliqué 1 fois/jour ou avec la crème à 1% d’oxymétazoline hydrochlorure principalement agoniste d’alpha-1a appliquée 1 fois/jour.

Les cas rebelles peuvent être sensibles à l’isotrétinoïne par voie orale.
Les techniques de traitement du rhinophyma comprennent la dermabrasion, l’ablation au laser, et l’exérèse de tissu; les résultats esthétiques sont bons.
Les techniques de traitement de la télangiectasie comprennent le laser et l’électrocoagulation.

Sources:

  • Mouna KOURDA; La rosacée, Revue Dermatologie Pratique
  • https://www.msdmanuals.com

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