![]() Increased activation of the innate immune system is partially due to overexpression of toll-like receptors leading to activation of NF-kB with subsequent production of inflammatory cytokines, mast cells, and macrophages. The initial cause of dysregulation of inflammatory cells, vasculature, and lymphatics underlying rosacea is multifactorial and has not been completely elucidated. Rosacea often starts between the ages of 20 to 30 with telangiectasias and excessive facial flushing exacerbated by vasoactive substances, including but not limited to caffeine, alcohol, and ultraviolet light. However, given the high frequency of overlapping clinical features and etiologies within subtypes, the classification of rosacea has now taken a phenotype-based diagnostic approach to accurately characterize patients. Rosacea has previously been thought to progress sequentially through various subtypes, including erythematotelangiectatic rosacea, papulopustular rosacea, and phymatous rosacea. Hollywood has used rhinophyma to indicate distasteful or villainous characters: in "Snow White and the Seven Dwarfs" (1937), the villain Queen was given a rhinophyma, besides deep rhytids and periorbital swelling. The direct causal relationship between rhinophyma and alcohol has not been substantiated and has promoted a social stigma, as colloquial names for this condition include "whiskey nose" and "gin blossom." "Potato nose" is another common lay description of this type of nose. An additional social challenge is a commonly presumed link to excessive alcohol use. This disfiguring disorder is essential to treat, as patients are subject to psychological distress and respiratory issues when alar thickening can obstruct the external nasal valves. Historically, the condition has been known to exist, as seen in a 15th Century painting by Domenico Ghirlandaio (1490), "An Old Man and His Grandson," which shows a man with a large rhinophyma (See Figure). Rosacea is the precursor condition to the later development of rhinophyma and was linked to this disease as the ultimate expression of rosacea in 1846 by Ferdinando Hebra Von (1816-1880).
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