Rosacea

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Rosacea
Classification and external resources
Domenico ghirlandaio, ritratto di nonno con nipote.jpg
An Old Man and His Grandson, by Domenico Ghirlandaio shows skin damage from rhinophyma[1]
ICD-10L71
ICD-9695.3
DiseasesDB96
MedlinePlus000879
eMedicinederm/377
MeSHD012393
 
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Rosacea
Classification and external resources
Domenico ghirlandaio, ritratto di nonno con nipote.jpg
An Old Man and His Grandson, by Domenico Ghirlandaio shows skin damage from rhinophyma[1]
ICD-10L71
ICD-9695.3
DiseasesDB96
MedlinePlus000879
eMedicinederm/377
MeSHD012393

Rosacea /rˈzʃiə/ is a chronic condition characterized by facial erythema (redness)[2] and sometimes pimples.[3] Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting the eyes (ocular type). Left untreated it worsens over time. Treatment in the form of topical steroids can aggravate the condition.[4]

It primarily affects people of northwestern European descent and has been nicknamed the 'curse of the Celts' by some in Britain and Ireland, although recently this has been questioned.[5] Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.[citation needed]

Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp.[6] In some cases, additional symptoms, such as semi-permanent redness, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.

Classification[edit]

Zones

There are four identified rosacea subtypes[7] and patients may have more than one subtype present:[8]:176

  1. Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and/or itching sensations.[citation needed] People with this ETR type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, symptoms can also appear on the ears, neck, chest, upper back, and scalp.[9]
  2. Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (can last 1–4 days or longer; extremely varied syptoms); this subtype can be easily confused with acne.
  3. Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma).[10] Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
  4. Ocular rosacea: Red (due to telangiectasias), dry, irritated or gritty, eyes and eyelids. Watery eyes. Eyelids often develop cysts. Some other symptoms include foreign body sensations, itching, burning, stinging, and sensitivity to light. Eyes can become more susceptible to infection. About half of the people with subtypes 1-3 also have eye symptoms. Blurry vision and loss of vision can occur.

There are a number of variants of rosacea, including:[11]:689

Cause[edit]

Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some food and drinks that can trigger flushing, including alcohol, food and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food. Foods high in histamine (red wine, aged cheeses, yogurt, beer, cured pork products such as bacon, etc.) can even cause persistent facial flushing in those individuals without rosacea due to a separate condition, histamine intolerance.

Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.

A survey by the National Rosacea Society of 1,066 rosacea patients showed which factors affect the most people:[12]

It should be noted however that there exists significant disagreement amongst sufferers and clinicians as to the validity of these aggravators/triggers being categorized as causes of rosacea. The claim of rosacea being caused (as opposed to aggravated) by the above list has not been established by epidemiological scientific study.[13] Many sufferers report that elimination of triggers has little or no eventual impact on the actual progression of the disease. The above list should in no way be taken as an explanation of rosacea causes, as the spectrum disease is more complex than simply a direct or sole result of habits and diet.

Cathelicidins[edit]

Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin[14] and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea but they may only work because they inhibit some SCTEs.[15]

Intestinal flora[edit]

Intestinal flora may play a role in causing the disease. A recent study subjected patients to a hydrogen breath test to detect the occurrence of small intestinal bacterial overgrowth (SIBO). It was found that significantly more patients were hydrogen-positive than controls indicating the presence of intestinal flora overgrowth (47% v. 5%, p<0.001).

Hydrogen-positive patients were then given a 10-day course of rifaximin, a non-absorbable antibiotic that does not leave the digestive tract and therefore does not enter the circulation or reach the skin. 96% of patients experienced a complete remission of rosacea symptoms that lasted beyond 9 months. These patients were also negative when retested for intestinal flora overgrowth. In the 4% of patients that experienced relapse, it was found that intestinal flora overgrowth had returned. These patients were given a second course of rifaximin which again cleared rosacea symptoms and normalized hydrogen excretion.[16]

In another study, it was found that some rosacea patients that tested hydrogen-negative were still positive for intestinal flora overgrowth when using a methane breath test instead. These patients showed little improvement with rifaximin, as found in the previous study, but experienced clearance of rosacea symptoms and normalization of methane excretion following administration of the antibiotic metronidazole, which is effective at targeting methanogens.[17]

These results suggest that optimal antibiotic therapy may vary between patients and that diverse species of intestinal flora appear to be capable of mediating rosacea symptoms.

This may also explain the improvement in symptoms experienced by some patients when given a reduced carbohydrate diet.[18] Such a diet would restrict the available substrates for the microorganisms thought to be causative.

Demodex mites[edit]

Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea.[19] When large numbers are present they may play a role along with other triggers. On other occasions demodicidosis (mange) is a separate condition that may have "rosacea-like" appearances.[20] Demodex has also been implicated in rosacea in that it is theorised to be caused by a reaction to bacteria in the mite's faeces.[21]

Diagnosis[edit]

Most people with rosacea have only mild redness and are never formally diagnosed or treated. There is no single, specific test for rosacea.

In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.

The disorder can be confused with, and co-exist with acne vulgaris and/or seborrhoeic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.

Treatments[edit]

Treating rosacea varies depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists.[22] Mild cases are often not treated at all, or are simply covered up with normal cosmetics. Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of erythema and inflammatory lesions, decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents.[23] While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually one to two years, may result in permanent control of the condition for some patients.[citation needed] Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.[citation needed]

Behaviour[edit]

Avoiding physical things or mental states that increase the ability to visibly detect rocasea by a physician are considered a phrase called "trigger avoidance". Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. It is sometimes recommended that a journal be kept to help identify and reduce food and beverage triggers.[24]

Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims.

Like sunlight, emotional stress can also serve as a trigger for rosacea.

People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily, gentle cleansing of the eyelids with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.[citation needed]

A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.[25]

Medications[edit]

Oral tetracycline antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defense prescribed by doctors to relieve papules, pustules, inflammation and some redness.[26] Topical azelaic acid such as Finacea (15%) or Skinoren (20%) may help reduce inflammatory lesions, bumps and papules. Using alpha-hydroxy acid peels may help relieve redness caused by irritation, and reduce papules and pustules associated with rosacea.[27] Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.[28] Isotretinoin has many side effects and is normally used to treat severe acne but in low dosages is proven to be effective against papulopustular and phymatous rosacea. Some individuals respond well to the topical application of sandalwood oil on the affected area, particularly in reducing the prevalence of pustules and erythema.

The treatment of flushing and blushing has been attempted by means of the centrally acting α-2 agonist clonidine, but this is of limited benefit on just this one aspect of the disorder.[29] The same is true of the beta-blockers like nadolol and propranolol. If flushing occurs with red wine consumption, then complete avoidance helps. There is no evidence at all that antihistamines are of any benefit in rosacea. However: people with underlying allergies and who respond strongly to foods that are high in histamine or that release a lot of histamine in the body do find sometimes that their flushing symptoms diminish with oral antihistamines (for instance loratadine). Another medication that can help some people with facial flushing and burning is mirtazapine (remeron).

Recently, a clinically trialled topical product combining plant-sourced methylsulfonylmethane (MSM) and silymarin showed effectiveness in one study treating rosacea, skin redness and flushing.[30]

Laser[edit]

Dermatological vascular laser (single wavelength) or intense pulsed light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin.[31] They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxy-hemoglobin, which heat up, causing the capillary walls to heat up to 70 °C (158 °F), damaging them, causing them to be absorbed by the body's natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly formed capillaries.

CO2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporise tissue. Low level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it.[32][33][34]

Notable cases[edit]

Famous people with rosacea include:

See also[edit]

References[edit]

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  2. ^ "rosacea" at Dorland's Medical Dictionary
  3. ^ "Glossary - Dermatology - Online Medical Encyclopedia - University of Rochester Medical Center". Retrieved 2009-02-21. 
  4. ^ "Rosacea". DermNet, New Zealand Dermatological Society. Retrieved 2011-02-03. 
  5. ^ Wollina, U; Verma, SB (2009 Sep). "Rosacea and rhinophyma: not curse of the Celts but Indo Eurasians.". Journal of cosmetic dermatology 8 (3): 234–5. doi:10.1111/j.1473-2165.2009.00456.x. PMID 19735524. 
  6. ^ "All About Rosacea". National Rosacea Society. Retrieved 2008-11-10. 
  7. ^ Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R, Powell F (2004). "Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea" (PDF reprint). J Am Acad Dermatol 50 (6): 907–12. doi:10.1016/j.jaad.2004.01.048. PMID 15153893. 
  8. ^ Marks, James G; Miller, Jeffery (2006). Lookingbill and Marks' Principles of Dermatology (4th ed.). Elsevier Inc. ISBN 1-4160-3185-5.
  9. ^ "What Rosacea Looks Like". Retrieved 2013-01-30. 
  10. ^ Jansen T, Plewig G (1998). "Clinical and histological variants of rhinophyma, including nonsurgical treatment modalities". Facial Plast Surg 14 (4): 241–53. doi:10.1055/s-2008-1064456. PMID 11816064. 
  11. ^ Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. ISBN 0-07-138076-0.
  12. ^ Rosacea.org: The National Rosacea Society
  13. ^ Lisa Faulkner: My unsightly rosacea - Celebrity gossip on Now Magazine
  14. ^ Yamasaki K, Di Nardo A, Bardan A, et al. (August 2007). "Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea". Nat. Med. 13 (8): 975–80. doi:10.1038/nm1616. PMID 17676051. 
  15. ^ See the August 5, 2007, issue of Nature Medicine for details.
  16. ^ Parodi A,Paolino S,Greco A,Drago F,Mansi C,Rebora A,Parodi AU,Savarino V (May 2008). "Small Intestinal Bacterial Overgrowth in Rosacea: Clinical Effectiveness of Its Eradication". Clin Gastroenterol Hepatol. 6 (7): 759–64. doi:10.1016/j.cgh.2008.02.054. PMID 18456568. 
  17. ^ UEGW Vienna 2008 - 16th United European Gastroenterology Week
  18. ^ Intestinal Disaccharidase Activity in Rosacea - Paton et al. 1 (5485): 459 - British Medical Journal
  19. ^ Erbagcaronci Z, Özgöztascedili O (June 1998). "The significance of Demodex folliculorum density in rosacea". Int J Dermatol. 37 (6): 421–5. doi:10.1046/j.1365-4362.1998.00218.x. PMID 9646125. 
  20. ^ a b Baima B, Sticherling M (2002). "Demodicidosis revisited". Acta Derm Venereol 82 (1): 3–6. doi:10.1080/000155502753600795. PMID 12013194. 
  21. ^ MacKenzie, Debora (30 August 2012). "Rosacea may be caused by mite faeces in your pores". New Scientist. 
  22. ^ Aaron F. Cohen, MD, and Jeffrey D. Tiemstra, MD (May–June 2002). "Diagnosis and treatment of rosacea". J Am Board Fam Pract 15 (3): 214–7. PMID 12038728. 
  23. ^ Noah Scheinfeld, MD, JD, and Thomas Berk, BA (January 2010). "A Review of the Diagnosis and Treatment of Rosacea". Postgraduate Medicine. 122 (1): 139–43. doi:10.3810/pgm.2010.01.2107. PMID 20107297. 
  24. ^ Eating a Healthy, Well-rounded Diet Can be the Best Recipe for Healthy Skin
  25. ^ Dahl, Colin (2008). A Practical Understanding of Rosacea - part one.. Australian Sciences. 
  26. ^ Dahl MV, Katz HI, Krueger GG, Millikan LE, Odom RB, Parker F, Wolf JE Jr, Aly R, Bayles C, Reusser B, Weidner M, Coleman E, Patrignelli R, Tuley MR, Baker MO, Herndon JH Jr, Czernielewski JM (June 1998). "Topical metronidazole maintains remissions of rosacea". Arch Dermatol 134 (6): 679–83. doi:10.1001/archderm.134.6.679. PMID 9645635. 
  27. ^ Tung, RC; Bergfeld, WF; Vidimos, AT; Remzi, BK (2000). "alpha-Hydroxy acid-based cosmetic procedures. Guid... [Am J Clin Dermatol. 2000 Mar-Apr] - PubMed result". American journal of clinical dermatology 1 (2): 81–8. PMID 11702315. 
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  29. ^ Cunliffe WJ, Dodman B, Binner JG (January 1977). "Clonidine and facial flushing in rosacea". Br Med J 1 (6053): 105. doi:10.1136/bmj.1.6053.105. PMC 1604111. PMID 137764. 
  30. ^ Berardesca E, Cameli N, Cavallotti C, Levy JL, Piérard GE, de Paoli Ambrosi G (2008). "Combined effects of silymarin and methylsulfonylmethane in the management of rosacea: clinical and instrumental evaluation". J Cosmet Dermatol 7 (1): 8–14. doi:10.1111/j.1473-2165.2008.00355.x. PMID 18254805. 
  31. ^ Marla C Angermeier (1999). "Treatment of facial vascular lesions with intense pulsed light". J Cutan Laser Ther. 1 (2): 95–100. doi:10.1080/14628839950516922. PMID 11357295. 
  32. ^ Rigel, Darrell S.; Robert A. Weiss, Henry W. Lim, Jeffrey S. Dover (2004). Photoaging. Informa Health Care. p. 174. ISBN 0-8247-5450-6. 
  33. ^ "PHOTO REJUVENATION". Archived from the original on 2008-08-04. Retrieved 2008-08-14. 
  34. ^ "Research a cosmetic surgery procedure". Retrieved 2008-08-14. 
  35. ^ Subscription Center - News Archive
  36. ^ 4 May 2009-4-5 p.m.
  37. ^ Armstrong, Lisa (2007-02-16). "Ive got thighs and buttocks Im never going to be a size zero". The Times (London). Retrieved 2010-05-22. 
  38. ^ a b c Jane E. Brody (March 16, 2004). "Sometimes Rosy Cheeks Are Just Rosy Cheeks". New York Times. 
  39. ^ Lisa Faulkner: My unslightly rosacea - Celebrity gossip on Now Magazine
  40. ^ Fergie back in business after heart scare - ABC News (Australian Broadcasting Corporation)
  41. ^ 11 June 2012 (2012-06-11). "Diane Kruger: Make-up swamps me". Belfasttelegraph.co.uk. Retrieved 2013-02-23. 
  42. ^ Burnham, Virginia (2003). The Two-Edged Sword: A Study of the Paranoid Personality in Action. Sunstone Press. p. 61. ISBN 978-0-86534-147-0. 
  43. ^ "Rosacea - Living with Rosacea: An Interview with Cynthia Nixon". Empowher.com. 2012-04-19. Retrieved 2013-02-23. 
  44. ^ Rosie O'Donnell - ELLE
  45. ^ Appleyard, Diana (2011-02-27). "I'm not drunk I have rosacea: Carol Smillie tells embarrassing story of facial flushes". Daily Mail (London). 
  46. ^ Swords Against the Senate: The Rise of the Roman Army and the Fall of the Republic, by Erik Hildinger. Da Capo Press, 2003, p.99
  47. ^ Dita Von Teese on conquering rosacea
  48. ^ Amstell, Simon (2005-08-21). "Q&A". The Guardian (London). Retrieved 2010-05-22. 

External links[edit]