VIRGINIA BEACH DERMATOLOGY ASSOCIATES, PLLC.

ROSACEA

Yes, Rosacea has been around for a very long time. But until recently the public did not realize rosacea’s prevalence. Thanks to a national public awareness campaign, combined with our increasingly vain and looks centered society, many more people are cognizant of this moderately disfiguring entity.

In fact, it estimated that rosacea affects one in twenty Americans.

WHAT IS ROSACEA?

Rosacea (properly pronounced rose-ay-shah) is a facial dermatitis that causes a blushing discoloration peppered with thin red blood vessels. Often pimples and pustules erupt which led to its antiquated moniker of acne rosacea. It is usually divided into the erythemo-telangiectatic component and the papular-pustular component.

Rosacea is a very slow, indolent condition. In its early stages it is barely perceptible, but with time can become quite disfiguring.

PROGRESSION OF ROSACEA

The first sign of rosacea is usually an excessive sensitivity to outside forces. The face will turn red easily, say with a cold wind or the application of an alcohol containing skin product. Persistent redness of the face, especially the cheeks and nose is noted.

The redness is caused by dilated blood vessels. It is felt that these vessels constantly dilate and constrict, dilate and constrict until eventually they ‘wear out” and become permanently dilated. Once dilated, they leak fluid causing the thickening of the skin which is another manifestation of rosacea. The dilatation thus produces the red blush, the telangiectases (or “broken” blood vessels), the edema (swelling) and the thickened skin—all hallmarks of rosacea.

The second component is hypertrophy (excessive development) of the sebaceous (oil) glands. This results in knobby bumps and lumps on the nose.

The enlargement of the sebaceous glands with their oily secretion provides a hospitable environment for bacteria and the Demodex mite. Although the Demodex mite is can be detected on normal skin, my friend Dr. Ed Edwards and I observed the Demodex mite three times more commonly in those afflicted with rosacea.

The excessive oils probably also encourage the growth of bacteria. This may account for some of the welcome response to antibiotics.

WHO GETS ROSACEA?

People of fair complexion. It appears most commonly in those of Celtic descent, although all races and ethnic groups may contract this condition.

If you were known to blush easily as a little girl, you carry the tendency to develop rosacea later in life.

Although it is felt that both sexes develop rosacea equally, women are more susceptible to the erythrmo-telangiectatic type, while men fall prey to the paupular-pustular variety .Men are more likely to contract rhinophyma—an end-stage rosacea which results in a coarse, knobby nose.

TRIGGER FACTORS

Trigger factors are very important in rosacea. If the rosacea patient is able to avoid these trigger factors, then there should be substantial improvement.

Anything that causes the blood vessels of the face to dilate should be a trigger factor. Some trigger factors such as emotion and exposure to wind may be hard to avoid. However, other trigger factors such as the sun and various foods and vitamins may be more easily dodged.

The following are known trigger factor:

Hot foods – hot coffee or tea
Spicy foods – Mexican or Szechwan for instance
Vitamin B3 (Niacin)
Medications which dilate the blood vessels such as Beta Blockers
Sun
Heavy lifting
Alcohol
Please see the Rosacea Daily Checklist to enable you to monitor your progress.

TREATMENT

General treatment

Individuals with rosacea are advised to treat their face gently. People with rosacea are more prone to have a flare up if they utilize topical products with alcohol or acids.

Only soaps and cleansers that are very mild should be used on the face. I recommend Dove, Cetaphil or Aquanil.

The face should be gently wiped and never scrubbed.

I personally like my patients to use a good moisturizer since patients with rosacea tend to have a dry face. When used with topical medications, moisturizers should be applied after the topical medication has had the opportunity to dry.

Do not forget to apply a moisturizer if going out in the ;sun. Sun exposure is known to aggravate rosacea.

One tip I like is as follows. If you are going into the hot sun, carry a cup of crushed ice, cold water or a cold soda (tonic if you are from New England). Sip on this while outside. This deceives your mouth into thinking it is cool out, and may prevent the face from dilating its blood vessels.

If you ski, be sure to buy a ski mask to protect your skin from the cold harsh winds.

Women should be careful that their perfume does not sting or irritate their face. Another trick is to apply the perfume to one side of the face or neck and after a few weeks judge whether your rosacea is worse on that side.

TOPICAL MEDICATIONS

Metronidazole – this antibiotic was originally used to combat Trichamonas, a parasitic vaginal infection. In the form of Metrocream, Metrogel, Metrolotion and Noritate it has gained widespread popularity as a treatment for rosacea. Whether it works due to its antibiotic properties, anti-inflammatory properties, or even by killing the infamous Demodex mite is unclear.

Sulfa – Sulfa , of course is an antibiotic. It seems to help rosacea on its own and sometimes combined with sulfur. When alone it is a product named Klaron and when it is combined with sulfur, the products are Sulfacet Lotion and Novacet Lotion. The sulfa products appear to be about as good as the Metronidazole products. If you are allergic to sulfa you should not use these entities. It should also be remembered that Sulfur, an old time topical antibiotic for acne, might be irritating.

Speaking of old time, were you aware that the Romans and other ancients travelled miles to sulfur baths. They did this in order to rid themselves of lice and mites. This accounted for the unrivaled popularity of these spas during ancient times. Clindomycin – In the form of Cleocin gel, pads or lotion, Clindomycin is an effective topical for treating rosacea. Most dermatologists prefer the lotion form since it is the mildest of the three.

ORAL ANTIBIOTICS

Most dermatologists favor Tetracycline due to its low cost, effectiveness and safety. Personally I start nearly all my rosacea patients on this medication, along with topical antibiotics. As their condition improves, I cut back on the dosage of the oral medication but continue the topical medications. Once the rosacea is under control, the oral medications are withdrawn.

Other drugs in the tetracycline family such as Minocycline (Dynacin and Minocin) or Doxycycline (Doryx or Mondox) are also used. It is an advantage that these medications may be taken with meals. They are more expensive, however, and in the case of Minocycline they may have serious side effects.

Erythromycin, Ampicillin, and Sulfa drugs are also sometimes used, but in my opinion they are not as effective.

Occasionally, oral Metronidazole is prescribed, most often in stubborn cases. This drug may cause a peripheral neuropathy (tingling or strange sensations in the hands or feet) or seizures. Since it is related to a drug called Antabuse, you should not consume alcohol or cough syrup while taking this pill.

OTHER ORAL MEDICATIONS

Accutane – Isotretinoin – the bulwark of severe cystic acne treatment may be a highly effective drug for treating those with the papular-pustular type of rosacea. It works by shrinking up the sebaceous glands. The usual patient is the man with early rhinophyma, but occasionally a female is treated with Accutane. The well-known precautions to absolutely avoid pregnancy should be emphasized.

RHINOPHYMA

You have all seen men with a red bulbous, knobby nose. This is rhinophyma. As the number of bumps increases, the nose becomes swollen and inflamed. Rhinophyma results.

The first sign of ensuing rhinophyma is widening of the pores of the nose. If you have rosacea you should look for them. Your physician should probably use more aggressive treatment.

Rhinophyma may be treated with laser or electrosurgery.

W.C. Fields and J. P. Morgan are the most famous individuals to showcase this condition.

OCULAR ROSCEA

Over half the people with rosacea will develop eye symptoms. About twenty per cent of the time the eye changes precede the skin changes.

Grittiness, redness and unexplained tearing are symptoms of ocular rosacea. Ocular rosacea may actually progress to vision loss. Often, an oral antibiotic will suffice to treat ocular rosacea. However, those who don’t respond to this simple measure should be seen by an ophthalmologist.

OTHER TREATMENTS

Sometimes, electorsurgery (using an electric needle) may be helpful for the tiny telangiectasias (“broken” blood vessels).More pronounced cases may find laser treatment beneficial.

Plastic surgery may be needed for Rhinophyma if the electrosurgery or laser fails to help.

HELICOBACETER PYLORI

A piece on rosacea would not be complete without mentioning the Helicobacter Pylori organism.

In the past few years, some people have felt that rosacea may be caused or aggrevated by the H. Pylori bacillus. It is speculated that this bacteria may lie in the stomach and release vaso-active proteins. These proteins may cause the blood vessels of the face to dilate, hence causing rosacea.

People who believe in this theory point to the long-standing notion that those with rosacea seem to have a lot of gastro-intestinal complaints.

If other treatments fail, a protocol to counter this bacteria may be employed., This protocol includes antibiotics, Tagamet and Pepto-Bismol.