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Rosacea

Medical White Paper on Rosacea

Facial burning, stinging and itching are commonly reported by many rosacea patients. Certain rosacea sufferers may also experience some swelling (edema) in the face that may become noticeable as early as the initial stage of the disease. It is also believed that in some patients this swelling process may contribute to the development of excess tissue on the nose (rhinophyma), the condition that gave the late comedian W.C. Fields his trademark nose.

It is often thought that fair-skinned patients who tend to flush or blush easily are believed to be at greatest risk, while in fact facial redness from rosacea is simply more obvious in lighter skin. A normal blush or sunburn may appear the same, as can flushing from medications such as niacin or some antihypertension drugs. Flushing occurs when a large amount of blood flows through vessels quickly and the vessels expand under the skin to handle the flow. However, people with extensive sun damage, certain skin types and even treated rosacea patients can still have a red face or blood vessel streaks, which is often misdiagnosed as active rosacea. This is because visible blood vessels (telangiectasia) not only develop with rosacea (or were likely always there), but there may be some residual persistence of redness from the dilation of blood vessels during active disease. Unfortunately these patients continue their medications unnecessarily while more appropriate treatments include camouflage makeup, sunscreens, a vascular laser, or intense pulsed light source.

Unlike some conditions, there are no histological, serological or other diagnostic tests for rosacea. A thorough examination of signs (appearance of bumps or pimples) and symptoms (redness, flushing, and swelling, burning, itching or stinging) as well as a medical history of potential triggers lead to the diagnosis. The National Rosacea Society suggests that the most common triggers of rosacea were sun exposure, emotional stress, hot or cold weather, wind, alcohol, spicy foods, heavy exercise, hot baths, heated beverages and certain skin-care products. In other words, almost anything that is potentially stimulating is bad news for rosacea. Unfortunately for some, certain conditions such as lupus, seborrheic dermatitis, drug eruptions, and even rare forms of lymphoma can look just like rosacea and are often missed by the untrained eye or worse when the patients are diagnosing themselves.

Rosacea is not an infectious disease, and there is no evidence that it can be spread by contact with the skin or through inhaling airborne bacteria. However, there has long been a theory that parasites in the hair follicles or oil glands or the face can stimulate inflammation by their activity or even their presence. One such organism is the Demodex folliculorum mite, which studies have shown to be more prevalent and active in rosacea patients then in control groups. Early vascular and connective tissue changes probably create a favorable setting for a growth of Demodex folliculorum. This may represent an important cofactor especially in papulopustular rosacea, in which a delayed hypersensitivity reaction is suspected, but it is not the cause of rosacea. On the other hand, clearing rosacea signs after oral tetracycline or sulfur ointment may not affect the resident demodex population.

The incidence of demodex is age related. It was found up to 20 years in about 25%, up to 50 years in about 30%, up to 80 years in about 50% and in all aged 90 or older. In healthy persons, one can find one or more Demodex in every tenth eyelash. This index rise with increasing age. In blepharitis or other external eye diseases, demodex is found in about every sixth eyelash. Therapy of chronic blepharitis in association with demodex may include antibiotics, steroids, Quecksilber 2% or Lindane. Massage of lid margins is essential because local treatment is of no effect as long as the mite remains deep in the pilosebaceous complex.

As rosacea is characterized by flare-ups and remissions, and research has shown that long-term medical therapy significantly increased the rate of remission in rosacea patients, it behooves patients to use a maintenance regimen. In a six-month multicenter clinical study, 42 percent of those not using medication had relapsed, compared to 23 percent of those who continued to apply a topical antibiotic. Therefore, treatment between flare-ups can prevent them. A rosacea facial care routine often starts with a gentle a refreshing cleansing of the face each morning. Sufferers should use a mild soap or cleanser that is not grainy or abrasive, and spread it with their fingertips. A soft pad or washcloth can also be used, but avoid rough washcloths, loofahs, brushes or sponges. The face should be rinsed with lukewarm water several times and blot dry with a thick cotton towel.

A new treatment available is seabuckthorn oil (Hippophae rhamnoides), which is the active ingredient in facedoctor soap. Its activity is targeted against the mite to reduce the inflammation under the skin and therefore provide relief of the mechanisms that cause the rosacea complex of symptoms. The advantage that patients find with the soap is the elegance of the cleansing vehicle in otherwise sensitive skin, the presence of Vitamin E and aloe Vera which provide additional healing properties, and other active ingredients such as astragalus membraceus and spirodela polyrhiza, useful yeasts that augment the activity of the seabuckthorn oil.

My patients have found this to be well tolerated and useful either as monotherapy or in addition to their other topical and/or systemic medications. We conducted a small placebo-controlled double-blind study in the office which showed that the majority of patients had a reduction of symptomatic erythema as well as reduction of response to triggers.

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