Rosacea is a skin disorder that affects approximately 13 million Americans. Physicians and skin care professionals are seeing rapidly increasing numbers of individuals affected by rosacea as the “over 40″ population continues to grow. Rosacea is also gaining general public awareness as evidenced by the designation of March as “National Rosacea Awareness Month.” This often baffling disease can be difficult to treat and can cause severe emotional distress due to the visible facial involvement.

The disease rosacea was originally called “acne rosacea.” That name is no longer considered correct. Even though many aspects of rosacea may closely mimic the description and characteristics of acne, it is a completely separate entity. Rosacea is a common, chronic inflammatory disorder, usually affecting the central portion of the face and occasionally the V-shaped area of the chest, the back, and even the scalp. It is characterized by facial redness, telangiectasia (dilated capillaries), and sometimes lesions that look like acne papules and pustules. It is often difficult to diagnose rosacea because the lesions can so closely resemble acne. However, even though a rosacea papule or pustule may imitate acne, the key differentiation is that in rosacea, no microcomedone activity is present.¹

Most commonly, the clinical onset of rosacea begins between ages 30 and 50 years, but it can occur in adolescence or in the elderly. Also, rosacea is much more prevalent among females; but, when men get rosacea, it is usually far more severe. Lastly, there is a much higher incidence of rosacea in fair-skinned individuals.

IMPORTANT FACTS ABOUT ROSACEA

• Rosacea is not acne, but it can be present at the same time as acne.
• Rosacea is a progressive disease and must be taken seriously.
• Rosacea is not just sensitive or “cuperose” skin.

What causes Rosacea?

It is not known for certain what causes rosacea. However, there are a number of prominent theories. The most common theory is that rosacea is caused or aggravated by a microscopic pest known as the demodex mite (domox fulliculoneum).² Other theories include gastrointestinal disease or possible lesions on the hypothalamus gland. However, none of these theories are proven. Recent research indicates that the cause of rosacea may involve a variety of possibilities and that the factors causing or exacerbating rosacea can vary greatly from person to person.

New data has identified factors that trigger certain symptoms associated with rosacea. Everyone has responses to inflammatory triggers, which are con­sidered not only normal but necessary. However, it has been determined that individuals with rosacea express abnor­mally high levels of a protein referred to as “catheliciden.”³ Cathelicidens assist in killing microbes and also are criti­cal in signaling inflammatory responses. Production of abnormally high levels of catheliciden peptides appears to cause the skin to react as though there is an in­flammatory threat even though one may not be present. This may be an important factor as to why individuals with rosacea exhibit erythema and vascular dilation.

The only absolute certainty is that cumulative sun exposure and resulting sun damage always play a major role in the development of rosacea.⁴ Sun damage decreases the integrity of dermal connective tissues, which then al­lows for passive dilation of blood vessels.

Stages of Rosacea

(How the disease progresses)

Pre-Stage I Rosacea

It is believed that some individuals may be predisposed to developing rosacea either because of hereditary factors or certain innate characteristics that they possess. These people tend to show early signs that may indicate the tendency to develop rosacea. While these signs do not guarantee that they will develop rosacea, at the very least, precautionary measures can be initiated that may assist in delaying or preventing the actual onset of the disease, or more effectively control the outward symptoms. Persons who may have pre-stage I rosacea are often referred to as “flush­ers and blushers.” For example, a young woman in her early 20s might have a glass of wine, eat spicy food or become emotional. Instead of a possible momentary flush, her face, neck and chest may turn red and the redness might persist for 10-30 minutes. In people who develop rosacea, reactive flushing and blushing eventually leads to permanent erythema (redness).

Stage I Rosacea/Erythematotelangi­ectatic Rosacea (persistent moderate erythema)

The most common characteristics of stage I rosacea is persistent redness. While this erythema (redness) may be intermittent, it is usually present for hours or days at a time. Capillaries dilate and form vascular spray-like designs on the nose, nasolabial folds, and cheeks. The skin may become more sensitive and may react to certain cosmetics. In addition, the skin is more reactive to most physical and chemical stimuli.

Stage II Rosacea/Papulopustular Ro­sacea (persistent erythema, numerous telangectases papules and pustules)

Stage II rosacea includes the outward characteristics of stage I, along with acne-like papules and pustules. These lesions can be present intermittently or may persist for weeks at a time. Once again, it is important to remember that these are not actual acne lesions. The deeper inflammatory rosacea lesions can produce shallow scars.

As stage II progresses, the sebaceous follicles become larger and more prominent, further contributing to the formation of papules and pustules. It is also important to note that pustules and papules are a result of inflammatory causes and not bacteria. The larger lesions contribute more to shallow scarring, further adding to the devastat­ing effect that rosacea can have on the patient’s self-image.

Stage III Rosacea/Severe Papulopus­tular Rosacea (persistent deep erythema, dense numerous telangectases that form sprays or vessels, especially in the nose area, papules, pustules and nodules with variable plaque-like edema)

Generally, only a small number of individuals will progress to stage III rosacea. In stage III, patients exhibit all of the characteristics of stages I and II, along with a gradual deformatory of facial features. As stage III progresses, facial features may become thicker, coarser and irregular. The sebaceous glands continue toward extreme enlargement, contributing further to extensive large inflammatory nodules. The appearance of someone with stage III rosacea can be similar to individuals exhibiting the most severe cystic acne.

Variations of Rosacea

Ophthalmic Rosacea
It is not uncommon for the eyes to be involved with rosacea. The signs of ophthalmic rosacea may include persistent redness, itching, swelling, inflamed and crusting eyelids, and light sensitivity. Usually ophthalmic rosacea responds well to treatment. However, it is important to seek early diagnosis and treatment to avoid possible complications. It is possible for extreme cases of untreated ophthalmic rosacea to lead to blindness.

Rosacea Conglobata
This form of rosacea is relatively rare. It occurs mainly in females. The disease is generally limited to the face and mimics the appearance of severe disfiguring acne.

Rosacea Fulminans
This variation is possibly the most extreme form of rosacea. Rosacea fulminans only occurs in women. It is characterized by its very rapid onset, often reaching the peak of severity within only days to weeks. Lesions form in the appearance of giant abscesses and multiple lesions and the resulting disfigurement is hideous. Even though rosacea fulminans is so disfiguring and debilitating, the prognosis is excellent. Typically the disease is treated with Accutane™ and steroids. Once rosacea fulminans is under control, it does not recur.

Steroid Rosacea
Steroid rosacea occurs when an individual has been treated for extended periods of time with topical steroids, such as cortisone-type creams. Usually, this is a patient who started out with stage I rosacea and was treated for the persistent redness with a topical steroid cream. Topical steroid medications should be used for short duration only. Unfortunately, when long-term topical steroid treatment is discontinued, one side effect is a marked worsening of the very rosacea characteristics that the medication was intended to address. Steroid rosacea is often difficult to treat because the disease becomes even more pronounced when the physician tries to eliminate the topical steroid.

Rhinophyma
This variation generally occurs only in men. The most common visual char­acteristic is an extremely bulbous nose that becomes progressively larger over many years. A common misconception is that rhinophyma is caused by exces­sive alcohol consumption and the dis­ease is often associated with alcoholics. Alcohol does not cause rhinophyma. As with any form of rosacea, alcohol can exacerbate many of the symptoms, but other perhaps unknown factors are the causative issue. There are also a number of rhinophyma variations that include:

• Glandular Form
• Febrous Form
• Febroangiomatous Form
• Actenic Form

Things to remember about Rosacea

• Rosacea is not curable.
• Rosacea is treatable and can be con­trolled.
• Rosacea is varied and complex.
• Treatment requires dedication and perseverance.
• Diet must be considered.
• The patient must be compliant and flexible.
• Broad-spectrum sunscreen is an abso­lute must.
• Rosacea is difficult to treat because there is no one specific target organ­ism or cause.

TREATMENT OPTIONS

General At-Home Care

• Patients should avoid all known irritants and sources of local irritation.
• Broad-spectrum sunscreen is an abso­lute must.
• Topical prescription products should be in a non-alcohol base.

Prescription Topical Treatment

• Topical Metronidazole (Metro-Gel™)
• Available in gel, lotion & cream at 0.75% Excellent results
• Part anti-inflammatory, part insecticide, part antibacterial
• Topical Noritate
• 1% Metronidazole in a cream formulation
• Topical Klaron™ (Sodium Sulfaceta­mide Lotion)
• Azelaic Acid (Azalex™)⁵

Prescription Systemic Treatment

Many forms of rosacea respond well to oral antibiotics. It may be prudent to have patients on an oral medication at least until the symptoms are lessened and the disease is more stable. They include:

• Tetracycline
• Doxycycline
• Minocycline

For the more severe rosacea variants, more aggressive measures may need to be taken. Rosacea fulminans responds well to a short course of oral cortisone. Once rosacea fulminans has “calmed down,” Accutane™ is the usual choice to stabilize the condition and assist the patient in achieving an acceptable outcome.

Oracea

Oracea is a recently approved prescription oral anti-inflamma­tory for the treatment of inflam­matory rosacea lesions. Oracea is a 40 mg. dose of the oral antibi­otic Doxycycline. Because the low dosage does not kill bacteria, Oracea is not classified as an antibiotic but strictly as an anti-inflammatory. In clinical trials Oracea has not been demonstrated to cause antibiotic resistance, photosensitivity or vaginal candidiasis. It is suitable for long term or indefinite use. Many patients have reported the substantial lessening or absence of many of their rosacea symptoms. Oracea appears to be an effective new tool for the treatment of rosacea.

COSMETIC OPTIONS

The good news is that there are a number of newer vascular lasers that can greatly, if not entirely, eliminate the embarrassing and frustrating redness associated with rosacea. Many physicians have seen evidence that these lasers may greatly improve the symptoms of rosacea. Many patients report that they have fewer or no eruptions and that their skin is far more “normal.” The other exciting feature of these newer lasers is that there is very little recovery period. Patients may experience temporary redness for a few hours or a day, but there is no interruption in their usual schedules. As rosacea awareness increases, there will no doubt be a greater demand for research and treatment options to address this complex and often frustrating disorder.

Non-Prescription Topical Options

• Rosacea appears to respond extremely well to a combination of azelaic acid, glycolic acid and salicylic acid — patients report a lessening of redness and fewer lesions.

Glycolic Acid

Studies show:

• A marked reduction in redness
• A decrease in facial papules
• Less scaling
• Decreased sensitivity of facial skin
• Lessening of telangiectasia
• Gradual and overall continued improvement
• Patients’ rosacea remained under control
• Some physicians believe that glycolic acid may prevent the attachment of the demodex mite in the follicle

Miscellaneous Supplemental Options

• Topical all-trans-retinol
• Oral antihistamines

REFERENCES

1. Am Fam Physician, 2002: 66: 435-440
2. British Journal of Dermatology, 2007: 157 (3): 474-81
3. Nature Medicine, 2007: Aug 13 (8): 975-80
4. Przegl Lek, Jan 2008; 65 (4): 180-3
5. J Am Acad Dermatol 1999; 40 (6 pt 1): 961-5

Most people don’t realize that approximately 90–95 percent of what we perceive as inevitable aging is caused by sun exposure. Sunscreen is the most effective skin care product that prevents the outward signs of aging. As the occurrence of dangerous skin cancers continues to rise, there is overwhelming data that supports consistent sunscreen use.

Following are the 11 reasons why you should protect yourself from the harmful effects of the sun. Remember, achieving a youthful appearance is as easy as, well, sunscreen!

Reason #1. When you look in the mirror at those first fine lines, coarsening texture, sallow tones and uneven pigmentation, you may think they are unavoidable. Not so! As much as 90–95 percent of what we consider “inevitable aging” is actually sun damage. Most of this damage occurs before the age of 10, and at least 80 percent of it takes place before the age of 18. However, it can take up to 30 years for this damage to finally become evident.

Although wrinkled, sun damaged skin is cosmetically undesirable, the outer damage is also representative of the decreased normal functions of the skin. These include the inability to retain water, compromised immune function, increased sensitivity, reduction of active sweat glands, delayed healing, and changes in pigment cells, just to name a few.

Reason #2. In 1935, approximately one out of 1,500 people in the U.S. were diagnosed with malignant melanoma — the most deadly form of skin cancer. Today, that number has jumped to one out of 70 people in the U.S., and malignant melanoma is projected to affect one out of 50 by 2010.

Tanning did not become fashionable until Coco Chanel traveled to the French Riviera in the 1920’s and returned home with a deep suntan. So it has been less than 100 years that we have chosen to drastically increase our sun exposure — an obvious reason for the prevalence in deadly skin cancer. While some malignant melanoma cases are simply genetic, the remainder is influenced by sun exposure. In fact, the risk of developing malignant melanoma is mainly due to extreme exposure to the sun, including sunburns before the age of 10.

Reason #3. Rosacea is a skin disease of vassal motor instability that is primarily characterized by persistent facial redness and enlarged capillaries known as Telangiectasia. As the disease progresses, sufferers may also experience lesions that mimic acne, along with a host of other unsightly and disfiguring attributes.

Rosacea now affects approximately 13 million Americans, and the numbers are growing rapidly. While the specific cause of rosacea is unknown, it has been established that one of the primary causative factors is sun exposure. The average age of onset for rosacea is between 30 and 50. However, this is another psychologically damaging and often embarrassing skin condition that can be prevented.

Reason #4. If you thought cataracts were primarily an inevitable aspect of growing old, think again. Cataracts occur when an ocular opacity partially or completely obscures vision in one or both eyes, resulting in impaired vision or even complete blindness.

While there are a number of conditions and diseases that can contribute to, or cause cataracts, cumulative sun exposure is (once again) a major causative or exacerbating factor in age-related cataracts.

Reason #5. We seldom hear of people dying from the more common melanoma skin cancers such as Basal Cell Carcinoma or Squamous Cell Carcinoma. Basal cell cancers are usually slow growing, while Squamous cell cancers are far more aggressive and can metastasize.

In some cases, skin cancer can be easily and superficially removed. But in many instances, these cancers can substantially reach beyond the superficial borders, necessitating invasive and disfiguring surgical removal. The risk for developing these types of skin cancers increases after years of cumulative sun exposure.

Reason #6. While skin cancer is one of the worst villains, Actinic Keratosis, or precancerous lesions, is also harmful. Actinic Keratosis may appear as unsightly reddish or yellowish brown spots, and may be raised or scaly in texture. Because these lesions are a precursor to skin cancer, they necessitate aggressive treatment, which can be highly effective and prevent the precancerous areas from progressing. Nevertheless, prevention is the better choice.

Reason #7. Solar Lentigines are brown-pigmented areas that can be found on the face, hands and other areas that are exposed to the sun. They are commonly referred to as age spots or liver spots. Usually, Solar Lentigines appear post sunburn, or in older people who have experienced years of chronic sun exposure.

Solar Lentigines can be removed through various methods, but they are cosmetically undesirable and can be prevented by simply wearing sunscreen.

Reason #8. A common misconception is that the sun assists in clearing up acne. Because sun exposure hardens the outer layers of the skin, eruptions may be temporarily suppressed. However, sun exposure stimulates greater oil production, which in turn, provides more fuel for bacteria. When an individual lessens the time spent sunbathing, he or she may experience a major acne flareup. As the outer layer of skin softens, the retentive material rapidly surfaces, resulting in a worsening of the condition.

Reason #9. Oftentimes, unsightly discolorations are left behind once an acne lesion clears up. Referred to as flat macular pigmentation or post-inflammatory hyperpigmentation, these marks are usually reddish, purplish or brownish. Additionally, they are difficult to resolve, and sun exposure makes them darker and more resistant to treatment.

Reason #10. Hair is also vulnerable to the sun. Cumulative sun exposure can cause hair to become dull looking and brittle to the touch. Technically, the sun causes photooxidative splitting of cystine linkages and initializes the formation of free radicals that are detrimental to the protein matrix.

The sun also ages hair by removing its color. Like skin, lighter colored hair with less color pigment is more vulnerable than darker hair with more pigment. Hair products with UV protecting agents are beneficial, but it’s even better to wear a hat.

Reason #11. It is hard to believe that tanning beds were once touted as a safe alternative to outdoor sun exposure. In recent years, numerous medical studies have proven that tanning beds are equally, if not more harmful than natural sunlight.

Most indoor tanning sources emit as much as 95 percent of UVA rays (as opposed to UVB rays). UVA radiation penetrates more deeply into the skin, and the remaining light is UVB, which affects the uppermost layers of skin and is often associated with sunburn. Because there is less superficial burning with tanning beds, there is a false sense that indoor tanning is less harmful.

According to Elizabeth Whitmore, M.D., associate professor of dermatology at Johns Hopkins University School of Medicine, indoor tanning light can – and does – lead to skin cancer and should be avoided.

Look Better, Live Healthier

While youthful, healthy looking skin is greatly desirable, we mustn’t forget that sun protection is not just a cosmetic issue — it’s a serious health issue. Wear your sun protection . . . and wear it daily!