what is Rosacea
Rosacea is a common chronic inflammatory disorder of the hair follicles, sebaceous glands and vasculature of the face. The role of Demodex mite in the pathogenesis of Rosacea is controversial.
Rosacea sufferers have recurrent flushing, exacerbated by heat (shower, hot drinks), spicy foods, sunlight, cold, alcohol, and stress. They have sensitive skin, and may complain of dry and gritty eyes.
The peak incidence of Rosacea is 30—50 yr; Females being more affected than Males.
Rosacea sufferers may develop erythema, telangiectases, papules, and pustules of central face; there are no comedones in contrast to acne. Sebaceous hyperplasia, seborrheic dermatitis and facial lymphedema are also more common.
There are 4 Major Subtypes of Rosacea:
Erythematotelangiectatic, papulopustular, ocular, and phymatous.
Chronic inflammation may progress to rhinophyma (enlarged nose; in males). Ocular involvement is also common (e.g., gritty, conjunctival injection, styes, photophobia).
Investigations include clinical diagnosis; uncommonly, skin biopsy is indicated to rule out lupus or sarcoidosis.
Similar conditions that needs to be differentiated from Rosacea are: Acne, lupus erythematosus, perioral dermatitis, sarcoidosis, seborrheic dermatitis.
Treatment of Rosacea is based on severity and subtype.
Lifestyle modification:
Avoid triggers; sun protection and avoidance; facial massage for lymphedema.
Topical antibiotics:
Metronidazole 0.75% gel or 1% cream bid.
Sodium sulfacetamide lotion 10% bid.
Oral antibiotics (moderate to severe cases with inflammatory papulopustular component):
Tetracycline 500 mg po bid
Minocycline 100 mg po od—bid.
Doxycycline 20 mg po bid (subantimicrobial dose therapy) or 100 mg po qd–bid.
Isotretinoin (low dose); less commonly, topical retinoids may be used.
Laser therapy (e.g., PDL, IPL) for telangiectases and ablative laser (e.g., CO2) for rhinophyma.
Camouflage makeup (e.g., Dermablend, Covermark) for erythema.
Ophthalmologist to assess for ocular Rosacea (blepharitis, conjunctivitis, episcleritis).
Monday, July 21, 2008
Rosacea: Make-Up Techniques
For those who have red splotches caused by rosacea or natural light skin pigment, Eve delivers a method that ensures a quick fix.
Tuesday, July 8, 2008
Ocular Rosacea
Ocular Rosacea
The exact prevalence of ocular involvement in patients with Acne Rosacea is unknown, although it has been reported to be as low as 3 percent and as high as 58 percent. The disease may begin in the eye and escape diagnosis for a long time, even years, and be accompanied by inappropriate treatments. Ocular manifestations may develop prior to cutaneous manifestations in up to 20 percent of patients with Ocular Rosacea. Approximately half of these patients develop skin lesions first, and a minority develop both manifestations simultaneously. The Ocular complications are independent of the severity of facial rosacea. However, there is a strong correlation between the degree of eye involvement and tendency to flushing.
The Ocular signs are variable including blepharitis, conjunctivitis, iritis, iridocyclitis, hypopyoniritis, and even keratitis The term Ocular rosacea (ophthalmorosacea) covers all these signs, also discourteously referred to as rabbit eyes.
Rosacea keratitis has an unfavorable prognosis, and in extreme cases can lead to blindness because of corneal opacity. The most frequent eye sign, which may never progress, is chronically inflamed margins of the eyelids, with scales and crusts, quite similar to seborrheic dermatitis, with which it is often confused. Pain and photophobia may be present. It is instructive to ask rosacea patients how their eyes react to bright sunlight. All patients with progressive rosacea should be seen by an ophthalmologist for a thorough examination to detect other subclinical complications. Indeed, such rosacea patients are ideally managed by the cooperative efforts of the dermatologist and the ophthalmologist.
Management of the Ocular disease requires both systemic and topical treatment, including lid hygiene, lubrication, and, occasionally, short-term topical corticosteroids.
The exact prevalence of ocular involvement in patients with Acne Rosacea is unknown, although it has been reported to be as low as 3 percent and as high as 58 percent. The disease may begin in the eye and escape diagnosis for a long time, even years, and be accompanied by inappropriate treatments. Ocular manifestations may develop prior to cutaneous manifestations in up to 20 percent of patients with Ocular Rosacea. Approximately half of these patients develop skin lesions first, and a minority develop both manifestations simultaneously. The Ocular complications are independent of the severity of facial rosacea. However, there is a strong correlation between the degree of eye involvement and tendency to flushing.
The Ocular signs are variable including blepharitis, conjunctivitis, iritis, iridocyclitis, hypopyoniritis, and even keratitis The term Ocular rosacea (ophthalmorosacea) covers all these signs, also discourteously referred to as rabbit eyes.
Rosacea keratitis has an unfavorable prognosis, and in extreme cases can lead to blindness because of corneal opacity. The most frequent eye sign, which may never progress, is chronically inflamed margins of the eyelids, with scales and crusts, quite similar to seborrheic dermatitis, with which it is often confused. Pain and photophobia may be present. It is instructive to ask rosacea patients how their eyes react to bright sunlight. All patients with progressive rosacea should be seen by an ophthalmologist for a thorough examination to detect other subclinical complications. Indeed, such rosacea patients are ideally managed by the cooperative efforts of the dermatologist and the ophthalmologist.
Management of the Ocular disease requires both systemic and topical treatment, including lid hygiene, lubrication, and, occasionally, short-term topical corticosteroids.
Topical Rosacea Treatment
Topical Rosacea Treatment
Acne Rosacea patients have a skin that is unusually vulnerable to chemical and physical insults. All sources of local irritation, such as soaps, alcoholic cleansers, tinctures, astringents, abrasives, and peeling agents must be avoided. Only mild soaps or cleansers are advised. Protection against sunlight must be emphasized.
Antibiotics, as used in acne, are sometimes effective. Topical tetracyclines, clindamycin, and erythromycin, usually in concentrations from 0.5% to 2.0%, are commercially available. Erythromycin and clindamycin seem to be superior. Tetracycline is effective orally, but a disappointment topically. An inhibition of chemotaxis or inflammatory cells or a direct effect on vascular endothelium may be responsible for its action.
Metronidazole has become an important addition to the Anti-Rosacea repertoire. The observation that topical metronidazole was comparable in its effects to oral tetracycline (250 mg bid) led to placebo-controlled double-blind clinical studies demonstrating its effectiveness. In many countries throughout the world there is a 0.75% gel, cream, or lotion, as well as a 1% cream available. It is applied once or twice daily and has its greatest effect on papules and pustules, and reduces erythema to a lesser degree. It does not alter telangiectases or flushing. Topical metronidazole may be used as monotherapy or, in more severe forms, in combination with oral antibiotics. One study found that 0.75% metronidazole gel rapidly reduced inflammatory lesions during the first 3 weeks of treatment, potentially allowing quick tapering and discontinuation of oral medication. Long-term use of 0.75% metronidazole gel has been shown to keep Acne Rosacea in remission. A study involving 88 patients whose Acne Rosacea was initially controlled with a combination of oral tetracycline and metronidazole found that more than 80 percent of those patients given metronidazole remained in remission after 6 months, while 40 percent of those patients given placebo relapsed. The mechanism by which metronidazole ameliorates the inflammatory lesions and erythema of Acne Rosacea may be related to anti-inflammatory or immunosuppressive actions of the drug.
Imidazoles are also gaining popularity with the treatment of Acne Rosacea. Best results are with ketoconazole cream applied once or twice daily. The imidazoles are anti-inflammatory agents, affect gram-positive bacteria, and, above all, are well tolerated by most Acne Rosacea patients with sensitive skin.
Old-time remedies should not be forgotten, even though their use is not supported by evidence-based trials. Drying lotions fall into this category, with a very thin application at night recommended. Lotions with 2% to 5% sulfur have been used successfully. Because they are messy, we no longer use them. Other topical medications proven effective for treating Acne Rosacea include sulfacetamide sodium 10% lotion, as well as sulfacetamide sodium 10% and sulfur 5% lotion, which may be tinted or tint free. They are used in a similar fashion and for the same purpose as metronidazole.
Retinoids are worth a trial. In an uncontrolled clinical study, women with Acne Rosacea used 0.025% tretinoin cream over a period of several months. After a predictable early exacerbation of symptoms, the patients then appeared to develop hardening and side effects diminished. Gratifying long-term results were reported, including a reduction in erythema. Alternative topical retinoids may prove easier to use. There is preliminary evidence that 0.2% isotretinoin in a bland cream is helpful. It is less irritating than tretinoin, and suppresses inflammatory lesions in stage II and III Acne Rosacea. No data exist for adapalene, which seems to be the least irritating of all topical retinoids.
In a clinical study, 20% azelaic acid cream was more effective than its vehicle cream in reducing the number of inflammatory lesions and degree of erythema associated with Acne Rosacea. In a recent study, 20% azelaic acid cream gave results comparable to 0.75% metronidazole cream with the added benefit of increased patient satisfaction. The efficacy of azelaic acid in Acne Rosacea may be due to the anti-inflammatory properties of this compound.
As stated earlier, Demodex folliculorum mites are not considered to play a causative role in Acne Rosacea, although massive infestation of Demodex folliculorum mites may sometimes aggravate the condition. Nevertheless, it is good to check for mites. This is best done with the skin-surface biopsy technique of placing a drop of cyanoacrylate on a glass slide that is covered with immersion oil and analyzed with the 10 or 20 × objective in the light microscope. The mites are hard to control with any of the antiparasitic drugs such as lindane (hexachlorocyclohexane), crotamiton, permethrin, or benzyl benzoate. The effect of treatment on the mite population can be monitored by cyanoacrylate skin-surface biopsies.
Sunscreens, preferably of the broad spectrum UVA plus UVB and infrared type, with a skin protection factor (SPF) of 15 or higher are always recommended to Acne Rosacea patients and should be used every day of the year. The sunscreens with a base of micronized zinc oxide or titanium oxide are nonirritating and work well for anyone with the sensitive skin of Acne Rosacea, but they leave sometimes an opaque hue on the skin, especially in the spacious facial pores. For this reason patients often turn away from these products.
Glucocorticoids should never be used. The only exception is with Acne Rosacea conglobata and Acne Rosacea fulminans. In these patients, short courses of oral and topical glucocorticoids are a reasonable option because of their anti-inflammatory properties.
Acne Rosacea patients have a skin that is unusually vulnerable to chemical and physical insults. All sources of local irritation, such as soaps, alcoholic cleansers, tinctures, astringents, abrasives, and peeling agents must be avoided. Only mild soaps or cleansers are advised. Protection against sunlight must be emphasized.
Antibiotics, as used in acne, are sometimes effective. Topical tetracyclines, clindamycin, and erythromycin, usually in concentrations from 0.5% to 2.0%, are commercially available. Erythromycin and clindamycin seem to be superior. Tetracycline is effective orally, but a disappointment topically. An inhibition of chemotaxis or inflammatory cells or a direct effect on vascular endothelium may be responsible for its action.
Metronidazole has become an important addition to the Anti-Rosacea repertoire. The observation that topical metronidazole was comparable in its effects to oral tetracycline (250 mg bid) led to placebo-controlled double-blind clinical studies demonstrating its effectiveness. In many countries throughout the world there is a 0.75% gel, cream, or lotion, as well as a 1% cream available. It is applied once or twice daily and has its greatest effect on papules and pustules, and reduces erythema to a lesser degree. It does not alter telangiectases or flushing. Topical metronidazole may be used as monotherapy or, in more severe forms, in combination with oral antibiotics. One study found that 0.75% metronidazole gel rapidly reduced inflammatory lesions during the first 3 weeks of treatment, potentially allowing quick tapering and discontinuation of oral medication. Long-term use of 0.75% metronidazole gel has been shown to keep Acne Rosacea in remission. A study involving 88 patients whose Acne Rosacea was initially controlled with a combination of oral tetracycline and metronidazole found that more than 80 percent of those patients given metronidazole remained in remission after 6 months, while 40 percent of those patients given placebo relapsed. The mechanism by which metronidazole ameliorates the inflammatory lesions and erythema of Acne Rosacea may be related to anti-inflammatory or immunosuppressive actions of the drug.
Imidazoles are also gaining popularity with the treatment of Acne Rosacea. Best results are with ketoconazole cream applied once or twice daily. The imidazoles are anti-inflammatory agents, affect gram-positive bacteria, and, above all, are well tolerated by most Acne Rosacea patients with sensitive skin.
Old-time remedies should not be forgotten, even though their use is not supported by evidence-based trials. Drying lotions fall into this category, with a very thin application at night recommended. Lotions with 2% to 5% sulfur have been used successfully. Because they are messy, we no longer use them. Other topical medications proven effective for treating Acne Rosacea include sulfacetamide sodium 10% lotion, as well as sulfacetamide sodium 10% and sulfur 5% lotion, which may be tinted or tint free. They are used in a similar fashion and for the same purpose as metronidazole.
Retinoids are worth a trial. In an uncontrolled clinical study, women with Acne Rosacea used 0.025% tretinoin cream over a period of several months. After a predictable early exacerbation of symptoms, the patients then appeared to develop hardening and side effects diminished. Gratifying long-term results were reported, including a reduction in erythema. Alternative topical retinoids may prove easier to use. There is preliminary evidence that 0.2% isotretinoin in a bland cream is helpful. It is less irritating than tretinoin, and suppresses inflammatory lesions in stage II and III Acne Rosacea. No data exist for adapalene, which seems to be the least irritating of all topical retinoids.
In a clinical study, 20% azelaic acid cream was more effective than its vehicle cream in reducing the number of inflammatory lesions and degree of erythema associated with Acne Rosacea. In a recent study, 20% azelaic acid cream gave results comparable to 0.75% metronidazole cream with the added benefit of increased patient satisfaction. The efficacy of azelaic acid in Acne Rosacea may be due to the anti-inflammatory properties of this compound.
As stated earlier, Demodex folliculorum mites are not considered to play a causative role in Acne Rosacea, although massive infestation of Demodex folliculorum mites may sometimes aggravate the condition. Nevertheless, it is good to check for mites. This is best done with the skin-surface biopsy technique of placing a drop of cyanoacrylate on a glass slide that is covered with immersion oil and analyzed with the 10 or 20 × objective in the light microscope. The mites are hard to control with any of the antiparasitic drugs such as lindane (hexachlorocyclohexane), crotamiton, permethrin, or benzyl benzoate. The effect of treatment on the mite population can be monitored by cyanoacrylate skin-surface biopsies.
Sunscreens, preferably of the broad spectrum UVA plus UVB and infrared type, with a skin protection factor (SPF) of 15 or higher are always recommended to Acne Rosacea patients and should be used every day of the year. The sunscreens with a base of micronized zinc oxide or titanium oxide are nonirritating and work well for anyone with the sensitive skin of Acne Rosacea, but they leave sometimes an opaque hue on the skin, especially in the spacious facial pores. For this reason patients often turn away from these products.
Glucocorticoids should never be used. The only exception is with Acne Rosacea conglobata and Acne Rosacea fulminans. In these patients, short courses of oral and topical glucocorticoids are a reasonable option because of their anti-inflammatory properties.
Sunday, July 6, 2008
Systemic Rosacea Treatment
Systemic Rosacea Treatment
ANTIBIOTICS
The most agreeable feature of Acne Rosacea is that it generally responds well to oral antibiotics. Tetracycline-HCl, oxytetracycline, doxycycline, and minocycline are usually quite effective in controlling papulopustular Acne Rosacea and even reducing erythema. It is important to start with full doses, for example, 1.0 to 1.5 g tetracycline-HCl or oxytetracycline per day. Likewise 50 mg of minocycline (our own choice) or doxycycline twice daily can be given. If tetracyclines are ineffective or not tolerated, erythromycin or other macrolides such as clarithromycin 34 or azithromycin 35 may be used. As soon as full control of papulopustules is achieved, usually after 2 to 3 weeks, maintenance doses of 250 to 500 mg tetracycline-HCl or oxytetracycline, or 50 mg minocycline or doxycycline per day or every other day are generally sufficient. Acne Rosacea sufferers often know how to titrate disease activity and vary dosage accordingly. Some get by with 250 mg tetracycline-HCl every other day. The sufferer's input should be encouraged and antibiotic usage should be carefully monitored. The disease has exacerbations and remissions and topical drugs may be sufficient during inactive periods. Some sufferers seem to become “addicted” to oral antibiotics and find ways to get them without prescription. Tetracycline therapy is mandatory for ophthalmic Acne Rosacea.
ISOTRETINOIN
This drug is exceptionally effective, although accompanied by far greater risks than tetracyclines. Before using it, one has to consider indications, contraindications, and all risks. Isotretinoin may be appropriate for all forms of severe or therapy-resistant Acne Rosacea, especially the variants which are unresponsive to antibiotics, such as lupoid Acne Rosacea, stage III Acne Rosacea, Acne Rosacea conglobata, gram-negative Acne Rosacea, and Acne Rosacea fulminans. It is particularly helpful in sufferers who have oily, wide-pored skin and multiple, often many dozens of sebaceous gland hyperplasias. Furthermore, all forms of phymas are worthwhile indications. The dose required for the control of severe Acne Rosacea varies. Tailored doses are recommended. The standard dose of isotretinoin is lower than in acne, namely 0.2 to 0.5 mg/kg body weight per day. Side effects on the eyes make this low dose unbearable for some sufferers. Ophthalmic Acne Rosacea may get worse, complaints of dry eyes can increase, and so can blepharitis. This may lead to the inability to use contact lenses. The standard dose is only used in Acne Rosacea fulminans, or preoperatively for a couple of months to shrink rhinophyma before surgical reduction of the bulbous nose. More recent studies demonstrate the efficacy of low-dose isotretinoin in the treatment of Acne Rosacea. In this schedule, initially 10 mg or 20 mg daily (not adjusted to body weight) are used. This dose is helpful in many forms of the disease, especially stage III Acne Rosacea, lupoid Acne Rosacea, and persistent edema in Acne Rosacea. After 1 to 2 months, this is further reduced to 10 mg every other day or even to two or three of seven days per week. Side effects on the eyes are minimal. Duration of therapy is longer as with the standard dose, for about 6 months. The cumulative dose, however, is very low. The usual precautions apply as in the therapy of acne. Isotretinoin is a teratogen and is contraindicated for women of childbearing age unless the sufferer meets all the requirements printed in detail in the package insert. Laboratory monitoring includes liver transaminases, bilirubin, cholesterol, and triglycerides before therapy and at monthly or bimonthly intervals thereafter.
METRONIDAZOLE
This is a synthetic nitroimidazole-derivative antibacterial and antiprotozoal agent for the treatment of infections caused by Trichomonas vaginalis, Entamoeba histolytica, and several anaerobic organisms. The usual dose is 500 mg twice daily for 6 days. Oral metronidazole is generally effective in all types of Acne Rosacea, including stage II and III. However, it may require 20 to 60 days to achieve control with a daily dose of 500 mg. The use of oral metronidazole is limited by concerns over adverse systemic effects and toxicity with long-term therapy, and it is not approved for Acne Rosacea treatment. Consequently, oral metronidazole is a second-line drug that may be tried when other methods are not working. It is very helpful for the treatment of Demodex folliculitis, even its worst form, such as Demodex-associated abscesses and furunculoid nodules. The dose is 750 to 1500 mg daily in divided doses for 10 to 14 days.
ANTIBIOTICS
The most agreeable feature of Acne Rosacea is that it generally responds well to oral antibiotics. Tetracycline-HCl, oxytetracycline, doxycycline, and minocycline are usually quite effective in controlling papulopustular Acne Rosacea and even reducing erythema. It is important to start with full doses, for example, 1.0 to 1.5 g tetracycline-HCl or oxytetracycline per day. Likewise 50 mg of minocycline (our own choice) or doxycycline twice daily can be given. If tetracyclines are ineffective or not tolerated, erythromycin or other macrolides such as clarithromycin 34 or azithromycin 35 may be used. As soon as full control of papulopustules is achieved, usually after 2 to 3 weeks, maintenance doses of 250 to 500 mg tetracycline-HCl or oxytetracycline, or 50 mg minocycline or doxycycline per day or every other day are generally sufficient. Acne Rosacea sufferers often know how to titrate disease activity and vary dosage accordingly. Some get by with 250 mg tetracycline-HCl every other day. The sufferer's input should be encouraged and antibiotic usage should be carefully monitored. The disease has exacerbations and remissions and topical drugs may be sufficient during inactive periods. Some sufferers seem to become “addicted” to oral antibiotics and find ways to get them without prescription. Tetracycline therapy is mandatory for ophthalmic Acne Rosacea.
ISOTRETINOIN
This drug is exceptionally effective, although accompanied by far greater risks than tetracyclines. Before using it, one has to consider indications, contraindications, and all risks. Isotretinoin may be appropriate for all forms of severe or therapy-resistant Acne Rosacea, especially the variants which are unresponsive to antibiotics, such as lupoid Acne Rosacea, stage III Acne Rosacea, Acne Rosacea conglobata, gram-negative Acne Rosacea, and Acne Rosacea fulminans. It is particularly helpful in sufferers who have oily, wide-pored skin and multiple, often many dozens of sebaceous gland hyperplasias. Furthermore, all forms of phymas are worthwhile indications. The dose required for the control of severe Acne Rosacea varies. Tailored doses are recommended. The standard dose of isotretinoin is lower than in acne, namely 0.2 to 0.5 mg/kg body weight per day. Side effects on the eyes make this low dose unbearable for some sufferers. Ophthalmic Acne Rosacea may get worse, complaints of dry eyes can increase, and so can blepharitis. This may lead to the inability to use contact lenses. The standard dose is only used in Acne Rosacea fulminans, or preoperatively for a couple of months to shrink rhinophyma before surgical reduction of the bulbous nose. More recent studies demonstrate the efficacy of low-dose isotretinoin in the treatment of Acne Rosacea. In this schedule, initially 10 mg or 20 mg daily (not adjusted to body weight) are used. This dose is helpful in many forms of the disease, especially stage III Acne Rosacea, lupoid Acne Rosacea, and persistent edema in Acne Rosacea. After 1 to 2 months, this is further reduced to 10 mg every other day or even to two or three of seven days per week. Side effects on the eyes are minimal. Duration of therapy is longer as with the standard dose, for about 6 months. The cumulative dose, however, is very low. The usual precautions apply as in the therapy of acne. Isotretinoin is a teratogen and is contraindicated for women of childbearing age unless the sufferer meets all the requirements printed in detail in the package insert. Laboratory monitoring includes liver transaminases, bilirubin, cholesterol, and triglycerides before therapy and at monthly or bimonthly intervals thereafter.
METRONIDAZOLE
This is a synthetic nitroimidazole-derivative antibacterial and antiprotozoal agent for the treatment of infections caused by Trichomonas vaginalis, Entamoeba histolytica, and several anaerobic organisms. The usual dose is 500 mg twice daily for 6 days. Oral metronidazole is generally effective in all types of Acne Rosacea, including stage II and III. However, it may require 20 to 60 days to achieve control with a daily dose of 500 mg. The use of oral metronidazole is limited by concerns over adverse systemic effects and toxicity with long-term therapy, and it is not approved for Acne Rosacea treatment. Consequently, oral metronidazole is a second-line drug that may be tried when other methods are not working. It is very helpful for the treatment of Demodex folliculitis, even its worst form, such as Demodex-associated abscesses and furunculoid nodules. The dose is 750 to 1500 mg daily in divided doses for 10 to 14 days.
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