Rosacea

Definition:
Rosacea has been defined as a persistent redness of the central part of the face lasting for at least three months, and often including features such as flushing, red lumps and pustules, and small dilated blood vessels. Exactly which symptoms develop defines which particular subtype of rosacea is present.

It primarily affects Caucasians of mainly northwestern European descent and has been nicknamed the ‘curse of the Celts’ by some in Britain and Ireland, but can also affect people of other ethnicities. Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.

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. 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.

Clasifications:
There are four identified rosacea subtypes  and patients may have more than one subtype present :176:

1.Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning or itching sensations.

2.Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (which typically last 1–4 days); 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).   Small blood vessels visible near the surface of the skin (telangiectasias) may be present.

4.Ocular rosacea: Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.
There are a number of variants of rosacea including:689

*Rosacea conglobata…....click & see
*Rosacea fulminans…...click & see
*Phymas in rosacea…….click & see

Symptoms:
Signs and symptoms of rosacea i.nclude:

*Red areas on your face

*Small, red bumps or pustules on your nose, cheeks, forehead and chin (but not the same as whiteheads or blackheads)

*Red, bulbous nose (rhinophyma)

*Visible small blood vessels on your nose and cheeks (telangiectasia)

*Burning or gritty sensation in your eyes (ocular rosacea)

*Tendency to flush or blush easily
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Rosacea usually appears in phases:

*Pre-rosacea. Rosacea may begin as a simple tendency to flush or blush easily, and then progress to a persistent redness in the central portion of your face, particularly your nose. This redness results from the dilation of blood vessels close to your skin’s surface. This phase may sometimes be referred to as pre-rosacea.Vascular rosacea. As signs and symptoms worsen, vascular rosacea may develop — small blood vessels on your nose and cheeks swell and become visible (telangiectasia). Your skin may become overly sensitive.

* Vascular rosacea may also be accompanied by oily skin and dandruff.

*Inflammatory rosacea. Small, red bumps or pustules may appear and persist, spreading across your nose, cheeks, forehead and chin. This is sometimes known as inflammatory rosacea.

In addition, about 1 in 2 people with rosacea also experience ocular rosacea — a burning and gritty sensation in the eyes. Rosacea may cause the inner skin of the eyelids to become inflamed or appear scaly, a condition known as conjunctivitis.

Late in the course of rosacea, some people, mainly middle-aged men, may develop red, round, raised bumps (papules) and a bulbous nose, a condition known as rhinophyma.

Causes:
Although the cause isn’t known, a number of factors which may play a part have been identified.
CauseTriggers 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:

*Sun exposure 81%
*Emotional stress 79%
*Hot weather 75%
*Wind 57%
*Heavy exercise 56%
*Alcohol consumption 52%
*Hot baths 51%
*Cold weather 46%
*Spicy foods 45%
*Humidity 44%
*Indoor heat 41%
*Certain skin-care products 41%
*Heated beverages 36%
*Certain cosmetics 27%
*Medications (specifically stimulants) 15%
*Medical conditions 15%
*Certain fruits 13%
*Marinated meats 10%
*Certain vegetables 9%
*Dairy products 8%

Cathelicidins
Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin   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.

Intestinal bacteria
Intestinal bacteria 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 bacterial 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 bacterial overgrowth. In the 4% of patients that experienced relapse, it was found that bacterial overgrowth had returned. These patients were given a second course of rifaximin which again cleared rosacea symptoms and normalized hydrogen excretion.

In another study, it was found that some rosacea patients that tested hydrogen-negative were still positive for bacterial 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 methanogenic intestinal bacteria.

These results suggest that optimal antibiotic therapy may vary between patients and that diverse species of intestinal bacteria 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.  Such a diet would restrict the available material necessary for bacterial fermentation and thereby reduce intestinal bacterial populations.

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Demodex mites:
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.  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.
Risk Factors:
Although anyone can develop rosacea, you may be more likely to develop rosacea if you:

*Have fair skin and light hair and eye color
*Are between the ages of 30 and 60, especially if you’re going through menopause
*Experience frequent flushing or blushing
*Have a family history of rosacea

Complications:
In severe and rare cases, the oil glands (sebaceous glands) in your nose and sometimes your cheeks become enlarged, resulting in a buildup of tissue on and around your nose — a condition called rhinophyma (ri-no-FI-muh). This complication is much more common in men and develops slowly over a period of years.

Diagnosis:
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:
Treating rosacea varies depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists.  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.   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.  Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.

Behaviour
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..

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.

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.

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

Medications:
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.  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.  Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.  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.

The treatment of flushing and blushing has been attempted by means of the centrally acting ?-2 agonist clonidine, but this is of limited benefit on just this one aspect of the disorder.  The same is true of the beta-blockers 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 product range combining plant-sourced methylsulfonylmethane (MSM) and silymarin has been used to treat rosacea, skin redness and flushing.

Laser:
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.   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
Lifestyle & Homeremedies:
One of the most important things you can do if you have rosacea is to minimize your exposure to anything that causes a flare-up. Find out what factors affect you so that you can avoid them. Keep a list of things that trigger your flare-ups, and try to avoid your triggers.

Here are other suggestions for preventing flare-ups:

*Wear broad-spectrum sunscreen with a sun protection factor (SPF) of 30 or higher to protect your face from the sun.

*Protect your face in the winter with a scarf or ski mask.

*Avoid irritating your facial skin by rubbing or touching it too much.

*Wash problem areas with a gentle cleanser (Dove, Cetaphil).

*Avoid facial products that contain alcohol or other skin irritants.

*When using moisturizer and a topical medication, apply the moisturizer after the medication has dried.

*Use products that are labeled noncomedogenic. These won’t clog your oil and sweat gland openings (pores) as much.

*Avoid overheating.

*If you wear makeup, consider using green- or yellow-tinted pre-foundation creams and powders, because they’re designed to counter skin redness.

*Avoid drinking alcohol.

Alternative medicine:

Many alternative therapies — including colloidal silver, emu oil, laurelwood, oregano oil and vitamin K — have been touted as possible ways to treat rosacea. However, there’s no conclusive evidence that any of these alternative therapies are effective.

If you’re considering dietary supplements or other alternative therapies to treat rosacea, consult your doctor. He or she can help you weigh the pros and cons of specific alternative therapies.
Prognosis:
Rosacea tends to wax and wane over time but eventually, with the use of treatment, most people reach a fairly stable state of relative control of their condition.

Disclaimer: This information is not meant to be a substitute for professional medical advise or help. It is always best to consult with a Physician about serious health concerns. This information is in no way intended to diagnose or prescribe remedies.This is purely for educational purpose.

Resources:
http://www.mayoclinic.com/health/rosacea/DS00308
http://www.bbc.co.uk/health/physical_health/conditions/rosacea1.shtml
http://en.wikipedia.org/wiki/Rosacea
http://www.rosacea.org/patients/allaboutrosacea.php
http://wegoodinfo.com/rosacea-symptoms/

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