ROSACEA - CLINICAL ISSUES

News-Medical.Net
Common clinical problem, Rosacea
Posted By: News-Medical in Medical Condition News
Published: Thursday, 24-Feb-2005

The New England Journal of Medicine (NEJM) this week features a case study of a common clinical problem, Rosacea.
A number of clinical symptoms and signs are included under the broad group Rosacea. Facial flushing, the appearance of broken blood vessels and persistent redness of the face, eruption of inflamed spots & pimples, on the face and thickening of the sebaceous glands of the nose, with swelling & congestion in that area. Changes in the eyes are present in more than 50 percent of patients and range from mild dryness and irritation with inflammation of the eyelid and & conjunctivitis (common symptoms), to a sight-threatening, but rare, disease of the cornea.
Patients with Rosacea may experience increased sensitivity of the facial skin and may have dry, flaking facial dermatitis, swelling of the upper face, or persistent spots & pimples. Clinical features can overlap, but in the majority of patients, a particular manifestation of Rosacea dominates the clinical picture.

The disease can be classified into four subtypes: -
Erythematotelangiectatic - rash,
Papulopustular - skin eruptions,
Phymatous - swelling,
Ocular - eye infections.

Each subtype is graded according to the severity of the condition; 1 (mild), 2 (moderate), or 3 (severe). The disease can have serious psychological, social, and occupational effects on the patient and these factors should be considered when treatment decisions are being made.

The onset of Rosacea usually occurs between the ages of 30 and 50 years. The course of the disease is typically chronic, with remissions and relapses. Some patients can identify exacerbating factors such as heat, alcohol, sunlight, hot beverages, stress, menstruation, certain medications, and certain foods. Rosacea is more common in women than in men, but men with Rosacea are more prone to the development of thickening and distorting skin changes. Rosacea has been reported to be associated with an oily, greasy skin condition-Seborrheic Dermatitis, with migraine headaches in women, and with an infectious gastric disease -Helicobacter pylori. A

Rosacea-like eruption can sometimes occur when fluorinated Corticosteroids and Tacrolimus ointments are used on the facial skin. Two European population studies illustrating the prevalence of Rosacea reported a 1.5 percent and 10 percent incidence, but estimates are complicated by the difficulty of distinguishing between sun damaged skin and genuine cases of Rosacea.

Rosacea can occur in all racial and ethnic groups, but is more common in white, Anglo Saxon groups; it is rarely seen in dark complexions. There is evidence that Rosacea is an hereditary condition.

Unfortunately the common misconception generally held that both the facial redness and the thickening of the nose area are a direct result of excessive alcohol consumption makes Rosacea a socially embarrassing and stigmatizing condition for many patient.

The diagnosis of Rosacea is a clinical one. There is no reliable laboratory test, and biopsy is only justified in ruling out alternative diagnoses;
Diagnosis and therapy varies according to subtype.

1. Erythematotelangiectatic - rash
Flushing, one of the most common presentation of rosacea, is difficult to treat, but the condition may improve with the management of other manifestations, [ psychosocial factors, anxiety or menopause], and the avoidance of provoking or triggering factors,[ certain foods, alcohol or drugs]. Skin inflammations are usually responsive to medical therapies and heal without scarring, whereas damaged blood vessels and swollen areas often require laser or surgical intervention. Prolonged episodes of severe flushing accompanied by sweating, flushing that is not limited to the face, and, especially, symptoms such as diarrhea, wheezing, headache, palpitations, or weakness need further investigations to rule out rare conditions .
Abnormal blood vessels are usually prominent on the cheeks and nose in grades 2 and 3 of this subtype 1, and cause the facial rash. This form of Rosacea is difficult to distinguish from the effects of sun damage sensitive, easily irritated skin, which may be another factor. It is poorly responsive to treatment . The two conditions require similar treatment. Similarities to facial contact dermatitis, & other conditions suggest further investigations may be needed. Studies of the effectiveness of medical treatments offer little evidence to support the effectiveness of treatments.

2. Papulopustular – skin eruptions
Small, eruptions, some of which have tiny pustules, on the central portion of the face, with a background rash distinguish this form of Rosacea. In grade 3 of the disease, inflammed lesions, abnormal blood vessels, swelling, eye inflammation, flushing are all common. Acne and forms of dermatitis are included in this group.
Antibiotics are often the main therapy used. Moderate-to-severe cases may require a variety of therapy to achieve results; milder cases of the disease can often be treated with topical medications alone. Many clinicians recommend a combination of topical and systemic therapies for the treatment of moderate-to-severe cases.
Oral treatments also proved effective, some research suggesting that intermittent low-dose antibiotic treatment may be as effective as multiple daily doses. About one quarter of patients relapse within weeks of therapy ceasing; remission may be maintained with topical therapy for up to six months . some patients skin free of lesions by applying topical therapy on alternate days or twice weekly.

3. Phymatous - swelling
Phymatous Rosacea is rare; the most common symptom being the swelling & redness of the nose. This is a disfiguring condition which occurs much more often in men than women. The diagnosis is usually made on a clinical basis, but a biopsy may be necessary to eliminate other conditions. Clinical experience has shown good results with surgery electrosurgery,& laser therapy.

4. Ocular - eye infections
Ocular Rosacea is common but often not recognized. It may precede, follow, or occur simultaneously with the skin changes typical of Rosacea. In the absence of accompanying skin changes, ocular rosacea can be difficult to diagnose, and there is no test that will confirm the diagnosis. Patients usually have mild, symptoms, such as burning or stinging of the eyes, dryness with poor tear secretion. Mild-to-moderate Ocular Rosacea occurs frequently, whereas serious (grade 3) disease with the potential for visual loss, occurs rarely.

Artificial tears, eyelid hygiene (i.e., cleaning the lids with warm water twice daily), fucidic acid, and metronidazole gel applied to lid margins are treatments that are frequently used to treat mild ocular rosacea. Antibiotics are often additionally required for grade-2-to-3 disease, although limited data are available to support these approaches. such treatment may be inadequate for moderate-to-severe ocular rosacea, and patients with persistent or potentially serious ocular symptoms should be referred to an ophthalmologist.

The causes of Rosacea remain unclear. The possibility of emergence and carriage on the skin of resistant organisms is a concern with regard to the prolonged use of topical and systemic antibiotics. There are no specific guidelines for the management of rosacea.
See http://content.nejm.org/ and http://content.nejm.org/cgi/content/short/352/8/793

A new rosacea treatment or just the same old Metrogel

Last Updated: 2003-11-17 16:00:20 -0400 (Reuters Health)
NEW YORK (Reuters Health) - For people with the skin condition rosacea, a new formulation of an old acne drug relieves symptoms more effectively than a commonly used treatment, researchers report.
In a head-to-head study, people who used the new gel (Finacea, Berlex Laboratories) experienced a greater reduction in rosacea lesions than people treated with the older gel (Metrogel, Galderma Laboratories). Redness also diminished more in people taking Finacea, researchers report in the latest issue of the journal Archives of Dermatology.
The authors received financial compensation from Berlex Laboratories, which makes Finacea. In January 2003, the Food and Drug Administration approved Finacea for treating mild to moderate rosacea.
Rosacea is a common skin condition that is characterized by redness on the nose and cheeks. This redness often occurs after physical activity. Other symptoms include pimple-like lesions and a swollen nose.
Antibiotic ointments may help relieve some symptoms. And a drug called metronidazole - the active ingredient in Metrogel - can alleviate some symptoms of the skin condition.
Previous studies have shown that azelaic acid, a common treatment for acne, is better than a dummy placebo for rosacea. Finacea is an azelaic-acid gel that was designed specifically to treat rosacea.
In the new study, Dr. Boni E. Elewski of the University of Alabama at Birmingham and colleagues compared Finacea and Metrogel in 251 patients with rosacea. Volunteers were randomly assigned to use the azelaic acid gel or the metronidazole gel twice a day for 15 weeks.
Rosacea improved in both groups, but the improvements were greater in people using the azelaic acid gel, Elewski's team reports.
Rosacea-related lesions were reduced significantly more in the azelaic acid gel group. And while the lesion-reducing benefits of metronidazole seemed to plateau after 8 weeks, the number of lesions continued to drop throughout the study in the azelaic acid group.
Facial redness also improved in both groups, but the changes were more pronounced in people using the azelaic acid gel. The severity of redness improved in 56 percent of people using azelaic acid compared to 42 percent of those in the metronidazole group.
None of the participants experienced any severe side effects. More people using the azelaic acid gel stopped treatment or switched to a lower dose than people using the older rosacea treatment, although the numbers were small.
Galderma Laboratories, the Forth Worth, Texas-based company that makes Metrogel, did not respond to the finding by press time.
SOURCE: Archives of Dermatology, November 2003.

Green Tea Helps Reduce Rosacea Redness

Study Shows a Cream Extract from Green Tea is Effective
By Peggy PeckWebMD Medical News
Reviewed By Brunilda Nazario, MDon Wednesday, February 23, 2005

Feb. 22, 2005 -- Green tea may be a safe and beneficial treatment for rosacea.
Green tea already is a favorite among fans of "natural" medicinal products. Now a cream made from an extract of freshly baked green tea leaves may be an effective treatment for a type of acne called papulopustular rosacea.
Women treated with the green tea extract cream had a 70% improvement in rosacea compared with women treated with a placebo says Tanweer Syed, MD, PhD, an associate professor of dermatology at the University of San Francisco, Calif., who developed the tea extract.
The study was presented at the American Academy of Dermatology meeting in San Francisco.
Rosacea is a common skin condition which develops in phases. Typically, it starts with a tendency to blush -- rosy cheeks or redness and swelling in the center of the face which can progress to papulopustular rosacea. Tiny pimples begin to appear in and around the red areas. Treatment can control the symptoms and prevent the condition from getting worse. Untreated, the condition can lead to chronic inflammation; the nose takes on the appearance of becoming red and enlarged.
Syed tested the green tea extract cream in 60 women aged 25 to 50. All had visible signs of rosacea with papules and pustules as well as redness and swelling.
Prior to starting treatment, and weekly after treatment began, photographs were taken of the women's faces.
Half of the women received the green tea extract cream and half received a placebo cream. The women applied the cream to their faces twice a day for four weeks.
At the end of four weeks, "marked beneficial improvement" was observed in both groups, say the researchers. However, treatment with the green tea extract resulted in significantly fewer facial inflammatory lesions than placebo treatment, says Syed. Clear, minimal or mild improvement of inflammation was seen in 70% of the women treated with the extract cream.
Syed says green tea extract cream was a natural choice for the rosacea because earlier research suggested that green tea extract has natural anti-aging and anti-acne properties.
"The green tea has a soothing quality that helps the redness," Syed says.
The difference in this product versus others on the market, he says, is that the green tea leaves are picked and used within five hours, before turning dark and fermenting.
Guy Webster, MD, vice chairman of dermatology at Jefferson Medical College, Philadelphia says the study involved only a small number of participants and more work needs to be done before the cream can be marketed. Webster was not involved in the study.
"However, these results are tantalizing. These women obviously had rosacea and blushing. There is not much you can do for this. But the faces were looking distinctively red and they are coming out not distinctively red," he says.
The study was 75% funded by Syed Skincare, Inc.

Available Treatments for Rosacea

Available Treatments for Rosacea

1. LASER - this treatment is most effective at removing the structurally damaged blood vessels and diminishing some of the constant facial redness. For the past 5 years, the pulsed dye laser has been the ‘gold standard’. However, newer systems such as the Photoderm VL/PL (Intense Pulsed Light Source) are now available. This treatment offers a greater degree of selectivity for the treatment of the superficial facial microvessels (it does not damage facial skin) and can also target the larger and deeper blood vessels. It also effectively treats more extensive areas of the face with less pain and greater speed. Photoderm experts who specialize in the treatment of rosacea are able to achieve good to excellent clearance of telangiectasia and the chronic red face, as well as significantly decrease the intensity and duration of the facial flush or blush in many patients.

2. ISOTRETINOIN (accutane) - this is a vitamin A analog that has been used with much success to treat severe nodulocystic acne, disorders of keratinization and various other dermatological diseases. Isotretinoin works by inhibiting sebaceous gland function and physically shrinking these problematic glands. It also has potent anti-inflammatory properties, which make isotretinoin a good option for the treatment of resistant rosacea patients. It achieves long-term benefits and remission of papules, pustules, rhinophyma and a decrease in facial burning in almost half of the patients. Another benefit is that it allows patients to discontinue the use of acne products resulting in less facial irritation. Some do experience a relapse, but the symptoms are usually much milder. Many physicians find that 1 or 2 courses of low-dose isotretinoin may significantly decrease the severity of the entire disease process. Side effects include dry lips and skin, a transient elevation in cholesterol and triglyceride levels, mild headaches and dry eyes. One serious side effect (and the one that causes most physicians to not use this medication) is that it can cause severe deformities to the unborn fetus. Thus its use is contraindicated for women who are trying to get pregnant or who are not using birth control (at least two forms) while sexually active. With this said, the use of low-dose isotretinoin can be a godsend to many rosacea sufferers.

3. A GENTLE PROTECTIVE BARRIER - It is speculated that the outer layer of facial skin (epidermis), which forms a protective barrier from the outside elements, may be physically or functionally abnormal in many rosacea patients. This could lead to greater penetration of topical products (causing skin irritation and moisture loss) or in an abnormal release of inflammatory mediators from epidermal cells, resulting in a local inflammatory response with a resultant increase in facial blood flow (a facial flare). Therefore, one goal in the treatment of rosacea is to find a protective barrier that helps in normalizing epidermal water-holding properties, thus alleviating environmental or skincare mediated facial flares. Two substances have been shown to exert such beneficial actions - zinc oxide and dimethicone. Zinc oxide is approved by the FDA as a Category I skin protectant. It is used as a soothing preparation for facial redness and steroid-induced thinning of the epidermis. Dimethicone is also a good skin protectant as well as a non-greasy moisturizer. In a recently published clinical article, physicians studying rosacea sensitive skin found that dimethicone significantly decreased irritation to certain skincare products such as sunscreens. The only problem with a zinc oxide-dimethicone protectant cream is that it is usually not very elegant (i.e., it is thick and leaves a white residue on the face). However, with newer technology, skincare laboratories can now micronize zinc oxide into extremely fine particles and then bind it to dimethicone - resulting in a very elegant formulation. This new formulation has been found to be virtually transparent to the naked eye (i.e., it is very elegant), to have the broadest attenuation spectrum of all transparent sunblocks (i.e., it is an excellent sunblock) and to be able to absorb sunlight and remain photostable (i.e., it does not undergo any chemical or structural changes that could decrease its effectiveness or cause facial irritation). This special zinc oxide-dimethicone formulation could prove to be very useful for the daily protection of rosacea-sensitive skin against irritation from sunlight, wind, makeup, and other various skincare products.