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New Treatments for Rosacea

Although rosacea is now recognized as a common skin disorder which develops gradually. Initially, patients may be unaware of their condition and thus not seek medical attention, thinking the redness, flushing, and occasional papules or pustules of rosacea are simply normal flushing, adult acne, or sunburn. However, early recognition is important because untreated rosacea can lead to disfigurement and potential vision impairment.

Range of occurrence

Rosacea is a chronic and progressive dermatosis characterized by erythema, papules and pustules, telangiectasia, and potential hyperplasia over the central portion of the face. There is little information on incidence, but a Swedish study of 809 randomly selected clerical workers (2) showed a prevalence of 14% in women and 5% in men.

Rosacea appears to occur most often in fair-skinned people of northern and eastern European descent, particularly Celtic, English, and Scottish. It often affects multiple members of the same family, presumably because of their similar complexions and genetic heritage. The condition has also been observed in African Americans (3), Koreans (4), and other more highly pigmented individuals, as well as in children (5), but reports of such occurrences are rosasea.

Potential causes

The new therapies for Helicobacter pylori in peptic ulcer disease have occasionally been associated with an improvement.

Diagnosis and stages

Trauma (ie, cold injury), prolonged sun exposure, or exposure to irritants (eg, soap, benzoyl peroxide) is often sufficient.

Target areas for all symptoms include the cheeks, nose, chin, and forehead (figure 1: not shown). Women are more likely to show symptoms on the chin and cheeks (figure 2: not shown). In men, symptoms occur somewhat more often on the nose, and rhinophyma is far more common in men than in women. Symptoms on the forehead occur at similar rates.

Rosacea is characterized by periods of remission and relapse and occurs in three stages. A prerosacea stage can be identified in susceptible individuals before first-stage symptoms become evident.

The first stage is vascular. Transient erythema appears over central areas of the face (figure 3: not shown), and fine telangiectasia may develop. Ocular lesions may also occur. The disorder often progresses to the second stage within a year.

Ocular signs appear in advance of facial symptoms in probably about 20% of patients. Therefore, eyelid symptoms such as inflammation, swelling, redness, or presence of crusted mucus as well as burning, dryness, or foreign body sensation may indicate incipient rosacea even in the absence of dermatologic or other signs (9).

Managing the symptoms and the emotions

Appropriate management of rosacea can control symptoms and prevent severe complications. Medical therapy.

Medical therapy
Each flare-up contributes damage that may exacerbate further eruptions; thus treatment is advisable to halt disease progression as well as to control current symptoms.

An initial dose of an oral antibiotic, usually tetracycline in doses of less than 0.5 g/day up to 1.5 g/day, is often prescribed to bring rosacea under immediate control. Erythromycin, clarithromycin (Biaxin) or, especially in refractory cases, ampicillin.

Typically, oral medication is gradually tapered and is accompanied and/or followed by a topical antibiotic, usually metronidazole 0.75% (MetroCream, MetroGel) or metronidazole 1.0% (Noritate). Long-term use of topical antibiotics.

One study involving 59 rosacea patients (10) found that metronidazole 0.75% rapidly reduced inflammatory lesions.

Long-term use of topical metronidazole 0.75% has also been shown to keep rosacea in remission.

Topical metronidazole 0.75% has been associated with a low incidence of adverse reactions, ranging from less than 2% to 3%.

Metronidazole has been the most extensively studied therapy for rosacea, but not all patients show a response to it. To reduce background erythema in patients in whom irritation is a significant factor, a class V or VI corticosteroid lotion, such as desonide (DesOwen, Tridesilon), aclometasone dipropionate (Aclovate), or flurandrenolide (Cordran).

Counseling

A variety of factors can be involved, and those that affect one patient may not affect another (table 2). Flare-ups are often triggered by environmental and lifestyle factors, most of which seem to be related to flushing, and may also result from reaction to medications, including fluorinated corticosteroids, vasodilators (13), angiotensin-converting enzyme inhibitors.

As with allergy patients, rosacea patients should record the risk factors they encounter each day (see Patient Diary Checklist: not shown) to establish an individual risk-factor profile. Patients should be advised to monitor their condition.

Surgical therapy
Telangiectasia and rhinophyma do not respond to medical therapy; however, there are several surgical alternatives. The pulse dye laser can be used to eradicate telangiectasia and help shrink a bumpy, swollen nose.

In patients with rhinophyma, the CO2 laser can be used as a bloodless scalpel to remove excess tissue and recontour the nose; this procedure does require local anesthesia. Dermabrasion, sculpting with a scalpel, or hot loop electrocoagulation.