Thursday 4 September 2014

Rosacea

Rosacea



Rosacea
Classification and external resources
Domenico ghirlandaio, ritratto di nonno con nipote.jpg
An Old Man and His Grandson, by Domenico Ghirlandaio shows skin damage from rhinophyma[1]
ICD-10L71
ICD-9695.3
DiseasesDB96
MedlinePlus000879
eMedicinederm/377
MeSHD012393
Rosacea /roʊˈzeɪʃiə/ is a chronic condition characterized by facial erythema (redness)[2] and sometimes pimples.[3] Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting the eyes (ocular type). Left untreated it worsens over time. Treatment in the form of topical steroids can aggravate the condition.[4]
It primarily affects people of northwestern European descent and has been nicknamed the 'curse of the Celts' by some in Britain and Ireland, although recently this has been questioned.[5] Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.[citation needed]
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.[6] 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.

Classification


Zones
There are four identified rosacea subtypes[7] and patients may have more than one subtype present:[8]:176
  1. Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency toflush and blush easily. It is also common to have small widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and/or itching sensations.[citation needed] People with this ETR type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, symptoms can also appear on the ears, neck, chest, upper back, and scalp.[9]
  2. Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (can last 1–4 days or longer; extremely varied symptoms); 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).[10] Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
  4. Ocular rosacea: Red (due to telangiectasias), dry, irritated or gritty, eyes and eyelids. Watery eyes. Eyelids often develop cysts. Some other symptoms include foreign body sensations, itching, burning, stinging, and sensitivity to light. Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and loss of vision can occur.
There are a number of variants of rosacea, including:[11]:689

Cause

Triggers 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 inhistamines 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. Steroidinduced 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:[12]
  • 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%
It should be noted however that there exists significant disagreement amongst sufferers and clinicians as to the validity of these aggravators/triggers being categorized as causes of rosacea. The claim of rosacea being caused (as opposed to aggravated) by the above list has not been established by epidemiological scientific study.[13] Many sufferers report that elimination of triggers has little or no eventual impact on the actual progression of the disease. The above list should in no way be taken as an explanation of rosacea causes, as the spectrum disease is more complex than simply a direct or sole result of habits and diet.

Cathelicidins

Richard Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin[14] 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.[15]

Intestinal flora

Main article: Small intestinal bacterial overgrowth
Intestinal flora 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 intestinal flora 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 nine months. These patients were also negative when retested for intestinal flora overgrowth. In the 4% of patients that experienced relapse, it was found that intestinal flora overgrowth had returned. These patients were given a second course of rifaximin which again cleared rosacea symptoms and normalized hydrogen excretion.[16]
In another study, it was found that some rosacea patients that tested hydrogen-negative were still positive for intestinal flora 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 antibioticmetronidazole, which is effective at targeting methanogens.[17]
These results suggest that optimal antibiotic therapy may vary between patients and that diverse species of intestinal flora 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.[18] Such a diet would restrict the available substrates for the microorganisms thought to be causative.

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.[19] 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.[20] Demodex has also been implicated in rosacea in that it is theorised to be caused by a reaction to bacteria in the mite's faeces.[21]

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.[22] 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.[23] Laser therapy has also been classified as a form of treatment.[24] 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.[24] [24]Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.[24] [24]

Behaviour

Avoiding physical things or mental states that increase the ability to visibly detect rosacea by a physician are considered a phrase called "trigger avoidance". 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.[25]
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.
Like sunlight, emotional stress can also serve as a trigger for rosacea.
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.[citation needed]
A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.[26]

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.[27] 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.[28] Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed.[29] 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. Some individuals respond well to the topical application of sandalwood oil on the affected area, particularly in reducing the prevalence of pustules and erythema.[citation needed]
The treatment of flushing and blushing has been attempted by means of the centrally acting α-2 agonist clonidine, but this is of limited benefit on just this one aspect of the disorder.[30] The same is true of the beta-blockers like 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).
In 2008, a clinically trialled topical product combining plant-sourced methylsulfonylmethane (MSM) and silymarin showed effectiveness in one study treating rosacea, skin redness and flushing.[31]

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.[32] They use light to penetrate the epidermis to target the capillaries in thedermis 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.[24]
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.[33][34][35]

Notable cases

Famous people with rosacea include:


                              
                    
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