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ROSACEA Dr. Charlene DeHaven M.D. Papules and pustules may be visible in rosacea as in Clinical Director, INNOVATIVE SKINCARE ® acne. However, sebaceous plugging is not causative in rosacea as it is in acne. There may be bacterial PREVALENCE overgrowth as the disease becomes more severe, but Rosacea is a common but greatly misunderstood the presence of bacteria is also not causative as disorder of the facial skin that is estimated to affect in acne. upwards of 14 million adult Americans, with approximately only 25% of the population even aware The first stage of rosacea is merely vascular of it. This serious disorder is known to affect more hyperreactivity. This can occur in the 20s or 30s and is women than men; however, men are far more likely to usually not identified as rosacea. In fact, rosacea seek treatment. Specifically, more men develop the progresses so gradually that it may go completely advanced sequelae of severe telangiectasias (dilated undetected and undiagnosed, even after the facial blood vessels, or spider veins) and rhinophyma (red, changes are obvious. The early stage is very difficult to bulbous nose). treat, except, for particular individuals, by avoiding some triggers (listed on page 2). As rosacea typically begins between the ages of 30 and 50, the first stages may be barely detectable by the During the course of rosacea, at least 50% of patients patient and not at all by others. The most common have some type of ocular (eye-related) symptom. age for onset is in the 40s and 50s. The vascular Ocular symptoms can be found in the first stage and reactivity seen in rosacea is most common in may be the only symptoms the patient notices; fair-skinned individuals of Irish and Scandinavian however, ocular symptoms are frequently found as the descent and is seen in persons who already have disease progresses. Ocular complaints may include dry vascular hyperreactivity, or tendency for the central eye, stye development, contact lens intolerance, face to redden easily (e.g., those who blush easily). redness of the eyelids, or even corneal damage with ulcerations. When the patient complains only of eye ETIOLOGY (CAUSE) AND PROGRESSION OF DISEASE symptoms, the term ocular rosacea is sometimes used. Rosacea is a chronic and progressive disease with many flare-ups and remissions. The etiology of rosacea lies After an initial stage of intermittent facial flushing, the with hyperresponsiveness of the blood vessels of the disease most often progresses to constant erythema central face. Exactly why some people develop rosacea (redness) of the cheeks, forehead, chin, and nose; and others do not is uncertain. A number of factors stinging or burning of the face; increased pore size; may play a role, including genetic background, and ocular symptoms. Then papules and pustules composition of skin microflora, individual inflammatory develop, telangiectasias appear, and nasal bumps that mediators, individual triggers, and others. Alcohol was increase in number and size until, finally, rhinophyma once thought to be causative, but it has never been occurs. Rhinophyma is certainly disfiguring, and even proven to be linked directly to the development of the the papular/pustular stage is very unattractive. The disease. However, alcohol does cause vasodilatation skin and subcutaneous (just below the skin) tissue of and can serve as a disease trigger. the nose are affected by rhinophyma, but the supporting structures of cartilage and bone remain intact and are not affected. The lack of involvement of 1 www.innovativeskincare.com All materials contained on this document are protected by United States copyright law. You may not modify, remove, delete, publish, transmit, reproduce or in any way exploit the content of this document, in whole or in part. © 2014 Science of Skincare, LLC. All rights reserved. the supporting framework of the nose makes been known for some time, persons with rosacea used rhinophyma more amenable to surgical treatment than to be assumed to be alcoholics. The occurrence of it would be if these structures were affected. rosacea does not mean the individual is an alcoholic. Rosacea can be considered an age-related disease. DISEASE TRIGGERS Even though the very first symptoms of disease can The following substances are known to trigger rosacea, appear in the 20s, 30s, or 40s, most people are not although this occurs with varying frequency. The most actually diagnosed with rosacea until their 40s or 50s well-known trigger is alcohol. It should be emphasized because of its slow, gradual progression. again that the occurrence of rosacea should not label a person an alcoholic. The occurrence of rosacea, The progression of this disorder also means that however, will cause the physician to recommend patients’ quality of life can be affected. Degrees of avoidance of alcohol since this is such a psychological distress range from mild to severe. common trigger. Individuals affected may quantify the severity of their symptoms according to the RosaQol, a 21-question Foods also can be common triggers. Potential food quality-of-life rating scale describing the individual’s triggers include hot peppers, Mexican food, Thai food, symptom severity. The RosaQol is a standardized red pepper, hot sausage, black pepper, vinegar, assessment tool which is well-described in the medical paprika, white pepper, and garlic. These foods are literature and commonly used by doctors who treat listed in descending order of reported frequency for rosacea patients. triggering rosacea. Very hot beverages may be a trigger in some patients. Note that these foods also Assessment of the severity of rosacea can be performed are known for causing vasodilatation, which would by the clinician according to the following parameters: lead to flushing. (1) investigator global assessment of rosacea severity (IGA score), (2) erythema, (3) papule/pustule count, Other potential triggers are environmental, such as sun and (4) telangiectasias. exposure and cold weather. Stress also may trigger an exacerbation of symptoms. MISDIAGNOSIS OF ROSACEA Rosacea is commonly misdiagnosed. Rosacea is not TREATMENT acne, although this is its most common mislabeling. Rosacea may prove frustrating to treat, for both patient The cause of rosacea is different from that of acne. and clinician, although several topical and systemic Some of the drugs used to treat rosacea are also used pharmaceuticals are available. The first line of to treat acne, and this may add to the confusion. treatment is to avoid any triggering or exacerbating factors. Topical antibiotics such as metronidazole, Tumors, such as lymphoma, basal cell carcinoma of the azelaic acid, or other agents may be long-term options. nose or face, or squamous cell carcinoma of the nose Topical retinoid therapy may be used along with or face, also may be confused with rosacea in its later systemic treatment with oral antibiotics. In severe stages. This can have disastrous consequences for the cases, surgery (including laser therapy and other patient, leaving a potentially treatable condition to techniques) may be used for unsightly telangiectasias progress to a more serious stage that is much more or rhinophyma. difficult to treat or may even be untreatable. Over-the-counter preparations are often tried by Sarcoid presenting in the nose can appear to be persons with rosacea, either as a first try at treatment rosacea. Because alcohol as a triggering factor has or because of frustration with prescribed medications. 2 www.innovativeskincare.com All materials contained on this document are protected by United States copyright law. You may not modify, remove, delete, publish, transmit, reproduce or in any way exploit the content of this document, in whole or in part. © 2014 Science of Skincare, LLC. All rights reserved. The formulation method and choice of ingredients, including vehicles (dissolving agents), is very vanZuuren EJ et al, “Interventions for Rosacea,” Cochrane Database Syst Rev. 2011 Mar16;(3):CD003262. Lazaridou E et al, “The Potential Role of Microorganisms in the Development of Rosacea,” J DtschDermatolGes (English). 2011Jan;9(1):21-5. important in the efficacy and success of over-the-counter products. PRODUCT RECOMMENDATIONS iS CLINICAL ® products recommended for rosacea include CREAM CLEANSER, CLEANSING COMPLEX, HYDRA-COOL ® SERUM, YOUTH EYE ™ COMPLEX, Del Rosso JQ, “Effectiveness and Safety of Doxycycline 40 mg (30 mg Immediate-Release and 10 mg Delayed-Release Beads) Once Daily as Add-On Therapy to Existing Topical Regimens for the Treatment of Papulopustular Rosacea: Results from a Community-Based Trial,” Cutis. 2010Nov;86(5Suppl):16-25. Webster GF, “An Open-Label, Community-Based, 12-Week Assessment of the Effectiveness and Safety of Monotherapy with Doxycycline 40 mg (30 mg Immediate-Release and 10 mg Delayed-Release Beads),” Cutis. 2010Nov;86(5Suppl):7-15. BODY COMPLEX, EYE COMPLEX, MOISTURIZING COMPLEX, and PRO-HEAL ® SERUM ADVANCE + ®. Scheinfeld N et al, “A Review of the Diagnosis and Treatment of Rosacea,” Postgrad Med. 2010 Jan;122(1):139-43. Recommended iS products for rosacea include PROTECTIVE MOISTURIZER SPF 15, EXTREME PROTECT SPF 30, COOLMINT REVITALIZING MASQUE, REPARATIVE MOISTURIZER, RESTORATIVE EYE COMPLEX, and ECLIPSE SPF 50+. Recommended INNOVATIVE SKINCARE ® Professional Products for rosacea include REJUVENATING MASQUE. Odom R et al, “Standard Management Options for Rosacea, Part II: Options According to Subtype,” Cutis. 2009Aug;84(2):97-104. Odom R et al, “Standard Management Options for Rosacea, Part I: Overview and Broad Spectrum of Care,” Cutis. 2009Jul;84(1):43-7. Thiboutot DM et al, “A Multicenter Study of Topical Azelaic Acid 15% Gel in Combination with Oral Doxycycline as Initial Therapy and Azelaic Acid 15% Gel as Maintenance Monotherapy,” J Drugs Dermatol. 2009Jul;8(7):639-4. Nicholson K et al, “A Pilot Quality-of-Life Instrument for Rosacea,” J Am AcadDermatol. 2007Aug;57(2):213-21. REFERENCES Steinhoff M et al, “Clinical, Cellular, and Molecular Aspects in the Pathophysiology of Rosacea,” J InvestigDermatolSymp Proc. 2011 Dec;15(1):2-11. Meyer-Hoffert U et al, “Epidermal Proteases in the Pathogenesis of Rosacea,” J InvestigDermatolSymp Proc. 2011 Dec;15(1):16-23. Nakatsuji T et al, “Antimicrobial Peptides: Old Molecules with New Ideas,” J Invest Dermatol. 2011 Dec8;(Epub). vanZuuren EJ et al, “Effective and Evidence-Based Management Strategies for Rosacea: Summary of a Cochrane Systematic Review,” Br J Dermatol. 2011Oct;165(4):760-81. Wolf JE Jr et al, “The CLEAR Trial: Results of a Large Community-Based Study of Metronidazole Gel in Rosacea,” Cutis. 2007Jan(1):73-80. vanZuuren EJ et al, “Systematic Review of Rosacea Treatments,” J Am AcadDermatol. 2007 Jan;56(1):107-15. Fleischer A et al, “The Face and Mind Evaluation Study: an Examination of the Efficacy of Rosacea Treatment Using Physician Ratings and Patients’ Self-Reported Quality-of-Life,” J Drugs Dermatol. 2005Sep-Oct;4(5):585-90. Buechner SA, “Rosacea: an Update,” Dermatology. 2005;210(2):100-8. Bamford J et al, “Measurement of the Severity of Rosacea,” J Am AcadDermatol. 2004Nov;51(5):697-703. Gallo RL et al, “Microbial Symbiosis with the Innate Immune Defense System of the Skin,” J Invest Dermatol. 2011Oct;131(10):1974-80. Crawford GH et al, “Rosacea: I. Etiology, Pathogenesis, and Subtype Classification,” J Am AcadDermatol. 2004Sep;51(3):327-41. Levin J et al, “A Guide to the Ingredients and Potential Benefits of Over-the-Counter Cleansers and Moisturizers for Rosacea Patients,” J ClinAesthetDermatol. 2011Aug;4(8):31-49. Gupta AK et al, “Critical Review of the Manner in Which Efficacy of Therapies for Rosacea Are Evaluated,”Int J Dermatol. 2003Nov;42(11):909-16. Fleischer AB Jr, “Inflammation in Rosacea and Acne: Implications for Patient Care,” J Drugs Dermatol. 2011 Jun;10(6):614-20. Gessert CE et al, “Measuring the Severity of Rosacea: a Review,”Int J Dermatol. 2003Jun;42(6):444-8. Jackson JM et al, “Topical Rosacea Therapy: The Importance of Vehicles for Efficacy, Tolerability, and Compliance,” J Drugs Dermatol. 2011 Jun;10(6):627-33. DeNoon, “Rosacea,” WebMD Health, Aug 21, 2003. 3 www.innovativeskincare.com All materials contained on this document are protected by United States copyright law. You may not modify, remove, delete, publish, transmit, reproduce or in any way exploit the content of this document, in whole or in part. © 2014 Science of Skincare, LLC. All rights reserved. Berkley C, “More Foods Act as Rosacea Triggers,” WebMD Health; Jul 25, 2003. Rohrich RJ, Griffin JR, Adams WP, “Rhinophyma: Review and Update,”PlastReconstrSurg, 2002Sep 1;110(3):860-69. Blount BW, Pelletier AL, “Rosacea: a Common, yet Commonly Overlooked, Condition”; Am FamPhysician, 2002 Aug 1;66(3):442 Shenefelt PD, “Hypnosis in Dermatology,” Arch Dermatol, 2000 Mar;136(3):393-9. Millikan L, “Recognizing Rosacea,” Postgrad Med, 1999 Feb;105(2):149-50, 153-8. Webster GF, “Acne and Rosacea,” Med Clin North Am, 1998 Sep;82(5):1145-5. 4 www.innovativeskincare.com All materials contained on this document are protected by United States copyright law. You may not modify, remove, delete, publish, transmit, reproduce or in any way exploit the content of this document, in whole or in part. © 2014 Science of Skincare, LLC. All rights reserved.