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Mar 08

Rosacea

Monday, March 08, 2010 @ 09:57 pm Comments Off on Rosacea

by Dr. R Genesis Mar 8, 2010 This diagnosis is well known by the public because it is common and conspicuous.  It is estimated that 5 – 10 % of certain Caucasian populations suffer Rosacea, but it is not limited to fair skinned individuals.  It may be increasing in incidence in the darker skin groups such as Aboriginals and Asians. Although Rosacea is not life threatening, the conspicuous facial redness, flushing, blemishes, burning and itching, and unsightly veins may deeply impact patients’ self esteem.  This symptom complex is stigmatizing and psychologically challenging.  The enlarged knobby nose made famous by W.C.Fields is another variant of this disease that is highly disfiguring, but fortunately less common. The impact of Rosacea on psychological measures is not to be understated, especially in view of the fact that long lasting remission is now an option.  Approximately 50% of sufferers of Rosacea experience stares and / or comments from others.  Surveys of Rosacea sufferers have revealed that 75% experience low self-esteem, 70% are frustrated, and 60% feel that social/career/happiness levels have been negatively impacted.  It would be a challenge to walk a mile in their shoes….. The rosy red face is the most recognized symptom that prompted the term, Rosacea.  Many patients invest in green camouflage make-up to neutralize the tone, and this is then covered with a thick layer of foundation.  For women who typically use cover make up, they must spend extra time daily, and often several times daily, to keep their secret.  MsH never went out of the house without a couple of layers of makeup.  It is a way of life, and these patients often dream of the freedom of “no makeup”.  Men, however, are less inclined to resort to cover up make-up, and hence more likely to experience the stares and comments.  MrJ was a CEO who grew sensitive to the comments of others about his red face.  Prior to treatment, he looked as though he were made up as a clown with red circles on his cheeks.  Mr.B was also tired of the comments from his male coworkers.  He was not naturally a person who fussed over appearances, but he did not care to be the butt of jokes or comments.  He felt that others assumed that his facial redness reflected a heavy alcohol consumption pattern, and it did not.  Children often assume that the red-faced person is sick.  MsD said that her son’s friends often asked him “Is your mom is sick?”  Others assume that blood pressure is up, and they will express concern about this.  And some individuals might unfortunately be suffering a more focal variant of Rosacea, such that the face appears normal except for the nose or the chin.  For them, terms of endearment might include “Rudolph”, or other attempts at humor. In fact, many Rosacea sufferers do not indulge in any alcoholic beverage while out in public because it is typical that the Rosacea patient will flush intensely after exposure to alcohol, or other triggers such as exertion, emotion, wind, extremes of temperature, sunshine, etc.  The flush is a vasodilation event that results in intense red with engorgement and swelling of the flushed zones.  The patient is conspicuous and observers will notice.  Of course, this precipitates further embarrassment and exacerbation of the flushing.  There is no concealing the flushing.  The flush is the most debilitating of the symptoms for some sufferers because they feel exposed and vulnerable.  There is no sanctum of privacy.  It is impossible to remain “cool” about inner emotions when your face gives it all away.  This doesn’t work for many in the workplace who are debilitated by the risk of a flush in front of the boss or in a meeting.  This was the case for the professor who flushed in front of his large class, or the M.D. whose ears glowed whenever he was rushed or rattled.  Flushing becomes more frequent in advanced conditions, occurring many times per day, or it may simply remain sustained for several hours at a time. The growth of red – purple small veins on face is classic.  These vessels become increasingly unsightly and they become highly reactive.  That is, they dilate readily, and hence they are responsible for the frequent intense flushing.  They are often mistakenly referred to as “broken capillaries”.  It is difficult to keep these vessels concealed with cover make up for more than an hour or two.  The other common frustration with these vessels is the misconception that anyone with red veins on the nose or cheeks must be drinking heavily.  It is true that those who drink heavily might develop veins on their cheeks or nose, but not all of those with veins on their cheeks or nose are necessarily heavy drinkers.  Naturally this misconception prompts some to seek removal of the aberrant blood vessels, and fortunately, they can be diminished.  It was imperative that MrC take steps to eradicate his facial veins because he believed that his coworkers had doubts about his alcohol consumption patterns on the basis of these veins. The blemishes that occur in Rosacea are often mistaken for acne.  Many Rosacea sufferers have had acne and hence they conclude that the blemishes are simply “an acne problem”.  Quite often acne resolves in adulthood while Rosacea presents and perpetuates the blemish pattern.  The patient may continue treating for acne, without much benefit.  The pattern of the blemishes is variable but they are generally considered longer lasting and smaller with more fluid and less puss compared to acne.  The rash may be quite intractable and very frustrating for the patient.  Mr R did not want to continue oral antibiotics to suppress the blemish pattern that was really disturbing him.  It was like suffering acne all over again in his middle age.  He felt embarrassed by the recurrent pattern of “zits” on his face at the peak of his career.  He did not want to continue long term oral antibiotic therapy that did not appear to produce a stable remission, rather just a state of suppression with relapse on withdrawal of pills.  Fortunately, the inflammation usually subsides after treatment of the underlying vascular condition with Intense Pulsed Light. Although the exact mechanisms of the disease are poorly understood still, it is clear that the pathology is “pore oriented”, with inflammatory and fibrotic changes.  The blood vessels are densely grown and unstable in the skin.  Enlarged pores are often visibly present, and in some they become grossly enlarged.  These unfortunate individuals suffer a deforming variant of rosacea, like the nose on WC Fields.  Quite often this individual presents late, looking for a solution to the enlarged and unsightly nose.  The wife, (usually this patient is a male), has often made a suggestion that “something might be done”.   Something can be done, but treatment is easier if presentation is early.  Mr J was a man who felt at odds with asking for treatment for a “cosmetic problem”, and would not have appeared if it were not for his wife. At the time of presentation for treatment, Ms L expressed her intense frustration with itching and burning on her face.  She held her hands open with long tense fingers ready to scratch her face as an illustration of her suffering.  She described highly sensitive skin, and itching, in particular, was getting her down.  She was absolutely thrilled when she returned after her first Intense Pulsed Light treatment, as she related that the itching and burning was gone nearly immediately afterward.  Almost all Rosacea sufferers will talk of their “sensitive skin”. Only a decade ago, the options for treatment included “support group”.  Now, therapy is very different.  Some of the basics of understanding and lifestyle still exist, such as UV protection and avoidance of strong triggers.  The topical creams/gels are helpful as always, although many patients become frustrated by the perceived slow and minimal response, so they discontinue.  Oral antibiotics will bring about remission, but as the disease advances the requirement for antibiotic is continuous in many.  The duration of benefit from Accutane has not been promising, especially considering the cost and risk of this therapy.  Fortunately, an evidence based approach known as Intense Pulsed Light Therapy with a Vasculight medical device has obtained Health Canada clearance for the treatment of this vascular/inflammatory condition.  And finally, Photodynamic Therapy has been consistently beneficial in reducing the symptoms of this condition.  It is not possible to say a cure is available with any or all of the above, but at least the disease may be put into remission for periods of months to years with the light based therapies, without pills or creams.  And cosmetic improvement is also noted with the course of light based therapies, including reduction of redness to near normal, reduction of facial veins, diminished flushing pattern, reduction of sensitive skin, remission or reduction of blemishes, and smaller appearance of pores. This is good news for many who suffer the psychological effects of this stigmatizing dermatologic condition.


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