Re: Medscape Article on cea

July 3, 2002

Matija, I'm always uncomfortable commenting upon articles you

generously go out of your way to read and post, wishing not to

discredit the quality filtering you already bring to the group. And I

don't mean to over-react to a phrase. But " Marjorie-approved " is

absolutely not the spirit with which I'm sharing my impressions of

the articles posted in this group.

Regarding this article, I'm not familiar with this particular

journal, but if it's from the Board then it is probably for

physicians training or trained in family practice, to study for

Boards certification/recertification. If so, it wouldn't be expected

to be cutting edge accurate or be useful in patient education or even

clinical practice. Its goal is to communicate a great deal of

information succinctly and (this is key) include information likely

to be on the Boards test -- as opposed to wasting the studiers' time

with material that's important for clinical practice. We all know how

it is when cramming for a standardized test. <g>

Certainly this group needs and DESERVES the best foundation of

factual knowledge, so each can evaluate their own health care needs,

easily distinguish between known fact and theory on rosacea, and

judge the appropriateness of new therapies, conventional and

alternative. For example, I'm struck by recent posters asking for

basic information on Eidel, on the differences among the various

laser therapies, and on how to take tetracycline. If objective

information were everpresent and available to address the core

aspects of rosacea, then posters could freely share their personal

experiences knowing that they will be put in the the most useful

perspective and context.

In this group, posts that share core information get lost in the

shuffle or are forgotten a day later, and not easily recoverable. How

is someone who lurks or joins next week with the same question

regarding facial edema going to know that today you had your question

answered below unless they post, you answer, and you remember? That's

not efficient at all, and other methods are even less satisfying: the

Yahoo search engine isn't very powerful or well-filtered, and the

very laudable efforts put into the group's FAQs and archives as

information database is, frankly, marred as dated, incomplete, and

biased.

Marjorie

Marjorie Lazoff, MD

> Hi,

>

> I found this article on Medscape which was dated May 2002. It's

> geared towards primary care physicians and has some old news and

some

> stuff that really irritates some of our skin (like topical Retin A

> and Vitamin C). It also has some new information (to me, at least)

on

> the mechanisms behind edema. I don't know if this article will

> be " Marjorie-approved " but it looks like a good one.

>

> Take care,

> Matija

>

> Diagnosis and Treatment of cea

> from Journal of the American Board of Family Practice

> F. Cohen, MD, D. Tiemstra, MD

> Abstract and Introduction

> Abstract

> Background: cea is a common skin disorder affecting middle-aged

> and older adults. Many patients mistakenly assume that early

rosacea

> is normally aging skin and are not aware that effective treatments

> exist to prevent progression to permanent disfiguring skin changes.

> Methods: The medical literature was reviewed on the

pathophysiology,

> diagnosis, and treatment of rosacea. MEDLINE was searched using the

> key search

> terms " rosacea, " " rhinophyma, " " metronidazole, " " Helicobacter

> pylori, " and " facial redness. "

> Results and Conclusions: cea is easily diagnosed by physician

> observation, and physicians should initiate discussion of rosacea

> treatment with patients. Effective treatment of rosacea includes

> avoidance of triggers, topical and oral antibiotic therapy, both

> topical and oral retinoid therapy, topical vitamin C therapy, and

> cosmetic surgery.

> Introduction

> As the general population ages and the baby boomers increasingly

> dominate clinical practice, a frequent complaint is the red face.

Of

> the many causes of the red face, rosacea will be the diagnosis for

> approximately 13 million Americans.[1] Although not a life-

> threatening condition, rosacea produces conspicuous facial redness

> and blemishes that can have a deep impact on a patient's self-

esteem

> and quality of life. Rhinophyma, the most prominent feature of

> advanced rosacea, is often mistakenly associated with alcoholism,

as

> caricatured by W.C. Fields, further stigmatizing rosacea patients.

A

> survey by the National cea Society reported that 75% of rosacea

> patients felt low self-esteem, 70% felt embarrassment, 69% report

> frustration, 56% felt that they had been " robbed of pleasure or

> happiness, " 60% felt the disorder negatively affected their

> professional interactions, and 57% believed that it adversely

> affected their social lives.[2] Much of this suffering is

> unnecessary, however, because rosacea is a condition that can be

> easily diagnosed and effectively treated in most patients.

> Methods

> We undertook a literature review on the pathophysiology, diagnosis,

> and treatment of rosacea using MEDLINE. Key search terms

> included " rosacea, " " rhinophyma, " " metronidazole, " " Helicobacter

> pylori, " and " facial redness. "

> Diagnosis

> cea develops gradually. Many patients, unaware that they suffer

> from a treatable skin condition, assume that the intermittent

facial

> flushing, papules, and pustules are adult acne, sun or wind burn,

or

> normal effects of aging. Correct diagnosis and early treatment of

> rosacea are important because, if left untreated, rosacea can

> progress to irreversible disfigurement and vision loss.[3] cea

is

> a vascular disorder of distinct, predictable symptoms that follows

a

> remarkably homogenous clinical course. cea generally involves

the

> cheeks, nose, chin, and forehead, with a predilection for the nose

in

> men.[4]

> There are four acknowledged general stages of rosacea. Stage I can

be

> described as pre-rosacea. This stage is characterized by frequent

> blushing, especially in those who have a family history of rosacea.

> Blushing as a symptom of rosacea can start in childhood, although

the

> typical age of onset for rosacea is 30 to 60 years.[5] There might

be

> increased frequency of facial flushing or complaints of burning,

> redness, and stinging when using common skin care products or

> antiacne therapies. The second stage of rosacea is vascular. At

this

> point in the disease progression, transitory erythema of midfacial

> areas, as well as slight telangiectasias, become apparent.[4] In

the

> third stage of rosacea, the facial redness becomes deeper and

> permanent. Telangiectasias increase, and papules and pustules begin

> to develop. During this stage, ocular changes, such as

conjunctivitis

> and blepharitis, can develop.[6] Edema can develop in the region

> above the nasolabial folds. In the fourth stage, there is continued

> and increased skin and ocular inflammation. Ocular inflammation can

> progress to keratitis and result in loss of vision. Multiple

> telangiectasias can be found in the paranasal region. It is at this

> point that fibroplasia and sebaceous hyperplasia of the skin

produces

> the nasal enlargement known as rhinophyma.[4]

> Several skin conditions share some clinical features with rosacea.

> Acne vulgaris causes comedones, papules, pustules, and localized

> inflammatory nodules but not the generalized erythema,

> telangiectasias, and other vascular features of rosacea. Seborrheic

> dermatitis, perioral dermatitis, and the malar rash of lupus can

all

> cause mild erythema, but these conditions will not produce the

> characteristic flushing, telangiectasias, papules, and pustules of

> rosacea.[1] Sarcoidosis can closely mimic rosacea by producing red

> papules on the face, but the disease will usually manifest itself

in

> other organs as well. In addition, a biopsy will show sarcoid

> granulomas.[7]

>

> Pathophysiology

> Although the exact pathogenesis of rosacea is unknown, the

pathologic

> process is well described. The erythema of rosacea is caused by

> dilation of the superficial vasculature of the face.[1] It is

thought

> that atrophy of the papillary dermis provides for easier

> visualization of the dermal capillaries.[9] Edema can develop as a

> result of the increased blood flow in the superficial vasculature.

> This edema might contribute to the late-stage fibroplasia and

> rhinophyma.[1] It has been suggested that Helicobacter pylori

> infection is a cause of rosacea. H pylori, originally implicated as

> the cause of gastric ulcers, has more recently been associated with

> urticaria, Henoch-Schödonlein purpura, and Sjödogren syndrome. In a

> 1999 study, however, Bamford et al[10] found there was no benefit

in

> the eradication of H pylori compared with placebo in the treatment

of

> rosacea, although both subjects and controls experienced

improvement

> in the rosacea symptoms. Thus the role of H pylori in rosacea

remains

> uncertain, and the cause of rosacea remains elusive.

> Treatment

> The most important first step in the treatment of rosacea is the

> avoidance of triggers. Triggers are both exposures and situations

> that can cause a flare-up of the flushing and skin changes in

> rosacea. Principal among these is sun exposure. cea patients

must

> be advised always to apply a nonirritating facial sun block when

> outdoors. Stress, through autonomic activation, can also increase

the

> flushing. Alcohol consumption, while not a cause in itself, can

> aggravate this condition through peripheral vasodilation. Spicy

foods

> can also aggravate the symptoms of rosacea through autonomic

> stimulation. Finally, care must be taken to use only those facial

> cleansers, lotions, and cosmetics that are nonirritating,

> hypoallergenic, and noncomedogenic.

> cea should be treated at its earliest manifestations to

mitigate

> progression to the stages of edema and irreversible fibrosis.

> Antibiotics have traditionally been considered the first line of

> therapy, although their success is considered to be primarily due

to

> anti-inflammatory effects rather than antimicrobial ones.[4]

Topical

> metronidazole, which is effective for stage I and stage II rosacea

> and avoids the toxicity of systemic treatment, is considered first-

> line therapy.[11] Metronidazole is available in a twice-daily

> application of 0.75% cream or gel and in a newer once-daily 1.0%

> formulation.[4] No significant difference in efficacy has been

found

> between the once-daily 1.0% medicine and the twice-daily 0.75%

> medicine.[12] Sulfacetamide lotion can also be used in place of

> metronidazole. In certain patients, sulfacetamide might be less

> irritating than metronidazole.[4]

> cea responds well to oral antibiotics. Starting treatment with

> simultaneous oral and topical therapy reduces initial prominent

> symptoms, prevents relapse when oral therapy is discontinued, and

> maintains long-term control.[6] Oral therapy is generally continued

> until inflammatory lesions clear or for 12 weeks, whichever comes

> first.[12] Tetracycline is the primary oral antibiotic prescribed

for

> rosacea therapy, at a dosage of 1.0 to 1.5 g/d divided into 2 to 4

> daily doses. Minocycline at 100 mg two times a day is an acceptable

> alternative.[13] Doxycycline is another acceptable alternative,

> although the monohydrate formulation, in a dosage of 100 mg once

> daily, is more consistently effective and has fewer

gastrointestinal

> side effects than the hyclate form.[13,14] Clarithromycin, 250 mg

to

> 500 mg twice daily, has been found to be as effective as

doxycycline

> but with a more benign side effect profile.[15]

> New Therapies

> Azelaic acid is a naturally occurring, dicarboxylic acid possessing

> antibacterial activity. It is available as a 20% cream and is

> generally used as an alternative treatment for acne vulgaris. In

1999

> Maddin[16] compared once-daily applications of azelaic acid with

> topical metronidazole 0.75% cream for treatment of papulopustular

> rosacea. Maddin concluded that both medicines were equally

effective

> in reducing the number of inflammatory lesions and the associated

> signs and symptoms of rosacea. When the study physicians' rating of

> the overall improvement was considered, however, the azelaic acid

was

> considered to be considerably more effective. The patients involved

> in the study also preferred the azelaic acid.[16]

> Topical retinoic acid has been shown to have a beneficial effect on

> the vascular component of rosacea.[17] The drawbacks of retinoic

acid

> therapy include delayed onset of effectiveness, dry skin, erythema,

> burning, and stinging.[17] Retinaldehyde is intermediate in the

> natural metabolism of retinoids, between retinal and retinoic acid,

> and is generally well tolerated while retaining most of the

> therapeutic activity of retinoic acid.[17] Daily application of a

> 0.05% retinaldehyde cream for 6 months was found to yield positive

> and statistically significant outcomes in 75% of those patients

> undergoing treatment.[17] Specifically, improvements were found in

> erythema and telangiectasias, the vascular components of rosacea.

> Topical vitamin C preparations have recently been studied in the

> reduction of the erythema of rosacea.[18] Daily use of an over-the-

> counter cosmetic 5.0% vitamin C (L-ascorbic acid) preparation was

> used in an observer-blinded and placebo-controlled study. Nine of

the

> 12 participants experienced both objective and subjective

improvement

> in their erythema.[18] It was suggested that free-radical

production

> might play a role in the inflammatory reaction of rosacea, and that

> the antioxidant effect of L-ascorbic acid might be responsible for

> its effect. These promising preliminary results still need to be

> confirmed in larger, long-term studies.

> Treatment of Advanced Disease

> Recalcitrant rosacea can respond to oral isotretinoin therapy. In a

> recent study of 22 patients with mild to moderate rosacea, major

> reductions in erythema, papules, and telangiectasias were noted by

> the ninth week of treatment.[19] Isotretinoin reduces the size of

> sebaceous glands and alters keratinization. Recalcitrant cases of

> rosacea have been successfully treated with 0.5 mg/kg/d of

> isotretinoin.[12] Isotretinoin, of course, has serious side-

effects,

> most notably its teratogenic potential. Female patients of

> childbearing age must be strongly advised to use effective birth

> control. Stage IV of rosacea, involving irreversible fibrotic

> changes, such as rhinophyma, does not respond well to medical

> therapy. At that point, the patient should be referred for cosmetic

> surgery, such as cryosurgery and laser therapy.

> In the aging US population, rosacea is an increasingly common

> disorder. Althoug h rosacea causes only limited physical effects,

the

> prominent visibility of these changes often yields intense

> psychosocial distress. Although the exact cause of rosacea is

> unknown, its progression, signs, and symptoms can be readily

> alleviated by the primary care physician.

>

> F. Cohen, MD, and D. Tiemstra, MD, Family Physicians

of

> Naperville, Family Practice Residency Department, Provena

> Health/Saint ph Medical Center, Naperville, Ill.

July 3, 2002