Medscape Article on cea

July 1, 2002

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 1, 2002