Topics Discussed
Below
I. General Questions:
- Are there any diagnostic tests for rosacea?
- What are the primary symptoms we should look for in our patients?
- What are the primary triggers we should look for in our patients?
- Do children and teenagers develop "true" rosacea?
- What should we recommend to young patients with rosacea?
- Is rosacea a progressive disorder?
- Is rosacea caused by sun damage?
- Is rosacea an autoimmune disorder of the facial skin?
- Is rosacea a psychosomatic disorder?
- Is rosacea a disorder of 'superficial' or 'deep' blood vessels?
II. Treatment
Questions:
- Should rosacea patients fight through irritation caused by
topicals?
- Should rosacea be treated aggressively?
- Are there any dangers to long-term use of topical medications?
- What types of sunscreens should we recommend to our patients?
- Do over-the-counter steroids help or hurt rosacea?
- Do oral steroids have a place in rosacea treatment?
I. General Questions
1. Are there any diagnostic
tests for rosacea?
There are no histological,
serological or other diagnostic tests for rosacea. A skin biopsy
is not helpful either. A diagnosis of rosacea must come from your
physician after a thorough examination of your signs, symptoms,
and medical history. During your exam you should explain any problems
you are having with your face, such as redness, flushing, broken
blood vessels, papules, pustules, swelling, burning, itching or
stinging sensations.
2. What are the primary
symptoms we should look for in our patients?
At the most basic level,
rosacea is a disorder of the facial blood vessels. Therefore, the
primary symptoms should be blood vessel related. Facial redness,
flushing and blushing are exhibited in most rosacea sufferers. Papules,
pustules and swelling are also exhibited in patients. These are
the primary diagnostic criteria.
3. What are the primary
triggers we should look for in our patients?
Flushing to warm or hot
environments, emotions, stress, foods/beverages, cold or windy environments,
skin care products, alcohol and physical exertion. Some patients
may exhibit only one or two triggers, while others may experience
all of the triggers. The degree of trigger susceptibility is directly
related to the severity of the vascular disorder.
4. Do children and
teenagers develop "true" rosacea?
Yes. Dozens of case studies
indicate that children and teenagers can develop rosacea. Frequent
facial flushing that remains for an abnormal period of time is the
most obvious sign. Some children also present with papules or pustules.
5. What should we recommend
to young patients with rosacea?
With young patients, recommendations
should be kept simple and user friendly. Patients should be instructed
to discontinue using irritating skincare products and anti-acne
products. They should also be instructed to use a sunblock with
an SPF of 15 or greater. These two recommendations may be very helpful……but,
just as important, they are simple and do not disrupt one's lifestyle.
6. Is rosacea a progressive
disorder?
Rosacea is a progressive
disorder. It will get worse over time if left untreated. As blood
vessels become more damaged and hyper-responsive, this causes increased
flushing, papules and pustules. It must be stressed that everyone
is different in their susceptibility to flushing. For example, it
may take one rosacea sufferer several months to progress from pre-rosacea
to mild rosacea; while it may take another rosacea sufferers a decade
to progress to the next stage.
7. Is rosacea caused
by sun damage?
Rosacea is never caused
by one trigger or environmental influence. However, sun damage is
a strong trigger for facial flushing and causes direct damage to
superficial blood vessels and dermal inflammation. So, sun damage
can cause progression of rosacea in those genetically predisposed
to developing the disorder.
8. Is rosacea an autoimmune
disorder of the facial skin?
Under normal conditions,
the immune system protects the human body from foreign invaders
such as bacteria, viruses, and other harmful microorganisms. The
immune system also plays an important role in clearing up skin inflammation.
However, in certain inflammatory skin disorders such as rosacea,
immune cells can do more harm than good. In rosacea, chronic facial
flushing and inflammation cause the immune system to become over-reactive.
The immune system sends gobs of normal immune cells into the facial
skin. These normal immune cells then set up camp around facial blood
vessels, releasing inflammatory substances that trigger dilation,
weaken blood vessel walls, and cause inflammatory papules.
It is important for rosacea
sufferers and general physicians to understand that rosacea is not
an auto-immune disease. The immune system does not produce antibodies
or specifically 'attack' the facial skin cells or blood vessels.
The average rosacea sufferer has a perfectly healthy immune system.
In rosacea sufferers, the immune system is simply over-reacting
to facial inflammation and flushing. Over time, this immune system
response becomes exaggerated and counterproductive.
9. Is rosacea a psychosomatic
disorder?
When a physician examines
a rosacea sufferer, he often notices symptoms such as sadness, depression,
anxiety, hopelessness, and frustration. A general physician who
performs brief, incomplete examinations may conclude that the patient
has an underlying psychological disorder, and that the patient's
mental state is causing his or her rosacea. However, rosacea experts
who perform in-depth examinations and question their patients rigorously
will often come to much different conclusions; they usually find
that the patient's rosacea is causing the sadness, depression, anxiety,
hopelessness, and frustration. After thorough examination and questioning,
medical experts often find that: (1) The patient has already seen
countless physicians without much help, (2) The patient cannot perform
normal activities without moderate facial flushing and aggravation
of the disease, (3) The patient experiences daily burning sensations
that interfere with his or her lifestyle, and (4) The patient has
been given incorrect medical treatment in the past, or no real hope
for leading a normal life. Of course patients will be saddened,
depressed, anxious, hopeless and frustrated by this disorder and
its prognosis!
10. Is rosacea a disorder
of 'superficial' or 'deep' blood vessels?
Rosacea is a disorder
of both superficial and deep blood vessels. The small, thin walled
superficial blood vessels exhibit physical damage and become hyper-responsive.
The deeper blood vessels do not undergo physical damage, but are
the main pathways through which large volumes of blood enter the
superficial blood vessels of the face. These deeper blood vessels
are hyper-responsive to neural and hormonal factors.
II. Treatment Questions
1. Should rosacea patients
fight through irritation caused by topicals?
Most rosacea sufferers
should not fight through irritation because this usually aggravates
the underlying vascular disorder. For this reason, rosacea experts
instruct their patients to never fight through facial irritation
or redness. Medical experts instruct patients with sensitive skin
that any form of irritation makes the skin more vulnerable to subsequent
irritation. Recovery of sensitive skin and blood vessels only occurs
when exposure to topical irritants is stopped, and the skin is allowed
to heal.
Fighting through irritation
can set into motion a disturbing series of events: physicians prescribe
topical irritants to treat rosacea bumps and uneven skin texture
….. these irritants increase facial inflammation and flushing
….. physicians then prescribe topical steroids to reduce the
facial inflammation ….. these steroids thin the facial skin,
weaken the blood vessels, and cause vascular hyper-reactivity. This
results in significant progression of the entire vascular disorder.
This vicious cycle, once set into motion, is very difficult to break.
2. Should rosacea be
treated aggressively?
In moderate to severe
cases with frequent or intense flushing, rosacea should be treated
aggressively. The goal is to stop the progression of the disorder
and reverse the symptoms and vascular dysfunction. This often necessitates
a multi-tiered approach with laser therapy, topical anti-inflammatory
medications and oral medications.
3. Are there any dangers
to long-term use of topical medications?
There are no dangers to
using topical rosacea medications long-term. They do not thin the
facial skin or have negative actions on the underlying blood vessels.
Doctors often prescribe topical antibiotics for long-term treatment
of rosacea, and no study to date has documented any reason for danger
or concern. Topical treatments usually minimize side effects because
the amount of medication absorbed into the bloodstream is either
absent or minuscule.
4. What type of sunscreens
should we recommend to our patients?
The current recommendations
are to use sunscreens with inert physical blockers such as micronized
zinc oxide or titanium dioxide. These ingredients are excellent
sunscreens and they very rarely cause irritation to the skin. In
addition, they help to decrease facial skin temperature that is
usually associated with outdoor sun exposure.
5. Do over-the-counter
steroids help or hurt rosacea?
It is not wise to use
over the counter topical steroids. Although mild topical steroids
are sometimes prescribed for short periods to help control redness
in rosacea patients -- especially during initial treatment -- the
long-term use of steroids has been found to aggravate rosacea and
even induce rosacea-like symptoms in many patients.
6. Do oral steroids
have a place in rosacea treatment?
Short term treatment with oral steroids does have a place
in rosacea therapy (i.e. 5- to 7-day dose packs). In many cases,
pulse-dosing with oral steroids helps relieve facial inflammation
and swelling in moderate to severe rosacea sufferers. The goal of
this treatment is to knock down the inflammation so that rosacea
sufferers can maintain clearance on topical rosacea medications.
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