Good News for Accutane Users

This growing body of proof is actually quite important because oral isotretinoin is not officially approved as a treatment for rosacea. Doctors can prescribe accutane off-label for use in rosacea, so more comprehensive trials of accutane can only be a good thing. Further, the growing difficulty in finding a doctor who will actually prescribe accutane means that rosacea sufferers need all the proof that they can get their hands on.

My Take

The paper referenced below was highlighted last year as Doxycycline is as good as Low Dose Accutane (0.3mg/kg/day). It is worth repeating that even though doses of around 20mg a day of accutane compared favourably to 100/50mg of doxycycline, the two drugs have quite different safety profiles. The advice of your doctor is going to be important here.

Rosacea : Systemic therapy with retinoids

Hautarzt. 2011 Oct 22, Thielitz A, Gollnick H, Universitätsklinik für Dermatologie und Venerologie , Otto-von-Guericke Universität, Leipziger Str. 44, 39120, Magdeburg, Deutschland

[Article in German]

Systemic isotretinoin has been known for decades as an effective and safe therapeutic option in the treatment of severe and refractory forms of rosacea. It can also be used in special treatment-resistant forms of rosacea, e. g. granulomatous rosacea, as efficacious second-line therapy.

Previously, the effect of isotretinoin in rosacea has been mainly studied in small cohorts or anecdotal reports.

Recently, a big randomized double-blind dose-response and comparative study revealed that an optimized dosage of 0,3 mg/kg was superior to other dosages and non-inferior to doxycycline as gold standard of systemic rosacea treatment and proved effective and safe in papulopustular and phymatous subtypes.

However, the substance is still not licensed for this indication The efficacy of isotretinoin in rosacea is probably mainly related to anti-inflammatory mechanisms as well as anti-oxidative, anti-angiogenic and antifibrotic properties. The classical antiseborrheic effect of isotretinoin might play a role in special subtypes like the phymatous type or rosacea fulminans.

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Why the misery of ‘adult acne’ could be caused by blushing

By LAURA TENNANT

Last updated at 12:35 AM on 9th August 2011

… I asked to be referred to a dermatologist at St Thomas’ Hospital in London. He advised me that it was bad for my general health to remain on antibiotics long-term, and that I should first finish the course and then come back.

When I returned, I was treated by a different dermatologist, who prescribed another course of antibiotics, plus a topical treatment containing zinc, Dalacin T.

Two months on, with my skin no better, I returned to Dr Williams, who told me about another treatment option — a low dose of Roaccutane, or isotretinoin, a medication originally developed to treat brain and pancreatic cancer.

It has a three-fold effect, preventing hyper keratinisation, slowing down sebum production, and also serving as an anti-inflammatory and anti-bacterial.

It is commonly prescribed for rosacea in Europe — but not here. She agreed that I was a suitable candidate.

The effects last for many years and in some cases are permanent.

While the drug itself costs under £25 for a month’s supply, patients must also commit to monthly consultations to undergo blood tests (to check liver function) and a urine test (for pregnancy, since roaccutane is strongly contra-indicated for pregnancy). For me, the total cost is likely to be about £1,500.

Of course, the cost was a factor I had to consider, but life, I decided, was simply too short to go on suffering for a minute longer.

The change in me has been immediate and noticeable to all around me.

After a month of treatment, I’m fresh-faced, flawless and ready to answer the door to the postman without a layer of foundation.

Because Roaccutane has been associated with depression and even suicide, I’ve been alert to changes of mood. But rosacea responds well to such a low dose of the drug that its rare side-effects become even less likely.

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The patient experienced relief from both rosacea and seborrheic dermatitis, two conditions that together sometimes prove tricky to treat.

Bear in mind, though, that this paper is a case study of just one patient.

Rational management of papulopustular rosacea with concomitant facial seborrheic dermatitis: a case report

J Clin Aesthet Dermatol. 2011 Jan;4(1):40-2., McFalda WL, Roebuck HL., Clarkston Dermatology, Clarkston, Michigan.

Objective: To report a case of papulopustular rosacea with concomitant seborrheic dermatitis and discuss how signs and symptoms were ameliorated using a rational therapeutic approach.

Design: Patient case report. Setting: Clinical practice.

Participant: One male patient with rosacea, seborrheic dermatitis, and actinic keratoses.

Measurements: Change in signs and symptoms over time.

Results: Improved skin care practices and treatment with azelaic acid 15% gel twice daily in combination with low-dosage oral isotretinoin resulted in improvement in symptoms of both rosacea and seborrheic dermatitis.

Conclusion: In patients with multiple skin disorders, use of medications with benefits for more than one of the skin conditions may, in some cases, reduce the overall number of medications needed, thus simplifying treatment.

We know from some recent research that Finacea, as well as being a recognised treatment for the papules and pustules of rosacea, has anti-fungal and anti-inflammatory properties that can help in the treatment of seborrheic dermatitis. Here from Rosacea News in Feb 2009;

Seborrheic Dermatitis: state of the art, Finacea 3 stars

The author mentions recent research that links seborrheic dermatitis with a spore known as Malassezia Globosa. He makes the point that azelaic acid, as found in Finacea contains agents that give it anti-inflammatory, antikeratinizing and antifungal properties; 3 properties felt to be important in battling seborrheic dermatitis. As finacea also helps the papules and pustules of rosacea, and some rosacea sufferers have rosacea combined with seborrheic dermatitis, it is a product worth keeping in your treatment arsenal.

Hey all you Finacea Users

If  you have used Finacea and suffer from SD, did you notice any improvement?

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This study as described in a AAD Poster Session, compared 3 different doses of isotretinoin/accutane with a somewhat standard low dose  regime of doxycyline.

The study was able to show that 0.3mg/kg/day of accutane was as effective as 100mg of Doxycycline for 14 days; followed by 50mg a day thereafter.

A dose of accutane of 0.3mg/kg/day is 18mg per day for a 60kg person (132 pounds).

There are other studies for low dose accutane that used doses more like the the very low 0.1mg/kg/day also examined in this trial.

The standard therapy with oral antibiotics for rosacea is described here as 100mg a day of doxycycline for 14 days and then the sub-antimicrobial dose of 50mg a day thereafter. Oracea is a similar low dose doxycycline, comprising a daily treatment of 30mg plus 10mg delayed release.

My Take

Whilst this study was able to show that around 20mg a day of accutane compared favorably to 100/50mg of doxycyline, because of the higher safety concerns with accutane, I would think doxycycline would win in most clinical situations. If you are getting a benefit from a low dose of doxycycline, seek thorough advice before considering switching to accutane.

J Am Acad Dermatol 2009;60:AB41. Abstract P1162

http://www.aad.org/meetings/annual/_doc/JaadPosterAbstractSupplement.pdf

Double-blind, double-dummy, randomized, placebo-controlled, five armed, multicenter phase II/III study to evaluate the efficacy and safety of different concentrations of isotretinoin versus doxycycline in the treatment of rosacea, subtype II and III

Harald Gollnick, University Magdeburg, Magdeburg, Sachsen-Anhalt, Germany, Carmen Matthies, Almirall Hermal GmbH, Reinbek, Schleswig-Holstein, Germany, Renate von der Weth, Almirall Hermal GmbH, Reinbek, SchleswigHolstein, Germany

A double-blind, randomized, placebo-controlled, five-armed, multicenter study including 573 patients with rosacea subtypes II and III in 35 centers in Germany was performed to evaluate the efficacy and safety of different concentrations of isotretinoin in the treatment of rosacea. Patients were treated in a randomized assignment either with one of three different doses of isotretinoin (0.1, 0.3, or 0.5 mg/kg body weight), with standard therapy with oral antibiotics (100 mg doxycycline daily for 14 days, then reduction to 50 mg daily), or with placebo.

As the primary objective, the reduction in the total sum of facial papules and pustules/noduli after a 12-week treatment was compared between the treatment groups.

In an interim analysis after about 45 patients per group had been treated, all three isotretinoin doses showed a clearly higher reduction of lesions compared to placebo, whereas treatment with 0.3 mg/kg showed the clearest reduction of lesions with a statistically significant superiority versus placebo (P < .005).

In the second part of the study, the efficacy of the most efficient isotretinoin dose (0.3 mg/kg) was compared to standard therapy with doxycycline, and the other arms of the study were closed. Treatment with isotretinoin 0.3 mg/kg showed statistically significant non inferiority versus treatment with doxycycline (P <  .001).

With isotretinoin 0.3 mg/kg, lesions were reduced for 90% compared to 83% with doxycycline treatment. Physicians diagnosed complete remission in 24% and marked improvement in further 57% of the patients with isotretinoin treatment, versus remission in 14% and marked improvement in 55% of the patients treated with doxycycline. Seventy-eight per cent of the patients treated with isotretinoin rated therapy success as ‘‘excellent’’ or ‘‘good,’’ compared to 64% of the patients treated with doxycycline.

Data on drug safety reveal a similar safety profile for the treatment of rosacea with isotretinoin 0.3 mg/kg as with treatment of acne with isotretinoin. No new, severe safety concerns were found; only an increase of cholesterol occurred slightly more often (in 19% of patients) than in acne treatment. Clinically relevant changes in blood count did not occur in any patient. Because of the low dose, isotretinoin has a positive risk/benefit profile for the treatment of rosacea.

Isotretinoin 0.3 mg/kg is an efficient and well tolerated treatment for rosacea subtypes II and III and can be used as an alternative to standard therapy with oral antibiotics.

Commercial support: The study was sponsored by Laboratories Almirall, S.A.

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A paper that Rosacea News previewed in November last year: Accutane dose of 22mg a day works best: EADV has now been published in the JDDG: Journal of German Society of Dermatology.

As we learned from the EADV paper, the Spanish pharmaceutical company Almirall is hoping to promote their “branded version of isotretinoin in the treatment of rosacea.” It seems like a bold move; to attempt to market oral isotretinoin as an alternative to oral antibiotics.

For those enrolled in this blind study, 0.3 mg/kg per day was found to be as effective as 50mg a day of doxycycline at treating the papules, pustules and phymatous growth of rosacea.

Getting the dose right is important if you want to try Isotretinoin as a treatment for your troublesome rosacea. How do you know if you are taking too much ? A high dose of accutane can lead to unpleasant side effects and even worsen the flushing associated with rosacea.

If you consider an average weight of 166 pounds (around 75kg) this paper would lead to a recommended dosage of around 22mg a day. Even this amount may be viewed as moderate to high when compared to advice from Dr. Plewig that “doses of isotretinoin typically used in the United States and Europe are far too high. For many patients, as little as 2.5 mg twice a week, which he describes as `a drop of rain on a dusty road’ is adequate.”

For more information see what accutane dose works for rosacea ?

Systemic isotretinoin in the treatment of rosacea – doxycycline- and placebo-controlled, randomized clinical study. J Dtsch Dermatol Ges. 2010 Mar 12.

Authors: Gollnick H, Blume-Peytavi U, Szabó EL, Meyer KG, Hauptmann P, Popp G, Sebastian M, Zwingers T, Willers C, von der Weth R

Summary Background: Systemic isotretinoin has been known for decades to be effective in the treatment of severe forms of rosacea, but it must be used off-label because of the lack of evidence-based data.

Patients and Methods: 573 patients with rosacea subtype II and III received one of three different dosages of isotretinoin (0.1 mg, 0.3 mg, or 0.5 mg per kg body weight), doxycycline (100 mg daily for 14 days, then 50 mg daily) or placebo in a double-blinded, randomized way for 12 weeks in 35 German centers.

Results: Isotretinoin 0.3 mg/kg proved to be the most effective dose with significant superiority versus placebo. Isotretinoin 0.3 mg/kg showed also significant non-inferiority versus doxycycline with reduction of lesions of 90 % compared to 83 % with doxycycline. Investigators diagnosed complete remission in 24 % and marked improvement in further 57 % of patients with isotretinoin treatment, in contrast to remission in 14 % and marked improvement in 55 % of patients treated with doxycycline. Isotretinoin 0.3 mg/kg revealed a similar safety profile as for the treatment of acne. Isotretinoin 0.5 mg/kg showed more dermatitis facialis as compared to 0.3 mg/kg.

Conclusions: Isotretinoin 0.3 mg/kg is an effective and well-tolerated therapy option for the treatment of rosacea subtype II and III and can therefore be used successfully as an alternative to therapy with oral antibiotics.

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A summary from a the recent 18th Congress of the European Academy of Dermatology and Venereology has presented some findings relating to the most effect dosage of accutane to treat rosacea.

Accutane (Isotretinoin) has been successfully prescribed in low doses to treat rosacea, and especially the `lumps and bumps’ of rosacea that have not responded to other treatments.

Despite some good published papers that deal with treating rosacea with low doses of accutane, officially isotretinoin needs to be prescribed `off label’ for treating rosacea.

For those enrolled in this blind study, 0.3 mg/kg per day was found to be as effective as 50mg a day of doxycycline at treating the papules, pustules and phymatous growth of rosacea.

Getting the dose right is important if you want to try Isotretinoin as a treatment for your troublesome rosacea. How do you know if you are taking too much ? A high dose of accutane can lead to unpleasant side effects and even worsen the flushing associated with rosacea.

If you consider an average weight of 166 pounds (around 75kg) this paper would lead to a recommended dosage of around 22mg a day. Even this amount may be viewed as moderate to high when compared to advice from Dr. Plewig that “doses of isotretinoin typically used in the United States and Europe are far too high. For many patients, as little as 2.5 mg twice a week, which he describes as `a drop of rain on a dusty road’ is adequate.”

Dr. Erdogan et.al. suggested that “In our small group, using a daily dose of 10 mg of isotretinoin, we did not observe such adverse effects. Although we selected patients resistant to treatment with a long history of complaints, our results confirmed the efficacy of isotretinoin use, but whether remissions will continue after the cessation of treatment is not addressed by our study.”

Further, advice from Dr. Hofer suggests doses of around 3mg to 8mg in what he calls his continuous microdose regime are suitable for treating rosacea. In 2000, Palmer et al. showed that continuous microdose isotretinoin (CMI) treatment (0.04-0.11 mg/kg daily) was sufficient to control adult relapsing acne, but they mentioned that this is an unlicensed method administration.

This paper will hopefully give some weight to the argument that under controlled circumstances, in the right doses, and for the indicated rosacea symptoms, low dose accutane can be a viable treatment.

If indeed this research helps lead to accutane being available as an on-label prescription for rosacea sufferers, then that is good news especially for those desperate for relief from the recalcitrant lumps and bumps of rosacea.

Optimal Isotretinoin Dosing for Rosacea Identified

BERLIN (EGMN)–Isotretinoin could be headed for a new indication as a licensed treatment for rosacea.

The workhorse oral retinoid has been used off label to treat challenging cases of rosacea for more than 2 decades. However, Barcelona-based Almirall recently sponsored a successful multicenter randomized trial aimed at earning an indication from regulatory authorities for its branded version of isotretinoin in the treatment of rosacea, Dr. Harald Gollnick said at the annual congress of the European Academy of Dermatology and Venereology.

The double-blind, 12-week study involved 224 patients with the papulopustular or phymatous forms of rosacea. Participants in the five-armed trial were randomized to isotretinoin at 0.1, 0.3, or 0.5 mg/kg per day; doxycycline at 100 mg per day followed by 50 mg per day; or placebo, explained Dr. Gollnick, professor of dermatology at Otto-von-Guericke University, Magdeburg, Germany, and president of the European Board of Dermato-Venereology.

The optimal isotretinoin dose proved to be 0.3 mg/kg per day. Its efficacy was superior to placebo and similar to that of doxycycline, with both regimens achieving a 90% reduction in papules and pustules at 12 weeks, according to Dr. Gollnick, who is also chairman of the Global Alliance to Improve Outcomes in Acne, an international group of acne experts.

“That means in the near future we’ll most probably have an on-label indication for isotretinoin in rosacea,” he said.

Over the years isotretinoin has been used off label to treat rosacea, but the best dose was a matter of guesswork. The Almirall-sponsored trial is particularly welcome because it is the first formal study aimed at defining the optimal dose, added Dr. Gollnick.

The 0.3 mg/kg dose was associated with a low rate of side effects, consisting mainly of mild lipid changes and liver enzyme elevations. The 0.5 mg/kg dose wasn’t any more effective, and it produced more irritation and facial dermatitis. The 0.1 mg/kg dose, while significantly better than placebo, was less effective than 0.3 mg/kg.

Topical therapies for rosacea include 0.5%-2% metronidazole, azelaic acid, 0.025% tretinoin, and 2.5%-5% permethrin. Systemic treatments include metronidazole at 500 mg/day, minocycline at 50 mg/day, tetracyclines at 0.5-1.5 g/day, and a subantimicrobial formulation of doxycycline.

Over to You

What dose of accutane have you found to work best for you ?

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This just published abstract is suggesting that it appears to be safe to consume alcohol while taking accutane.

Whilst the Accutane Prescribing Information does not prohibit the consumption of alcohol, it does suggest that alcohol may add to any issues with triglycerides induced by accutane. So it is probably wise to moderate alcohol consumption, despite this study using several patients with `considerable weekly alcohol intake’. Accutane is thought to cause depression in some people, and adding a depressant like alcohol to this combination could be risky.

Interesting that the study found a steep enough drop off in the studied teratogenics after 1 month post treatment to suggest that pregnancy would be safe. The Accutane Prescribing Information also suggests that you should not donate blood for 1 month following ceasing treatment.

This is just one study of course. When you read the list of potential side effects you can’t but think you still need to follow a doctor’s advice carefully. I’d be inclined to read the prescribing information closely and heed my doctor’s advice before taking this study’s findings too far.

One final word of warning, although there is no substantive link between alcohol and rosacea, alcohol can cause strong flushing symptoms. As most rosacea sufferers will tell you, reducing obvious flushing triggers, where possible, is worthwhile pursuing.

The metabolism and pharmacokinetics of isotretinoin in patients with acne and rosacea are not influenced by ethanol, Br J Dermatol. 2009 May 21, Grønhøj Larsen F, Jakobsen P, Grønhøj Larsen C, Heidenheim M, Held E, Nielsen-Kudsk F.

Background: Isotretinoin is effective in the treatment of severe acne and rosacea. Both parent drug and its main metabolite 4-oxo-isotretinoin are potentially teratogenic compounds and contain a carboxylic acid moiety. In the presence of ethanol, naturally occurring as well as synthetic retinoids also containing a carboxylic acid moiety are capable of undergoing an ethyl esterification with the metabolic formation of more lipophilic compounds with a much longer terminal half-life.

Objectives: To determine if isotretinoin (13-cis-RA), its main metabolite 4-oxo-isotretinoin (4-oxo-13-cis-RA), and other possible metabolites in the presence or absence of ethanol are converted to their corresponding ethyl derivatives in patients with severe acne or rosacea after multiple isotretinoin dosing. In addition, pharmacokinetic parameters of the parent drug and its 4-oxo metabolite were determined.

Patients/methods: Eleven patients with severe acne or rosacea were treated with isotretinoin daily for 3 months and investigated pharmacokinetically during 24 h after 1 month of treatment and for up to 28 days after discontinuation of therapy. A possible influence of ethanol was evaluated using a simple self-administered questionnaire and by measuring serum ethanol levels during treatment. The concentrations of isotretinoin, 4-oxo-isotretinoin and possible ethylated and nonethylated metabolites were measured by reverse-phase high-performance liquid chromatography.

Results: Although seven of 11 patients had a considerable weekly alcohol intake, no endogenous synthesis of ethyl derivatives of isotretinoin, the main 4-oxo metabolite or the all-trans compounds was chromatographically detectable in any of the patients’ plasma samples during the treatment period. Multiple dose pharmacokinetic data for the parent drug and its main metabolite were comparable to previous studies.

Conclusions: The metabolism and pharmacokinetics of isotretinoin and its main metabolites are not influenced by ethanol during long-term isotretinoin treatment. After ceasing long-term isotretinoin therapy the recommended period of 1 month for using anticonceptive measures in fertile women seems adequate.

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The red swollen nose of rosacea is a much hated symptom. I know that this was the symptom that I despised most and indeed drove me 10 years ago to start to look for good information about how to treat rosacea. Incidentally, this drive lead to the creation of the internet based Rosacea Support Group in 1998.

I hated that I looked like I had adult acne and a constant sun-burned nose. Especially as I have somewhat fair skin, a red nose stood out a mile away.

There has been quite a lot of interest in a article I wrote titled “how to cure a red face (facial erythema or redness)“. That article gave some tips on how to deal with general facial redness. What about a red and swollen nose ? What can you do to treat a red rosacea nose ? Read on for some suggestions.

A rosacea nose has the extra complication that one might end up suffering from rhinophyma. Although rare, rhinophyma is also a much hated symptom of rosacea. While we don’t know for sure how any particular rosacea sufferer’s symptoms will progress, reducing your inflammation and flushing is a good start to winning the battle.

Here are my top tips for dealing with the red nose of rosacea.

Rosacea-LTD III

Rosacea-LTD was one of my first discoveries after starting to look for treatments on the internet in 1998. They consist of compressed disks of sulfur and various salts. You wet your face and glide them over the skin, leaving a thin film. For me these `disks’ did a great job of reducing the papules and pustules on my nose. I could feel them shrinking all those acne looking lumps and bumps. As much of my redness was associated with my papules and pustules, this treatment was a good step in the right direction. I continued to use rosacea-ltd for several years.

Disclaimer: rosacea-ltd is a site sponsor of rosacea-support.org

Oral Antibiotics

If the nasal swelling is associated with the papules and pustules normally seen in rosacea, then systemic antibiotics along with topical metrogel or finacea may also be of benefit. Once the papules and pustules are under control, the associated swelling may be reduced enough to see an overall benefit in appearance. One of the newer antibiotics on the market is a low dose form of doxycycline called Oracea, which may be useful in helping to maintain a long term benefit from antibiotic usage.

Accutane

Accutane or roaccutane has been used for many years to treat cystic acne. There is a good body of evidence to say that you can successfully treat rosacea with accutane. Additionally there are some published papers that deal specifically with treating rhinophyma with accutane.

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

…

Isotretinoin has also been demonstrated to decrease nasal volume in rhinophyma. The most significant regression has been noted in younger patients with less advanced disease.

Biopsy specimens from phymatous skin prior to isotretinoin therapy showed numerous large sebaceous glands. During isotretinoin therapy, the glands diminished in size and number. Other studies have confirmed the usefulness of isotretinoin for phymatous change.

[See treating rhinophyma with accutane]

Accutane is not a drug to be taken lightly. If you would like to try this as an option, the above references might help you find a doctor that can support you using this as a treatment option. You may also want to discuss the option of low-dose accutane with your doctor.

Covering Up

As you start to reduce the inflammation, you will probably also benefit from covering over some of the redness. Some options include the easily available Clinique Redness Solutions, or Eucerin Redness Relief which may be able to offer some relief from the redness. Additionally the green tinted version of the Tone Perfecting Cream may cover some redness.

Perhaps you can find some foundation or tinted moisturizer that you can also include in your daily regime. It might not be easily obtainable worldwide, but The Cancer Council in Australia has a range of tinted moisturiser SPF 25 that looks interesting. Don’t discount a liquid foundation as a possibility, even if you are a guy.

IPL and Lasers

We now know that IPL is excellent for treating a red face and broken blood vessels. Will any of the benefits of IPL also help a red swollen nose ? In general IPL and pulsed dye lasers are useful in reducing the redness flushing, burning,  itching, dryness and swelling of rosacea.

The AAD suggests that for thickening of the skin on the nose and cheeks as seen in rhinophyma, the CO2 laser and erbium:YAG laser can be used.

Surgical Options

When the growth of the nose tissue becomes impossible to manage with topicals or isotretinion, surgical intervention can be an option. Surgery can naturally have its own risks. With the removal of extra tissue also comes the risk of scarring.

CO2 Laser

A 2004  paper; The Gold Standard for Decortication of Rhinophyma: Combined Erbium-YAG/CO2 Laser, details how the authors suggest that the combined YAG/CO2 laser is superior to other lasers, scalpel, radiotherapy and skin grafts in dealing with rhinophyma.

Also some related comments from the AAD page Is laser treatment right for your rosacea? ;

Some patients with longstanding rosacea develop thickening skin on the nose and cheeks, which is called rhinophyma. The CO₂ laser and erbium:YAG laser can be used to remove this thickening skin and improve the contour of the nose. Other surgical procedures used to treat this condition include dermabrasion and excision with a scalpel. Treatment options may be combined to obtain best results.

Dermatologists recommend early treatment of rhinophyma to help prevent the condition from progressing and becoming more difficult to treat. In the advanced stages, rhinophyma can cause difficulty breathing through the nose. It also is possible for the nostrils to collapse.

Other Surgical Methods

A 2003 paper; New surgical adjuncts in the treatment of rhinophyma: the microdebrider and FloSeal details a novel technique using a standard microdebrider followed by a haemostatic sealant to eliminate bleeding.

Now Over to You

What have you found to be useful in your battles with a red nose ? Please help your fellow rosacea sufferers by leaving a comment below.

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A question we hear from time to time from rosacea sufferers is `how do I go about reducing the size of my skin pores ?’ This is quite a difficult question to properly answer. The enlarged pores that you sometimes see with rosacea or acne can feel like they will never go away.

You are here on this page because you feel sure that there must be a way to reduce the inflammation that leads to swollen pores on your face.

Here are some insightful thoughts from Dr. Linda Sy;

Pores can appear enlarged if filled with sebum & keratinized cells. When the epithelial cells are exfoliated or the sebum production is inhibited (example: by topical tretinoin or accutane prescription), the pores appear smaller. Therefore, any prescription that will reduce accumulation of sebum & keratin in the pores, will most likely help reduce the size.

I doubt that many doctors would recommend that you undertake a treatment regime of accutane just to reduce visible facial pores. If you also have the lump and bumps of acne, or severe pustules and redness of rosacea, you may find accutane is helpful in reducing the pore size also.

The NRS Ask the Doctors Blog also has a post asking Rosacea has made the pores on my face large. When I get my rosacea under control, will my pores return to their normal size?

The Rosacea Experts also come to a similar conclusion as Dr. Sy;

Topical and oral antibiotic therapy may be prescribed for mild cases, but more severe cases may sometimes be treated with isotretinoin, which is an oral medication typically used for severe acne. Clinical studies have shown that patients’ large sebaceous glands were diminished in size and number during isotretinoin therapy. There is also evidence that retinoids, topical medications with many of the same properties of isotretinoin, may decrease skin thickening and sebaceous gland enlargement. Spironolactone, a mild diuretic with anti-androgen properties, can also be used to decrease pore size.

Good to see some more suggested treatments for enlarged pores as I know this is something that worries many rosacea sufferers.

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Over To You

Please leave a comment below with any hints or tips you have found that have helped you answer the question “how do I reduce the size of my pores ?”

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• topical vitamins A, C, E and B3
• Low Dose Accutane

One often asked question by newly diagnosed sufferers is `can you get rosacea on areas other than your face’. The usual answer is no; you normally only see rosacea symptoms on the flushing zone areas in the central areas of your face. This paper slightly dispels this idea with a case report about one patient who had rosacea lesions on his arm, and upper chest area.

Rosacea with extensive extrafacial lesions, Int J Dermatol. 2008 Jan;47(1):52-5, Pereira TM, Vieira AP, Basto AS

Rosacea is a very common skin disorder in the clinical practice that primarily affects the convex areas of the face. Extrafacial rosacea lesions have occasionally been described, but extensive involvement is exceptional. In the absence of its typical clinical or histological features, the diagnosis of extrafacial rosacea may be problematic. We describe an unusual case of rosacea with very exuberant extrafacial lesions, when compared with the limited involvement of the face.

The patient had papules, red nodules, pustules and large granulomatous lesions involving the face, neck and upper chest, and extending from the left shoulder along the whole left arm. It was mostly missing from the central facial region. Demodex was not seen as a possibility.

The treatment regime was deflazacort (an oral steroid) 30mg for 3 weeks, azithromycin at 500mg, 3 days a week for 4 weeks and isotretinoin (accutane) 10mg a day for 1 year. The accutane was reduced in the later months. The patient was advised to avoid the sun and use a physical sunscreen (i.e. zinc oxide or titanium dioxide based).

After 1 year, the chest, left shoulder and arm were clear, with some facial redness remaining.

In order to diagnose these symptoms as being rosacea-like, the doctors had to rule out several other possibilities like infectious folliculitis and demodicosis.

Therefore, in this case, the presence clinically of inflammatory papules, pustules, and nodules on a congestive background, with spread from the typical midfacial involvement to other areas of the body, and the presence of poorly organized epithelial granulomas and follicular pustules in the biopsy allow the diagnosis of extrafacial rosacea.

A review of 53 cases of granulomatous rosacea found extrafacial lesions in 15% of the patients.

Interestingly the patient was treated with low-dose accutane and pulse dosing with azithromycin. A 3 week dose of oral steroids was also included.

The paper ends with the following conclusion.

Reports of extrafacial rosacea are rather scarce. However, it may be
more common than it is thought, because it is generally not considered and/or not researched. We presented an unusual setting of extrafacial rosacea that is remarkable for the exuberant and extensive involvement, when comparing with facial involvement, the initial diagnostic difficulty and the good therapeutic results obtained

What about you, have you ever suspected that you have `extrafacial rosacea’ ? How did you treat it ? Leave a comment below.

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