The prevalence of rosacea is an often reported fact. Most media releases will start with a statement of the number of rosacea sufferers in the US.

The latest 2010 estimates from the NRS suggest that 16 million Americans suffer from rosacea, up from the last estimate of 14 million.

Various studies have found rosacea to be present in around 6–14% of the population. The higher incidence is thought to be related to the prevalence of fair-skinned individuals.

It makes sense that as the population ages and also as the general knowledge of rosacea improves, we see increases in estimates of the number of rosacea sufferers out there.

Dr. Wilkin cautions on the whole art of estimating rosacea sufferers: “In actuality, all of these studies may understate the true incidence of rosacea because they examined only the presence of signs and symptoms at the time of the study, while rosacea is a chronic underlying condition whose outward signs and symptoms are characterized by relapses and remissions,

Thus, at any given time, millions of additional rosacea sufferers may simply be in temporary remission.”

What do you think, do you see more people around you with visible signs of rosacea ?

This paper is Part 2 in the series of Standard Management Options for Rosacea. Part 1 was devoted to the Overview and Broad Spectrum of Care. Now, Part 2 will expand to discuss management options according to the rosacea subtype.

Lets do some quick revision. In 2002, the National Rosacea Society Expert Committee reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes. In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.

The standard classification system for rosacea breaks rosacea down in to 4 sub types.

• Subtype 1: Erythematotelangiectatic Rosacea (ETTR)
• Subtype 2: Papulopustular Rosacea (PPR)
• Subtype 3: Phymatous Rosacea (PR)
• Subtype 4: Ocular Rosacea (OR)

Understanding that some rosacea  sufferers may have multiple subtypes, the overall management of rosacea symptoms should be keyed to the rosacea subtype in question.

So below is a summary of the 2009 Standard management options for rosacea, part 2. I have given a quick view of each section. For further details, including several disclaimers about the information supplied, see the full text of the paper. The PDF can be purchased for $5 online at cutis.com. I can also email a copy if you would like to read a copy for your own rosacea treatment.

Many of the rosacea experts credited as authoring this paper have links to pharmaceutical companies, and their links are listed. Interestingly Dr. Wilkin is listed as “a scientific and regulatory affairs consultant for 145 companies, including some that products for rosacea.” Wow that is a lot of consulting !

See also Standard Management Options 1: overview and broad spectrum of care.

Erythematotelangiectatic Rosacea

The following therapeutic approaches are listed according to the grade of the redness and broken blood vessels of ETTR.

The committee notes that no drugs to reduce flushing have been approved by the FDA but off-label use may have some moderating effects for grade 2 and 3 flushing.

Papulopustular Rosacea

An approach of topical and oral therapies is detailed to bring the papules and pustules of rosacea into remission.

Additionally the following advice is offered for use a tetracycline other than the FDA approved-for-rosacea Oracea;

In some cases, oral drug therapy for grades 2 and 3 and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followedby 0.5 g/d for 2 to 3 weeks.

Some physicians may prescribe higher doses, longer courses, or other tetracyclines
such as doxycycline or minocycline.

Further, here you will find some less common known oral and topical therapies ;

In refractory cases, off label oral trimethoprimsulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

The possibility of some role for demodex, and the resulting therapy of topical permethrin and systemic ivermectin is also mentioned. Caution is suggested when using these potentially irritating agents.

This is the first time that I have seen the recommendation of demodex mite treatments in such a distinguished paper on rosacea.

Phymatous Rosacea

Grade 1 symptoms are treated with topical and systemic antibiotics.  We are told that Isotretinoin (accutane) has been shown to decrease nasal volume in younger patients with less advanced disease – although the volume may increase again after accutane is stopped. Topical retinoids may also reduce fibrosis, elastosis and sebaceous gland hypertrophy.

Ocular Rosacea

We are reminded that ocular symptoms may appear before skin symptoms and that more than 60% of patients with skin symptoms of rosacea also may have ocular symptoms.

Conclusion

As another stake in the ground, this paper will serve rosacea sufferers very well.

The committee suggests that the classification and grading of rosacea symptoms can help by subsequently leading to an effective management regime. Certainly attacking your rosacea symptoms by dividing and conquering the subtypes is a good place to start.

Those interested in a more thorough treatment of up to date rosacea treatment and diagnosis may be interested in my Book Review: Rosacea: Diagnosis and Management, Frank C. Powell which was written by one of the expert authors of this paper.

Standard management options for rosacea, part 2: options according to subtype.

Cutis. 2009 Aug;84(2):97-104.

Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J;

and further Collaborators

Bamford J, Berg M, Del Rosso J, Geronemus R, Goldberg D, Granstein R, James W, Kligman A, Mannis M, Marks R, Pelle M,Scheinfeld N, Sires B, Torok H, Wolf J, Yaar M

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss the standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) management options according to subtype. The menu of options is considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanisms of action of therapies are more definitively established.

Related Articles

• Standard Management Options 1: overview and broad spectrum of care
• Book Review: Rosacea Diagnosis and Management
• Standard Classification of Rosacea
• Rosacea Grading System

Briefly some history: In 2002, the National Rosacea Society Expert Committee reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes. In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.

As we have always known, the classification system for rosacea is provisional and based on what can be observed rather than any common understanding of what causes rosacea (pathogenesis) or assumed progression of symptoms between the defined subtypes.

Now, the committee has developed standard management options for rosacea. The committee was expanded to include additional experts in dermatology, skin care, laser therapy and ophthalmology.

Many of the rosacea experts credited as authoring this paper have links to pharmaceutical companies, and their links are listed. Interestingly Dr. Wilkin is listed as “a scientific and regulatory affairs consultant for 145 companies, including some that products for rosacea.” Wow that is a lot of consulting !

See also Standard Management Options 2: according to subtype.

My Review

Below is a summary of the 2009 Standard management options for rosacea, part 1. I have given a quick view of each section. For further details, including several disclaimers about the information supplied, see the full text of the paper. The PDF can be purchased for $5 online at cutis.com. I can also email a copy if you would like to read a copy for your own rosacea treatment.

The committee is emphasizing the importance of how lifestyle changes and skincare and understanding the particular role of a treatment to achieving the best results for an individual patient.

The standard management options are a menu, you aren’t meant to do them all, just pick and choose what is relevant for your symptoms.

Medical History

A medical history is seen as necessary as some features of rosacea may not be visible when you front up at a doctor’s surgery. Also some tricky alternative diagnoses must be eliminated first.

A few paragraphs are very similar to that Dr. Powell says in his book Rosacea Diagnosis and Management, Frank C. Powell. eg. sun sensitive skin as in heliodermatitis can be confused with the redness and broken blood vessels  (ETTR) or rosacea. Undiagnosed ocular involvement is another reason for a detailed medical history.

Drug Therapy

The papules and pustules of rosacea can be effectively treated by well known drugs like Finacea and Oracea which have been officially approved by the FDA for treating rosacea. Options for off-label medications will be detailed in Part 2 of this series.

The committee acknowledges the need for research into and treatments for the background redness of rosacea as this is a great unmet clinical need.

Laser and Light Therapy

Most lasers that treat the vascular component of rosacea have wavelengths in the 500-600nm range. Also mentioned also is long-pulsed dye lasers, the 532nm KTP laser along with IPL. The er:YAG and 10,600nm CO2 ablative lasers are also given a mention for subtype 3 of rosacea.

Lifestyle Management

This is the bit of rosacea therapy that always seems wanting to me. The committee is suggesting that rosacea sufferers keep a record of or try to avoid their triggers. This just seems so impractical for real life.

Adjunctive Care

Skin Care is an important component of rosacea management because of the sensitive and easily irritated nature of rosacea skin. If chemical sunscreens cause irritation, physical sunblocks using zinc or titanium dioxide are recommended.

As stinging most often occurs when the skin is wet, rosacea sufferers are advised to apply wait 5 – 30 minutes for the face to dry after gentle cleansing, before applying topicals.

Avoid any product that causes burning, stinging itching etc. Good advice, but may be quite hard to follow if one cannot find the perfect moisturiser or cleanser for their regime.

“New cosmetics should be regularly purchased to minimize microbial contamination and degradation”. That advice sounds expensive !

Conclusion

Overall there is little here that is new to most rosacea sufferers. This paper does though serve well as a starting point when trying to find a regime that will relieve your symptoms.

Certainly the weight of authors involved in this paper will go a long way to help convince your doctor that the advice herein is well heeded.

Those interested in a more thorough treatment of up to date rosacea treatment and diagnosis may be interested in my Book Review: Rosacea: Diagnosis and Management, Frank C. Powell which was written by one of the expert authors of this paper.

Standard management options for rosacea, part 1: overview and broad spectrum of care.

Cutis. 2009 Jul;84(1):43-7.

Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J; National Rosacea Society Expert Committee on the Classification and Staging of Roasacea. ( <- yes pubmed does indeed mis-spell rosacea!)

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) options according to subtype. The options are considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanism of action of therapies are more definitively established.

Related Articles

• Book Review: Rosacea Diagnosis and Management
• Standard Classification of Rosacea
• Rosacea Grading System
• Standard Management Options 2: according to subtype

The National Rosacea Society wants your input to determine what information you would like to see on their web site. As the most popular rosacea web site on the internet, rosacea.org is often the first stop for newly diagnosed rosacea sufferers. The NRS has access to the most noted rosacea experts and have been responsible for the creation of the standard classification system and standard grading system for rosacea. More recently they have also motivated the publication of a 2 part Standard Management Options for rosacea.

Among other publications they are responsible for are the surveys they conduct. Often these surveys are the only ones available for researchers to quote in their publications.

So here we go, rosacea sufferers are invited to let the National Rosacea Society know what they should be providing via their web site.

Survey on Future Content

The National Rosacea Society constantly strives to provide relevant, accurate and up-to-date information on all aspects of this widespread disorder. To help make Rosacea.org as useful as possible, please give us your input on current and possible future content. The information you provide will serve as a guide for the continuing expansion of the site. Thank you very much for your help.

To take the survey, click here.

Related Articles

• NRS Awards 2009 Research Grants
• NRS updates rosacea patients web site
• NRS Introduces Clinical Scorecard For Evaluating Rosacea Patients

The update mentions the `Gallo Research’ and describes it ; “Dr. Richard Gallo at the University of California-San Diego found a consistently aberrant innate immune response in individuals with rosacea to environmental and emotional triggers.”

Spin-off research related to type I interferon, plasmacytoid dendritic cells and enzyme involvement is also underway.

A possible link between flushing and inflammation via endothelin-converting enzyme (ECE) is being studied and gets a mention.

Finally the role of G and beta-arrestin proteins in a particular type of flushing and the demodex bacteria Bacillus oleronius are also discussed.

Check out the full rosacea research update for more information.

More Background

Also see the related Rosacea News items around these some of these studies:

demodex bacteria, one baby step at a time

demodex mite bacteria causes the inflammation ?

Focus on cathelicidin and its role in rosacea

Related Articles

• NRS Awards 2009 Research Grants
• NRS announces 2008 research grants
• NRS announces 2007 research grants

From New Grants Available

Monday, July 27, 2009

New grants are available from the National Rosacea Society (NRS) to support research on potential causes and other key aspects of rosacea that may lead to improvements in its treatment and potential cure or prevention. Medical researchers can obtain application forms by contacting the National Rosacea Society, 800 South Northwest Highway, Suite 200, Barrington, Illinois 60010, telephone 888/662-5874, fax 847/382-5567, e-mail rosaceas@aol.com or by filling out the request form here.

The deadline for submitting applications is November 15, 2009. Grants will be issued following selection by the NRS medical advisory board.

Because the etiology of rosacea is unknown, a high priority in awarding grants will be given to studies relating to such areas as the pathogenesis, progression, mechanism of action, cell biology and potential genetic factors of rosacea. Research in such areas as epidemiology, predisposition, quality of life and relationships with environmental and lifestyle factors may also be funded.

More information on the NRS research grants program may be found in the Research Grants section.

Related Articles

• NRS Awards 2009 Research Grants
• NRS wants your feedback on Research !
• NRS announces 2008 research grants

Sadly there was no conclusion as to whether the extra incidence of sunburn contributed to the severity of their rosacea or if the rosacea symptoms lead to more sunburn events.

Sunburn Linked to Rosacea

Both a blistering sunburn and a family history of rosacea were associated with the presence of rosacea, according to study results presented by Dr. Alexa Boer Kimball, associate professor of dermatology at Harvard Medical School, at the recent annual meeting of the American Academy of Dermatology.

…

While it was not clear whether sunburns contributed to rosacea or patients with rosacea were more likely to sunburn, she said, preventive measures could help lessen rosacea’s severity. Sun has been named the top flare-up trigger by 81 percent of patients in a National Rosacea Society survey (NRS), and in another NRS survey nearly 52 percent said someone else in their family had rosacea.

I think any possible thought that sun damage can cause rosacea is enough to highlight the fact that rosacea sufferers should use a sunscreen every day. A daily sunscreen will also help mitigate any weakness in the skin’s natural protection that might be caused by the diseased skin of rosacea.

Many rosacea sufferers find that physical sunscreens i.e. those that contain zinc oxide or titanium dioxide as their main protective agent can work quite well to protect against the sun and elements. Additionally tinted sunscreens can also help hide the redness often associated with rosacea.

[Update] The presentation from Dr. Kimball is available online: STUDY FINDS FAMILY HISTORY, HIGHER INCIDENCE OF SUNBURNS ASSOCIATED WITH ROSACEA

Whilst no link was found between body mass index and rosacea, Dr. Kimball notes “Future studies should explore the possible connection between a higher BMI and rosacea, as excess weight could be found to be a contributing factor to the condition.” This is worth considering as a possible contributing factor to rosacea – perhaps being overweight places and extra burden on our bodies and could cause problems with increasing our tendency to flush for eg.

Related Articles

• micronized zinc oxide dimethicone a safe sunscreen
• Zinc Oxide or Avobenzone boosts sunscreen protection

• Dr. Richard Gallo, who has received a lot of press coverage from the research on the role of cathelicidins, and Dr. Kenshi Yamasaki of the Veterans Medical Research Foundation were awarded $25,000 to continue their NRS-funded research of how cathelicidins may play a role in the development of subtype 2 (papulopustular) rosacea.
• Dr. Curdin Conrad, senior postdoctoral research fellow, Department of Immunology, MD Anderson Cancer Center, and Dr. Alexander Navarini, senior postdoctoral research fellow, Department of Dermatology, University Hospital of Zurich, Switzerland, were awarded $21,450 to study the role of plasmacytoid dendritic cells and interferon alpha in rosacea.
• Dr. Robert W. Walters, assistant professor, Division of Dermatology, and Dr. Robert J. Lefkowitz, professor, Department of Medicine, Duke University Medical Center, were awarded $25,000 to study the role of beta-arrestin in cutaneous flushing. The researchers pointed out that niacin, or vitamin B3, long associated with severe flushing, stimulates receptors on skin cells that react by activating both G and beta-arrestin proteins. However, they noted that a recent study has identified niacin-like drugs that can stimulate only the G protein but do not induce flushing, suggesting that it is the beta-arrestins that may regulate flushing. The results of the new project are intended to lead to better understanding of changes in skin blood flow and possible treatments for this significant symptom of rosacea.
• Dr. Joseph Rothnagel, associate professor, and Dr. Manuela Trabi, adjunct lecturer, Department of Molecular and Microbial Sciences, The University of Queensland, Australia, were awarded $18,000 for their study, "The role of tissue kallikreins in rosacea." This study will also build from the work of Dr. Gallo and colleagues. They noted that these previous studies reported involvement of the enzyme hK5 and protein CAP18, and hypothesize that at least one other enzyme is also elevated in rosacea. They will study whether proteins known to be crucial for skin integrity are also digested at a higher than normal rate by these enzymes, allowing easier access for pathogens.

Congratulations to the successful applicants.

If you would like to directly donate to rosacea research, just visit the NRS Donate to Research page. All donations received via the NRS web site are automatically directed towards their research program. You may also designate donations towards their research program by noting so on your check.

Related Articles

• NRS announces 2008 research grants
• NRS announces 2007 research grants
• NRS awards 5 more Rosacea Grants
• Focus on cathelicidin and its role in rosacea

From Taking Science Personally;

What makes the story of the Michael J. Fox Foundation different — nay, what makes it important — is that it doesn’t just dole out money to scientists and hope for the best. It has used its money to take control of Parkinson’s research like few other foundations have ever done. In the process of trying to solve the mysteries of Parkinson’s, it has upended the way scientific research is done, and the way academics interact with pharmaceutical and biotech companies, at least in its little corner of the world. It demands accountability and information sharing that is almost unheard of in the broad scientific community. And it has managed to become, in its short seven-year life, the most credible voice on Parkinson’s research in the world.

…

They all use their money, unabashedly, as weaponry, to finance targeted research, hold conferences where scientists must share information and underwrite clinical trials conducted by drug companies. They are hard not to admire.

…

Meanwhile, the Fox Foundation wanted a change: in how it financed research, and what kind of research it financed. Instead of simply doling out money for a certain period of time — and hoping for the best — it began to keep closer track of researchers, using its money to accelerate research that was going well, or shift direction if it wasn’t. It expected its researchers to report problems and progress. It established markers and other goals that researchers were expected to meet. It insisted that the money it gave went very specifically to research that was directly related to Parkinson’s — and it was unafraid to finance risky ideas. “We throw 100 ideas up against the wall,” Ms. Brooks said. “One of the most important things we do is de-risk ideas” — and in so doing make them more palatable for industry and other researchers to pursue.

…

A few years later, Ms. Brooks and Mr. Fox made another important shift. Instead of relying on the scientific advisory board to make “yea” or “nay” decisions on grants, it decided to hire its own Ph.D.’s. It now has six in-house scientists. The Ph.D.’s allow the foundation to move faster still, since it no longer has to wait for the scientific advisory board to meet to make decisions. But it has other benefits as well: the Fox scientists are young, early enough in their careers that they are not set in their ways. There are perfectly happy to ask different kinds of questions and do things in a different way. In effect, they have allowed the Michael J. Fox Foundation to not just pursue important research already being done, but also to set the agenda for research it thinks ought to be pursued. And that is what has happened.

I find this really interesting. It obviously helps to have a rich contributor like ex Intel boss Andy Grove, but nonetheless a fresh approach to keenly develop treatments is working for Parkinson’s Disease.

I’m also reminded of the efforts of Lance Armstrong who is returning to professional racing next season with the primary idea of advancing his cancer foundation.

These sorts of approaches certainly differ from what we see in rosacea, where rosacea sufferers are for eg. left waiting for a bigpharma company to push through a product like sansrosa.

I’m also impressed with the idea to employ your own Ph.Ds. After reading what I can of the last few year’s worth of rosacea research I do sometimes wonder just who exactly is undertaking truly forward thinking research.

Over to you:

What are your thoughts ? Do you think rosacea research needs an overhaul from the current thinking and way of doing things ? Are we missing a motivated celebrity sufferer to head up our cause ?

My wife believes that our 10-year-old son might have rosacea. She is a sufferer, and he flushes a lot and has a lot of pimple-like bumps. Do children get rosacea?

While rare, cases of rosacea during childhood have been reported in the medical literature. Whether your son has rosacea or not, he may benefit from seeing a dermatologist for a proper examination, diagnosis and treatment as may be appropriate.

…

Also, if your son experiences any eye discomfort, make sure the doctor is informed of this as ocular rosacea may be especially important to identify and treat during childhood.

Related Articles

• ocular rosacea in children
• childhood stye might lead to adult ocular rosacea