Up until now the best known group of rosacea experts was organised by the National Rosacea Society, and was referred to as the Rosacea Expert Committee.

The NRS Expert Committee over the years has been responsible for amongst others the 4 following landmark rosacea publications;

• Standard Classification of Rosacea
• Standard Grading System for Rosacea
• Standard Treatments for Rosacea: Overall
• Standard Treatments for Rosacea by Subtype

According to this new paper, it has proven difficult to achieve international consensus on therapy guidelines for rosacea.

Interestingly, one of the authors of this paper, Dr. Zoe Draelos, is also listed an author of Standard management options for rosacea and is additionally a member of the NRS Expert Committee itself, so I don’t see this new ROSIE expert group being in competition with, but complementing the NRS expert efforts.

The paper proposes extra emphasis on three prongs of patient education, skin care and drug and physical therapies. Further, the paper suggests that sub-type based treatments might not serve the patient best especially if more than one subtype is present.

The group seems to prefer a regime based on the signs and symptoms of rosacea rather than a subtype classification, but this doesn’t seem to be in conflict with the standard treatments for rosacea, which also seeks to classify symptoms in order to treat them.

Rosacea sufferers can only benefit from more experts getting together and proposing ways to best treat rosacea.

Regardless of what they have to say, you do have to admit that ROSIE is a cute name for a group associated with a red faced disease such as rosacea

Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group

J Eur Acad Dermatol Venereol., 2010 Jun 23, Elewski BE, Draelos Z, Dréno B, Jansen T, Layton A, Picardo M.

Background: The absence of specific histological or serological markers, the gaps in understanding the aetiology and pathophysiology of rosacea, and the broad diversity in its clinical manifestations has made it difficult to reach international consensus on therapy guidelines.

Objectives: The main objective was to highlight the global diversity in current thinking about rosacea pathophysiology, classification and medical features, under particular consideration of the relevance of the findings to optimization of therapy.

Methods: The article presents findings, proposals and conclusions reached by the ROSacea International Expert group (ROSIE), comprising European and US rosacea experts.

Results: New findings on pathogenesis provide a rationale for the development of novel therapies. Thus, recent findings suggest a central role of the antimicrobial peptide cathelicidin and its activator kallikrein-5 by eliciting an exacerbated response of the innate immune system. Cathelicidin/kallikrein-5 also provide a rationale for the effect of tetracyclines and azelaic acid against rosacea.

Clinically, the ROSIE group emphasized the need for a comprehensive therapy strategy – the triad of rosacea care – that integrates patient education including psychological and social aspects, skin care with dermo-cosmetics as well as drug- and physical therapies.

Classification of rosacea into stages or subgroups, with or without progression, remained controversial. However, the ROSIE group proposed that therapy decision making should be in accordance with a treatment algorithm based on the signs and symptoms of rosacea rather than on a prior classification.

Conclusion: The ROSIE group reviewed rosacea pathophysiology and medical features and the impact on patients and treatment options. The group suggested a rational, evidence-based approach to treatment for the various symptoms of the condition. In daily practice this approach might be more easily handled than prior subtype classification, in particular since patients often may show clinical features of more than one subtype at the same time.

Related Articles

• Standard Management Options: Broad Care
• Standard Management Options: according to Subtype
• Standard Classification of Rosacea
• Standard grading system for rosacea

The answer is brief but I’m encouraged to see the NRS discussing further the possibility of using beta blockers for flushing in rosacea sufferers.

In severe cases, a beta-blocker may sometimes be prescribed to help reduce emotionally triggered flushing that is controlled by the autonomic nerves — the nerves that control functions such as heart rate. This type of flushing usually results from emotional stress such as embarrassment, presenting a talk or performing on a test or onstage. Often, the blushing is accompanied by a sensation of the heart beating, a more rapid pulse, dry mouth and a feeling of tightening of facial skin.

The dosage of the beta-blocker is generally lower than for other medical conditions and the heart rate needs to be monitored to avoid too slow a pulse. Patients with peripheral vascular disease or asthma may need to avoid these treatments.

In the Spring 2000 Rosacea Review, the NRS also mentioned the use of “a centrally-acting alpha-2 agonist such as clonidine or beta-blockers such as propranolol and nadolol”.

Related Articles

• RSRP Beta-Blockers & Alpha Antagonists
• Ask the Doctors: NRS acknowledges children can get rosacea
• Ask the Doctors: contact lenses and ocular rosacea, tips and advice
• rosacea flushing and propranolol

Research Grants Awarded

Thursday, April 22, 2010

The National Rosacea Society (NRS) has awarded funding to three new studies and continues to fund three ongoing studies as part of its research grants program to advance scientific knowledge of the potential causes and other key aspects of this potentially life-disruptive disorder.

The three new studies are:

• Cellular and molecular analysis of transient receptor potential (TRP) ion channels and neurovascular regulation in rosacea patients
• Role of skin sympathetic nerve activity in rosacea
• Evaluation of the effect antibiotics used in the management of rosacea have on the immortalized human sebocyte cell line (SZ95) — in vitro studies.

Full details at the NRS Blog: Research Grants Awarded

Related Articles

• NRS Awards 2009 Research Grants
• NRS announces 2008 research grants
• NRS awards 5 more Rosacea Grants
• NRS announces 2007 research grants

I was quietly hopeful that a publication `produced by volunteers and written by dermatologists, physicians, researchers and patients’ could be something worthwhile and progressive for the field of rosacea. Sadly my hopes were dashed in the first few pages. Read on to find out why.

Before we do continue though, let me pose a question. Who would want to publish an article in the RRDi journal ? Would an acknowledged researcher offer original research ? Probably not. If original research was of sufficiently high enough quality, it would be submitted to an established Journal. Would it be helpful and kind professionals ? Would it be someone you found on the internet with views that are not helpful ?

The key question boils down to “Where in the scale from internet lunacy to original research should this journal set its sights ?” The answer, I fear, is that this journal isn’t quite sure and will publish anything.

Calling something a Journal already sets a certain expectation in people’s minds. Without a peer review process supported by a group of experts armed with a sensible selection criteria, any publication will struggle to get above the paper at the bottom of the bird cage.

What happens when you don’t have the fundamentals right to start with ? Well, any ridiculous internet theory from anyone with a keyboard is in danger of sitting right next to something of real cognitive value.

A publication that hasn’t helped its readers distinguish the difference between good and useless has failed.

I fear that the first issue of this journal amounts to an unfortunate mixed bag of articles that will both confuse and inform.

Introduction Disingenuous

I have to take issue with the Introduction first up. The introduction does a disservice to rosacea sufferers.

The Associate Editor, Brady Barrows, says that there is a “mystery and bewilderment surrounding rosacea that baffles not only the experts but also those suffering with this disease.” This is a tired statement that is regularly peddled by Barrows.

I find this egregious on 2 fronts. Firstly it is patently false and secondly this statement becomes self-fulfilling with the poor quality of some of the articles that follow in the journal.

Rosacea cannot honestly be characterised as a baffling condition. Rosacea as defined by the experts has a standard system of diagnosing the disease and standard severity of symptoms as well as a standard set of treatment options. Clinical trials for PPR and ETTR, Ocular rosacea as well as Phymatous rosacea show that the vast majority of participants enjoy excellent clearance for their symptoms.

Thus it is entirely reasonable to suggest that the population at large also in the vast majority gain measurable relief from their rosacea symptoms. Spend too much time with sick people and you start to think that everyone is sick, no ?

Now to the second part of my objection to the `Rosacea is all so mysterious and baffling’ statement. It seems so disingenuous to push this statement and then allow any theory, any therapy to be promoted unchallenged.

What should one do if they truly believe that rosacea is confusing ? Filtering out the junk and highlighting quality would be a good start. What you don’t write about is as important as what you do write about or promote.

Article Breakdown

The articles appear all together. In order to see whether the one you are reading is opinion, patient perspective, review or original you need to flip back to the front each time to consult the index page. It would have been more helpful if each article was clearly labelled as to what category the editors consider each item belonged to.

Opinion

A new class of topical medications may soon be available to treat facial redness

ROBERT T. BRODELL, M.D.

Dr. Brodell is a member of the RRDi MAC.

The first in the opinion section is by Robert T. Brodell, M.D., on the new class of topical vasoconstrictors currently being investigated. It is short, snappy and populist enough to be a news item in the Dermatology Times. Brodell explains that these new topicals are radically different, asks can they possibly work and replies we don’t yet know.

Ocular rosacea, the number one contributor to poor ocular surface health

ROBERT LATKANY, M.D.

Dr. Latkany is a member of the RRDi MAC.

The second article is even shorter (just 273 words) and is by an eye specialist. Robert Latkany, M.D., believes that "Rosacea is far more common than suggested" and "ocular rosacea  is probably the number one contributor to poor ocular surface health".

Rheumatic autoimmunity as the cause of rosacea

LANCE CHRISTIANSEN, D.O.

"Rheumatic autoimmunity as the cause of rosacea" was written by Lance Christiansen, D.O., a retired general practitioner of osteopathic medicine. The article is full of sweeping claims and erroneous beliefs presented as if established fact, for example that rheumatism is now called fibromyalgia, and that "Most physicians know the word "autoimmune", but they do not understand it and they have no idea of how autoimmune diseases affect people (and other vertebrates)."

We are also told that rosacea is common on the palms and soles of the feet.

Christiansen claims that rosacea is "an autoimmune disease caused by a common microorganism, Streptococcus pyogenes" which also causes strep throat, rheumatic fever, scarlet fever, erysepilas, streptococcal impetigo, and puerperal fever.

He then, with no evidence, lists a vast range of conditions including rheumatoid arthritis, scleroderma, Sjogren’s syndrome, ulcerative colitis, Crohn’s disease, allergies, asthma, Addison’s disease, Cushing’s syndrome, pancreatitis, and Tourette’s syndrome as being more likely to occur "in patients with demonstrated rosacea".

To decrease inflammation, he recommends a routine daily cocktail of aspirin, Prilosec, Indocin, Benadryl, Zyrtec, Omega 3 and penicillin.

Anyone googling the author’s name immediately learns that Christiansen’s retirement from the three clinics he ran in Washington state came after his license was suspended in 2005 by his regulating board and the Department of Health on the grounds that he posed "a serious danger to the health, safety, and welfare of the public". After six of his patients died of drug overdoses, Christiansen was accused of prescribing excessive amounts of medication, failing to examine patients before making his diagnosis, failing to maintain adequate records, and failing to consult with specialists and/or follow the recommendations of specialists. His license was permanently surrendered with no right to reapply.

( Suspended Lewis County physician to surrender license permanently,
Doctor Suspended, Accused Of Over-Prescribing )

Christiansen has churned out his theories for years and been ignored, as he explains in the 9,829 word comment he attached to a biotechnology blog in October 2008 in an attempt to find a research organization somewhere in the world that might give him access to patients in a hospital setting. He was, he wrote, struggling "because I am semi-retired, sixty-eight, an osteopathic general practitioner, and not an allopathic physician, because I have never worked in a research organization and I have not had any research published."

Christiansen is on the RRDi’s Board of Directors, and does mention that he doesn’t hold a license to practice medicine after retiring `under pressure’ from the DOH. This pressure, we are told by Christiansen, was as a result of a conspiracy to remove him from his position.

His claim of seeing 230,000 patients as a GP is truly staggering. This would equate to 21 patients a day, 6 days a week, 50 weeks a year for his 36 years. Impressive, but believable ?

Inside rosacea

BEN JOHNSON, M.D.

Dr. Johnson is a member of RRDi MAC.

The last of the four articles in the Opinion section is ‘Inside Rosacea’ by Ben Johnson, M.D., CEO of Osmosis LLC, which sells health and beauty products including skincare, herbs and ‘natural remedies’.  For Johnson "Digestion is the key to this condition" whether through candida, low levels of hydrochloric acid, H. Pylori, or IBS. He encourages the consumption of aloe vera juice without warning of the increased risk of colorectal cancer, melanosis coli or hepatitis, or mentioning any of the medical conditions for which it is contraindicated.

(See Aloe vera Safety)

In the article Johnson twice plugs the health benefits of ‘Harmonized Water’ without letting on that he runs the company that sells it @ $30 per half-litre. On Harmonized Water’s web site the product is described as "a combination of waters that contain different vibrational frequencies". "Water has the ability to carry "frequency messages" for extended periods of time and we have found that some of these messages harmonize internal imbalances in our body."

Anti-quackery sites warn "Talk about "vibrations" is usually a dead giveaway that snake oil is being flogged. "Balance" and "harmony" are other words that have no physiological meaning, and so are widely employed to mislead the credulous."

(See Energized Water: pseudoscientific snake oil)

Harmonized Water LLC warns against trusting rival waters such as structured water – "There is little evidence that any of the handfuls of claims of frequency enhanced waters actually maintain their frequencies. In addition, most waters are not actually frequency enhanced with beneficial frequencies. By definition, frequency enhanced water could be enhanced by being; "prayed over", "put next to music", "treated with light". because all of these methods emanate frequencies. You will find that Harmonized Water is different." "Unfortunately, the effects of structured water are temporary and likely to "re-cluster" by the time consumers get these beverages at the store. Harmonized water enhances the outer shell of the protons/electrons of all the water molecules and its effects on water molecules lasts for several years." http://www.harmonizedwater.com/FAQ_css.html

Rosacea Control

Optimizing redness reduction, part I: Rosacea and skin care

ZOE DIANA DRAELOS, M.D.

Dr. Draelos is well known to rosacea sufferers from being on the expert panel that recently published the Standard Rosacea Management Options and is a member of the RRDi MAC.

In this article Dr. Draelos discusses the importance of the correct selection of a facial cleanser and moisturizer. The article describes how and why a particular formulation of cleanser and moisturizer might suit a skin type and things for rosacea sufferers to avoid. Oily skin may be suited to Ivory, `normal skin’ to Oil of Olay, Dove and Cetaphil Bar, and dry skin to Cetaphil Cleanser, CeraVe and Aquanil. The theory of cleansing cloths and how facial moisturizers work are detailed. Several recommendations for moisturizers with sunscreen for daytime and also moisturizers for night wear are listed.

The importance of essential fatty acids for rosacea

LAURA KOPEC, M.A., C.N.C

Laura Kopec is known to rosacea sufferers via the Rosacea Relief product from Kopec Naturals and is a member of the RRDi MAC.

This article poses the question `Can an understanding of the importance of essential fatty acids fill in the missing gaps for rosacea sufferers and allow one to take personal action toward better health and clearer skin?’

After discussing the benefits of the essential fatty acids to general health Kopec tells us that `it is unclear exactly how much essential fatty acid is important to overcome certain skin conditions such as rosacea’.

Some research is available that shows EFAs are necessary for good health, and as an example the supplementation for cardiovascular and Alzheimer’s disease are worthwhile.

The conclusion is that future considerations should be given to explore the possibility of a link between a deficiency in EFAs and rosacea.

Food choices for rosacea immunity

LAURA KOPEC, M.A., C.N.C

This article explores how, if one accepts that rosacea is an immune disorder, the selection of food can have an effect on our immune system and thus assist in overcoming rosacea.

Amongst other advice, we are told to avoid white flour and sugar, eat brown rice and quinoa.

One bold statement is that “Processed food may some day be linked to every known illness.”

The conclusion is that the important foods to avoid while overcoming rosacea are white flour, cow’s milk, sugar and processed food. Additionally we are implored to consume hormone free meat, aloe vera juice and green food and EFA supplements – in a diet rich in whole foods.

Review Articles

Rosacea, inflammation, and aging: The inefficiency of stress

RAYMOND PEAT, PH.D.

Dr. Peat is a member of the RRDi MAC.

Despite this article being marked as Editor’s Choice, I just couldn’t grasp what the author was trying to get at.

Even the Editor’s recommendation -

Dr Peat makes the remarkable observation that rosacea has the potential to act as a model system for the study of other diseases which share the processes of neovascularization and fibrosis.

This insight should promote a renewed interest in rosacea research, which in turn has the potential to advance our understanding of debilitating chronic illnesses such as diabetes, kidney disease and cancer

still left me wondering what the paper was actually trying to say.

There are several pages of statements about cellular stress and at least a dozen other topics, but I can’t fuse them into something meaningful. The paper’s tightly packed paragraphs, lack of any sections or titles (or a single blank line!) or a discernable conclusion ensures that the reader is left foundering.

Psychological stress and rosacea

DAPHNE SU AND PROFESSOR PETER D. DRUMMOND, PH.D.

Professor Drummond is a member of the RRDi MAC and supervised the PhD program of Daphne Su, which I believe is the first doctoral dissertation on the topic of rosacea. I have met both of the authors.

In this article Su and Drummond lay out their thoughts under the headings:

• The Relationship between Stress and Skin Disorders
• Physiological Mechanisms of Facial Flushing and Blushing
• Emotional Factors associated with Blushing and Flushing
• The Function of Blushing, Blushing Studies
• Emotional Influences on Flushing in Rosacea
• Psychological Well-being and Skin Disorders
• Rosacea and Mental Health
• Psychological Intervention.

The article leads to the following summary:

As the experience of having a skin condition can be distressing, it is not surprising that psychological disorders such as anxiety and depression are prevalent in dermatological settings. While research in the area of rosacea is limited, the few papers published appear to indicate that rosacea sufferers, particularly individuals with severe symptoms, may experience psychological distress. Furthermore, while psychological intervention appears to be helpful for dermatological patients in general to better cope with their condition, more studies are needed to understand and evaluate the role of psychological intervention specifically for rosacea.

The role of Demodex mites in the pathogenesis of rosacea and blepharitis and their control

KOSTA Y. MUMCUOGLU, PH. D. AND OLEG E. AKILOV, M. D., PH.D.

Dr. Mumcuoglu is a member of the RRDi MAC.

Whilst the title of this article suggests that the role of demodex in rosacea will be discussed, my reading would suggest that something along the lines of the “The role of demodex in demodicosis and blepharitis” would be a more descriptive title. Rosacea is discussed only sparingly in the paper.

Was it really 1925 that the possibility of a link between rosacea and demodex folliculorum was first raised ? 85 years later we are still talking about a possible link.

The paper outlines how demodex infestation may be visible as ocular and facial symptoms (and thus demodicosis can be diagnosed), how the mites can be detected and also detailed treatment options.

Anyone seeing the title of this paper would think that there is an establish role for demodex in how rosacea progresses, but this is not the case. This paper needs to be re-titled.

A molecular link between rosacea and gastrointestinal disease

JOANNE WHITEHEAD, PH.D.

Joanne Whitehead is the Editor in Chief of the Journal of the RRDi.

Dr. Whitehead explores the possibility of an enzyme known as Intestinal Alkaline Phosphatase (IAP) being a link between intestinal bacteria and rosacea symptoms.

Many dietary and hormonal factors are known to affect the severity of rosacea symptoms, several of which also modulate the activity of the enzyme intestinal alkaline phosphatase (IAP). The role of IAP in inhibiting an inflammatory response to intestinal bacteria suggests a mechanism by which intestinal pathologies may be linked to the skin inflammation characteristic of rosacea

…

More importantly, the safe and long term control of rosacea could be undertaken by patients themselves through dietary modification to naturally increase IAP activity.

This paper appears to be a copy of a previously published paper: Intestinal alkaline phosphatase: the molecular link between rosacea and gastrointestinal disease?, Med Hypotheses. Whitehead J., 2009 Dec;73(6):1019-22. Epub 2009 Jul 1.

According to the description of the Journal Medical Hypotheses, it doesn’t appear to a peer reviewed journal but somewhere that a hypothesis can be explored.

The papers chosen may contain radical ideas, but may be judged acceptable so long as they are coherent and clearly expressed. The authors’ responsibility for the integrity, precision and accuracy of their work is paramount.

Papers in Medical Hypotheses take a standard scientific form in terms of style, structure and referencing. The journal therefore constitutes a bridge between cutting-edge theory and the mainstream of medical and scientific communication, which ideas must eventually enter if they are to be critiqued and tested against observations

Original Research

Signal Transduction Modulators to treat rosacea

JEFFRY B. STOCK, PH.D.

Signum Biosciences featured recently in Rosacea News (Signum Biosciences developing SIG990 for Rosacea). Dr. Stock is the chairman of Signum Biosciences.

The article introduces a class of topicals known as Signal Transduction Modulators (STMs), which are said to attack the redness of rosacea.

We are told that this article has been published as Supplement to Volume 129, Journal of Investigative Dermatology,  1 April 2009 and also Society for Investigative Dermatology meeting in Montreal, 2009 (poster 126):

This class of anti-inflammatory STMs inhibits inflammation by reducing the release of critical inflammatory mediators that underlie rosacea pathogenesis, including tumor necrosis factor alpha, interleukins IL-1, IL-6, and IL-8. This leads to a dramatic reduction in neutrophil infiltration and the consequent production of toxic reactive oxygen species.

We are told that STMs have been shown to have superior activity in reducing erythema compared to metronidazole, azelaic acid and brimonidine. This is quite exciting because if this technology leads to a product that can be tested against rosacea then there may be another option for the treatment of the red face of rosacea.

A first-generation STM known as Arazine is to be released to the Japanese market in early 2010.

Patient Perspectives

The effect of dietary salt on rosacea

HELEN COOPER

Helen Cooper is listed as a RRDi Corporate Member.

This article suggests that a condition known as Hypochloryhydria (the lack of stomach acid) causes the poor digestion of food which leads to flushing and rosacea. The trigger for this condition is said to be a lack of salt in our diet.

One can read all sorts of rosacea cures on the internet. Many of the cures are partnered with a conspiracy theory about how large pharmaceutical companies are responsible for suppressing the flow of information.

As to why my salt cure had never been discovered, the most alarming idea is that perhaps it has — but remains unrevealed. There are products on the market that treat rosacea with varying degrees of success and keeping this salt cure a secret would protect profits.

…

I doubt, however, that there is a collusion to hide valuable information. It’s just that the solution cannot be found in the laboratory.

It is unclear to me whether the author really wants a global conspiracy to exist or not. Certainly it would help the author answer the question as to why the method by simply increasing our salt intake isn’t taking off as a rosacea cure.

Perhaps a better answer to this question is that with such a large number of rosacea sufferers out there, one is bound to find a handful (at least) of fellow sufferers who share any particular experience or unsupported theory.

Is it possible for rosaceans to do research?

JOEL T. BAMFORD, M.D., F.A.A.D.

Dr. Bamford is a member of the RRDi MAC.

Dr. Bamford wants to encourage rosacea sufferers to consider that they could be responsible for some research themselves. He cites two studies that were presented as poster sessions but never progressed to academic papers. These studies looked at the correlation between “extra facial lesions” and the diagnosis of rosacea. The studies were not controlled so could not be considered for publication. The suggestion is put that with volunteer effort a controlled study could be achieved.

Literature

2009 Research Highlights

JOANNE WHITEHEAD , PH.D.

Dr. Whitehead mentions updates that the NRS Expert Committee published in 2009 on the overview of rosacea care and recommended treatment for each subtype.

A survey on rosacea treatment in the USA was mentioned along with a paper discussing the prevalence of rosacea in India.

The review ends with a brief comment of the unifying theory emerging from the research into cathelicidins.

Books and articles to be published in the future

PROFESSOR GERD PLEWIG , M.D.

Professor Plewig is a member of the RRDi MAC.

Plewig doesn’t appear to have contributed to the journal but is mentioned as being involved in 3 upcoming books.

Second Edition Next Year ?

There has been a call for papers for the next volume of this journal. The editors have said that this volume will be subject to peer review, but so far it isn’t clear what that actually means.

Related Articles

• Read more Rosacea Book Reviews

Call for Papers, RRDi Journal Volume 2

We welcome articles on any aspect of rosacea for the second volume of the RRDi Journal. Health professionals and researchers are invited to submit research articles, clinical trial reports, case studies, review papers and opinion pieces, which will be subject to peer review. We also welcome personal statements from rosacea patients, news bulletins, and other relevant short pieces for inclusion in the journal.

Please direct all enquiries to Joanne Whitehead, Editor in Chief: joanne@irosacea.org

Citations should be numbered in superscript in the text, and references listed numerically. Figures should be greyscale in 300 dpi tiff format. For colour figures, please inquire.

I haven’t ever got that excited about the annual awareness month for rosacea, as, well I’m quite aware of it.

It is obvious though, from looking around the population that plenty of people are not aware of the condition.

Why don’t you, as a reader of Rosacea News, do something to support Rosacea Awareness this year. Perhaps there is something you can online or offline to promote the education and awareness of rosacea ?

Awareness Month in April

Thursday, February 4, 2010

Although the number of people with rosacea continues to rise with the growth and aging of the U.S. population, most fail to recognize the warning signs of this potentially life-disruptive disorder now estimated to affect well over 14 million Americans. The National Rosacea Society (NRS) has designated April as Rosacea Awareness Month to alert the public to the signs and symptoms of this chronic and conspicuous facial condition and to emphasize the importance of seeking medical help.

…

In an effort to reach the growing number of rosacea sufferers, public education activities will be conducted by the NRS to increase awareness and understanding of this widespread disorder, emphasizing the warning signs and urging those who suspect they may have rosacea to see a dermatologist or other physician. In addition, bulk quantities of NRS educational materials are available to health professionals for their patients.

…

For more information, visit All About Rosacea.

It obviously costs a lot to be able to educate a large population and target physicians and sufferers alike. This is a huge undertaking that you have to wonder, if not attempted by the National Rosacea Society, would there be anyone out there keeping rosacea in the public eye ?

Rosacea Resources

Here are some resources that might help with your own quest to raise rosacea awareness:

• Standard Classification of Rosacea :

  The National Rosacea Society assembled a committee to develop a standard classification system that can serve as a diagnostic instrument to investigate the manifestations and relationships of the several subtypes and potential variants of rosacea.

• Rosacea Grading System :

  To enhance the utility of the (standard classification) system for both clinicians and researchers, the committee has devised a standard method for assessing gradations of the severity of rosacea. In addition to the classification system, a standard grading system is often essential to perform research, analyze results, and compare data from different sources, and in turn provides a common reference for diagnosis, treatment, and assessment of results in clinical practice.

• Standard Management Options: Broad Care :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.

  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.

• Standard Management Options: according to Subtype :

  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.

As part of an effort to raise the global awareness of Rosacea, I can send you a copy of the of any of these rosacea expert documents. Drop me an email at david@rosacea-support.org

The journal has been produced by volunteer rosacea sufferers and consists of `articles by dermatologists, physicians, naturopaths, researchers and patients’.

This first edition is available for $15 from amazon.com and iUniverse. The purchase price is used to further the journal’s publication and lead to some novel rosacea research – although one can imagine that many thousands will need be sold to be able to fund research.

Volume 1, Number 1 Contents.

• A new class of topical medications may soon be available to treat facial redness
• Ocular rosacea, the number one contributor to poor ocular surface health
• Rheumatic autoimmunity as the cause of rosacea
• Inside rosacea
• Optimizing redness reduction, part I: Rosacea and skin care
• The importance of essential fatty acids for rosacea
• Food choices for rosacea immunity
• Rosacea, inflammation, and aging: The inefficiency of stress
• Psychological stress and rosacea
• The role of Demodex mites in the pathogenesis of rosacea and blepharitis and their control
• A molecular link between rosacea and gastrointestinal disease
• Signal Transduction Modulators to treat rosacea
• The effect of dietary salt on rosacea
• Is it possible for rosaceans to do research?
• Research Highlights
• Books and articles to be published in the future

When I am able to read a copy I’ll post a review of the contents. Congratulations to all who contributed to this publication.

Related Articles

• Book Review: Rosacea Diagnosis and Management
• My list of Rosacea Book Reviews

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.”

[Update:] The NRS have posted a new blog entry: Rosacea Incidence on Rise with more background on the research behind their estimate of 16 million Americans.

The NRS had previously estimated the number of rosacea sufferers in the United States at 14 million, and recent epidemiological studies have also found the incidence may be much higher. Despite its prevalence, however, most Americans are unaware of its signs and symptoms, and medical data suggest that only a small percentage of rosacea sufferers are being treated.

[Update 2:] some more research on rosacea prevalence has been published.

Your Thoughts

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

Authored by a who’s who of Rosacea Experts, the National Rosacea Society has again brought about a publication that puts a stake in the ground for rosacea treatment and management.

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