Always quick to generate a press release, Pyratine XR has been seen some recently published research, this time on the long term efficacy when treating mild to moderate rosacea.

This latest research is in addition to the May 2009 JDD article, Topical PRK 124 (0.125%) lotion for improving the signs and symptoms of rosacea, and the 2007 Topical kinetin 0.1% lotion for improving the signs and symptoms of rosacea

So now we have the June 2010 Journal of Drugs in Dermatology article; Long-term Efficacy and Safety of Topical PRK-124 (0.125%) Lotion (PyratineXR™) in the Treatment of Mild-to-Moderate Rosacea.

Although this study only included 14 patients, it did last 48 weeks which seems to be much longer than the usual period for a study of this type. It is potentially good news that Pyratine XR offers sustained benefit over the long term.

At worst the product didn’t seem to induce an irritation and at best offers a measurable benefit for the redness and papules and pustules of rosacea.

Pyratine XR continues to attract only modest attention in the online rosacea forums. For some snippets of user feedback see Pyratine XR user reviews.

Long-term Efficacy and Safety of Topical PRK 124 (0.125%) Lotion (Pyratine-XR) in the Treatment of Mild-to-Moderate Rosacea

J Drugs Dermatol. 2010 June;9(6):647.

Background: Many patients with rosacea cannot tolerate extended treatment periods with topical agents because their skin sensitivity is often increased.

Objective: To determine the long-term efficacy and tolerability of a new moisturizing lotion for improving the signs and symptoms of mild-to-moderate rosacea.

Methods: In a 48-week, open-label study, a moisturizing lotion containing furfuryl tetrahydropyranyladenine as PRK-124 (0.125%, Pyratine-XR™, Senetek PLC, Napa, CA) was applied twice daily by 18 subjects with mild-to-moderate rosacea. Clinical improvements were assessed by the treating physician. Skin barrier function was measured by transepidermal water loss after treatment. Tolerability and cosmetic outcome were evaluated by subjects.

Results: Subjects experienced a mean 44 percent reduction in erythema severity and a mean 89 percent reduction in inflammatory lesion count at week 48. Reductions were significant (P≤0.05) in both erythema and lesions at weeks 24, 36 and 48. Statistically significant (P≤0.05) improvements in telangiectasias, transepidermal water loss and dryness were noted. Overall clinical improvement was observed in 81 percent of subjects and the investigator’s global assessment steadily improved throughout the study. Treatments were well-tolerated and cosmetically acceptable. Treatment-induced skin irritation was not observed.

Conclusion: The new moisturizing lotion containing furfuryl tetrahydropyranyladenine as PRK 124 is efficacious, does not irritate skin, and is well tolerated for at least 48 weeks.

Featured Product

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The incidence of rosacea is studied because there is a belief that the statistical analysis will reveal pearls of wisdom. This wisdom could come from such discoveries as a rosacea gene, clues from environmental factors or some statistical correlation with a population group for eg.

In the first of these 2 studies, from a small random group of 350 sufferers from a group of Estonian workers, researchers found that 22% had rosacea and 15% had frequent episodes of flushing without rosacea symptoms. This seems like quite a high incidence.

The second study looked at the symptoms of a group of Koreans who had already been diagnosed with rosacea, using the Rosacea Classification System to group features and found that almost all of the patients had the redness of rosacea, 1/2 had the papules and pustules of rosacea. There was a strong correlation between sun exposure and the redness of rosacea, but not the papules and pustules of rosacea, and in general the patients didn’t identify any factor that relieved their symptoms.

Prevalence of rosacea in an estonian working population using a standard classification.

Acta Derm Venereol. 2010 May;90(3):269-73.

Data about the prevalence of rosacea are scarce. The aim of this study was to evaluate the prevalence rate of rosacea according to the American National Rosacea Society Expert Committee (NRSEC) classification.

A cross-sectional study of 348 subjects randomly selected from a working population >or= 30 years of age was performed. All subjects completed a questionnaire. Skin status was examined according to NRSEC criteria.

Of the 348 subjects, 78 (22%) had one or more primary features of rosacea. The most common features were erythema (21%) and telangiectasia (18%). Of the subjects with rosacea, 78% had erythematotelangiectatic rosacea and 22% had papulopustular rosacea. Fifteen percent of the study subjects had experienced frequent episodes of flushing without permanent features of rosacea. No significant gender-related differences were found between study groups.

In conclusion, according to the NRSEC, rosacea is a more common skin condition over the age of 30 years than previously thought.

The following study could easily lead to rosacea sufferers thinking that they are destined to suffer from rosacea for around 3-4 years. Unfortunately the structure of the study doesn’t actually suggest that, but it seems to be a common belief – that rosacea has some kind of natural longevity.

Ann Dermatol. 2009 Aug;21(3):243-9. Epub 2009 Aug 31.

Clinical evaluation of 168 korean patients with rosacea: the sun exposure correlates with the erythematotelangiectatic subtype.

BACKGROUND: Although rosacea is a chronic cutaneous inflammatory disorder that’s commonly seen in adults, the etiology and pathogenesis of the illness remain unclear. A well established diagnostic classification and grading system may play a critical role in performing research and it would serve as a diagnostic reference in the clinical field.

OBJECTIVE: We sought to classify the patients with the new standard classification and grading system and we wanted determine the peculiar features and relationships of each subtype. We also analyzed the relationships between the degree of sun exposure and each subtype.

METHODS: We reviewed the medical records and clinical photos of 168 patients who were diagnosed with rosacea from 2002 to 2007 at our hospital. The standard classification and grading system suggested by the National Rosacea Society (NRS) Expert Committee was adopted to evaluate each patient’s subtype and the severity.

RESULTS: The male:female ratio was 1:2.29. The mean age at the time of diagnosis was 47.8 years. The mean duration of disease was 3.5 years. Sun exposure and hot baths/exercise were the two most common precipitating factors, while the majority of patients did not have any specific factor that relieved their symptoms. According to the NRS classification and grading system, the patients were classified into four subtypes. One hundred sixty two (96.4%) patients were diagnosed with the erythematotelangiectatic subtype irrespective of severity. Eighty five (50.6%) patients had the papulopustular subtype and 24 (14.3%) patients had ocular rosacea. Eight (4.8%) patients displayed mild phymatous change. The degree of sun exposure had significant correlation with the development and severity of the erythematotelangiectatic subtype (p<0.05), while it had no correlation with the papulopustular, ocular and phymatous subtypes.

CONCLUSION: Although the erythematotelangiectatic subtype was the most common subtype of rosacea, many patients also had other subtypes of rosacea simultaneously. Based on our results, we proved that ocular rosacea is an extension of the clinical spectrum of erythematotelangiectatic rosacea. In addition, the results of our study particularly suggest that sun exposure has a different influence on each subtype of rosacea.

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Serum 25-Hydroxyvitamin D and the Incidence of Acute Viral Respiratory Tract Infections in Healthy Adults, PLoS One. 2010 Jun 14;5(6):e11088.

Background: Declining serum concentrations of 25-hydroxyvitamin D seen in the fall and winter as distance increases from the equator may be a factor in the seasonal increased prevalence of influenza and other viral infections. This study was done to determine if serum 25-hydroxyvitamin D concentrations correlated with the incidence of acute viral respiratory tract infections.

Conclusions/Significance: Maintenance of a 25-hydroxyvitamin D serum concentration of 38 ng/ml or higher should significantly reduce the incidence of acute viral respiratory tract infections and the burden of illness caused thereby, at least during the fall and winter in temperate zones. The findings of the present study provide direction for and call for future interventional studies examining the efficacy of vitamin D supplementation in reducing the incidence and severity of specific viral infections, including influenza, in the general population and in subpopulations with lower 25-hydroxyvitamin D concentrations, such as pregnant women, dark skinned individuals, and the obese.

One additional paragraph was also interesting

Vitamin D has known effects on the immune system. The production of the antimicrobial peptides cathelicidin by macrophages and β-defensin by endothelial cells is upregulated by vitamin D. These peptides may be involved in the direct inactivation of viruses. Vitamin D may modulate the production of cytokines, suppressing inflammation, and, thereby, reduce the severity of viral pneumonia.

Whilst the conclusion may not look directly relevant to rosacea sufferers, the tie-in with Vitamin D, and the suggestion that cathelicidin is involved in the `inactivation’ of viruses is an interesting find.

Even for a well done study, the exact results and how they apply to large groups of the population are normally relatively small. Even so these results are interesting because further research might uncover how Vitamin D and Cathelicidin interact with with other important pathways in the body.

Read more about Vitamin D’s role in fighting colds and flu from Clinuvel Blog.

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I have been approached by someone who is contemplating writing an article that would be interesting for rosacea sufferers to read. This article could be published in a magazine or journal and depending on the topic could contain some useful research as well.

So here is your chance to suggest what you would most like to read about.

Go for it, what do you want to see written about ?

1. Intense pulsed light in the treatment of non-aesthetic facial and neck vascular lesions: report of 85 cases

IPL treatments were given 4-6 times 3 weeks apart. 35 rosacea `lesions’ were studied overall. The abstract links the results of rosacea and Poikiloderma of Civatte together, saying that the vast majority of lesions showed a marked improvement after 12 months.

The study concludes “Our study confirms how by minimizing side-effects, time and costs, IPL can be effective and safe for the treatment of non-aesthetic facial and neck vascular lesions

2. Acne rosacea: effectiveness of 532 nm laser on the cosmetic appearance of the skin

Study looked at treating rosacea using 532 nm laser therapy with and without a retinaldehyde-based topical application. Half of the face was treated with just the laser and the other half of the face included the topical. At the end of the study evaluators who didn’t know which side was which was able to note the treated side in 47% of cases.

Hardly an astounding result, in fact one could say a disappointing result for those who suggested these sorts of topicals as an adjunct to laser therapy.

3. Stress and the skin

Stress can affect or even exacerbate skin conditions including rosacea, we are told. A direct pathophysiologic link between stress factors and cutaneous disease manifestation remains unclear but it is believed that stress influences the disease process through the release of neuropeptides, neurotrophins, lymphokines and other chemical mediators from nerve endings and dermal cells. The central role in cellular skin reactivity to various stressors might be attributed to dermal mast cells, as they show close connections with sensory nerve endings and may release a huge number of proinflammatory mediators.

Paper ends with the conclusion that the skin, edocrine, nervous and immune systems need to be treated together.

Signum Biosciences has several molecules under development, SIG990 is their lead candidate for rosacea.

Anti-Redness Efficacy of SIG0990

In an article perhaps somewhat cryptically titled Signal transduction modulators to treat rosacea, Signum Biosciences introduced us to their work “that targets several stages of the inflammatory cascade, resulting in a significant reduction of redness and erythema. 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.”

(extract) Activity of STMs and topical rosacea treatments.

Using a mouse ear model of inflammation, compounds were tested for activity measuring for the reduction of erythema. Compounds azelaic acid (Finacea 15%), metronidazole (Metrogel 1%), brimonidine 0.2%, STMs (SIG0990 4%).

The above graph extracted from the article published in the RRDi journal is a teaser for more detailed data that has been presented at the Society of Investigative Dermatology 2010 Annual Meeting in Atlanta, Georgia. More on that paper soon.

The graph suggests that in their studies, SIG990 potentially has superior anti-erythema effects compared to both the well known Finacea and Metrogel products and the yet-to-be-approved Brimodine based (Sansrosa) product.

Good News for Rosacea Sufferers

If this research translates safely and effectively to human skin then Signum Biosciences’s data suggests that they may have a new class of anti-erythema product on its hands.

As we know from the development pipeline of other developing treatments, the path from interesting molecule to approved product is measured in years and fraught with delays and pitfalls. Dr. Pérez estimation of this product being several years away seems to be a fair estimate to heed.

Arazine Available Soon

Dr. Pérez has confirmed that their first-generation-molecule based product known as Arazine will available next month (June 2010) via Rohto Pharmaceuticals in Japan.

[update]: DRx AFC Medirepair (Arazine) is now available in Japan.

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According to Signum Bioscience’s Development Pipeline, SIG990 is in the preclinical phase as a rosacea treatment.

G-protein Modulators

Signum Bioscience’s patented compounds and methods revolve around a group of derivatives called prenyl peptides. Signum’s GPM Technology Platform constitutes a new class of non-steroidal anti-inflammatories that have broad utility over multiple therapeutic areas by acting as G-protein modulators (GPMs). Initially anti-aging and anti-inflammatory compounds will have immediate impact in skin care products as topical cosmeceuticals (e.g. Arazine™) followed by pharmaceutical inflammatory skin applications. Furthermore, Signum’s goal is the development of anti-inflammatory pharmaceuticals.

Some further extracts from their web site;

GPM Pharmaceutical Development

The most common topical treatment options include antimicrobial agents (e.g. Metrogel, Clindamycin, Clindamycin-Benzoyl peroxide, Sodium Sulfacetamide/Sulfur and Finacea) which inhibit ROS generation by neutrophils, thereby reducing inflammation. However, these treatments do not reduce the initiating inflammatory events (inflammatory mediator release and neutrophil recruitment) of rosacea.

Conversely, GPMs inhibit inflammation directly and indirectly by reducing activity and/or expression of all the key players in rosacea, not just ROS production

Results demonstrate that GPMs:

• Inhibit release of key inflammatory mediators (e.g. TNF-α, IL-6, IL-8, VCAM-1, GM-CSF, Gro-α, MCP-1)
• Inhibit neutrophil adhesion and infiltration
• Inhibit ROS production from neutrophils

Given Arazine’s safety and effectiveness as an anti-inflammatory, second generation GPM compounds, provide an effective nonsteroidal alternative for patients suffering from skin diseases such as: rosacea, acne, psoriasis and eczema.

The first GPM based topical containing Arazine is planned to be released to the Japanese market in the second quarter of 2010.

In February 2010 Diane Thiboutot, MD joined Signum Biosciences’s scientific advisory board. Dr. Thiboutot is known to rosacea sufferers for her contribution to the standard rosacea treatments, the rosacea classification and severity system as well as presentations to the AAD on the use of off-label rosacea treatments.

Dr. Zoe Draelos MD is also listed as a GPM Scientific Advisor.

It is very early in the development cycle for Signum Biosciences, but it is encouraging to see a new class of anti-inflammatory being researched.

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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.

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According to Albert M. Kligman, 93, dermatology researcher, Dr. Kligman cowrote 14 books, beginning with Textbook on Dermatology, published by W.B. Saunders in Philadelphia in 1956, and ending with the third edition of Acne and Rosacea, published by Springer Verlag in Berlin in 2000.

Dr. Kligman passed away on Feb 9, 2010 aged 93.

Kligman’s 2004 Critique on the state of Knowledge of Rosacea was scathing about the poor State of the Art of Rosacea Research and Development.

This quote was quite insightful: “It seems that rosacea is a physician-friendly disorder in which everything works. This brings to mind the old clinical adage that when everything works, nothing works! Of course, we all understand how it happens that industry supported research is unlikely to yield negative results” and further “I hold that studies of papulo-pustular rosacea has brought in the marketplace too many drugs of marginal efficacy making it almost impossible for clinicians to make rational choices among the offerings, especially when these are backed up by heavy investments in marketing”

Kligman is credited in the Standard grading system for rosacea, the Standard classification of rosacea as well as the Standard Management Options for rosacea.

In his recently published book, Rosacea: Diagnosis and Management, Dr. Powell tells us that the 1993 book Acne & Rosacea by Plewig & Kligman is still the preferred authorative medical reference for rosacea. This is a bit of a shame because this book is out of print. You may be able to find a copy in your library, or you can also sometimes purchase a second hand copy via Amazon.com.

The good news is that an updated hardcover version, Pathogenesis and Treatment of Acne and Rosacea, edited in parth by Kligman is due to be released in August 2010.

Albert M. Kilgman is considered truly as one who was larger than life. A 2006 paper in the Journal of Investigative Dermatology said of him “Albert Kligman is among many other things, a dreamer.
Through his vision and its implementation he has been a major force in directing dermatology toward a better future. His dermatologic dreams have been well realized”

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Professor Frank Powell has created something quite valuable for rosacea sufferers and their physicians, an authorative and approachable medical text.

If you want to get hold of the best rosacea book you can buy, then this is the book for you. Find out why I think so in the detailed review below.

Author: Frank C. Powell
Title: Rosacea Diagnosis and Management
Review Date: December 2009
Available at Amazon.com

Some Background

First some background on Prof. Powell. Rosacea News has in the past published 3 articles that feature publications from Powell; rosacea sufferers less interested in alternative medicine, demodex mite bacteria causes the inflammation ? and rosacea: its all in the follicles !

Powell has been a consultant dermatologist at the Mater Private Hospital in Dublin, Ireland for 25 years. He has received rosacea research grants from the NRS, has been on the Medical Advisory Board of the NRS since 2000 and was also a co-author of the ground-breaking Standard Classification of Rosacea and the companion Standard Granding System for Rosacea.

Powell has an impressive list of peer reviewed publications: 18 chapters on Dermatology and related medical subjects, 18 Letters to the Editor and 98 publications in Medical and Dermatology journals. Additionally Powell is a reviewer for the Journal American Academy of Dermatology, Archives of Dermatology, British Journal of Dermatology and several others.

Even a cursory glance on PubMed shows dozens of papers published with several on rosacea.

How the book feels

My first thought when I first received my review copy, `wow it is small, it fits in my hand’.

The book is hardcover and consists of 140 gorgeous glossy pages. The high resolution colour photographs are crisp and detailed.

One thing I really liked about the book is that all of the photographs (around 64 of them) are all of Dr. Powell’s patients. This helps consolidate the authority of the text. These are real, genuine photographs of actual patients under the care of the book’s author. What an awesome body of clinical experience we can tap – simply by having access to this book.

As you will appreciate, this book must have been many years in the making.

The book also features a dozen wonderful drawings of rosacea from medical publications that existed before photographs were common. This gives us a good glimpse into how long people have been suffering from rosacea ! The cover of the book features an elegant 19th century gentleman with the erythema, papules and pustules of rosacea clearly visible.

Who is the book for ?

Dr. Powell targets the book at clinicians – `consisting of an overview of the subtypes, differential diagnosis with a practical approach to current therapeutic modalities’. We are told that the book intends to fill the gap that textbooks leave when devising solutions for individual patients. This is something that the book does well, it is not a dry medical text book steeped in theory, but also not a rambling collection of disjointed self-help styled thoughts.

We are also told that the 1993 book Acne & Rosacea by Plewig & Kligman is still the preferred authorative medical reference for rosacea. This is a bit of a shame because this book is out of print. You may be able to find a copy in your library, or you can also sometimes purchase a second hand copy via Amazon.com.

Powell thanks the Photographic Department of the Mater Misericordiae University Hospital in Dublin and also acknowledges Dr. Jonathan Wilkin’s help especially in the chapters on Flushing and `General Considerations’.

Lets look briefly at each chapter.

Chapter 1: Structure, Function, Type, and Sensitivity of Skin [14 pages]

Chapter 1 contains a description of skin structure, looking at the surface film, and the horny, granular, squamous and basal layers as well as meibomian glands, vascular plexuses and lymphatics. It concludes with a description of skin function, skin type and skin sensitivity.

Chapter 2: Flushing and Blushing [18 pages]

After defining the broad differences between flushing and blushing the book includes a detailed description of other conditions that may also cause flushing. Powell suggests that a detailed patient consultation is required to rule out other possible reasons for flushing. Powell suggests psychotherapy and cognitive behavior therapy may help desensitize social blushing and some patients may benefit from low dose beta-blockers. A table suggests other treatment options such as alpha-blockers, HRT, surgery and laser.

It was encouraging to see a mention of topical oxymetazoline with a refence to a 2007 paper. Even more encouraging is the mention of herbal possibilities like red clover, soy isoflavones, vitamin E, black cohosh and even acupuncture. Whilst the author cannot find conclusive studies in support of these supplementary therapies, it is great to see them at least given a mention.

Powell notes that even though there has been intense debate about the link between frequent facial flushing and the development of rosacea, the evidence is lacking. Prospective studies are required to unearth any link to the redness and blood vessels of rosacea, but those studies will be very difficult to execute. One patient note mentions a young man who suffered from a flushed face becoming anxious after viewing pictures of rhinophyma on the internet.

Suggested further reading includes a text from 1839 – seriously ! The Physiology or Mechanism of Blushing.

Chapter 3: The Classification and Grading of Severity of Rosacea [10 pages]

We learn in Chapter 3 that rosacea was first described in detail in 1813 by a former colleague of the English dermatologist Robert Willan. Willan was the first to call it acne rosacea. In those very early days rosacea was considered closely related to acne, perhaps sharing the same pathogenesis. As long ago as the early 20th century Radcliff-Crocker was proposing to drop acne from the name, postulating that rosacea was due to hyperreactivity of the facial blood vessels manifested by frequent flushing. Powell notes that the development of the classification of rosacea in 2002 was the first time that a widely accepted definition of rosacea was available since Willan in the early 1800s. The grading of severity of rosacea was then undertaken as a broad way of analysing the disease state and treatment progress.

Powell modestly drops his name from author listing when citing the Standard classification of rosacea and Standard grading system for rosacea at the end of this chapter.

Chapter 4: Erythematotelangiectatic Rosacea (Subtype 1) [17 pages]

A persistent facial redness, a tendency to frequent flushing, presence of multiple fixed dilated small blood vessels leads to the diagnosis of Erythematotelangiectatic Rosacea (ETTR).

A clinical example was offered for a classical case of ETTR, but also for someone diagnosed with the similar looking condition Heliodermatitis (chronic photodamage). Some clinicians use the terms ETTR and Heliodermatitis interchangeably as they appear similar and often respond to the same treatments. In this case the patient, a farmer, did not respond to metrogel or doxycycline so was told to use a sunscreen all year round and offered IPL.

An in interesting quote ;

Even though ETTR is classified as subtype 1 rosacea, this is not intended to suggest that it represents the first stage in the progressive development of the other subtypes of rosacea and many patients do not subsequently develop other manifestations of rosacea. The inflammatory papules and pustules of stage 2 (papulopustular) rosacea (PPR) do not develop as a consequence of the erythema and telangiecstasias in subtype 1 disease.

…

Typically the erythema associated with PPR is secondary to inflammatory changes in the skin rather than the presence of telangiectatic vessels.

We are told that the most important condition to rule out when diagnosis ETTR is systemic lupus erythematosus (SLE).

Treatments for ETTR include the usual suspects, but Powell does mention physical sunscreens containing Titanium Dixoide and Zinc Oxide and a moisturizer. Mention is also made of topical oxymetazoline as a recent possibility.

Chapter 5: Papulopustular Rosacea (Subtype 2) [30 pages]

One line appealed to me when describing PPR “New lesions appear as the older ones fade if effective treatment is not instituted”. This was so me ! I would look each morning to see where I was going to get the next red lump or pussy bump, having just seen on the current batch.

Powell mentions that it is possible for sufferers of male pattern baldness to have papulo pustular rosacea on their scalp. This is the first time I have read this.

A page is devoted to the the possible involvement of demodex mites in rosacea. Powell says that it is probably impossible to fully eradicate the mites from our skin as they see to recolonize rapidly following anti-mite therapy. Powell notes that some of the demodex related bacteria are susceptible to the antibiotics used to treat the papules and pustules of rosacea, perhaps suggesting a reason for the effectiveness of topical and systemic antibiotics in the management of rosacea.

Indeed the cause of rosacea is unknown so Powell also mentions the possible involvement of antimicrobial peptides, Vitamin D and sunlight as two interesting areas of research.

This chapter contains an excellent list of photographs and clinical notes for the several alternative diagnoses that may mimic papulopustular rosacea.

The therapy section contains all the well know topical and systemic therapies for the papules and pustules of rosacea.

Some treatments that caught my eye were Oxymetazolinea, Permethrin and Ivermectin. Yes it does indeed appear that demodex mite treatments are becoming mainstream for rosacea sufferers. Typically topical permethrin and systemic and topical ivermectin are used for mite infestation. Powell does note though that the use of these therapies is currently unproven.

A nice feature is the Algorithm management of PPR – a flow diagram on how to manage patients who present with PPR.

Chapter 6: Phymatous Rosacea (Subtype 3) [18 pages]

We are told that Rhinophyma is fortunately rare and often the most visible form of rosacea. It was first describe in the medical literature in 1845. Powell suggests that rhinophyma is more accurately designated as a condition of the skin that is closely associated with rosacea rather than a disorder that occurs as a consequence of the disease.

I wasn’t aware that there are actually several types of rhinophyma: glandular, angiomatous, actinic, acneform, fibrous and obstructive.

The management section details the use of isotretinoin for early stage glandular rhinophyma. Powell notes that there are conflicting reports about it’s efficacy, optimum dosage and long term outcomes. Dapsone  is also mentioned. The Pulse Dye and CO2 lasers are mentioned as possible treatments.

Chapter 7: Ocular Rosacea (Subtype 4) [14 pages]

This chapter starts with a great quote about ocular rosacea: “The Rabbit-eye of Rosacea” – Gerd Plewig.

In this chapter we learn that patients with PPR appear to be more likely to suffer from Ocular Rosacea (OR) but that OR symptoms may accompany, precede or follow skin symptoms of rosacea. The duration and severity of OR does not appear to parallel  the type, duration or severity of rosacea skin symptoms. The reason that ocular symptoms are associated with a dermatological condition is unknown.

Studies of sufferers of OR have shown that the normal tear breakup time of at least 10 seconds is reduced by half. The tear breakup time is the time after a blink when the tear dries and in some spot a dry area occurs.

System therapy used for PPR is effective for the inflammatory lesions of OR. Most patients present with mild symptoms so simple measure are often enough.

The table of treatments includes artificial tears, lid and lash hygiene, topical and systemic antibiotics.

Chapter 8: General Considerations [12 pages]

This final chapter implores doctors to seek to understand the psychological aspects of rosacea, be proactive in asking about ocular symptoms, be open to differential diagnosis. There is also some advice of general skin care and cosmetic advice. Powell does answer an old chestnut about whether prescription topicals should be used before or after other skincare. Drugs have priority-they go on first ! we are told in italics.

As far as pregnant patients are concerned, Powell states that topical erythromycin is a possible permissible treatment; with the agreement of the obstetrician and in extreme cases. All other prescription topicals and systemics are not advised.

Doctors are advised to reassure patients that progression to rhinophyma is rare, that `cure’ along the lines of pneumonia is not the case with rosacea, but that it can be episodic.

In the final chapters Powell encourages doctors to reassure their patients and support them. Powell suggests patients will appreciate being directed to web sites of the AAD, the EADV and BAD. A typo sadly directs sufferers to the National Rosacea Society as nrs.com instead of rosacea.org and indeed the AAD web address is wrong as well.

The book ends with a detailed 6 page index.

The Price

For those not used to medical texts, an asking price of $80 USD may seem a little shocking. Indeed the full price at the publisher’s web site: informa healthcare is $100 USD. Bearing in mind that the book is targeted primarily at physicians and taking in to account the authority of the writer and material presented, the book is reasonably priced. Whether that value will translate into something you as a rosacea sufferer will want to pay for I can’t say.

After reading the book I can say that Powell’s book does represent excellent value for rosacea sufferers to use in partnership with their doctor, especially if their doctor is not overly familiar with treating rosacea. Many doctors will want solid research-backed recommendations before embarking on a particular treatment path. This is the sort of text that you can use to convince a sceptical doctor.

Want to get more of an idea of what the book looks like before purchasing it ? You can see several actual pages via 2 routes. Firstly you can Search Inside the Book at Amazon and secondly you can see many of the colour plates via the very generous Google Book Search listing for this book.

Along with large chunks of the book being available to preview, you ought to have enough information to decide whether to invest in the book yourself.

Conclusion

This book gets off to an excellent start because the author is a genuine rosacea expert who is widely recognised. Professor Powell’s book is the sort of text that will see the understanding of rosacea symptoms, diagnosis and treatment increase world wide.

This book is by and far the best book on rosacea that you can get your hands on.

You can purchase the book at Amazon.com: Rosacea Diagnosis and Management.

See Also: other Rosacea Book Reviews