Book Review: Rosacea: Diagnosis and Management, Frank C. Powell

Written by on December 2, 2009 in in the news, research, reviews with 19 Comments

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

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

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 instead of 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.

Book Links


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 Rosacea Diagnosis and Management.

See Also: other Rosacea Book Reviews

Read more about: in the news, research, reviews

About the Author

About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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19 Reader Comments

  1. Matthew says:

    Thanks for the detailed review David. The book appears to be a wealth of information and definitely something worth reading.

  2. Thanks Matthew.

    If people can get past the price I think it will prove to be a truly excellent resource.

    Just to speak more to the price question. Us internet users have become accustomed to getting quite a lot of information for free on the internet. Much of that free information is of low value, (in my humble opinion).

    Well researched information still has value though, and we should be willing to pay for it.


  3. Peter says:

    Hello David

    That was a superb review of what appears to be a valuable reference manual for rosacea but primarily for those who already have a good understanding and knowledge of the condition. As you said it appears to be targeted at clinicians but looks useful for those of us who have been around for a long time and have an interest in rosacea.

    Obviously I haven’t got the complete book to read but looking at your comments and then going through the index which is viewable on-line I have some quick questions to ask.

    I can’t see any reference made to remission or the perceived average duration of the condition? Does he cover this as it’s a very important factor for sufferers to be aware of?

    Does he mention the use of anti-malarials e.g. Mepacrine to treat more stubborn cases rosacea? I couldn’t see their use mentioned in the index?

    I also saw Clonidine in the index but not Moxonodine?

    I thought the main reason for the effectiveness of topical and systemic antibiotics was due to their anti-inflammatory response with rosacea rather than any resulting action on bacteria or mites? A whole page devoted to the demodex mite does worry me a bit because I thought their involvement with rosacea had been dismissed by most of the experts?



  4. Peter wrote:
    “I thought the main reason for the effectiveness of topical and systemic antibiotics was due to their anti-inflammatory response with rosacea rather than any resulting action on bacteria or mites? A whole page devoted to the demodex mite does worry me a bit because I thought their involvement with rosacea had been dismissed by most of the experts?”

    You wanted something new Peter and what you think about demodex is old school. Demodectic Rosacea is now firmly fixed as a rosacea variant and must be ruled out as a factor in rosacea and Powell confirms this in his book. The ‘experts’ who continue to say demodex is not a factor in rosacea are singing an old song. Powell addresses this clearly in his book.

    Another new thought in Powell’s book is that he mentions the ‘lactic acid test’ for skin sensitivity to assess and grade a patient using this tool. If you have heard of this I would be surprised.

    Powell makes the point that rosacea may be the result of irritating effects of the environment rather than the effects of frequent flushing. Powell confirms how rosacea’s definition has been vague, that the etiology is unknown, yet suggests that ultraviolet light may be the culprit underlying the various pathogenic theories surrounding rosacea. If his book influences others to look into ultraviolet light as the culprit, this will change quite a few views on the etiology of rosacea.

    Probably the newest thing that Powell clears up is the confusion that flushing is at the heart of rosacea. His chapter on Flushing and Blushing confirms what other clinicians have found that while both are seen ’sufficiently often enough’ in rosacea patients and both flushing and/or blushing are the ‘first features of rosacea to appear in some patients,” nevertheless, “flushing and blushing are not necessarily a component of the clinical picture in all patients with rosacea.” He explains the only difference between flushing and blushing are the “different conditions which disparate initiating factors.” Flushing may be initiated by many factors other than emotional or psychological. Blushing is initiated by emotional and psychological factors. He does admit that there are ‘crossovers in the distribution of flushing and blushing’ and that flushing is more widespread. He goes into some detail how Charles Darwin wrote much about the subject of blushing which resulted in the public psyche associating ‘facial reddening and emotions’ leading to ’some curious theories relating to the etiology of rosacea.’

    Another matter Dr. Powell clears up is the notion that individuals with sensitive skin and who flush frequently should be classified as ‘pre-rosacea.’ He points out that the evidence is lacking for this theory mainly because of the ‘lack of [a] clear definition of both rosacea and the type of facial reaction that constitute[s] facial flushing or blushing.’

    These are just a few of the new items that i noticed.

  5. Peter says:


    I am sure this book is, or will be a valuable addition to the rosacea reference library but that doesn’t mean it has all the answers or is able to unravel all the mysterious of the condition. Of course it would be unfair to expect anything else as the mechanics of rosacea still appear to be poorly understood and that’s not a criticism of anybody but just a plain fact. As we both well know the jury is still out on many aspects of rosacea and the dermatologists themselves do not always agree with each other and may have differing theories on the potential cause(s) and the most effective treatment methods.

    I will have to bow to your superior knowledge then but my understanding of the domodex mite connection with rosacea is that it is thought that their presence exacerbates the condition, rather than causes it. Didn’t Powell himself say “Increased mites may play a part in the pathogenesis of rosacea by provoking inflammatory or allergic reactions, by mechanical blockage of follicles, or by acting as vectors for microorganisms.” Note the word “may”.

    Not sure I am convinced about his ultraviolet light theory either. We all know that the sun, particularly strong sunlight is a very common trigger for many rosacea sufferers (I used to be one myself) but I always suspected it was the actual heat itself rather than anything to do with that particular wavelength. As you probably know from my own individual case the paradox was that being exposed to the sun used to clear my rosacea up, hence my progression to experimenting with red light. Interesting to note that exposure to the sun is no longer a trigger for me.

    As you have Powell’s book can you confirm whether or not he endorses or even mentions the use of anti-malarials e.g. Mepacrine for more stubborn cases of rosacea? Although not a first line option this drug can produce good results for some and should therefore be included in any list of potential rosacea treatments.

    Also I would be interested in his view on why rosacea is often regarded to be a self-limiting condition and as remission can ocurr, what is his experience of this with his patients? For me the “remission” aspect is a must with any discussion or publication regarding rosacea because it is such an important factor for people to understand when they are first diagnosed.

    Anyway I do not have a copy of Powell’s book but if someone would like to loan me one, then I would be more than happy to submit my own review if anybody is interested in my opinion?

  6. Peter,

    While David says that Powell’s book “is by and far the best book on rosacea that you can get your hands on,” I would simply say it is one of the best and definitely in the top ten. I think that we need to see the following book before I would give Powell’s book the number one spot:

    Acne and Rosacea, 4th English edition, Springer-Verlag, Heidelberg. Gerd Plewig , Albert
    M. Kligman, Bodo Melnik and Thomas Jansen, to appear in 2010. 3rd edition included 744
    pages with 216 colored plates.

    The context of this thread is David Pascoe’s review of Powell’s book. I don’t think there is a book that will ‘unravel all the mysterious[ness] of the condition [rosacea].’ When that book comes out all these reviews, the various online rosacea support groups, all the rosacea books including the plethora of clinical and research studies and papers will be things of the past. Until that book comes out though, at this point Powell’s book reigns supreme as of this date today.

    Yes, the jury is still out on the pathogenesis of rosacea and Powell acknowledges this by saying in his introduction;

    “Knowledge relating to the epidemiology, etiology and pathogenesis of this facial disorder that affects adults in middle age is limited….The etiology of rosacea is unknown.”

    He never says that the demodex mite is the cause of rosacea. He does state, “Another theory of the pathogenesis relates to the presence of abundant Demodex folliculorum mites in the facial skin of patients with rosacea….but their role in the homeostasis of facial skin is unknown…These organisms seem to live in a harmonious relationship with their hosts and in normal circumstances do not excite an inflammatory reaction in the skin. It is not known if they perform any useful function in the human skin, and it is probably impossible to fully eradicate them as the skin seems to become recolonized following antimite treatment. In patients with rosacea, these mites are greatly increased in number and are found mainly in the centrofacial convexities —the areas typically affected by the inflammatory papules and pustules.

    Under the subheading, DIFFERENTIAL DIAGNOSIS AND INVESTIGATIONS, he states on page 71, “D. folliculorum mites are found in abundance in some individuals affected with this disorder [rosaceiform dermatitis], and their proliferation may be facilitated by the reduced level of immune reactivity.

    In discussing steroid-induced rosacea, Powell says on page 75, “These patients have also been shown to have a major increase in the demodex mite count on their facial skin using the cyanacrylate skin biopsy technique. The relationship ship of the eruptions induced by application of cortisone creams to the skin and PPR is unclear. They serve an interesting disease models and suggest that altering the cutaneous immune response in the face may permit local ecologic changes in the follicular canal. This could result in the facial demodex population flourishing, which in turn may result in the genesis of inflammatory lesions.”

    Further he discusses on page 80 thru 82 Pityriasis folliculorum which can be diagnosed with the use of dermatoscopy, ‘which shows a distinctive picture of the presence of multiple white keratotic material consisting of keratin encrusted demodex mites protruding upwards from the follicular orifices. Scraping the skin surface with the blunt side of a scapel blade and spreading the scrapings on a glass slide reveals the presence of multiple dead and living D. folliculorum mites. This condition appears to be caused by an overpopulation of mites facilitated by the frequent use of creams and lack of face washing with soap and water.”

    What Powell points out is to not dismiss demodex mites in a differential diagnosis and treatment of rosacea, since many ‘experts’ have dismissed the role demodex may play in rosacea. Demodex mites do not play a major role, but nevertheless, need to be ruled out or treated if found in abundance. So yes, as you quote Powell, ‘Increased mites MAY play a part in the pathogenesis of rosacea by provoking inflammatory or allergic reactions.” Obviously demodex does not play a role in EVERY case of rosacea.

    The reason Powell suggest to look into ultraviolet light being at the root of rosacea is stated in his introduction:

    “Because it occurs on sun-exposed skin in sun-senstive patients, ultra violet light is thought to play a part in its pathogenesis.” On page 7 he states, “Patients who have skin that is poorly melanized make up the majority of of rosacea sufferers. Sun damage (solar elastosis) is commonly seen in the upper dermis of skin biopsies taken from the face of patients with rosacea reflecting their susceptibility to solar radiation. Ultraviolet light can also be beneficial to the skin as it stimulates the production of biologically important vitamin D in the epidermal keratinocytes.”

    He then discusses in his introduction the other theories on the cause of rosacea and concludes:

    “It may well transpire that several of these factors are relevant and that each of the rosacea subtypes have different factors that are important to the initiation and pathogenesis.”

    I don’t recall reading anything about mepacrine for rosacea in Powell’s book or using antimalarials for rosacea, but I may have missed it. Nothing in the index about mepacrine or antimalarials. He mentions on page 27 that antimalarials may induce flushing.

    Powell mentions remission on page 130:

    “Patients should understand that while remissions can be long lived, there is no ‘cure’ analogous to treating pneumonia with antibiotics. However, in some older patients the disorder seems to ‘burn itself out’ and clear completely. Enquiry about the seasonal exacerbations may allow the physician to develop a strategic plan with the patient to discontinue medications at certain times when the disorder is likely to be in remission.”

    I could bring out many more interesting items in Powell’s book, and may do so later, but for now, I hope I have addressed your questions.

  7. Peter says:

    As you are aware Brady I am unable to read the entire book but as I said previously it sounds a very good reference manual on rosacea but what will probably put many off from buying the book is its cost. To say that Powell’s book reigns supreme seems a bit over the top to me but if someone is able to provide me with a copy, then I will gladly offer my opinion and then return it back to the sender in pristine condition.

    Briefly my comments are:

    Rosacea can occur at any age and not solely confined to “middle age” although 30 – 55 is deemed to be the most common time frame when it can appear.

    I still think too much time and money is wasted investigating the “demodex”.

    I’m not convinced that UV light plays a major role in someone developing rosacea although it remains one of the common triggers.

    Any book about rosacea and its treatments should really include the anti-malarial drug Mepacrine as an option for cases which are resistant to the first line treatments. I understand that it can have an ant-inflammatory action on rosacea which can be very effective at switching it off in some patients or unfortunately it just doesn’t work at all.

    Regarding remission, my understanding is that rosacea is usually considered to be a self-limiting condition and eventually it will disappear, although there is no way currently of predicting when this will be. Some experts will give it an average lifespan of around 10 – 12 years but I have heard of people where it’s duration has been relatively short and others where it has been in evidence for several decades e.g. over 30 years. It’s important with rosacea to seek prompt treatment and therefore increase your chances of keeping your skin in good shape for when it does burn itself out. Information regarding “remission” in rosacea is around but harder to find because these people naturally tend to disappear and fall of the radar.

    By the way David e mailed me to say he is currently on holiday but would reply to my comments next week.

  8. In the USA a person can go the library and if the book is not in stock can ask if the library can get it from another library in the system across the USA, called inter-library loan. Maybe something like that is available in the UK. After all, Powell is in Ireland, and the libraries in England should purchase a copy. So if you put a little pressure you might get a library to purchase it.

  9. Peter says:

    Thanks for the tip but I am not a member of the local library and it is a somewhat expensive, specialist book. I have another source where I may be able to get hold of a copy to read, so I’ll try that first.

    As David mentioned in his review there is a link on the Amazon site where you can search the whole book on-line for key words, so I decided to give it a try.

    I entered “Mepacrine” and there were zero results – that’s a shame because if this book is primarily aimed at physicians etc, then it would be important for them to be aware of this drug and its use in stubborn cases of rosacea or those where the first line treatments are not successful. Maybe Powell doesn’t prescribe this drug himself to his patients but he must be aware of it’s history and it should be included in every dermatologist’s tool box?

    A similar search for “anti-malarial” also revealed zero, as did “Moxonidine” and “Aloe Vera”.

    As you know Moxonidine can be used as an alternative to Clonidine for helping with flushing and for some rosacea sufferers it can be more effective. Aloe Vera gel can be a very useful natural topical for the rosacea skin and can help with seborrheic dermatitis.

    “Remission” revealed several results but I need to drill in a bit deeper to see the whole text, when I can get hold of the book.

    If you still have the book maybe you can check my searches or I’ll wait for David to return next week?

  10. I think it is fair enough that Dr. Powell gives a page to demodex mites as he has been at the front of research to try to find a link. He is responsible for the research that isolated the bacteria from demodex that induced an immune response in rosacea sufferers. This is the `best’ link found yet. Indeed this best link is still tenuous and requires careful wording to avoid suggesting that there is a provable link.

    Powell is careful to say that off-label treatments like clonidine may be useful but are not officially recognised. I would think that moxonidine is even more experimental as it is lesser known compared to clonidine.

    Anti-malarials are not talked about and again this is not too surprising as treatments on the fringe of normal clinical experience will take a while to become accepted/approved/recommended. I was actually surprised to see so many off-label treatments mentioned – you won’t find official medical channels even saying their names.

    Just my own comment on the remission/average duration idea. I have always thought that the whole argument was of limited valued because it didn’t help sufferers to understand much about the disease. Symptoms vary so much that making generalisations seems to end nowhere. If I was just diagnosed, I would hate to think there is nothing I can do to avoid a 10 year wait 🙁 Having said that, I probably had it for around that long !


  11. Peter says:

    Hello David

    I suppose I really need to get hold of the book and read it in its entirety. Personally I still think the “demodex” could turn out to be a dead end but I hope I’m wrong given the amount of NRS money and time that has been thrown at it over the years.

    Well I am very surprised by his comments regarding Clonidine because I thought it was recognised by most of the top dermatologists as being excellent at controlling the flushing associated with rosacea. My dermatologist was a big fan of this drug and under his guidance I took it for 4 years with superb results. He regularly prescribed Moxonodine as another option for those where Clonidine doesn’t suit and I wouldn’t describe it as experimental. I’m not sure whether it’s still the case but none of the vascular drugs are licensed for rosacea and this really is anomalous given that it is recognised that the primary abnormality in rosacea is vascular. Treating rosacea can often be a matter of trial of error until you settle on something that works but a good dermatologist will be prepared to think outside the box for those who do not respond to standard treatments.

    The influence of anti-malarials e.g. Mepacrine with rosacea has been known for years in some circles but they are not first line treatments and therefore some dermatologists may not have experience using them. Given that Powell is supposedly an expert then I am very surprised he hasn’t included them in his book.

    Sorry but I disagree with your comment on remission. I was told straight away that providing I received treatment then there was every chance that my rosacea would go away, although there was no way of predicting exactly when. This gave me hope and encouraged me to persevere with my treatment and made me confident that I wouldn’t finish up disfigured which is what many sufferers fear. I think it’s important that a patient is made aware that a diagnosis of rosacea isn’t the end of the world and that spontaneous remission is much more common then many think.



  12. Perhaps there is something useful in the whole remission argument, but I have always just glossed over what I read about the sometimes suggested `natural interval’ of rosacea.

    I would hope that sufferers can have faith in the proven outcomes for accepted treatments rather than faith in some kind of statistical average of duration of symptoms.

    Indeed it does seem that the mainstay of rosacea treatments do offer pretty good relief for the majority of sufferers. Those outside this group, however are the ones that really need to encouragement and resources of experts.


  13. Peter says:

    Hello David

    Well I suppose we should be grateful that rosacea is treatable and as you say for many with milder cases, then they are able to keep it under control and the condition is no more than just an occasional nuisance. I agree that for the more severe cases, then they do need help and encouragement together with the best advice from those professionals who care and are prepared to work with their patient to find the most suitable treatment.

    There isn’t a “natural interval” as such for this condition as it can vary so much to the individual but there is evidence out there of success stories and people who have gone into remission. I hope Powell has had patients where this has happened and included this in his book? I will leave you with a message someone sent me last year:


    Just a note to thank-you. Two years ago I was diagnosed with rosacea and was having a very hard time. I contacted you and you reassured me that the condition can be controlled and gave me hope that eventually remission could be a possibility.
    Since that time, I have found reference after reference of the disease eventually lessening. I started a file of these references. When my skin is out of control, I read and re-read these references and it helps me to not get so down about the condition of my face.
    I just wanted to thank-you for ‘planting the seed’ that rosacea, in some cases, can be self limiting. If one chooses to search, there are many people (including the National Rosacea Society) that claim that the disease eventually can fade.
    I know that it is not the general feeling of many on the message boards, but I prefer to think of rosacea as something that can go away, rather than a progressive, incurable condition.
    Thank-you for opening my eyes to other, more positive possibilities.”

  14. CLAREMORROW says:


  15. Barbara says:

    I have written before with regard to my “rosacea”. I have found many doctors reluctant to diagnose anything other than “rash” So many stories from many frustrated patients . . . I am one of them.

    I finally realized I was going to have to wing this one by myself. Tried all the various products out there. No lasting success w/any of them.

    The following are some of my random observations. I do not think rosacea and demodex mites necessarily always are concomitant.

    I think the demodex mites are opportunists who take permission from the body when another part of the support system is under extensive stress . . . when the approved helper cells are called in, the demodex also respond. I believe that because each of us has a complex, ever changing chemical system, some of us will respond to dis-ease differently, hence some of us are plagued with mites and gum disease, others respond to the “flight or fight” signals much differently.

    I firmly believe in the concept of “mind, body, spirit.” They are all intertwined. I do know that at the Duke Medical School, the mantra is beginning to be pushed that it is easier and cheaper to keep patients healthy . . . rather than wait until they are very sick and need much more extensive and expensive care.

    This very old concept is beginning to catch on with the
    ever proud and stubborn M.D. gang.

    I think that demodex mites invade many other parts of the body and are just as fond of mucus as they are oil . . . and will eventually be regarded as a red flag for many other serious conditions . . . And possibly be considered pathogenic in their own right under optimum circumstances.

    As far as bringing them back to their rightful numbers, I think it necessary to look at them as the symptom rather than the illness. Diet plays a huge part. Dumping sugar, carbohydrates, meat, and dairy helps immensely! After a couple of weeks, the body organs are not required to work so hard to compensate for another organ that is under siege from a lousy diet.

    This is just my own ignorant opinion . . . only based on observation . . . but I do not believe demodex mites have ever been considered or properly tested for other, seemingly unrelated conditions. There has simply been no interest or knowledge. This is probably why biochemists are going to be the next medical “rock stars”

  16. James Walker says:

    I continue to read as much as I can, and I try varous products and treatments. My rosacea has not improved, actually flairs up too often. Heat is a BIG trigger.

    I do not drink alcohol, no caffeine, little red meat, eat lots of fruits and vegs, exercise by walking 4 x’s a week, and try to wear a hat when out in the sun. Oral drugs is Oreca 940 mgs), doxacycline (100mg), minacycline (50mg’s). Oreca works for about 6 hours, same with doxacycline and minacycline about 2 hours. Never mix these. When I have a bad flush, I do sometimes take 50-100 mg’s of minicycline.

    Heat over 75 and direct sun and my face will either flush or turn red. A gradual redding. Yes, I need help. Any suggestions…………

  17. Aish says:

    Did i read that only one page about demodex has been in the book?
    I really thought this killing off mites would lead to the solution of rosacea!
    God, i wish this was just a nightmare and i could wake up with healthy skin!

  18. Barbara says:

    As one who has struggled endlessly with this gnarly problem ~ it is very rewarding to see some progress made in the right direction!

    I know for a fact that you cannot remain on antibiotics for your condition. Your system becomes resistant and they no longer work. Then, when you are in a crisis ~ you wind up with MRSA. That happened to me, and after 2 trips to the ER, I knew I would have to come up with the ‘happy medium’ approach.

    Found out after 2 IV rounds of clindamycin, that a very common drug : Bactrim, would help you in an emergency. The rest of my latest (sucessful) equation involved ~ washing face several times a day with a drying soap. I either use a sulfer soap or ‘Dawn’ dishsoap from the grocer. I also use Dawn to wash my hair Daily!

    I take a soak bath w/epsom salts (I like lavender), but just plain cheap epsom salts will do. I also make a cold rinse with epsom salts before my final hair rinse. Clean, clean clean! No short cuts!

    As for my complexion after washing w/Dawn dishsoap, if I have any active lesions, I spray that area with an epsom salt mixture. Demodex mites do Not Like mineral salts. They will flush to the surface quickly. W/o wiping off, I quickly dab that area with alcohol. This will kill the ones that have bolted the follicle. I let that dry naturally, then pat the offending area with ‘Clearasil’ tinted cream (again, drugstore stuff) that has sulfer and resorsinol. Do not use other variety which contains benzyol peroxide ~ does not work as well. This exercise gets you ready for bed looking not so scary. The other thing that I have found crucial at night is to wash your eyes very well. Then use the ‘Occu-Wipes Plus’. Keeps the mites from roaming at night.

    If you are able, also take an antihistimine at bedtime. That dries everything up, and you do not wake up w/gunky eyes. I also use ‘OXY cleansing pads when I wake up.that has salyicylic acid, which helps keep follicles clean and dead skin moving out!

    If you use make up, the mineral is best. I need a foundation in the ‘T’ zone and under eyes. I have found that ‘Almay clear complexion’ has a blemish control foundation that has a tiny bit of salicylic acid that seems to not let the pores get too full during day.

    I have gone on (& ON), only because of my personal battle, but because I know that there are a few desperate souls out there, just wanting to move on w/their lives! As an aside, when it all got so bad ~ to the MRSA point~ I lost all my eyebrows and eyelashes. It took about 6 mos, and 2 rounds of Bactrim, but they grew back!! My dr. was amazed ~ I was euphoric! 😀

    Best to all my fellow sufferers,

  19. Patty godale says:

    I suffer from ocular rosacea and no dr knows what to do with me

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