Rosacea Support Group

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

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