|Skin in Health and Disease|
Topics from the book
Acne Rosacea, the Red Face
In Canada, it is estimated that 2 million people (about 7% of the population) have the red face of Rosacea. The highest incidence is in white women between the ages of 30 to 50 years. The red flushing of topical rosacea is confined to the cheeks, nose and central forehead. The skin becomes dry and flaky skin and reacts to most medicines, lotions and creams. Red pimple-like bumps often develop in the affected skin. While Rosacea is common and most sufferers consult their MDs for treatment, there has been little progress in understanding and managing this disorder.
Chronic Rosacea Skin capillaries dilate with heat, causing flushing, and grow slowly to form permanent reddening Papules, nodules, and pustules can develop. Pustules are small (<1mm) and tend to occur on the apex of papule. Telangiectasias are clusters of capillaries that overgrow and leave the skin permanently red. When the capillaries grow, they leak fluid and deliver immune cells to the skin.
Significant cosmetic disfigurement may occur in the most severe Rosacea with skin swelling and enlargement. This is more common in men - the red face and bulbous nose of a chronic alcoholic is the classic presentation of the chronic, severe version of the disease. Sebaceous glands enlarge with skin edema that disfigure the nose, forehead, eyelids, ears, and chin. Rhinophyma is an enlarged nose; metophyma is a cushion-like swelling of the forehead, blepharophyma is swelling of the eyelids related to marked sebaceous gland hyperplasia, otophyma a cauliflower-like swelling of the ear lobes and gnathophyma is swelling of the chin.
The Rosacea diagnosis includes a range of inflammatory events in facial skin. The range is so broad that it is reasonable to ask if Rosacea is too fuzzy a term that can apply to diverse immune-mediated events in the skin with multiple causes.
The reader can recall our understanding of the skin as a meeting place for many characters in an ecological drama that unfolds every day. There is some evidence that the microbes and little animals who live on the skin participate in the Rosacea drama. It is also reasonable to suggest that sun exposure to the face damages the skin sufficiently that inflammatory events are more frequent and prolonged. Facial flushing is a normal response to heat, embarrassment and to some food and drinks such as coffee, tea, alcohol and hot spices. The sebaceous glands in the affected skin are often involved and may enlarge. Exposure to sun and all forms of heat causes exacerbations.
The oil glands in the skin of the nose and adjacent cheeks are prone to plugging with sebum that dries and stops flowing. The surface sebum turns black. The sebum plugs are good homes for bacteria and fungi and may contribute to skin inflammation.
Seborrhea is a related condition that involves the hair-bearing skin of the scalp and face, all expressions of infection with the fungus, pityriasis ovale. Seborrhea can involve the central forehead, skin under the eyebrows and beard and may contribute to or be confused with Rosacea.
Problems can arrive in the skin from the blood stream. When immune cells enter skin, they often take over with an inflammatory response that causes the skin to swell, itch, burn, and turn red. The red face and bulbous nose of chronic Rosacea has been associated with high living and heavy drinking; however, most people with Rosacea are not overindulgent hedonists.
A food connection has also been implicated and standard Rosacea advice has included abstinence from alcohol, coffee, tea, and spices that cause flushing. Delayed pattern food allergy may be a factor. Complete diet revision is advisable if other symptoms of food allergy are present.
Topical Treatment of Rosacea
Standard treatment involves oral and topical antibiotics - usually daily metronidazole cream or gel 0.75% to 1.0 %. The response to antibiotic treatment is partial at best and seldom cures the condition. Some skin eruptions are sometimes associated with scalp fungal infections and may respond to vigorous treatment of the scalp with Nizoral and/or Selsun shampoos. The oil glands in the skin of the nose and adjacent cheeks are prone to plugging with sebum that dries and stops flowing.
Seborrhea is a related condition that involves the hair-bearing skin of the scalp and face and has been related to the fungus, pityriasis ovale. Scalp scaling and inflammation can be treated with Nizoral and/or Selsun Blue shampoos. Seborrhea can involve the central forehead, skin under the eyebrows and beard and may contribute to and be confused with Rosacea. Topical application of antifungal agents ( such as Tinactin) to facial skin, especially around the nose may be helpful.
Steroids are known to occasionally aggravate Rosacea although why this occurs is not known. Steroid treatment alone may interfere with infection control in the skin and increased growth of bacteria and/or fungi may exacerbate Rosacea. Combined topical steroid, metronidazole and nizoral may sometimes be successful in controlling an aggressive inflammatory flare of Rosacea.
Protection from the sun is essential for Rosacea management. The nose and cheeks receive maximum sun exposure, compared with other parts of the body. The best sun protection is staying out of direct sun light. Wear a peaked cap or broad-brimmed hat. Sun screens are always used when outdoors. (see discussion of UV protective measures).
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