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  1. Rosacea: The Curse of the Celts ROSACEA The Curse of the Celts A Handbook for patients and the general public Prof Frank Powell, Professor of Dermatology, University College Dublin UCD Charles Institute for Dermatology Supported by the Health Research Board (HRB)

  2. Funders The Health Research Board is supporting the development of this handbook through their Knowledge Exchange and Dissemination Award, which aims to maximise the uptake of research findings into policy and/or practice (grant MRCG/2011/17/K). More information is available at Author Professor Frank Powell is a dermatologist and Chairman of the Board of Directors of UCD Charles Institute of Dermatology, and Director. He is a past-President of the European Academy of Dermatology and Venereology and is a Past-President of the Irish Association of Dermatologists. He is a member of several international dermatologic societies and honorary member of the American Dermatologic Association, and the Hungarian and Romanian Dermatology Associations and the Italian Society of Dermatology. Information for Patients The contents of this handbook, are for informational purposes only. While every effort has been made to ensure the accuracy of the information, this handbook is not intended as a substitute for professional medical advice, diagnosis, or treatment. You should always seek the advice of your doctor with any questions you may have about a medical condition. You should never disregard professional medical advice or delay in seeking it because of something you have read in this handbook. The authors are not responsible for any misprints or errors. No liability whatsoever is accepted by UCD for any action taken in reliance on the information contained in this handbook. The content of this brochure is the sole responsibility of the authors, and does not necessarily reflect the views of the funders or the University.

  3. Rosacea: The Curse of the Celts What is Rosacea? Contents What is Rosacea? 3 What are the Features of Rosacea? 5 Rosacea is a common skin disorder that causes redness of the skin of the face of many Irish people. It is seen in all countries and races but is most frequently seen in people who have fair sun sensitive skin, especially those of Celtic origin. What causes Rosacea? 7 How is Rosacea Treated? 8 What should I do if I think I have Rosacea? 10 Rosacea is sometimes called Acne Rosacea or Adult Acne. It has a superficial resemblance to Acne Vulgaris of teenagers. However these are completely separate disorders. Rosacea causes an unsightly redness of the central part of the face and in many cases red bumps and pimples. Rarely, patients with Rosacea can develop an enlargement of the nose, a condition called Rhinophyma. People who develop Rosacea may have a tendancy to flush (or blush) very easily. This occurs especially with change in environmental temperature (going from a hot to a cold atmosphere), or taking hot drinks, or drinking alcoholic beverages. Because the redness of Rosacea is made worse with alcohol intake some people have wrongly attributed the cause of this disorder to alcohol excess. This misconception causes additional social problems for people who suffer from Rosacea. Not only do these people have an unsightly skin condition on the most prominent part of their body, some of their friends may wrongly suspect that they are abusing alcohol! That is one of the reasons that public education about rosacea is so important. Until this message gets across there is a form of social stigmatization of people with Rosacea. This has led us to use the term “The Curse of the Celts” for Rosacea because it typically occurs in people of Celtic origin and the common misconception that excessive alcohol intake is the basis of the problem makes it a further handicap for the rosacea sufferer. 3

  4. Rosacea: The Curse of the Celts What are the Features of Rosacea? Rosacea is a skin condition that usually affects people in their 30s or 40s. Both men and women are affected, but the disorder appears to be more common in women, with men generally having more severe disease. Once the Rosacea starts it usually persists, fluctuating in severity over many months or even years. Eventually rosacea clears or ‘burns itself out” and it is rarely seen in elderly persons. A person who develops rosacea notices initially small red spots on their nose, chin, forehead or the cheeks. There is a slight stinging sensation from these spots, but no real itch, soreness or discomfort. The red spots typically appear in groups of two or three that persist for about 10 days (Figure 1). These spots gradually flatten and merge into the skin, leaving behind a slight red blotch like a “footprint” of where they have been. Unlike the lesions of teenage acne there is no tendency to scarring of the skin. New spots frequently appear as the old ones settle. The eruption fades and then reactivates without any identifiable cause in most cases. If no treatment is given this process continues over many months and gradually gets worse. The red blotches become more widespread and blend together so that the rosacea sufferer progressively develops a striking and embarrassing redness of the center of their face (Figure 2). In addition to developing spots rosacea sufferers may notice that their face reddens or flushes easily, especially if they go from a cold atmosphere into a warm one. Figure 1. Multiple grouped spots of Rosacea on the chin Figure 2. Diffuse redness of the face in a patient with rosacea 4

  5. Rosacea: The Curse of the Celts Common Features of Rosacea 1 2 3 4 5 6 DRY EASILY IRRITATED FACIAL SKIN RED SPOTS ON THE FACE AND NOSE PERSISTENT REDNESS OF THE CENTRAL FACE A TENDENCY TO FLUSH EASILY IRRITATION OF THE EYELIDS ENLARGEMENT OF THE NOSE (RARELY) Other factors that may cause increased facial redness or flushing include hot drinks (tea, coffee, soup, hot water), large hot meals, spicy foods and alcohol. These are sometimes called Triggers of Flushing (Table 1). This list is not exhaustive and patients with rosacea often find it helpful to keep a diary of the things to avoid that make them flush. This redness may be worsened by the appearance of tiny fine “broken” blood vessels called telangiectasias on the cheeks and sides of the nose which may form part of the clinical picture, especially in longstanding cases. Table 1. Some Triggers of Flushing 1 HOT HUMID ENVIRONMENT 2 HOT DRINKS 3 ALCOHOL 4 LARGE HOT MEALS 5 6 SPICY FOODS SOME MEDICATIONS 7 8 SUN OR WIND EXPOSURE EMOTIONAL STRESS 5

  6. Rosacea: The Curse of the Celts About half the people who get Rosacea notice an itchy, stinging, sensation of their eyes. This can be followed by the development of spots (styes) along the eyelids (Figure 3). The inflammation of the eyes is common but rarely serious. As we mentioned earlier, a complication that occurs rarely, and mostly in male sufferers is an overgrowth of the oil glands of the nose giving it an enlarged and distorted appearance called Rhinophyma (Figure 4). This is a very distressing condition. Inappropriate terms such as “clown nose” “rum blossum” and “whiskey nose” have been used to in the past to describe rhinophyma. This gives an idea of the poor level of understanding of rosacea and its manifestations. Another skin condition that sometimes accompanies Rosacea is called Seborrhoeic Dermatitis that shows up as a persistent dandruff of the scalp that is accompanied by a dry flakiness of the eyebrows and the sides of the nose. Seborrhoeic dermatitis responds usually well to medicated shampoos and creams. However, like rosacea, seborrhoeic dermatitis relapses after the treatment is stopped so maintenance therapy is usually necessary to keep the skin clear. Figure 3. Inflammation of the eye and eye lids in this patient with rosacea Figure 4. Enlargement and distortion of the nose (rhinophyma) caused by rosacea 6

  7. Rosacea: The Curse of the Celts What causes Rosacea? The cause of Rosacea is not known. About one in five people who get Rosacea have a family member who also has developed the disorder. This suggests that there is a genetic vulnerability to the disorder in some families.sacea. We know that people with fair skin are most susceptible to rosacea, but there is no evidence that sun exposure causes the problem. In fact some people feel that a moderate amount of sun exposure is helpful to their condition. Some doctors have suggested that repeated episodes of facial flushing lead on to the other changes of rosacea (red spots, eye changes and rhinophyma), but evidence of this is lacking. In fact most people with rosacea only develop the tendency to flush after the other skin changes have occurred. There is nothing to suggest that rosacea is due to an infection of the skin, but strangely it responds well to antibiotic treatment. This apparent paradox is explained by the fact that antibiotics used to treat rosacea have many other actions apart from their ability to kill bacteria including anti-inflammatory activities. Although certain dietary elements (including alcohol) may act as “triggers” to flushing or more rarely flare the skin eruptions, it is unlikely that these triggers are the cause of the problem and following strict diets does not clear the disorder. A consistent but often overlooked finding in the skin of patients with rosacea is the presence of tiny skin mites called demodex folliculorum (Figure 5). These microscopic creatures live in the oil canals of the face and the eyelids. Patients with rosacea have about four times as many demodex mites in their skin compared with people with clear skin. Research, funded by the Health Research Board (HRB) in Ireland has helped to determine what the relationship is between these mites and rosacea. This research has shown that the oil in the skin of rosacea patients is different, and possibly conducive to the multiplication of these mites. Interestingly, some anti-mite treatments can clear skin lesions in rosacea patients, but these treatments have not yet been studied in sufficient detail to ensure they are safe and effective in the long-term. Figure 5. Demodex Folliculorum Demodex Folliculorum mites have four pairs of legs and can move across the skin surface of the face 7

  8. Rosacea: The Curse of the Celts How is Rosacea Treated? The redness of the face seen in patients who experience repeated flushing episode is difficult to treat. These skin changes may be mainly due to wind and weathering of fair skin and therefore the consistent (winter and summer) use of sun block protective creams is important for all patients with rosacea. Avoidance of potential Trigger Factors (Table 1) is also important. Promising new creams and gels with the ability to reduce redness are being investigated in clinical trials and should be available in the near future. The spots of Rosacea usually respond well to antibiotic treatment. This treatment may be given in oral form (pills are taken for moderate or severe rosacea) or used topically (in the form of a cream or gel for milder rosacea). Sometimes a combination of the tablets and the topical treatments are prescribed. The treatment takes up to 6 weeks to completely flatten the red bumps and pimples. Initially the spots reduce in number; they don’t persist as long and flatten quickly on to the skin surface. The redness reduces as the spots clear. When the skin lesions settle the doctor often prescribes a “maintenance therapy” in the form of a cream or gel to be applied to the facial skin at night. When the skin remains un-inflamed for several months the redness gradually fades. If the skin remains clear after 6 months the maintenance treatment can gradually be stopped. Remember that rosacea is a disorder that comes and goes on for many months or even years in most people so don’t be disappointed if you get a reoccurrence. Usually this responds well to the same treatment as was given before. If you are unlucky enough to develop rhinophyma you will probably require a surgical approach to remedy the problem. This is usually done by a plastic surgeon who may use traditional surgical excision techniques, or alternatively a form of laser (CO2 laser) can be used. Either of these approaches can lead to very satisfactory results with a marked improvement in appearance. Occasionally after some years a patient may notice a mild re-occurrence of the rhinophyma and repeated treatment may be needed. Interestingly, the eye symptoms of rosacea (burning, stinging, dry or watery eyes) often respond to the same antibiotic treatment that is prescribed for the skin lesions. There are also eye drops and gels that can be prescribed by your doctor. Sometimes, if the eye symptoms are severe, or if you experience pain or blurred vision, you will be advised to see an eye specialist. 8

  9. Rosacea: The Curse of the Celts Herbal and Complimentary medical treatments are used by some people with rosacea. Tee Tree oil is probably the treatment that has been most researched and does appear to be of benefit in some patients. The exact role of these treatments and their safety profile has not of yet been fully clarified. Laser therapy can be used effectively to treat the broken blood vessels (telangiectasias) that contribute to the facial redness in some patients with rosacea. The use of cosmetic cover (products with a green or yellow tint mask the redness best) in the management of rosacea is appropriate and in most cases will not cause any deterioration in your skin condition. Remember to avoid vigorously cleansing the skin (gentle dabbing using luke warm water with a soft cotton cloth is much better than rubbing with a rough washcloth) and avoid any products (such as after shave lotions for men) that cause burning, sting, or itching of the skin. Avoid peeling agents as these are likely to irritate the sensitive rosaca skin. Treatments for Rosacea 1 2 3 4 5 6 7 AVOID TRIGGERS OF FLUSHING SUN BLOCK CREAMS APPLIED IN THE MORNING MOISTURIZERS APPLIED AT NIGHT EYE DROPS DAILY FOR EYE IRRITATION ORAL OR TOPICAL ANTIBIOTICS OTHER MEDICATIONS FOR ROSACEA SPOTS SURGERY OR LASER TREATMENT FOR RHINOPHYMA 9

  10. Rosacea: The Curse of the Celts What should I do if I think I have Rosacea? If you are concerned that you might be developing Rosacea you should consult your doctor. Several other medical conditions can look like rosacea, so don’t assume that redness of your face means that you have the condition. The internet gives useful information about skin disorders, but it is not designed to diagnose them and so is not a substitute for a proper medical assessment. Also, the information that patients put on the internet may not apply to others, with different forms of the disorder. Your family doctor is usually the best person to diagnose and successfully treat rosacea. If you continue to have problems in spite of treatment you might be referred to a skin specialist. As mentioned earlier if eye symptoms are severe you may need the advice of an eye specialist. In most cases rosacea is mild, can be successfully treated, and leaves no permanent damage in the skin. Further Information: If you want more information about rosacea and its causes, trigger factors, treatment etc., this information can be found in a book on Rosacea by the author of this publication called Rosacea: Diagnosis and Management, published by Informa Healthcare. The following websites will give you useful information about Rosacea: Research into the cause of Rosacea and this booklet has been kindly sponsored by the Health Research Bord of Ireland. 10

  11. Rosacea: The Curse of the Celts