Rosacea and lymphedema

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Rosacea and lymphedema

Postby patoco » Sun Jun 11, 2006 9:17 pm

Rosacea and lymphedema

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Rosacea lymphoedema of the eyelid.

Acta Ophthalmologica Scandinavica. 82(6):765-767, December 2004.
Lai, Tze Foon 1; Leibovitch, Igal 1; James, Craig 2; Huilgol, Shyamala C. 3; Selva, Dinesh 1
Purpose: To present a patient with rosacea lymphoedema of one upper eyelid resulting in unilateral complete ptosis.

Methods: A 51-year-old white man presented with a 12-month history of progressive painless swelling of the left upper eyelid. An incisional biopsy of the upper eyelid was performed.

Results: The biopsy showed dermal oedema with lymphangiectasia and telangiectasia, accompanied by a mild to moderate mixed chronic inflammatory infiltrate of lymphocytes, histiocytes, plasma cells and rare eosinophils. Stains for fungi and mycobacteria were negative. The lack of lichenoid reaction, dermal mucin or lip swelling indicated a lymphoedematous manifestation of rosacea. The patient was treated with minocycline and prednisolone with no effect.

Conclusion: Rosacea lymphoedema involving the eyelid, as in our case, is a rare complication and can present diagnostic and therapeutic challenges to the ophthalmologist.


Rosacea lymphedema

New Study Links Swelling and Excessive Tissue

Growing evidence now confirms that rhinophyma, the excess growth of tissue on the nose that represents the most advanced stage of rosacea, is a result of the chronic lymphedema (swelling) that often appears in rosacea, according to a new study published in the Journal of the American Academy of Dermatology.1

"This study's findings have tracked the link between the vascular system and the more permanent disfiguring effects of rosacea," said Dr. Jonathan Wilkin, director of Dermatologic and Dental Products, U.S. Food and Drug Administration. "This new finding emphasizes the importance of avoiding flushing to prevent later excess tissue growth that cannot be treated with medication."

Lymphedema is the swelling that occurs when excess fluid accumulates because of the lymphatic system's flawed ability to clear it away normally.2 The study, by Dr. Filippo Aloi and colleagues at the University of Turin in Italy, documented microscopic changes that indicate chronic edema leads to excess tissue. The researchers noted that inadequate drainage may be due to a mechanical obstruction.

An early sign of rhinophyma may be an indentation on the bridge of the nose after wearing glasses, Dr. Wilkin said. Some physicians have even noted that heavy glasses themselves can contribute to swelling of the nose. Opting for a lighter pair of glasses may help.

Associated References
Aloi F, Tomasini C, Soro E, Pippione M: The clinicopathologic spectrum of rhinophyma. Journal of the American Academy of Dermatology. 2000;42:468-472.

Wilkin JK: Rosacea: Pathophysiology and treatment. Archives of Dermatology. 1994;130:359-362.


Chronic eyelid lymphedema and acne rosacea. Report of two cases.

Bernardini FP, Kersten RC, Khouri LM, Moin M, Kulwin DR, Mutasim DF.

Ophthalmology Clinic, S. Martino Hospital, University of Genova School of Medicine, Genova, Italy.

OBJECTIVE: The authors describe the clinical findings and surgical treatment of two patients affected by chronic eyelid lymphedema associated with facial acne rosacea. DESIGN: Two interventional case reports.

METHODS AND INTERVENTION: The clinical diagnosis of acne rosacea was based on the physical examination and confirmed by the histopathologic findings obtained from biopsy of the involved tissue. Surgical treatment was required to address the disfiguring chronic eyelid lymphedema and to correct the resultant mechanical lower eyelid ectropion in both patients.

RESULTS: Surgical debulking of the affected soft tissue resulted in very satisfactory cosmetic and functional improvement in both patients.

CONCLUSIONS: To our knowledge, this is the first series of cases of chronic eyelid lymphedema secondary to acne rosacea reported in the ophthalmic literature. Six similar cases have been described previously in the dermatologic literature; all of which had been treated medically without satisfactory results. Surgical debulking of the involved eyelids should be considered in patients affected by persistent symptomatic rosacea lymphedema.

Publication Types:
Case Reports

PMID: 11097600 [PubMed - indexed for MEDLINE]


Facial Rosacea:

Major Symptoms of the Disorder

I. Introduction

II. Nine major symptoms of rosacea

Facial redness

Facial telangiectasia

Facial skin hyper-reactivity

Lumpy-bumpy facial skin

Facial papules

Facial pustules

Facial burning sensations

Facial swelling


I. Introduction
Rosacea is a progressive vascular disorder that affects the facial skin and eyes. It usually starts out quite innocently as a mild flush across the nose, cheeks, chin, and forehead. During the early stages, this flush comes and goes, seeming to have a mind of its own. As the disorder progresses, facial redness becomes more intense, taking on the appearance of mild sunburn or windburn. In areas of facial redness, tiny broken blood vessels and red bumps may also become visible. In the moderate to severe stages, facial inflammation usually intensifies, resulting in permanent redness, swelling, and burning sensations. In the most advanced cases, rosacea can cause facial disfigurement and disabling burning sensations.

Rosacea affects millions of people worldwide. In the United States an estimated 13 million Americans are afflicted by this disease (1 in 20 people). Personal communication with medical experts around the world indicates that other countries have large numbers of rosacea sufferers: Canada has an estimated 4 to 6 million rosacea sufferers, United Kingdom has an estimated 8 to 10 million sufferers, and millions more can be found throughout all parts of Europe, Ireland, Spain, China, Africa, and Russia.

II. Nine Major Symptoms of Rosacea

Facial Redness: Facial redness is the most common symptom of rosacea. This is caused by hundreds of tiny dilated blood vessels near the surface of the facial skin.

Facial Telangiectasia (tel-an-jek-tasia): These are tiny broken blood vessels that are permanently fixed in the dilated state. These blood vessels take on the appearance of fine red lines coursing through the surface of the facial skin.

Facial Skin Hyper-Reactivity: Facial skin hyper-reactivity is caused by sensitive, inflamed blood vessels near the surface of the skin. These blood vessels dilate very easily to topical triggers and physical insults. It is important to note that the term 'sensitive skin' is misleading to rosacea sufferers because the problem is based on sensitive blood vessels, and not sensitive skin cells.

Lumpy-Bumpy Facial Skin: Uneven skin texture, or lumpy-bumpy facial skin is caused by dilated blood vessels, localized swelling, and leakage of inflammatory cells into the superficial layers of the skin.

Facial Papules: Facial papules are small, red bumps about the size of a pinhead. These bumps are caused by vascular flushing. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the dermal skin. These inflammatory cells then migrate towards the surface of the skin, resulting in the inflammatory papules. Facial papules are not caused by bacteria or demodex mites.

Facial Pustules: Facial pustules are small red bumps with pus. These bumps are caused by vascular flushing in areas around sebaceous glands. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the dermal skin. These inflammatory cells then migrate towards the sebaceous gland or pore, resulting in inflammatory pustules.

Facial Burning Sensations: Facial burning sensations are caused by activation of sensory pain nerves in the facial skin. These pain fibers are primarily triggered by the heat associated with increased blood flow. These nerve endings can also be activated by inflammatory substances that leak through blood vessels. After chronic activation, pain nerve fibers may become sensitized to other triggers such as skincare products and environmental insults (i.e., sun, wind, heat, and cold). Facial burning sensations can become severe in some sufferers, causing debilitation.

Facial Swelling: Facial swelling occurs when fluid and proteins leak out of facial blood vessels at abnormal rates. Frequent facial flushing leads to increased movement of water and proteins across abnormal blood vessel walls. Over time, this "spillage" overwhelms the lymphatic system (drainage vessels), and leads to fluid build up in the facial skin.

Rhinophyma: Rhinophyma is a form of rosacea that is characterized by chronic redness, inflammation, and increased tissue growth of the nose. Rhinophyma can take on many different forms. In most forms, the nose is chronically red and inflamed. There is also evidence of swelling, and the skin often shows thickened skin with large pores, resembling the peel of an orange (peau d'orange). In some forms, sebaceous gland hypertrophy and hyperplasia (increased growth and number of sebaceous glands) can cause the nose to grow considerably, resulting in a bulbous appearance.
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Unraveling the mystery of rosacea

Postby patoco » Sun Jul 02, 2006 5:05 am

Unraveling the mystery of rosacea
Keys to getting the red out

Ken Landow, MD


Rosacea remains one of the last bastions of dermatologic ignorance. Once considered a variant of acne, this common skin disorder seems fairly well entrenched as a disease sui generis. Although oral and topical antibiotics are effective in treating the papular and pustular varieties of rosacea, evidence demonstrates the lack of an infectious origin.

Rosacea has been indelibly linked with the bulbous nose and "gin blossoms" of comedian and alcohol aficionado W. C. Fields, but the condition actually results from a disparate assortment of stimuli acting in concert on a genetically susceptible host. Additionally, an appropriate constitutional diathesis must exist. Although descriptions suggestive of rosacea harken back to biblical times, modern diagnosis and treatment seem intertwined with the pharmaceutical and advertising industries. Patients in our cosmetically conscious society flock to physicians' offices and demand topical salves in lieu of considering requisite behavior modification.

Causes and epidemiologic factors

The medical literature contains "evidence" both for and against the involvement of Demodex folliculorum and Helicobacter pylori in the genesis of rosacea. However, neither these agents nor any other microbes appear to be implicated, nor do vitamin deficiencies, hypertension, or gastroenterological novelties such as hypochlorhydria and dyspepsia. Consistent with our modern emphasis on biologic explanations, it is likely that a flaw in the autonomic innervation of the cutaneous vasculature is the root cause of rosacea. The link between rosacea and migraine and between rosacea and perimenopause is further evidence that a vascular abnormality is an important underlying factor (1).

Research indicates that aberrations in vascular endothelial growth factor and angiogenesis, substance P, serotonin, bradykinin, catecholamines, histamine, neuropeptides, endorphins, gastrin, and cytokines may be involved. The roles of matrix metalloproteinases, tumor necrosis factor, acetylcholine, vasoactive intestinal polypeptide, and prostaglandins also have been scrutinized (2).

By some accounts, the earliest signs of rosacea affect at least 13 million adults in the United States, and prevalence ranges between 5% and 10%. Generally associated with people of Celtic or Scandinavian ancestry, rosacea has an inverse relationship with increasing epidermal pigmentation (3). Thus, rosacea is uncommon in black people.

In spite of its association with middle age, rosacea often occurs during the late teens or early 20s. Women are affected at a younger age and more often than men, but the condition tends to be more severe in older men. The relative paucity of cases in young men may stem from a reticence to seek medical evaluation for what is considered an "insignificant" problem.

Clinical findings

The presence of rosacea may not be immediately apparent (table 1). In retrospect, recurrent flushing or blushing appears to be a harbinger of future problems. Patients often are unduly sensitive to warm rooms, bawdy stories, or vasoactive medications. The skin seems excessively prone to irritation by chemicals, fragrances, cosmetics, and sunscreens; sensitivity is manifested by stinging, burning, redness, or itching. Exposure to wind gusts often recreates these complaints. Many people never progress beyond this premonitory phase as they fluctuate between normal skin and periodic erythema in a centrofacial or butterfly pattern (figure 1). A history of acne can complicate diagnosis.

Table 1. Criteria for diagnosis of rosacea

Primary features
Flushing or blushing (frequent)
Persistent redness

Secondary features
Burning or stinging**
Red plaques without epidermal changes
Dry, rough, or scaly facial skin
Hard or nonpitting
Ocular manifestations
Burning or itching
Conjunctival hyperemia
Lid inflammation
Corneal damage
Peripheral locations other than face
Phymatous changes
Patulous follicles
Skin thickening or fibrosis
Bulbous appearance

*Not necessary for diagnosis. Typically transient early in the course.

**May also demonstrate scaling and dermatitis.

Adapted from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002;46(4):584-7.

Subtypes of rosacea

Rosacea can be described according to several arbitrary stages or subtypes, and symptoms in many patients encompass a combination of these categorizations (table 2). The overwhelming majority of affected persons have either episodic flushing (episodic erythema) or the earliest diagnosable form of rosacea (subtype 1), characterized by prolonged erythema and often telangiectasia (4) (figures 2 and 3). Differentiating the telangiectases of rosacea from those associated with aging or sun damage requires physician discretion. Fine telangiectases often spread over the forehead, malar eminences, and concha, and the coarser venules select the alae and malar prominences.

Table 2. Characteristics of subtypes and variants of rosacea

Subtype 1: Erythematotelangiectatic
Persistent facial erythema
Centrofacial edema

Subtype 2: Papulopustular
Persistent centrofacial erythema
Transient papules and pustules
Features of subtype 1 may be present

Subtype 3: Phymatous
Skin thickening
Irregular surface nodularities
Enlargement of tissue
Patulous follicles in involved areas
Features of subtype 1 or 2 may be present

Subtype 4: Ocular
Watery or bloodshot eyes
Foreign body sensation
Burning or stinging
Sensitivity to light
Blurred vision
Lid margin
Irregularity of eyelid margins
Chronic staphylococcal infection
Hordeolum (stye)
Decreased visual acuity
Corneal complications
Punctate keratitis
Corneal infiltrates or ulcers
Marginal keratitis
Cutaneous manifestations may be present

Granulomatous variant
Papules or nodules
Yellow, brown, or red
Less inflammatory than in subtypes 1-4
Generally appear on relatively normal-appearing skin
Symptoms of subtypes 1-4 not required for diagnosis

Adapted from Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002;46(4):584-7.

An intermediate phase (subtype 2), consisting of symmetrically placed erythematous papules and pustules, affects as many as 20% of patients with rosacea (figure 4). Lesions usually present in a centrofacial distribution, affecting primarily the butterfly area of the face. They occasionally extend to the chin and glabella but tend to spare the vermilion border and periocular skin. At times, a wider distribution may encroach on the retroauricular zone, the back, and the chest. This presentation can be confused with adult acne, when in reality it represents a manifestation of rosacea rather than of follicular involvement by Propionibacterium acnes (5). Supposedly, a lack of comedones is a reliable distinguishing feature of rosacea. However, the solar (senile) comedones of Favre-Racouchot nodular elastosis with cysts and comedones or superimposed cosmetic acne may obfuscate the diagnosis. Other findings of subtype 2 rosacea include prominent dilated follicles, pustules randomly distributed throughout the scalp, and chronic photodamage of the integument.

A small percentage of patients experience the wrath of full-fledged rosacea (also subtype 2). They present with large inflammatory nodules or furuncles, which are located on the cheeks and nose more often than the chin and forehead (6). The condition can be significantly disfiguring, resulting in scarring from the disease itself or from well-meaning but ill-advised medical intervention.

The phymas

Rhinophyma, long associated with excessive alcohol consumption, often accompanies subtype 3 rosacea, but it also may appear without the typical manifestations of less severe disease (figures 5 and 6). Several forms of rhinophyma are recognized, including glabellar, fibrous, actinic, and fibroangiomatous. Nasal involvement ranges from diffuse hyperplasia of the connective tissue to asymmetric, lobular hyperplasia of the sebaceous glands, which distorts the alae. Large purplish ectatic vessels may be present along with photodamaged skin, a pitted surface, and inflammation. The existence of these morphological entities emphasizes the polymorphous appearance of skin plagued by rosacea and the need to avoid preconceived diagnostic stereotypes. Although rhinophyma, by definition, involves the nose, a variety of phymas affect other areas, including the forehead (metophyma), eyelids (blepharophyma), earlobes (otophyma), and chin or jaw (gnathophyma) (5).

Morbihan's disease

Lymphedema, another complication of rosacea, seems to be considerably underdiagnosed. The current classification system identifies this manifestation as a secondary feature of rosacea. Previously referred to as Morbihan's disease, this hard, nonpitting edema supposedly results from lymphatic obstruction of drainage from the facial skin--primarily the forehead, glabella, eyelids, and nose (1). Consequences include thickening of the integument and prominence of the follicles. The condition may be quite mild, may mimic the appearance of skin stimulated by an excessive concentration of growth hormone, or may resemble the so-called peau d'orange (skin resembling an orange peel) changes of lymphoma.

Ocular rosacea

Ocular involvement in rosacea (subtype 4) remains a contentious issue. Reported prevalence varies greatly: between 3% and well over 75% of female patients older than 45 years who have rosacea ultimately present with a variety of ophthalmologic manifestations (7). The disease may be so mild as to be easily overlooked except by the trained observer. The initial cutaneous involvement in rosacea typically does not include the ocular tissues. However, in up to 20% of cases, the initial assault targets the skin surrounding the eyes. The meibomian gland dysfunction usually begins as tear instability, which consequently leads to complications of dry, itchy eyes; conjunctivitis; photophobia; eye pain; and grittiness or a foreign body sensation. Telangiectasia of the eyelid margins routinely occurs and tends to parallel the cutaneous flushing rather than the extent of skin eruption. Much less frequently, keratitis with ulceration and vascularization of the cornea develops (8,9). The precise mechanism linking the skin to the eye in rosacea remains unknown.

Granulomatous rosacea

Patients with this variant of rosacea exhibit small to mid-sized, relatively noninflammatory granulomatous papules or nodules on the cheeks or near the nostrils, eyes, or mouth. These red, yellow, or brown lesions may be present without the more traditional manifestations of rosacea and may lead to considerable diagnostic uncertainty. The precise categorization of granulomatous rosacea is likely to change as the cause of the disease becomes apparent.

Steroid rosacea

Abuse of topical fluorinated corticosteroids persists in spite of warnings to avoid application of these medicines to the face. Except for treatment of a few well-defined dermatologic disorders, use of these compounds should be discouraged. Profligate reliance on these potent antiinflammatory agents precipitates perioral dermatitis and a condition previously but incorrectly referred to as steroid rosacea.


Diagnosis of rosacea is rarely difficult. Occasionally, however, differentiating rosacea from seborrheic dermatitis or adult acne may be problematic. Since all of these conditions are common, they may occur simultaneously. Also, a shared genetic tendency may underlie the conditions, prompting their coexistence.

Differential diagnostic considerations include a variety of miscellaneous skin diseases, depending on the stage of rosacea under consideration (table 3). For patients in the earliest prodromal states manifesting only intermittent flushing, possible diagnoses include emotional factors (eg, anxiety), use of certain pharmaceutical agents, and fluctuation of not allowed hormones.

Table 3. Differential diagnostic considerations in rosacea

Acne conglobata
Carcinoid syndrome
Dermatophyte infection
Gram-negative folliculitis
Lupus vulgaris
Perioral dermatitis
Polymorphous light eruption
Seborrheic dermatitis
Steroid rosacea (due to use of fluorinated corticosteroids)
Systemic lupus erythematosus

Adapted from Murray AH. Differential diagnosis of a red face. J Cutan Med Surg 1998;2(Suppl 4):S11-5.

Biopsy of the skin rarely assists in diagnosis of rosacea, although it may exclude other diagnoses under consideration. Typical histologic findings include nonspecific lymphohistiocytic infiltration primarily in a perivascular pattern and often associated with telangiectasia. Sebaceous gland hyperplasia, fibrosis of the dermis, and inflamed follicles may be noted. Solar elastosis is noteworthy (2). Obviously, the precise pattern varies depending on the clinical stage of disease. The rate of sebum excretion appears to be normal except in rhinophyma, where it is increased.


Management of rosacea consists of behavior modification to avoid triggers as well as pharmacologic and other medical therapy.

Behavior modification

Establishing a reasonable treatment plan requires an understanding that rosacea occurs in a genetically susceptible person who experiences some intervening provocation. At times the initiating factor seems obvious (eg, alcohol consumption, an excessively warm shower, a spicy meal). Of course, not all patients are sensitive to the same triggers. Patients must identify those trip wires that inflame (rather than cause) their condition (table 4). Unfortunately, avoiding these exacerbating factors does not guarantee freedom from further flares.

Table 4. Trip wires that exacerbate rosacea symptoms

Heat (from bath, hot tub, Jacuzzi, sauna, shower)
Menopausal hot flashes
Strenuous exercise

Foods and beverages
Hot chocolate

Alcohol-containing cleansers
Peeling agents
Shaving lotion

Adapted from McDonnell and Tomecki (3) and Zuber (10).

Certain general advice seems prudent (10). Alcohol leads the list of verboten items. For most patients, exposure to heat is taboo. Topical irritants, astringents, and washcloths should be avoided. Short, tepid baths are preferable to prolonged hot showers. Patients should eschew Jacuzzis, hot tubs, and saunas. Consuming coffee or tea rarely elicits problems unless these beverages are too hot. Steam emanating from food can be problematic, as can hot, spicy seasoning. For some, a bawdy story leads to a reddened countenance, while for others, menstruation or an anxiety-inducing experience may induce flushing. In these situations, appropriate pharmaceutical intervention or behavioral changes seem justified.

A variety of drugs may precipitate worsening of rosacea (table 5), including disulfiram (Antabuse), metronidazole (eg, Flagyl), or chlorpropamide (Diabinese) taken in conjunction with alcohol. Niacin tablets are notorious for causing flushing. While ultraviolet light may lead to a flare of rosacea, heat is a more provocative factor than sunlight. Solar exposure during the cooler months rarely elicits problems.

Table 5. Drugs that may precipitate worsening of rosacea

Doxorubicin (Adriamycin, Rubex)
Nifedipine (Adalat, Procardia)
Prostaglandin E
Rifampin (Rifadin)
Vancomycin (Vancocin, Vancoled)

Exposure to excessive cold may be equally noxious. Wintertime outdoor activities often result in facial erythema. Similar logic warns against working in cold storage facilities such as in grocery stores or meatpacking plants. Appropriate protection may include wearing a face mask or coating the face with zinc oxide. Cold exposure leads to quixotic sequelae. While winter temperatures may trigger a flare-up, application of ice, a cold glass, or a cool mist may provide relief during warm weather. Finally, exercising for shorter intervals early or late in the day generally seems wise.

Oral agents

Drug therapy is especially effective during the papular and pustular stages of rosacea. Oral or topical antibiotics provide miraculous relief for patients who avoid the implicated trip wires. Except for the mildest cases, oral tetracyclines provide rapid relief. For moderate to severe disease, I prefer doxycycline, typically at a daily dose of 100 to 200 mg initially, then tapering over 30 to 60 days before discontinuing the medication, at least temporarily. Appropriate alternatives are tetracycline, beginning at 250 to 1,000 mg daily, and minocycline (Dynacin, Minocin), beginning at 50 to 200 mg daily (1,5,6).

The aforementioned medications function as anti-inflammatory agents in patients with rosacea and possibly counteract neutrophil chemotaxis, macrophage activation, cytokine signaling, or activation of complement or protein kinase C. The mode of action providing the therapeutic benefit remains ill-defined.

Less effective antibiotics include clarithromycin (Biaxin), trimethoprim-sulfamethoxazole (Bactrim, Cotrim, Septra), and erythromycin. In Europe, oral metronidazole beginning at a daily dose of 1,000 mg remains popular, but fear of toxicity limits prescription of this drug in North America to its topical form. Isotretinoin (Accutane) may offer relief for severe rosacea, but careful consideration of the risk-benefit ratio is essential. Most advocates limit the dose to less than 0.2 mg/kg per day, with acceptable doses of 2 to 15 mg continuing for a maximum of 6 months (1,5). Accutane use must be reserved for exceptionally resistant cases.

Under the most limited circumstances, the therapeutic armamentarium may include naloxone (Narcan), a beta blocker, or spironolactone (Aldactone).

Topical agents

Topical therapy may commence simultaneously with oral therapy or may be held until oral agents are tapered. Metronidazole remains the most popular topical agent and is available as a 0.75% cream, gel, or lotion (MetroCream, MetroGel, MetroLotion) or a 1% cream (Noritate). The 0.75% formulation may be used twice daily, depending on clinical necessity, but the 1% cream should be used once daily. Patients should apply the preparations 5 minutes after gently cleansing the skin (11).

A less popular alternative, sodium sulfacetamide 10% and sulfur 5% (Novacet Lotion, Sulfacet-R Lotion, Sulfacet-R Tint Free Lotion), may be applied up to three times a day, with precautions taken for patients who are allergic to sulfonamides or who have kidney disease. Sodium sulfacetamide without sulfur (Klaron) may provide some utility in patients with especially sensitive skin. These preparations assuage mild disease and may help prevent recrudescences.

Topical clindamycin phosphate (Cleocin T) provides an acceptable substitute for metronidazole. For some reason, topical erythromycin-containing preparations fail to offer the same relief (1).

Alternatively, topical tretinoin (Avita, Retin A) or adapalene (Differin) may be useful in recalcitrant cases. However, these preparations may cause considerable irritation. Some European experts use the related precursor compound retinaldehyde, which may replenish the depleted perivascular connective tissue and possibly function in the angiogenic pathway. Occasionally, azelaic acid (Azelex) and alpha-lipoic acid may provide relief without irritation. For patients with highly inflammatory skin, a short course of weak, nonfluorinated topical corticosteroids may be acceptable. Options include hydrocortisone, hydrocortisone valerate (Westcort), and desonide (DesOwen, Tridesilon).

Unconventional treatment

Traditional therapies offer little improvement for minor yet cosmetically troubling eruptions such as flushing, erythema, and telangiectasia. Occasionally, use of oral or topical antibiotics provides relief. Use of tinted cosmetics and Sulfacet-R can provide camouflage. For some patients, cautious application of retinoids may be beneficial. For those with telangiectasia, relief may be hastened by laser or intense pulsed light therapy or by electrocoagulation, which is more widely available and less expensive.

A major revolution in rosacea treatment appears under way. Intense pulsed light (VascuLight, Quantum) provides superior and long-lasting results for patients whose primary manifestations include telangiectasia and erythema. Recent suggestions indicate this treatment approach also represents a marked advance for those plagued by the papular and pustular subtypes of rosacea.

At present, use of carbon-dioxide laser therapy is relegated to severe manifestations, such as rhinophyma, as is use of surgical ablation, electrosurgery, cryosurgery, and dermabrasion (5). External ocular disease may yield to appropriate hygiene of the lids and use of a mild "baby" shampoo, oral or topical antibiotics, and artificial tears.

Medicine often straddles the delicate balance between art and science. This is no more obvious than when physicians care for patients with rosacea. The disorder is not physically threatening, but it often precipitates anxiety, depression, and social withdrawal (10). In today's era of high-tech medicine, compassion and understanding are essential elements of treatment.

Appropriate therapy for rosacea often includes topical or oral preparations, but continued improvement of this condition hinges on a frank discussion between physician and patient regarding lifestyle assessment and modification. Intense pulsed light and other nonablative therapies seem poised to dramatically alter the course of this once intractable and irrepressible skin condition. Rosacea stands in sharp contrast to more traditional abnormalities that prompt people to search frantically for a pharmacologic or surgical cure. With some alteration of our thought processes, patients and physicians alike will triumph over this enigma.
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