Rosacea, often incorrectly referred to as "adult acne" affects an estimated 14 million Americans each year. Many misconceptions exist and I personally encounter a bevy of "over diagnosed" patients as well. My goal is to help clarify rosacea its diagnosis, treatment and what you REALLY need to know.

WHO GETS ROSACEA?

Women are more often affected by rosacea. The condition tends to appear between the ages of 25-55.

Heredity plays a definite role in the probability of developing rosacea. Patients with fair skin from ethnic backgrounds such as Great Britain (including Ireland, Scotland and Wales), Germany and Scandinavia have a predilection towards rosacea; however, anyone of any race can develop rosacea.

Patients who've had a past history of significant acne, family histories of severe acne or rosacea have a greater incidence of rosacea.

HOW DO I KNOW I HAVE ROSACEA?

Rosacea is really a constellation of skin symptoms, not merely limited to blemishes. While not all patients are going to encounter all potential concerns, multiple features at once typically surface. These include:

• redness of the face
• flushing
• the presence of small blood vessels ("broken" blood vessels)
• acne (all forms papules, pustules, cysts)
• occasional surface irregularities of the nose (called rhinophyma)
• symptoms of redness, irritation or the feeling of "grit" in the eyes, and sometimes clear discharge (ocular rosacea)
• skin sensitivity or dryness
• oiliness
• enlarged sweat glands(sebaceous hyperplasia)

CALM, COOL & CORRECTED

In order for treatment to be effective, it must ideally address the entire spectrum of rosacea concerns, not be limited to "only" blemishes. This seems to be the limitation of most medical approaches to rosacea. Certainly clearing the skin of acne is a fundamental therapeutic concern. But many times treatment can inadvertently aggravate those other skin complaints.

DERMAdoctor Calm Cool & Corrected 2N1 Rosacea Tx translates scientifically proven technology into an effective multifunctional treatment targeting all symptoms and concerns experienced by those with rosacea. It does so by employing a sophisticated complex aggressively targeting the constellation of symptoms associated with rosacea while integrating powerful ingredients to help diminish signs of aging.

DERMAdoctor Calm Cool & Corrected 2N1 Rosacea Tx controls oil production, reduces inflammation, improves blemishes, diminishes cellular buildup, and minimizes bacteria production on the skin.

DHT, the active metabolite of testosterone, is responsible for undesirable androgenic skin changes such as sebaceous gland activation (oily skin) and acne formation. In vitro tests performed using the specialized patented ingredient complex contained in Calm Cool & Corrected showed a 68% reduction in 5 alpha-reductase, the enzyme responsible for DHT formation. In simple terms, lower DHT and reduce blemish formation and oiliness.

Nordihydroguiaretic acid, a natural, plant derived lipooxygenase inhibitor, reduces inflammation and substantiated by medical journal validation possesses the ability to reduce 5-alpha reductase function, the enzyme responsible for converting testosterone to DHT.

Oleanolic acid reduces inflammation and creates an environment hostile to normal skin flora by reducing sebum lipid (fatty acid) levels.

Together, visible signs of acne and rosacea are reduced.

Sebum Sequestering Micro-Particles, a form of polymer technology, effectively absorb excess surface skin oils without causing skin dryness.

A complex of gentle, calming botanicals and powerful antioxidants, including White Tea, provide balance; reduce skin inflammation calm and protect challenged skin while providing shielding against damaging free radicals.

While Calm, Cool & Corrected may in many cases supplant the need for additional therapies, it was designed to be complimentary with all prescription rosacea regimens, providing rejuvenation and working synergistically against rosacea symptoms. Today a whole host of powerful, effective prescription therapies exist to fight acne due to rosacea. Blemishes are often the easiest rosacea component to control. And as with teenage acne, treatment is aimed at lesion form and severity.

Prescription Acne Options In Rosacea Management:

• Topical Metronidazole

  Composed of the "Metros" (MetroLotion, MetroCream and MetroGel) and Noritate, this category comprises the use of topical antibiotic metronidazole (also known as Flagyl) to eradicate bacteria that help form acne lesions.

  MetroGel was the first prescription topical rosacea medication and was highly effective. However, rosacea patients often also have exquisitely sensitive skin gel formulations frequently exacerbate irritation. Fortunately, a gentler cream and lotion are now available.

  Noritate, similar to MetroCream need only be applied once daily, helping improve compliance by simplifying the daily regimen.

• Finacea

  Composed of 15% azelaic acid, this prescription topical both kills bacteria and helps normalize the keratinization process. In other words, it helps unplug the pore and take aim at specific causes of the blemish in the first place.

• Oral Antibiotics

  Just like treating "regular" acne, tetracycline and its derivatives, minocycline and doxycycline are the oral antibiotics of choice in trying to control more severe or resistant inflammatory acne, particularly when cysts are present.

• Topical Sulfa & Sodium Sulfacetamide Treatments

  Plexion led the way with both a lotion and a cleanser; several more have followed. The premise of therapy incorporates sulfa, an antibiotic and sulfur (no relation to sulfa) that helps unplug clogged pores and remove keratotic plugs. This is a NON-option for anyone with a SULFA allergy. Remember, being allergic to sulfa does not mean you have a sulfur allergy!

  Over-the-counter sulfur can be found in such products as Rezamid Acne Treatment Lotion and Peter Thomas Roth Acne Spot and Area Treatment as home substitutions. Sulfa containing medications are strictly availble by prescription only. Use sparingly and moisturize as necessary since both are in drying bases originally formulated for oily teens.

• Desowen and Sulfur Mixture

  Three percent precipitated sulfur in desowen cream is an "old fashioned" concoction that I fall back on when I find a rosacea patient that is difficult to clear. This formulation includes a mild potency topical prescription strength steroid that helps alleviate much of the redness and inflammation. I try not to have the patients use this too long due to long term risks of thinning the skin (causing atrophy)leading to loss of skin color, telangiectasia (spider vein) formation, easy bruising and even stretch marks. Usually a month is adequate to gain control with this "quick fix".

• Accutane

  When all else fails and cystic acne is severe, scarring and resistant to all other options, Accutane may be necessary. The 5 month, (20 week course) helps shut down significant acne and is the closest prescription "cure" for acne available to dermatologists. Treatment must be closely followed and monitored with bloodwork and pregnancy prevention during and 30 days following therapy.

Skin Sensitivity

Patients with rosacea often experience very sensitive skin. This can make it difficult to use "typical" acne medications, which can be drying and/or irritating. Rosacea patients who also suffer from heightened skin sensitivity may also find even the simplest task such as cleansing an ordeal. There are many prescription medicated cleansers on the market that contain antibiotics or sulfa to help kill yeast and mites known as Demodex that can drive rosacea outbreaks. Unfortunately, as effective as these treatments can be, they can also increase skin dryness, redness, flaking and sensitivity.

DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser is an ideal option. It combines the abilities of pyrithione zinc (known to kill yeast on the skin) with an incredibly gentle soap-free formulation. Dermatologists frequently recommend rosacea patients try the "off label" use (not officially FDA approved for a particular purpose) of pyrithione zinc or ketoconazole based-dandruff shampoos for cleansing the face. However, like their approved prescription antibiotic counterparts, they can dry and inflame tender rosacea-prone skin.

DERMAdoctor Born To Be Mild Medicated Face & Body Cleanser was tested against Cetaphil Gentle Skin Cleanser and found to be 100% as gentle, non-irritating and non-redness producing. But it's not just a simple mild cleanser, it's medicated, offering "off label" benefits.

For anyone looking for another gentle skin non-medicated option, consider Free & Clear Liquid Cleanser.

Plain moisturizers good for those with rosacea include MD Formulations Moisture Defense Antioxidant Creme, Cellex-C Sea Silk Oil-Free Moisturizer or Ole Henriksen Nurture Me. Whenever applying any product to the skin, remember it also provides moisture. So that sunscreen, skin care treatment or medication may at times be adequate.

GET RID OF THE RED

Redness can be due to a variety of factors: flushing, spider veins and skin irritation. Whenever a blood vessel dilates, it releases more blood to the surface of the skin, and automatically produces redness of the skin. Flushing tends to be due to other events mediated by hormones that trigger vasculature deeper within the skin to dilate. Here is a partial list of factors that can lead to temporary increased facial redness:

• Sun/wind/cold weather exposure
• Physical exertion or becoming overheated
• Stress
• Hot foods and beverages
• Spicy foods and beverages
• Alcohol
• Foods: Liver, citrus fruits, tomatoes, soy sauce, vinegars, some cheeses

Patients often present with wispy facial blood vessels convinced they have rosacea whether told so by a primary care physician or self-diagnosed. The presence of telangiectasias (aka spider veins) alone does not make for a diagnosis of rosacea. Certainly rosacea patients may be more prone to forming telangiectasias, but not all telangiectasias are due to rosacea.

Telangiectasias are often called "broken", but there's nothing broken about them. Rather they can develop on anyone with a history of sun damage, perhaps is getting a bit older, may have a fair complexion, possibly used steroids whether topical on face or taken systemically, or has a strong family history of telangiectasias can form these skin annoyances.

How do you know if you have "broken" blood vessels or actually have rosacea? You don't and neither does your doctor. However if telangiectasias are the sole complaint, I will treat them but I don't label the patient with the diagnosis of rosacea until other symptoms develop.

A blood test known as an ANA is often performed to eliminate lupus as a possible diagnosis since facial redness is a common presenting sign. This is more confusing if the patient presents with only facial redness or flushing and the clinical picture isn't clear-cut.

Eliminating redness is helpful for sheer aesthetics, but some therapy choices can also help improve other symptoms, usually acne.

Spider veins can respond to physical destruction with procedures such as electrocautery, dye laser eradication and IPL (intense pulsed light). extremely low voltage electricity. Since simple electrocautery tends to be sufficient for most telangiectasias and is most cost effective, this is an ideal point to begin with.

Injectable anesthesia is not typically used during electrocautery since it can cause transient skin whiteness, concealing their location.

If a topical is necessary, LMX 4% Topical Anesthetic Cream - 30gm or Betacaine may be applied to help improve comfort during the procedure.

Electrocautery is performed using a very tiny needle that literally zaps along the length of the blood vessel and killing it. There may be some swelling and redness for a day or 2. Depending upon the number of blood vessels present, 1 or 2 treatments are all that it should take. The session probably will last between 15-30 minutes and may cost approximately $200.00. Remember, just like other "age-related" growths, anyone prone to growing telangiectasias will probably continue to make more as time goes on. Prepare for some maintenance every now and then.

For resistant cases or the presence of an overwhelming number of veins, the pulsed dye laser (specific for blood vessels), and the IPL (intense pulsed light which is not a true laser for reducing redness) are other options. Laser and IPL may require a series of treatments (sometimes up to 12) and can run up to $1500.00.

General persistent redness often improves with oral tetracycline (500 mg twice daily for healthy non-pregnant and non-nursing adults). Topical Vitamin K containing products can help reduce visibility of spider veins and facial redness in many cases. Other solutions include DERMAdoctor Calm Cool & Corrected 2N1 Rosacea Tx (white tea is the most potent antioxidant form of tea extract and when blended with the other actives helps reduce inflammation and redness), Neova R2 Serum for Sensitive and Red Skin and Neova R2 Lotion Intermediate for Sensitive and Red Skin.

Flushing is much more difficult to control. Blood pressure medications such as propranolol (beta blockers) can be used, but are tricky in patients who have normal blood pressure. Treatment with nicatinamide and calcium channel blockers have also been tried to help reduce this annoying condition.

SUN PROTECTION

Sunscreen is extremely important for anyone with rosacea. Whether you require UV and visible light protection from Total Block or are looking for the lightest oil-free, oil-reducing, rejuvenating and rehydrating product you can find such as DERMAdoctor Body Guard Exquisitely Light SPF 30 For Face & Body, make sure you wear it daily. This will go the distance in helping minimize your redness!

CAMOUFLAGE

When treatment and procedures either aren't enough to handle the redness or perhaps they just haven't had time to kick in, you may want to consider strategic camouflage. T.LeClerc Corrector Palette, Tilleul is helpful in evening out red undertones. Green neutralizes red. It's that simple. That explains why your normal shade of "beige" or other neutral skin tone foundation doesn't hide the redness that peeks out from underneath.

Try applying the green prior to your foundation, or even layering the green with the beige or orchidee shades found in T.LeClerc Corrector Palette prior to your foundation for more stubborn redness. If you are oily, the rice powder versions are incredibly absorbent and won't clog your pores. In fact, the strict use of powder foundation is a good idea in addition to the concealer; it will be less likely to flare your acne.

THE VITAMIN A CONTROVERSY

A final word for those with telangiectasias. Controversy surrounds the use of topical Vitamin A therapy in the presence of facial telangiectasias. This includes retinols, tretinoin (Retin A, Renova, etc.) and Tazarotene (Tazorac and Avage).

Rarely the active ingredient in this category of prescription medication has been known to hasten the proliferation of telangiectasias in some patients.

There are certainly exceptions to this rule, and I have certainly given such prescriptions to some patients but always with the precaution that if they seem to be developing more telangiectasias faster than before, either back off or discontinue treatment. There is no need to fret about a smidgeon of Vitamin A present in your skin rejuvenation product.

The continued formation of telangiectasias is anticipated over time with or without topical vitamin A; it is the sheer number and rate that is being monitored rather than panicking over.

WILL I LOOK LIKE W.C. FIELDS?

Rhinophyma is the surface irregularity that can arise on the nose. Picture W.C. Fields. Everyone thinks his nose looked that way because of his drinking when in fact it was due to rosacea. Starting treatment early can help prevent these changes. Fortunately, rhinophyma is relatively uncommon. It responds in part to surgical repair.

THE EYES HAVE IT

Ocular rosacea can leave the eyes feeling irritated and "gritty". Patients may experience redness, tearing or crusting on the lashes. Many mistakenly think they have allergies. Use of prescription steroid based eye drops will usually help improve this condition. I have personally found that oral tetracycline or minocin is necessary as well for the more severe cases.

GOT ACNE AND WRINKLES?

How lucky can you get to hit 40 or 50 and have to deal with BOTH acne AND wrinkles? Or perhaps you're trying to prevent their formation in the first place. This was such a common concern from DERMAdoctor feedback that I chose to create DERMAdoctor Calm Cool & Corrected 2N1 Rosacea Tx and incorporate rejuvenating ingredients in a base appropriate for rosacea patients.

The problem with many skin rejuvenation treatments is often they are acid based and quite irritating or drying to someone prone to sensitive skin as is often seen with rosacea. I like using very calming, soothing skin rejuvenation ingredients for rosacea patients and select the base depending upon the individual's skin type.

Other rejuvenation products appropriate for those with rosacea include GHK copper peptide treatments and N-6 furgfuryladenine. Neova, Osmotics and Kinerase respectively are ideal options. Choose the base that's right for your skin type.

There is definitely something you can do to help you look your best. And you may find comfort to know you are not alone. But when it comes to having rosacea... only your dermatologist needs to know!

For those of you who would like further information on rosacea, you may consider contacting:
The National Rosacea Society
800 S. Northwest Highway, Suite 200
Barrington, IL 60010
website: www.rosacea.org

Thank you for taking the time to read my newsletter. I hope you have found it informative.

Audrey Kunin, M.D.

(Any topic discussed in this article is not intended as medical advice. If you have a medical concern, please check with your doctor.)

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