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  1. Trigger Factor List Rosacea 101 page 46 by permission of the author NOTE: Rosacea triggers are only proposed. There is not one rosacea trigger proposed that produces a rosacea flare up in every rosacea sufferer. Not one. sources for the triggers listed above are listed in the book, Rosacea 101, page 46 and also if you scroll to the bottom of this post. More info on Triggers ADDENDUM Add to the list above: Food & Drink: Vitamin B Complex Add Medical Conditions: Associated Diseases (Systemic comorbidities) [7] Environmental/Exposure Nickel Sensitivity [6] Footnotes for the Trigger List: * National Rosacea Society Trigger List [1] ** Rosacea 101—Rosacea Diet # Flushing Syndromes [2] ## Dermis [3] ^ Rosacea Support Group [4] + Ken Landow, MD [5] Frequent flushing Menopause Chronic cough Caffeine withdrawal syndrome Source of the above four medical conditions: NRS Factors That May Trigger Rosacea Flare-Ups End Notes [1] http://www.rosacea.o...ls/triggers.php [2] Flushing Syndromes list source Flushing Christian Nasr, MD; The Cleaveland Clinic, Published December 7, 2004 http://www.cleveland...ng/flushing.htm [3] Dermis Department of Clinical Social Medicine University of Heidelberg http://rosacea.dermi.../index_eng.html [4] http://rosacea-suppo...asked-questions [5] 2002/POSTGRADUATE MEDICINE Unraveling the mystery of rosacea Keys to getting the red out Ken Landow, MD VOL 112/NO 6/DECEMBER http://www.postgradm...2_02/landow.htm [6] Endocr Metab Immune Disord Drug Targets. 2019 Jan 01;: Nickel Sensitivity In Rosacea Patients: A Prospective Case Control Study. Çifci N [7] This list keeps growing. See Rosacea Theories Revisited > Associated Diseases (Systemic comorbidities)
  2. Admin

    Triggers

    This post has been promoted to an article
  3. Admin

    Triggers

    The following is an excerpt from Rosacea 101: includes the Rosacea Diet by permission of the author: The NRS does not distinguish tripwires from trigger factors using both terms to mean the same thing, which can be anything that MAY produce a rosacea flare-up. [252] What is the difference between a Trigger, a Tripwire, a Flareup, and a Flush? “… Rosacea tripwires are factors that may cause a rosacea sufferer to experience a flare-up—a more intense outbreak of redness, bumps or pimples . While the list of potential tripwires ranges from weather to emotions to foods, nearly all are related to flushing. As a rule, anything that causes a rosacea sufferer to flush may trigger a flare-up.…” [253] Note these typical definitions of rosacea: “Rosacea is a chronic skin condition involving inflammation of the cheeks, nose, chin, forehead, or eyelids. It may appear as redness, prominent spider-like blood vessels, swelling, or skin eruptions similar to acne.” [254] “Rosacea is a chronic facial eruption, most commonly seen in Caucasian adults, characterized by erythema of the central face, papules, pustules, telangiectasias and periods of exacerbation and remission.” [255] See Appendix V—Rosacea Defined for more information. The above definitions do not mention flushing. You can see what the definition is targeting and it isn’t flushing. The definitions center on the inflammation and redness and ignore flushing. It would be good to remember that what the problem is and has always been is rosacea, not flushing. Flushing aggravates rosacea and can be a chief concern. However, some may be more concerned about sensitive skin than flushing. Yet as the previous chapter points out about flushing, many rosaceans center their therapy on trigger flushing avoidance. Remember that trigger avoidance also includes other factors than just flushing and this is what this chapter is about. It includes not only triggers for flushing but also triggers that cause a rosacea flare up which might not include a flush. Sometimes rosacea is referred to as ‘adult acne’ and Dr. Kligman says is not such a bad idea. [256] The disease looks like acne. However, because flushing isn’t associated with acne and is one of the key factors differentiating acne from rosacea, flushing emerges as a top concern for many with rosacea by avoiding anything that may trigger a rosacea flare-up thinking that flushing is the only trigger. Not so. There are many other triggers in this chapter that are detailed that have nothing to do with flushing. Flushing factors may be getting more of the limelight but rosacea is the stop light. Making a list of potential trigger factors may be helpful but they are not set in stone. There are no lists of proven rosacea trigger factors that in every case produces a rosacea flare-up. In fact there is no proven single flushing factor that in every case produces a rosacea flare-up in every rosacean! Any flushing rosacea trigger factor or tripwire only MAY produce a rosacea flare-up, no matter who makes up the list. And one must remember this important point: Not all flushing produces a rosacea flare up. You may have a flush and later your face can calm down and the redness subsides. Try to relax. Not all flushing produces a rosacea flare up. Really. There is no evidence that every case of flushing produces a rosacea flare-up. You may simply just flush. If you carefully read what the NRS says about flushing remember that “As a rule, anything that causes a rosacea sufferer to flush may trigger a flare-up.” See the previous chapter on Flushing. This ‘rule’ doesn’t say a trigger will in every case produce a flare-up. Trigger and flushing avoidance is simply one way to control rosacea. It sometimes works but don’t become obsessed with this treatment excluding other treatments or make it your primary concern. If you recall in Chapter 5, there are several treatment options to choose. Trigger and flushing avoidance is just one way to go. Nevertheless, there are a number of trigger factors to consider. Remember that these trigger factors MAY NOT produce a rosacea flare up. You have to determine if any of the factors listed below trigger your rosacea. I repeat: There is no trigger factor list ever made that lists a single trigger that in EVERY CASE will produce a rosacea flare-up in every rosacean. Name a trigger factor that does this to every rosacean. You can’t. What triggers rosacea in one may not trigger it in another rosacean. It is the X-Factor. Diet Triggers Chemical Triggers Comprehensive Trigger List End Notes [252] Coping With Rosacea, National Rosacea Society, page 1 http://www.rosacea.o...php#Identifying [253] Coping With Rosacea, National Rosacea Society, page 1 http://www.rosacea.o...oping/intro.php [254] Medical Encyclopedia Powered by A.D.A.M., Merck & Co., Inc. A.D.A.M., Inc. is accredited by URAC, also known as the American Accreditation HealthCare; Review Date:5/3/2006 Reviewed By: Michael S. Lehrer, M.D., Department of Dermatology, University of Pennsylvania Medical Center, Philadelphia, PA. Review provided by VeriMed Healthcare Network.; http://tinyurl.com/3dzook [255] Emerging Concepts in Rosacea Management The Antibiotic Paradox: Benefits and Risks of Using Antimicrobial Oral Antibiotics for The Systemic Treatment of Rosacea James Del Rosso, D.O. http://www.rosaceato...oticParadox.asp [256] “It is interesting that the original term for rosacea was “acne rosacea”, which has more features in common with acne than currently realized. If the “acne” portion had been retained in the later works, rosacea might have received much greater investigative attention.” A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman, M.D., Ph.D. Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A.
  4. "Non-steroidal anti-inflammatory drugs, usually abbreviated to NSAIDs or NAIDs , are drugs with analgesic, antipyretic and, in higher doses, anti-inflammatory effects - they reduce pain, fever and inflammation. The term "non-steroidal" is used to distinguish these drugs from steroids, which (among a broad range of other effects) have a similar eicosanoid-depressing, anti-inflammatory action. As analgesics, NSAIDs are unusual in that they are non-narcotic. NSAIDs are sometimes also referred to as non-steroidal anti-inflammatory agents/analgesics (NSAIAs) or non-steroidal anti-inflammatory medicines (NSAIMs). The most prominent members of this group of drugs are aspirin, ibuprofen, and naproxen partly because they are available over-the-counter in many areas. (Paracetamol (acetaminophen) is classified as having antipyretic and analgesic properties, and is not an NSAID.) Beginning in 1829, with the isolation of salicin from the folk remedy white willow bark, NSAIDs have become an important part of the pharmaceutical treatment of pain (at low doses) and inflammation (at higher doses). Part of the popularity of NSAIDs is that, unlike opioids, they do not produce sedation or respiratory depression and have a very low addiction rate. NSAIDs, however, are not without their own problems (see below). Certain NSAIDs, including ibuprofen and aspirin, have become accepted as relatively safe and are available over-the-counter without prescription in some countries." [1] NSAIDs include, but are not limited to, naproxen, nabumetone, diclofenac, sulindac, oxaprosin, diflunisal, bromfenac, aspirin, piroxicam, indomethacin, etodolac, ibuprofen, fenoprofen, flurbiprofen, ketorolac, nimesulide, NS-398, ketoprofen, trisalicylates, acetominophen, oxaprosin, salsalate, rofecoxib, and celecoxib. NSAIDs are being used to treat rosacea due to its anti-inflammatory effects. For example: "A method of treating or preventing rosacea in a patient, comprising topical administration, of a pharmaceutical preparation comprising a nonsteroidal anti-inflammatory drug (NSAID) selected from the group consisting of piroxicam, diclofenac, ibuprofen, oxaprozin, indomethacin,. isoxicam, ketoprofen, sulindac, tolmetin, flurbiprofen, meclofenamic acid, suprofen, tenoxicam, zomepirac, diflunisal, naproxen, fenoprofen, flufenamic acid, and aspirin, and combinations thereof." [2] Methods of administering diclofenac compositions for treating rosacea United States Patent Application 20060062750 A method of treating rosacea includes: (a) providing a composition containing 1-3 wt. % diclofenac or a salt thereof, 0.5-1.5 wt. % benzyl alcohol, 10-30 wt. % PEG monomethyl ether, 0.1-3.0 wt. % sodium hyaluronate; and 70-80 wt. % water; and ( applying the composition, in an effective amount, to skin of a person in need of the treating. [3] US Patent 7105172 - Treatment of rosacea The present invention results from my discovery of a causal link between the activation of the bradykinin pathway and rosacea. Accordingly, the invention features a method of treating or preventing rosacea by administering a compound that inhibits a component or components of the bradykinin activation pathway. By "a nonsteroidal anti-inflammatory drug (NSAID)" is meant a compound that prevents or reduces inflammation. Preferred NSAIDs include, but are not limited to, naproxen, nabumetone, diclofenac, sulindac, oxaprosin, diflunisal, bromfenac, aspirin, piroxicam, indomethacin, etodolac, ibuprofen, fenoprofen, flurbiprofen, ketorolac, nimesulide, NS-398, ketoprofen, trisalicylates, acetominophen, oxaprosin, salsalate, rofecoxib, and celecoxib. [4] The present invention has the advantage of providing novel targets to regulate in the treatment of rosacea and to provide treatment alternatives to antibiotics. The antibiotics may have limited efficacy and cause adverse effects such as gastrointestinal intolerance, photosensitivity, the development of antibiotic-resistant infections, and yeast infections. BigPatents India ANTI - ACNE ROSACEA GEL COMPOSITION CONTAINING RUPTURABLE BEADS OF A NSAID Application 638/MUM/2008 published 2008-04-18, filed 2008-03-26 "In correspondence, published by the American Medical Association, oral administration of NSAID's, such as Motrin (oral ibuprofen), in full doses (tablets of 800 mg) is suggested during periods of high activity of rosacea. However, this modality cannot be recommended due to the known gastrointestinal side effects, which occur in high incidence of 4-16%. There remains a need therefore for a safe and effective treatment for rosacea to supplement or supplant current treatments. Summary of the invention The present invention comprises pharmaceutical preparations having enhanced efficacy for topical treatment of rosacea. These preparations comprise an NSAID as the therapeutic agent for the topical treatment of rosacea. Another aspect of this invention involves the use of an NSAID in combination with a nitroimidazole, for the treatment of rosacea." [5] "NSAIDs also play a role in the treatment of ocular surface disease, said Robert Latkany, M.D., founder and director, Dry Eye Clinic, New York Eye and Ear Infirmary, New York. “I use them in patients with ocular rosacea, allergic conjunctivitis, and dry eye,” he said. “They don’t work 100% of the time, but there’s a subgroup of patients who benefit nicely from them. And I think they’re safer than steroids.” He finds that ocular rosacea patients with secondary dry eye benefit the most from their use, with some patients taking them for months at a time, while others just use them as needed to quiet their symptoms. Dr. Latkany also has used NSAIDs in patients with Sjögren’s syndrome. “They’re a reasonable option,” he said." [6] Dr. Latkany is a member of the RRDi MAC. End Notes [1] Wikipedia [2] WIPO (WO/2002/074290) DERMATOLOGICAL PREPARATIONS CONTAINING A NSAID [3] www.freepatentsonline.com [4] US Patent 7105172 - Treatment of rosacea [5] www.wipo.int [6] Ocular pharmacology NSAIDs make a comeback
  5. An article in Dermatology Times by Rebecca Bryant entitled, Miracle-worker aspirin represses rosacea flushing, quotes Joseph B. Bikowski, M.D., a dermatologist practicing in Sewickley, Pa., and a clinical associate professor of dermatology at Ohio State University in Columbus as saying, "I have both migraines and rosacea. Several years ago, I was talking to Dr. Albert Klingman. He mentioned that there was an increased incidence of rosacea in people who have migraines. I knew some neurologists give one baby aspirin a day to migraine sufferers to try and prevent the dilation of blood vessels in the brain." The report goes on to say that Dr. Bikowski: "He asked his rosacea patients to take a daily aspirin (81 mg) and maintain a log of flushing incidents, rating each day on a 1 to 10 scale. Within a month, many patients were experiencing less flushing and shorter episodes of erythema. The goal of aspirin therapy is to suppress the vascular dilation associated with rosacea. In theory, that suppresses the body's flush response and reduces the incidence of persistent erythema." Therefore, asprin may help reduce flushing in rosacea and is a simple over-the-counter solution. The NRS says, "aspirin may reduce the effects of niacin-containing foods in sufferers affected by these substances." [1] Linda Sy M.D., suggests "At bedtime: Take 1 baby aspirin; 1 chlor-trimeton(4 mg) and 1 tab of Tums (Calcium Carbonate, an antacid to offset the gastric irritating effect of the aspirin." [2] Enteric Coated Asprin Dr. Bikowski asked his rosacea patients to take a daily aspirin (81 mg) and maintain a log of flushing incidents, rating each day on a 1 to 10 scale. Within a month, many patients were experiencing less flushing and shorter episodes of erythema. Dr. Bikowski argues, "Aspirin therapy is safe. It's great for the heart. It's great for the colon. Why not the skin?" He further notes that there are few contraindications for aspirin use, it's inexpensive and it can be taken in combination with most drugs. Dermatologists should advise patients of the standard warnings about the use of aspirin, even at low dosage. These include: Look for enteric-coated tablets, which are more likely to dissolve in the intestines, avoiding stomach problems. End Notes [1] NRS Tripwires [2] RSG quote
  6. Paxil (PAROXETINE), Zoloft (SERTRALINE), and Prozac (FLUOXETINE) are serotonin reuptake inhibitor (SSRI) used sometimes in the treatment for anxiety in rosacea sufferers. Xanax (alprazolam)—a benzodiazapene similar to Valium (diazepam) and Buspar (busprione) may also be used at times. {1] Psychotropics have also been used as reported in anecdotal reports. end notes [1] rosacea.derm.net
  7. Admin

    Botox For Rosacea

    “Botulinum toxin is a neurotoxin protein produced by the bacterium Clostridium botulinum. It is one of the most poisonous naturally occurring substances in the world. Though it is highly toxic, it is used in minute doses both to treat painful muscle spasms, and as a cosmetic treatment in some parts of the world. It is sold commercially under the brand names Botox and Dysport for this purpose. The terms Botox and Dysport are trade names and are not used generically to describe the neurotoxins produced by the clostridia species.” [1] Botox has been used as a novel method for the treatment of persistent facial flushing in rosacea sufferers. “We report a case of persistent facial flushing that was resistant to multiple pulsed dye laser treatments and was successfully treated with botulinum toxin A. Results: The post treatment appearance was dramatic, and the patient was highly satisfied with the cosmetic outcome.” [2] End Notes [1] Wikipedia [2] Botulinum Toxin for the Treatment of Facial Flushing Melanie Yuraitis, MS, and Carolyn I. Jacob, MD Dermatologic Surgery, Volume 30, Number 1, January 2004, pp. 102-104(3)
  8. “Additional topical therapies including benzoyl peroxide, clindamycin, retinoids, topical steroids, calcineurin inhibitors, and permethrin are not approved for the treatment of rosacea and play variable roles in the management of this condition.” Topical therapies for rosacea. Nally JB, Berson DS; J Drugs Dermatol. 2006 Jan;5(1):23-6
  9. Antibiotics have been used to treat rosacea for over fifty years. The most popular antibiotics used in the treatment for rosacea are: Azithromycin (Zithromax) Clindamycin (Clindagel, Cleocin and Cleocin T) Dapsone Doxycycline (Doryx, Oracea) Doxycycline Hyclate (Periostat) Doxycycline Monohydrate (Monodox) Erythromycin Minocycline Rifaximin Tetracycline Macrolide Antibiotics seem to be more popular with rosaceans than tetracycline. Macrolides include: erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin (Dynabac), roxithromycin (Rulid, Surlid). There are, of course, other antibiotics used to treat rosacea, which you can discuss with your physician. For example, Minocycline as Good as Doxycycline for Rosacea. An article issued in August 2012 reports, "it now seems clear that the role of antibiotics in patients with rosacea depends upon their anti-inflammatory rather than their antimicrobial properties." [1] Thus the emergence of Oracea or low dose doxycycline. Short term antibiotics for rosacea is an acceptable treatment, however, there may be issues with long term antibiotic treatment. Read Antibiotic Resistance, Bacterial Overgrowth. Another report says, Antibiotics targeting brain’s inflammatory response may exacerbate cognitive deficits in children. Why not add your experience by posting in this thread what antibiotic treatment your physician prescribed and your thoughts? End Notes [1] J Drugs Dermatol. 2012 Jun;11(6):725-30. Diagnosis and treatment of rosacea: state of the art. Baldwin HE.
  10. Methotrexate is sometimes prescribed for rosacea, ‘usually as second-line therapy.’ "Other second-line therapies include: trimethoprim-sulfamethoxazole (Bactrim, Septra), methotrexate, dapsone, primaquine, chloroquine (Aralen), and oral prednisone; however, no studies have evaluated the comparative efficacy or optimal dosing regimens of these agents." American Family Physician Rosacea: A Common, Yet Commonly Overlooked, Condition B. WAYNE BLOUNT, M.D., M.P.H. and ALLEN L. PELLETIER, M.D. See also: Prevention, Treatment and Complications of Rosacea By Groshan Fabiola, Ezine@rticles
  11. Rosacea 101 page 54-5 by permission of the author Sodium sulfacetamide-sulfur is an antibiotic and drying agent combination medicine and works by promoting the shedding of the top layer of skin (keratolysis). “The combination of sodium sulfacetamide and sulfur is unique in the rosacea armamentarium because of its dual use as topical therapy and therapeutic cleanser. Several formulations of sulfacetamide 10% and sulfur 5% are now available as topical lotions and cleansers. The sulfacetamide/sulfur cleansers serve as adjunctive therapy by providing additive effects to other topical and oral therapies for rosacea with favorable tolerability and cosmetic appeal.” [279] “After 12 weeks of treatment with sodium sulfacetamide 10% and sulfur 5% cream with sunscreens, there was a significantly greater percentage reduction (80%) in inflammatory lesions compared with metronidazole 0.75% cream (72%)(P = .04), as well as a significantly greater percentage of subjects with improved erythema (69% vs 45%, respectively; P = .0007). In addition, the sodium sulfacetamide 10% and sulfur 5% cream with sunscreens group had a significantly greater proportion of subjects with success in global improvement at week 12 compared with the metronidazole 0.75% cream group (79% vs 59%, respectively; P = .01).” [280] “Sulfur has antifungal, antibacterial, and keratolytic activity. In the past, its use was widespread in dermatological disorders such as acne vulgaris, rosacea, seborrheic dermatitis, dandruff, pityriasis versicolor, scabies, and warts. Adverse events associated with topically applied sulfur are rare and mainly involve mild application site reactions. Sulfur, used alone or in combination with agents such as sodium sulfacetamide or salicylic acid, has demonstrated efficacy in the treatment of many dermatological conditions.” [281] “Sulfur is a time-honored therapeutic agent useful in a variety of dermatologic disorders. Its keratolytic action is due to formation of hydrogen sulfide through a reaction that depends upon direct interaction between sulfur particles and keratinocytes. The smaller the particle size, the greater the degree of such interaction and the greater the therapeutic efficacy. When applied topically, sulfur induces various histologic changes, including hyperkeratosis, acanthosis, and dilatation of dermal vasculature.” [282] Avar, Avar e Green, Plexion, Plexion SCT, Plexion TS, Rosanil, Rosac, Rosula, and Rosula NS are brand name sodium sulfacetamide-sulfur prescriptions. Addendum Sulphur has been used for a long time to treat rosacea. 283 The following warning is issued by Mission Pharmacal about using sulfacetamide: "Sulfonamides are known to cause Stevens-Johnson syndrome in hypersensitive individuals. Stevens-Johnson syndrome also has been reported following the use of sodium sulfacetamide topically. Cases of drug-induced systemic lupus erythematosus from topical sulfacetamide also have been reported." [1] End Notes 279 Evaluating the role of topical therapies in the management of rosacea: focus on combination sodium sulfacetamide and sulfur formulations. Del Rosso JQ; Cutis. 2004 Jan;73(1 Suppl):29-33. 280 Combination sodium sulfacetamide 10% and sulfur 5% cream with sunscreens versus metronidazole 0.75% cream for rosacea. Torok HM, Webster G, Dunlap FE, Egan N, Jarratt M, Stewart D. Cutis. 2005 Jun;75(6):357-63. 281 The use of sulfur in dermatology. Gupta AK, Nicol K; J Drugs Dermatol. 2004 Jul-Aug;3(4):427-31. 282 Sulfur revisited. Lin AN, Reimer RJ, Carter DM; J Am Acad Dermatol. 1988 Mar;18(3):553-8. 283 PATIENT AT the Skin Clinic of the Women's Medical College. Rosacea is a chronic disease of the middle period of life. These "rosy drops" sometimes present a central point of a somewhat darker hue. In severe cases a fiery triangle may be seen on either cheek. In the most remarkable form of the disease the nose may attain the size of the fist. The eruption had troubled her more or less for six years and had been much worse than usual during the last month. She complained greatly of discomfort after eating and often vomited her food. The gastric irritability having subsided under a restricted diet, she was ordered Aug. 6, 1878, a mixture containing sulphate of iron and sulphate of magnesia, and for local application an ointment of sulphur, four parts, cosmoline, ninety-two parts. This was followed by rapid improvement, and when seen again on Sept. 17, all trace of the eruption had disappeared, and she felt much stronger and better. Source [1] Mission Pharmacal Contact Us page: WARNINGS Sulfonamides are known to cause Stevens-Johnson syndrome in hypersensitive individuals. Stevens-Johnson syndrome also has been reported following the use of sodium sulfacetamide topically. Cases of drug-induced systemic lupus erythematosus from topical sulfacetamide also have been reported. In one of these cases, there was a fatal outcome. KEEP OUT OF THE REACH OF CHILDREN.
  12. There are a number of drugs used by physicians as anti-flushing or as antihypertensive agents such as: Antihistamines, Clonidine, Epinephrine, Lanreotide, Megestrol acetate, Monoxidine, Propranolol (Inderal), Sandostatin LAR, Nadadol, Rilmenidine, and Veralipride. Ketamine 0.5% and Amitriptyline 1% has been reported in at least one case. Propranolol (Inderal) has been used for the treatment of persistent flushing in rosaceans. [1] Carvedilol (brand name Coreg) has also been used for treating Refractory Facial Flushing and Persistent Erythema of Rosacea. [2] For a comprehensive list of anti-flushing drugs (prescription and non prescription) click here. Discuss with your physician whether any of these drugs may help you. Prescription and Non Prescription Flushing Avoidance Blushing & Flushing Triggers End Notes [1] Symptomatic treatment of idiopathic and rosacea-associated cutaneous flushing with propranolol Helen Craige MD and Jack B. Cohen DO; Journal of the American Academy of Dermatology, Volume 53, Issue 5, November 2005, Pages 881-884. [2] Carvedilol for the Treatment of Refractory Facial Flushing and Persistent Erythema of Rosacea. Hsu CC, Lee JY. Arch Dermatol. 2011 Jul 18. More info on flushing click here.
  13. Admin

    Azelaic Acid

    Finacea (USA) and Azelex (Europe) are two brand name prescription azelaic acid formulas that rosaceans are reporting works to control rosacea. Finacea comes in a gel or a foam. Azelex cream is made by Allergan. Both products are made by Bayer Healthcare. According to OptimRx "Sandoz launched an authorized generic version." Bayer Healthcare is offering a savings coupon for Finacea by clicking here (For US audiences only) or you may try the Bayer Savings Card (For US audiences only) There are a number of over the counter azelaic acid treatments: Azelaic Acid Fine Powder 25 Grams Azelaic Acid Micro Powder 150 Grams 99% Ecological Formulas Strata Melazepam Emollient Cream GIGI Bioplasma Azelaic Cream 15% For Oily Skin The Ordinary Azelaic Acid Suspension 10% In 2007 here was the status of Azelaic acid: Rosacea 101 page 53-4 by permission of author There are conflicting reports about azelaic acid. Consider the first report reported in April 2007: “Results of this study demonstrated a significantly greater potential for irritation from azelaic acid compared with metronidazole gel.” [275] With this report done in August 2006: “Azelaic acid in 20% cream and 15% gel formulations appears to be effective in the treatment of papulopustular rosacea, particularly in regard to decreases in mean inflammatory lesion count and erythema severity. Compared with metronidazole, azelaic acid appears to be an equally effective, if not better, treatment option.” [276] However, some rosaceans may report irritation with azelaic acid while others report it is effective in controlling rosacea. Azelaic acid appears to be an accepted treatment so you should be aware of it use in rosacea. “Data pooled from three between-patient trials showed a clear improvement in the azelaic acid group.” [277] “Azelaic acid (AzA) initially was released in a 20% cream formulation, which has been shown to be effective in the treatment of mild to moderate rosacea. Recently, a 15% gel formulation was developed that vastly improved the delivery of AzA and has been proven by multiple studies to be effective in the treatment of rosacea. We present studies that examine both of these formulations, first in comparison with their vehicles and then in contrast with other well-accepted topical treatments of rosacea, such as metronidazole cream and gel.” [278] End Notes 275 Cumulative irritation potential among metronidazole gel 1%, metronidazole gel 0.75%, and azelaic acid gel 15%. Colón LE, Johnson LA, Gottschalk RW; Cutis. 2007 Apr;79(4):317-21. 276 Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Liu RH, Smith MK, Basta SA, Farmer ER; Arch Dermatol. 2006 Aug;142(8):1047-52. 277 Interventions for rosacea. van Zuuren EJ, Graber MA, Hollis S, Chaudhry M, Gupta AK, Gover M. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD003262. 278 A clinical overview of azelaic acid. Elewski B, Thiboutot D; Cutis. 2006 Feb;77(2 Suppl):12-6.
  14. Rosacea 101 page 55 by permission of the author Immunosuppressants are chemical agents (such as pimecrolimus or tacrolimus) that suppresses the immune response. Pimecrolimus (Elidel) and Tacrolimus (Protopic) are known as calcineurin inhibitors acting on immunophilins. Tacrolimus is a fungal product (Streptomyces tsukubaensis) and a macrolide lactone and acts by inhibiting calcineurin. “The topical calcineurin inhibitors (TCIs) pimecrolimus and tacrolimus are approved for atopic dermatitis but have additional potential in other inflammatory skin diseases … whereas the response in rosacea and rosacea-like eruptions has been mixed.” [283] Pimecrolimus has been used to treat steroid-induced rosacea. (See Chapter 8) “Tacrolimus ointment is increasingly used for anti-inflammatory treatment of sensitive areas such as the face, and recent observations indicate that the treatment is effective in steroid-aggravated rosacea and perioral dermatitis.” [284] “Topical calcineurin inhibitors have been efficacious in the treatment of other inflammatory disorders of the skin, and tacrolimus has been reported as an effective treatment option for erythrotelangiectatic rosacea.… It appears pimecrolimus may be efficacious in the treatment of erythrotelangiectatic and papulopustular rosacea and may be considered in patients with recalcitrant disease.” [285] “Twenty-four patients with erythrotelangiectatic or papulopustular rosacea were treated with 0.1% tacrolimus topical ointment in a 12-week open-label trial. Erythema was significantly improved in both rosacea subtypes (P<.05).” [286] Not all patients respond well to immunosuppressants. For example, “Six adult patients with inflammatory facial dermatoses were treated with tacrolimus ointment because of the ineffectiveness of standard treatments. Within 2 to 3 weeks of initially effective and well-tolerated treatment, 3 patients with a history of rosacea and 1 with a history of acne experienced sudden worsening with pustular rosaceiform lesions. Biopsy revealed an abundance of Demodex mites in 2 of these patients. In 1 patient with eyelid eczema, rosaceiform periocular dermatitis gradually appeared after 3 weeks of treatment. In 1 patient with atopic dermatitis, telangiectatic and papular rosacea insidiously appeared after 5 months of treatment.” [287] Another report said, “Unfortunately, Antille and colleagues now report the occurrence of a rosaceiform dermatitis as a complication of treatment with topical tacrolimus ointment.” [288] These drugs are not without side effects and risks. Because the majority of them act non-selectively, the immune system loses its ability to successfully resist infections and spreading of malignant cells. There are also other side effects like hypertension, dyslipidemia, hyperglycemia, peptic ulcers, liver and kidney injury. The immunosuppressive drugs also interact with other medicines and affect their metabolism and action. Addendum "Recently, reports have indicated that the continuous use of topical calcineurin inhibitors such as tacrolimus may induce rosacea-like dermatitis (RD)." [1] End Notes 283 The role of topical calcineurin inhibitors for skin diseases other than atopic dermatitis. Wollina U; Am J Clin Dermatol. 2007;8(3):157-73 284 Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment. Antille C, Saurat JH, Lubbe J; Arch Dermatol. 2004 Apr;140(4):457-60. 285 Pimecrolimus for treatment of acne rosacea. Crawford KM, Russ B, Bostrom P: Skinmed. 2005 May-Jun;4(3):147-50. 286 Tacrolimus effect on rosacea. Bamford JT, Elliott BA, Haller IV; J Am Acad Dermatol. 2004 Jan;50(1):107-8. 287 Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment. Antille C, Saurat JH, Lubbe J; Arch Dermatol. 2004 Apr;140(4):457-60. 288 ibid [1] Tacrolimus-Induced Rosacea-Like Dermatitis: A Clinical Analysis of 16 Cases Associated with Tacrolimus Ointment Application. Teraki Y, Hitomi K, Sato Y, Izaki S. Dermatology. 2012 May 22.
  15. Co-Existence with Rosacea There are numerous reports that rosacea and Seborrheic Dermatitis can co-exist! Yes, you can have SD and rosacea at the same time. [3] Misdiagnosed SD looks so much like rosacea that some rosaceans have reported that their rosacea was misdiagnosed as SD or vice versa! [4] Photos Images courtesy of DermNet NZ [8] Cause "The cause of seborrhoeic dermatitis remains unknown, although many factors have been implicated. The widely present yeast, Malassezia furfur (formerly known as Pityrosporum ovale), is involved, as well as genetic, environmental, hormonal, and immune-system factors. A theory that seborrhoeic dermatitis is an inflammatory response to the yeast has not been proven. Those afflicted with seborrhoeic dermatitis have an unfavourable epidermic response to the infection, with the skin becoming inflamed and flaking. In children, excessive vitamin A intake can cause seborrhoeic dermatitis. Lack of biotin, pyridoxine (vitamin B6) and riboflavin (vitamin B2) may also be a cause." [1] In May 2007 it was published, "The definitive cause of seborrheic dermatitis is unknown. However, proliferation of Malassezia species has been described as a contributing factor." [1a] An article published in 2007 [2] may help you if you have been diagnosed with SD since the real cause may be a fungi called Malassezia Globosa. The article mentions three factors that my be involved with SD; sebum, microbial metabolism (specifically, Malassezia yeasts), and individual susceptibility. "Pyrithione Zinc (PTZ) is a potent monographed anti-fungal agent against M. globosa. It treats seborrheic dermatitis/dandruff and provides symptomatic relief, reducing the irritation response while inhibiting the causal agent. The particles that comprise this anti-fungal can be engineered into flat platelet shapes to deliver optimized scalp coverage resulting in improved efficacy." [2a] "High colonization with Staphylococcus epidermidis, along with impaired skin permeability barrier function, contributes to the occurrence of SD....The results show a predominance of Acinetobacter, Staphylococcus, and Streptococcus on lesional sites. The authors suggest that, in addition to Malassezia, these commensal bacteria might contribute to SD development. Likewise, our preliminary study indicated a greater predominance of these phyla on SD lesional skin as compared to normal controls (unpublished data). Studies on both French and Chinese populations suggested that dandruff scalps, often associated with SD, are associated with a high incidence of M. restricta and Staphylococcus epidermidis." [21] "Although the causes of SD are not completely understood, it appears to result from a combination of the following three factors: sebaceous gland secretion, presence of Malassezia yeast, and the host immune response." [23] Not Contagious According to several reputable sources, SD is not contagious. [8] Support Groups You can use this thread if you have SD and post here and hopefully others with SD will do the same. Genetic Marker? "A new gene associated with a variant of psoriasis and seborrheic dermatitis has been identified by a research group led by Dr. Ohad Birk at the Morris Kahn Laboratory of Human Genetics at Ben Gurion University and Soroka Medical Center. ...Psoriasis and seborrheic dermatitis affect 2-3% of the population worldwide and 85% of AIDS patients...." [5] Number of SD Sufferers Worldwide If you take the 2% figure that would mean there are over 150 million Psoriasis/SD sufferers worldwide, less than the number of rosacea sufferers worldwide, which is probably not the case. The NPF says the number for psoriasis is 2 to 3 percent of the worldwide population. The number world wide who suffer from SD is said to be "1 to 5 percent" according this report, so clearly the combined number would be higher. Signs and Symptoms Wikipedia reports, "Seborrhoeic dermatitis' symptoms appear gradually and usually the first signs are flaky skin and scalp. Symptoms occur most commonly anywhere on the skin of the face, behind the ears and in areas where the skin folds. Flakes may be yellow, white or grayish. Redness and flaking may also occur on the skin near the eyelashes, on the forehead, around the sides of the nose, and the chest and upper back. In more severe cases, yellowish to reddish scaly pimples appear along the hairline, behind the ears, in the ear canal, on the eyebrows, on the bridge of the nose, around the nose, on the chest, and on the upper back. Commonly, patients experience mild redness, scaly skin lesions and in some cases hair loss. Other symptoms include patchy scaling or thick crusts on the scalp, red, greasy skin covered with flaky white or yellow scales, itching, soreness and yellow or white scales that may attach to the hair shaft. Seborrheic dermatitis can occur in infants younger than three months and it causes a thick, oily, yellowish crust around the hairline and on the scalp. Itching is not common among infants. Frequently, a stubborn diaper rash accompanies the scalp rash.[6] Usually, when it occurs in infants the condition resolves itself within days and with no treatment.[citation needed] In adults, symptoms of seborrheic dermatitis may last from a few weeks, to years. Many patients experience alternating periods of inflammation. The condition is referred to a specialist when self-care has proven unsuccessful. Treatments for Seborrheic Dermatitis Because of the microbial metabolism that may be involved, Wikipedia says Pyrithione Zinc (PTZ) is effective against SD. [7a] Biom8 [25] Ciclopiroxolamine 1% cream, twice daily for 28 days followed by once daily for 28 days [23] climbazole and piroctone olamine [19] Clotrimazole Crude honey [24] Dermadexin [14] Miconazole Nonpathogenic E. coli strain Nissle 1917 [20] Oral itraconazole given in a dose of 200mg/day for one week, followed by a maintenance dose, resulted in clinical improvement of SD symptoms in two open-label trials. [23] Ovace Promiseb Topical Cream for seborrheic dermatitis may be something to consider. "Promiseb®, desonide, mometasone furoate, and pimecrolimus were found to be effective topical treatments for facial SD, as they had the lowest recurrence rate, highest clearance rate, and the lowest severity scores (e.g., erythema, scaling, and pruritus), respectively. Ciclopirox olamine, ketoconazole, lithium (gluconate and succinate), and tacrolimus are also strongly recommended (level A recommendations) topical treatments for facial SD, as they are consistently effective across high-quality trials (randomized controlled trials)." [17] Sea Salt Baths (see post #2) "Seborrheic dermatitis is a common skin condition in infants, adolescents, and adults. The characteristic symptoms-scaling, erythema, and itching-occur most often on the scalp, face, chest, back, axilla, and groin. Seborrheic dermatitis is a clinical diagnosis based on the location and appearance of the lesions. The skin changes are thought to result from an inflammatory response to a common skin organism, Malassezia yeast. Treatment with antifungal agents such as topical ketoconazole is the mainstay of therapy for seborrheic dermatitis of the face and body. Because of possible adverse effects, anti-inflammatory agents such as topical corticosteroids and calcineurin inhibitors should be used only for short durations. Several over-the-counter shampoos are available for treatment of seborrheic dermatitis of the scalp, and patients should be directed to initiate therapy with one of these agents. Antifungal shampoos (long-term) and topical corticosteroids (short-term) can be used as second-line agents for treatment of scalp seborrheic dermatitis." [7] Sebuderm Stellate ganglion block (SGB) [26] "The therapy consists mainly of antifungal agents, corticosteroids, immunomodulators, and keratolytics." [6] "Treatment options for nonscalp and scalp seborrheic dermatitis include topical agents and shampoos containing antifungal agents, anti-inflammatory agents, keratolytic agents, and calcineurin inhibitors. Because multiple body sites are usually involved, the physician should examine all commonly affected areas. Patients should be made aware that seborrheic dermatitis is a chronic condition that will probably recur even after successful treatment." [9] topical 4% Quassia amara gel [18] Topical ketoconazole [15] Topical Nicotinamide (NCT) [12] topical corticosteroids (short-term) [16] "topical treatment with tacrolimus, fusidic acid, or moisturizers." [21] Urea [13] Anecdotal Reports Tom Busby's SD Treatment Protocol Seborrheic Dermatitis and Telangiectasia (dilated blood vessels) flurb says, "I am buying Fage brand 2% plain yogurt and I apply a thin layer for 20 minutes a day to my face. I then rinse it off and moisturize with MCT Oil and Cerave PM Moisturizer. I also shampoo my hair with Hegor 150. The yogurt is a mild exfoliator which helps with scaling but isn't irritating. It also helps with the mild acne caused by my rosacea. If you can't find Fage yogurt in your area, just try to find a thicker plain greek yogurt with live cultures in it." Rory (post #5) says, "Cyclopirox Olamine 1% cream, Ketoconazole 2 % cream or Climbazole 1% cream may be better options." gora recommends Excipial U Lipolotio [13] TJM23 recommends eliminating stress (post no 1) Jonu's Definitive Guide to Beat Malassezia Conditions Washing Clothes to Eliminate Malassezia Differences in Treatment "The topical anti-inflammatory treatments were more effective in achieving total clearance of symptoms than placebo by 1.4-fold to 8.5-fold, but there are no considerable differences in the anti-inflammatory topical treatments or in comparison with azoles for short-term treatment. There is no evidence of treatment effects in long-term, continuous, or intermittent use of these compounds despite the chronic nature of the disease." [10] "Lithium salts were more effective than azoles in producing total clearance." [11] Pityrosporum Folliculitis (PF) "Pityrosporum is part of the normal skin flora, but overgrows in certain conditions. Overgrowth is associated with oily skin, humidity or other pre-existing dermatologic conditions such as seborrheic dermatitis and severe dandruff." [22] So you might want to rule out PF from SD. End Notes [1] Wikipedia [1a] Adult Seborrheic Dermatitis A Status Report on Practical Topical Management James Q. Del Rosso, DO [2] J Investig Dermatol Symp Proc. 2007 Dec;12(2):15-9. Malassezia globosa and restricta: breakthrough understanding of the etiology and treatment of dandruff and seborrheic dermatitis through whole-genome analysis. Dawson TL Jr. [2a] Real cause of seborrhea discovered! by Artist » Thu Jan 31, 2008 5:17 pm [3] "Rosacea and seborrheic dermatitis are both inflammatory skin disorders that cause redness, lesions, and itching, and they frequently occur together." The Rosacea-Seborrheic Dermatitis Link, by Diana Rodriguez, Medically Reviewed by Lindsey Marcellin, MD, MPH, everyday Health [4] Misdiagnosed Rosacea [5] Psoriasis gene ID'd by Israeli researchers Posted by Randall, Google Groups, 6/14/2006 U-M scientists ID major psoriasis susceptibility gene By Sally Pobojewski Medical School Communications, University of Michigan [6] Seborrheic Dermatitis Aschoff R, Kempter W, Meurer M. Hautarzt. 2011 Mar 24. [7] Am Fam Physician. 2015 Feb 1;91(3):185-90. Diagnosis and treatment of seborrheic dermatitis. Clark GW, Pope SM, Jaboori KA. [7a] DermaHarmony Zinc Therapy Soap Noble Formula 2% Pyrithione Zinc Noble Formula Cream Noble Formula Zinc Spray [8] DermNet NZ • Mayo Clinic • CNN Health [9] J Clin Aesthet Dermatol. 2013 Feb;6(2):44-9. Optimizing treatment approaches in seborrheic dermatitis. Gary G. [10] JAMA Dermatol. 2015 Feb;151(2):221-2. doi: 10.1001/jamadermatol.2014.3186. Topical anti-inflammatory agents for seborrheic dermatitis of the face or scalp: summary of a Cochrane Review. Kastarinen H, Okokon EO, Verbeek JH. [11] Cochrane Database Syst Rev. 2014 May 19;(5):CD009446. doi: 10.1002/14651858.CD009446.pub2. Topical anti-inflammatory agents for seborrhoeic dermatitis of the face or scalp. Kastarinen H, Oksanen T, Okokon EO, Kiviniemi VV, Airola K, Jyrkkä J, Oravilahti T, Rannanheimo PK, Verbeek JH. [12] J Dermatolog Treat. 2014 Jun;25(3):241-5. doi: 10.3109/09546634.2013.814754. Epub 2013 Jul 5. Topical nicotinamide for seborrheic dermatitis: an open randomized study. Fabbrocini G1, Cantelli M, Monfrecola G. [13] Urea is mentioned as a treatment for SD in an article by Dermnet New Zealand Excipial Urea Excipial Urea Hydrating Healing Lotion EXCIPIAL U Lipolotion [14] Dermadexin™ A New Treatment for Dermatitis, Astion Pharma A/S "Cipher Pharmaceuticals announced it has acquired three products from Astion Pharma that are focused on inflammatory dermatological diseases. he products include Dermadexin, a topical barrier-repair cream containing the pharmacologically active ingredient P3GCM. Dermadexin was approved in the European Union (EU) in 2014 as a Class III medical device for treating seborrheic dermatitis." Cipher acquires three dermatology products from Astion Pharma, Healio Dermatology Cipher Pharmaceuticals has announced that "Dermadexin™ is a patent-protected topical barrier-repair cream containing P3GCM. It received approval in the European Union (EU) in 2014 as a Class III medical device for the alleviation of symptoms of facial dermatitis such as redness, scaling and itching." Source Dermadexin is a patent-protected topical barrier-repair cream containing the pharmacologically active ingredient P3GCM. The product was approved in the European Union (EU) in 2014 as a Class III medical device for the treatment of seborrheic dermatitis, an inflammatory skin disorder affecting the scalp, face, and torso. Dermadexin SD Cream has been tested in two placebo-controlled, multi center clinical trials (436 patients) where it displayed a marked and statistically significant effect on the symptoms of facial seborrhoeic dermatitis with a fast onset of action and an increasing effect over time. Source Also known as Helioclin® Dermatitis SD Cream in Europe. Source Cipher Pharmaceuticals announces acceptance of 510(k) submission for Dermadexin™ by FDA DermadexinTMa new treatment for dermatitis (pdf) FDA Accepts Dermadexin 510(K) Submission Company Overview of Astion Pharma, Worldwide Rights to Dermadexin, Pruridexin And ASF-1096 (Bloomberg) Cipher Pharmaceuticals Pipeline [15] "Treatment with antifungal agents such as topical ketoconazole is the mainstay of therapy for seborrheic dermatitis of the face and body." See end note [7] [16] "Antifungal shampoos (long-term) and topical corticosteroids (short-term) can be used as second-line agents for treatment of scalp seborrheic dermatitis." See end note [7] [17] Am J Clin Dermatol. 2017 Apr;18(2):193-213. doi: 10.1007/s40257-016-0232-2. Topical Treatment of Facial Seborrheic Dermatitis: A Systematic Review. Gupta AK,, Versteeg SG. [18] J Drugs Dermatol. 2013 Mar;12(3):312-5. Efficacy of topical 4% Quassia amara gel in facial seborrheic dermatitis:a randomized, double-blind, comparative study. Diehl C, Ferrari A. [19] "confirms the science for my positive experience using climbazole and piroctone olamine against malassezia: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5125955/ Ann Dermatol. 2016 Dec; 28(6): 733–739.Published online 2016 Nov 23. doi: 10.5021/ad.2016.28.6.733PMCID: PMC5125955Efficacy and Safety of Cream Containing Climbazole/Piroctone Olamine for Facial Seborrheic Dermatitis: A Single-Center, Open-Label Split-Face Clinical StudyHae Jeong Youn, Soo Young Kim, Minji Park, Won Hee Jung, Yang Won Lee, Yong Beom Choe, and Kyu Joong Ahn Begin Tom Busby comment about climbazole and piroctone olamine: "To convert µg/ml to percentage, move the decimal place 4 places to the left -- you can see in the Korean study (linked above) that very tiny percentages of climbazole and piroctone olamine are effective against malassezia. However, I make a true oil-in-water emulsion of dissolved climbazole and piroctone olamine, and it's not clear how the test-product was made (how climbazole and piroctone olamine powders were dissolved and then emulsified) -- this makes all the difference for effectiveness, in my opinion. Second, the Korean study refers to Sensibio DS+ cream as a "crude mixture," twice, which makes me think that the powders (climbazole and piroctone olamine) are not dissolved properly. Third, the test-culture medium used in the Korean study is capable of dissolving climbazole and pirocotone olamine powder, and so, the cosmetic itself, Sensibio DS+ cream, could be much less effective on the human skin. Finally, no one should buy or use the tested product, Sensibio DS+ cream, because the primary oil in it is coconut oil, which feeds malassezia. This is a terrible idea, and this product is not going to work, except in the manner of one step forward, two steps back. It's expensive too, about $24 for 40 ml." Tom Busby post #4 [20] Nonpathogenic E. coli strain Nissle 1917 [21] Chin Med J (Engl). 2017 Jul 20; 130(14): 1662–1669. doi: 10.4103/0366-6999.209895 PMCID: PMC5520552 High Staphylococcus epidermidis Colonization and Impaired Permeability Barrier in Facial Seborrheic Dermatitis Qian An, Meng Sun, Rui-Qun Qi, Li Zhang, Jin-Long Zhai, Yu-Xiao Hong, Bing Song, Hong-Duo Chen, and Xing-Hua Gao [22] "Pityrosporum is part of the normal skin flora, but overgrows in certain conditions. Overgrowth is associated with oily skin, humidity or other pre-existing dermatologic conditions such as seborrheic dermatitis and severe dandruff." Wikipedia More Info on Pityrosporum Folliculitis [PF] [23] J Clin Aesthet Dermatol. 2013 Feb; 6(2): 44–49. PMCID: PMC3579488 Optimizing Treatment Approaches in Seborrheic Dermatitis Goldenberg Gary, MD [24] Therapeutic and prophylactic effects of crude honey on chronic seborrheic dermatitis and dandruff. Al-Waili NS. Eur J Med Res. 2001 Jul 30;6(7):306-8. [25] Biom8 Official Web Site • Biom8 Review at RF • Biom8 are products by Michael Anders who runs Skindrone [26] Korean J Anesthesiol. 2016 Apr; 69(2): 171–174. Published online 2016 Mar 30. doi: [10.4097/kjae.2016.69.2.171] PMCID: PMC4823414 PMID: 27064785 Seborrheic dermatitis treatment with stellate ganglion block: a case report Gun Woo Kim, Ki Ho Mun, Jeong Yun Song, Byung Gun Kim, Jong Kwon Jung, Choon Soo Lee, Young Deog Cha, and Jang Ho Other Articles Treatment of Seborrheic Dermatitis BETTY ANNE JOHNSON, M.D., PH.D., and JULIA R. NUNLEY, M.D. Medical College of Virginia Campus of Virginia Commonwealth University, Richmond, Virginia
  16. Admin

    PF

    There are two PF skin conditions that are rosacea mimics to rule out. (1) Pityriasis folliculorum “Pityriasis folliculorum [PF] is an often over-looked clinical entity” and cases are ‘mostly female.’ Frank Powell, MD explains that there is ‘usually a history of rarely using soap or water to cleanse the facial skin but instead using cleansing creams.’ These individuals often apply moisturizers and complain of a burning or itchy sensation. He also states that the diagnosis of PF is ‘facilitated by use of dermatoscopy, which shows a distinctive picture of the presence of multiple white keratotic material consisting of keratin encrusted demodex mites protruding upwards from the follicular orifices.’ This condition ’seems to be caused by an over population of mites facilitated by the frequent use of creams and the lack of face washing with soap and water.’ [1] "Topical ivermectin has recently been FDA approved as therapy for rosacea. We present the case of a woman with pityriasis folliculorum who showed significant improvement from using topical ivermectin with no adverse events related to treatment." [2] (2) Pityrosporum Follicultis (another PF) or Malassezia folliculitis (MF) "Pityrosporum folliculitis or Malassezia folliculitis is a skin condition caused by infection by pityrosporum yeast." Wikipedia What is Pityrosporum Folliculitis? Dermnet NZ eMedicine Medscape Simple Skin Care Science See subheading Pityrosporum Follicultis in this post. "As acne vulgaris and MF coexist in 12.2 to 27 percent of cases, it may be necessary to combine antifungal treatments along with typical acne medications. Use of antibiotics; however, may alter normal flora and lead to the yeast’s overgrowth. For this reason, other anti-acne medications are preferred over antibiotics, as antibiotics are counterproductive." [3] End Notes [1] Rosacea Diagnosis and Management by Frank Powell with a Contribution by Jonathan Wilkin [2] Pityriasis Folliculorum: Response to Topical Ivermectin. J Drugs Dermatol. 2017 Dec 01;16(12):1290-1292 Darji K, Burkemper NM [3] J Clin Aesthet Dermatol. 2014 Mar; 7(3): 37–41. Malassezia (Pityrosporum) Folliculitis Richard M. Rubenstein, MD and Sarah A. Malerich, BS Links http://www.jaad.org/article/S0190-96...789-5/fulltexthttp://medf.nsu.ru/files/%D0%A0%D0%B...0%BA%D1%81.pdfhttps://www.ncbi.nlm.nih.gov/pubmed/22017468http://www.microbiologyresearch.org/...308661D481B318
  17. Lupoid rosacea (also known as "Granulomatous rosacea," "Micropapular tuberculid", or "Rosacea-like tuberculid of Lewandowsky") is characterized by the development of epithelioid (lupoid) granulomas in a diffuse pattern. [1] DermIS Photo of Lupoid Rosacea The NRS only recognizes one variant, Granulomatous Rosacea. However, most medical literature discuss several other rosacea variants and there is no universal agreement of what constitutes a rosacea variant. The RRDi recognizes a number of rosacea variants including Lupoid Rosacea, aka, Granulomatous rosacea. [1] Wikipedia
  18. Admin

    Lupus

    Lupus and its variants can mimic rosacea. One rosacean reported that an initial diagnosis of rosacea turned out to be Discoid Lupus. Lupus can also be a co-existing condition. Check out this Mayo Clinic Image of Lupus and how it looks like rosacea. Other Lupus Images by DermIS Some of the types of Lupus to consider in a differential diagnosis: Lupus chronic Lupus Erythematosus, Acute Lupus SLE Lupus Subacute Lupus Subcutaneous Lupus vulgaris Lupus miliaris disseminatus faciei [1] Subacute Cutaneous Lupus Erythematosus SCLE Systemic Lupus Erythematosus End Notes [1] Dermatology. 2003;206(2):120-3. Lupus miliaris disseminatus faciei: a distinctive rosacea-like syndrome and not a granulomatous form of rosacea. van de Scheur MR, van der Waal RI, Starink TM.
  19. Please read this notice about Subtypes This post has been promoted to an article
  20. Please read this notice about Subtypes NOTE This controversy existed since 2002 when the NRS proposed a subtype classification of rosacea. In November 2016 the RRDi endorsed the Phenotype classification of rosacea. Galderma acknowledged the phenotype classification about a year later. In November 2017 the NRS has now moved forward with classifying rosacea into phenotypes and published a paper recognizing phenotypes. [10] This article remains to explain why this controversy existed but the subtype controversy is no longer worth debating since we have moved into this new direction diagnosing rosacea into phenotypes, which has proved superior to the subtype classification. There is no controversy with the phenotype classification of rosacea. However, for those who want to learn why we have moved away from the subtype classification you may read the article below to understand the history of the subtype controversy. Updates on the Phenotype classification. The RRDi recognized Neurogenic Rosacea as a subtype of rosacea in 2011, but now recognizes it as a rosacea variant. In 2010, a report by the ROSIE [ROSacea International Expert] Group reports that, “Classification of rosacea into stages or subgroups, with or without progression, remained controversial.”[1] This ROSIE group is comprised of “European and US rosacea experts.” Two of the experts in the group are MAC members of the RRDi, Dr. Draelos and Dr. Jensen. The report, was released by J Eur Acad Dermatol Venereol and said, "the ROSIE group proposed that therapy decision making should be in accordance with a treatment algorithm based on the signs and symptoms of rosacea rather than on a prior classification." This prior classification of rosacea into subtypes and one variant was released by the National Rosacea Society in 2002 by an 'expert committee.' [2] The ROSIE group report concluded: "The group suggested a rational, evidence-based approach to treatment for the various symptoms of the condition. In daily practice this approach might be more easily handled than prior subtype classification, in particular since patients often may show clinical features of more than one subtype at the same time." [1] This is not a new controversy. The late Albert Kligman, a noted expert on rosacea, stated in 2003 about the NRS classification of rosacea into four subtypes and one variant: ”In my view this is a vast oversimplification which will not solve the diagnostic dilemmas that confront us. I see no reason not to give equal nosologic status to granulomatous rosacea, rosacea conglobata, rosacea inversa (formerly called pyoderma faciale), rosacea fulminans, edematous rosacea (a devastating variety) or combinations with seborrheic dermatitis, lupus erythematosus, acne vulgaris, and still other variants. Reducing the classification to four sub-types does little to clarify and eliminate the inherent complexities of this mysterious disease.” [3] Dr. Kligman passed away in 2010. Another report released after the ROSIE group report mentioned above had this remark about how a ‘proper standardization’ is needed: “It is to be remarked that the quality of most studies evaluating rosacea treatment is rather poor, mainly due to a lack of proper standardization. For a major breakthrough to occur in the management of rosacea, we need both a better understanding of its pathogenesis and the adherence of future clinical trials to clearly defined grading and inclusion criteria, which are crucial for investigators to correctly compare and interpret the results of their work.” [4] This controversy is simply because the NRS subtype classification is based not on nosology but rather on morphology." Nosology (from Ancient Greek νόσος (nosos), meaning "disease", and -λογία (-logia), meaning "study of-") is a branch of medicine that deals with classification of diseases. Diseases may be classified by etiology (cause), pathogenesis (mechanism by which the disease is caused), or by symptom(s).....A chief difficulty in nosology is that diseases often cannot be defined and classified clearly, especially when etiology or pathogenesis are unknown. Thus diagnostic terms often only reflect a symptom or set of symptoms (syndrome)." Wikipedia No doubt this controversy will continue until more is known about the cause of rosacea. What is the morphology of rosacea? Morphology in biology deals with the outward appearance (shape, structure, colour, pattern) as well as the form and structure as opposed to physiology which deals with the function of an organism. The NRS 'expert committee' said in its initial report on this classification of rosacea into subtypes and one variant: "As knowledge increases, it is hoped that the definition of rosacea may ultimately be based on causality, rather than on morphology alone." [2] So this was a start into everyone being on the same page when it comes to diagnosing rosacea. And the NRS 'expert committee' concluded in its report: "This investigational instrument is intended to set the stage for a better understanding of rosacea and its subtypes among researchers and practitioners by fostering communication and facilitating the development of a research-based classification system. As a provisional standard classification system, it is likely to require modification in the future as the pathogenesis and subtypes of rosacea become clearer, and as its relevance and applicability are tested by investigators and clinicians. The committee welcomes reports on the usefulness and limitations of these criteria." [2] The future is here and the ROSCO panel has moved the classification in a superior direction. [8] Since the jury is still out on what exactly is causing rosacea and the fact that rosacea's definition is still controversial amongst the medical community, we need to keep an open mind about what constitutes rosacea. What is puzzling is that the NRS 'expert' committee excluded three rosacea mimics as variants of rosacea: Rosacea fulminans, Steroid-induced acneiform eruption, and Perioral dermatitis. The committee has their reasons for this and said: "The committee noted that certain disorders may have been prematurely identified as associated with rosacea or as a variant of rosacea, and for clarity should be recognized at this time as separate entities. There is insufficient basis at present to include the following conditions as types of rosacea." [2] The RRDi classifies these as rosacea variants. What is puzzling is the NRS absolutely makes no mention of demodectic rosacea as a rosacea variant, while the RRDi does. In 2011 a new group of physicians have proposed a new subtype of rosacea called Neurogenic Rosacea. A paper published in Europe had this to say about this subject: "The classification of rosacea into stages or subtypes, without considering the possibility of progression from one to another, will probably remain controversial until additional knowledge on the pathophysiology of rosacea is obtained." [5] So if in the future we learn that rosacea is caused by a single entity or by several different entities or in combination we might have a completely different classification system or one similar but based upon 'causality' rather than morphology. And most important is that we certainly need more knowledge about rosacea. Until then, diagnosis of rosacea sometimes results in misdiagnosis and continues to be mysterious and bewildering. Dr. Frank Powell, at the 2012 annual meeting of the American Academy of Dermatology, is reported to have said that the subtypes in rosacea may be different conditions. [6] ROSCO Panel In 2016, the ROSCO panel wrote, "The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype." [7] “Given the overlap of rosacea features across subtypes and the fact that no single treatment completely addresses all rosacea features, the current approach of diagnosing and treating rosacea by subtype may hinder individualised patient management. A new approach is needed to bring us closer to helping each and every rosacea patient receive the right treatment according to their signs and symptoms.” Jerry Tan, MD [8] “While the rosacea management landscape has advanced, the current subtype-based view of the disease can hinder progress by limiting the way we consider treatment options. These new ROSCO recommendations should help to make a positive impact on future treatment development and ultimately help improve the lives of people with rosacea through a symptom-led approach.” Esther J. van Zuuren, MD [8] "The panel agreed on phenotype-based treatments for signs and symptoms presenting in individuals with rosacea." [9] The ROSCO panel doesn't discuss rosacea variants. RRDi Endorses the ROSCO Panel The RRDi has endorsed the phenotype based treatment diagnosis proposed by the ROSCO panel in November 2016, the first non profit organization for rosacea to do this. Please read this notice about Subtypes End Notes [1] Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group Elewski BE, Draelos Z, Dréno B, Jansen T, Layton A, Picardo M. J Eur Acad Dermatol Venereol. 2010 Jun 23. Full Text Available [2] Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea Wilkin J, Dahl M, Detmar M, Drake L, et al. Journal of the American Academy of Dermatology April 2002 &bull; Volume 46 &bull; Number 4 &bull; 2002;46:584-587. [3] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman, M.D., Ph.D. [4] Rosacea Treatments: What’s New and What’s on the Horizon? Gallo R, Drago F, Paolino S, Parodi A. Am J Clin Dermatol. 2010;11(5):299-30 [5] Clinical presentations and classification of rosacea. Jansen T. Department of Dermatology, Venereology and Allergology, University of Duisburg-Essen, Hufelandstrasse 55, 45122 Essen, Germany. Ann Dermatol Venereol. 2011 Nov;138 Suppl 3:S192-200. [6] Research suggests rosacea subtypes may be different conditions Dermatology Times, Dec 1, 2012, John Jesitus [7] Br J Dermatol. 2016 Oct 8. doi: 10.1111/bjd.15122. [Epub ahead of print] Updating the diagnosis, classification and assessment of rosacea: Recommendations from the global ROSacea COnsensus (ROSCO) panel. Tan J, Almeida L, Bewley A, Cribier B, Dlova N6, Gallo R, Kautz G, Mannis M, Oon H, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren E, Schaller M. [8] ROSCO Panel Recommends New Approach on Rosacea Diagnosis by Phenotype [9] Br J Dermatol. 2016 Nov 12. doi: 10.1111/bjd.15173. Rosacea treatment update: Recommendations from the global ROSacea COnsensus (ROSCO) panel. Schaller M, Almeida L, Bewley A, Cribier B, Dlova N, Kautz G, Mannis M, Oon H, Rajagopalan M, Steinhoff M, Thiboutot D, Troielli P, Webster G, Wu Y, van Zuuren E, Tan J. [10] Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee
  21. Pascoe is the founder of Rosacea Support and states emphatically, “Rosacea cannot honestly be characterised as a baffling condition.” [1] Is this true? Rosaceans are not baffled by rosacea and do not find rosacea mysterious or confusing? Dermatologists are not baffled either, nor do they find rosacea mysterious or confusing? What do you think? First, the cause of rosacea is still unknown, and second, the cure is not available yet. Not everyone agrees with Pascoe, but before citing what others say about rosacea’s mystery, confusion and bewilderment, lets note what Pascoe himself says about rosacea with the following: "Sometimes (but no longer) called acne rosacea, rosacea is surprising because of how common it is and secondly how poorly understood it is." This quote is made by David Pascoe on the home page of his flag ship website on rosacea, first paragraph under the heading "About rosacea:" Is describing rosacea as 'poorly understood' disingenuous or egregious? What do you think? Now let's look at what the NRS says about rosacea, which is an organization Mr. Pascoe wholeheartedly supports: On April 4, 2011 the National Rosacea Society said rosacea is [a] "widespread but poorly understood facial disorder." [19] On April 1, 2010, in a news release from the NRS, Dr. Jonathan Wilkin, chairman of the NRS medical advisory board, spoke of rosacea as a "widespread but poorly understood disorder." [21] Pascoe, the director of the now defunct, Rosacea Research Foundation, was instrumental in donating over $18K to the National Rosacea Society who says that rosacea is a 'widespread but poorly understood facial disorder' and as far as we know has never explained why the NRS can push such a 'disingenuous' statement on the public, or for that matter, why David also repeats this phrase on his own website. Are there any other disingenuous or egregious statements pushed on the public that rosacea is mysterious, baffling or a poorly understood facial disorder? What about the following statements about rosacea's baffling condition? Are the statements below disingenuous or egregious? The NRS and Pascoe can call rosacea 'a widespread but poorly understood facial disorder' statement yet Pascoe says it is wrong for me to says rosacea is baffling and mysterious? What do you think? Do you think that it is ok to say rosacea is poorly understood but it is wrong to say it is baffling or mysterious? Let's look at what some noted authorities on rosacea say about this subject, as well as, what medical authorities say about rosacea and see if you think the following quotes are "disingenuous and egregious." You be the judge. Statements About Rosacea "The cause of rosacea is complex, poorly understood, and likely multifactorial, with significant proposed contributions from dysfunctional cutaneous vasculature and innate immunity." [24] The late Dr. Albert Kligman, a noted rosacea expert, wrote in 2003 about the “inherent complexities of this mysterious disease.” [11] “Rosacea is a complex and often misdiagnosed condition.” [2] “Rosacea is a skin condition as misunderstood as sensitive skin..” [3] “Rosacea is a very common, but often misunderstood…” [4] “Although the basic pathophysiologic aspects of this enigmatic disorder remain mysterious, our ability to improve and control it is increasing…” [5] “Rosacea is a mysterious skin disorder affecting tens of millions of individuals worldwide.” [6] “Despite being common, acne rosacea remains mysterious.” [7] “Rosacea, also referred to as acne rosacea, is a mysterious and chronic disorder of the skin.” [8] “One of the most “mysterious” skin conditions is rosacea. Even experts know very little about rosacea…” [9]“ “As if today’s economy were not stressful enough, growing millions of Americans now face the embarrassment of a mysterious red-faced disorder that can wreak havoc on their emotional, social and professional lives……’The early clues to rosacea are confusing for many people because the signs and symptoms often come and go, and are easily mistaken for something else,’ said Dr. Jonathan Wilkin, chairman of the NRS medical advisory board.” [10] "Today's expanding knowledge of the many potential signs and symptoms of rosacea can help unmask this widespread but poorly understood facial disorder now estimated to affect more than 16 million Americans. " [10a] “What immediately stands out, which may shock the uninitiated, is the striking degree of controversy, conflict, confusion and contradictions, among the thicket of reports from all over the world. The parvenu to rosacea research will likely be puzzled by these quandaries, which may be off-setting to some, but an attraction to those who like to engage in fields where perplexities reign. There are profound disagreements among “experts” who write and talk about rosacea. I state forthrightly that the state of knowledge regarding the classification, pathogenesis, diagnosis and treatment of rosacea is embarrassing, if not scandalous, when compared to the impressive advances in all other fields of dermatologic research.”—Albert Kligman, M.D. [11] Mysterious and Baffling There are many other statements that many feel rosacea is indeed mysterious and baffling. The confusion about rosacea is discussed almost daily in the rosacea online rosacea groups and experts remark how rosacea is often confused with acne and other skin conditions. Does everyone who is searching the internet online for web sites on rosacea as well as posting in all the online rosacea groups and forums understand completely everything about their rosacea? Do they report successful visits from dermatologists, never complain about the diagnosis, are completely satisfied with the treatment, and are never bewildered or frustrated or confused about rosacea? Do all the dermatologists and physicians know everything about rosacea? What you think? Do you agree with David Pascoe that there is no confusion, mystery and bewilderment with rosacea? Yet that is what he wrote when slamming my editorial in the Journal of the RRDi: “The Associate Editor, Brady Barrows, says that there is a “mystery and bewilderment surrounding rosacea that baffles not only the experts but also those suffering with this disease.” This is a tired statement that is regularly peddled by Barrows. I find this egregious on 2 fronts. Firstly it is patently false and secondly this statement becomes self-fulfilling with the poor quality of some of the articles that follow in the journal. Rosacea cannot honestly be characterised as a baffling condition…” [1] Do you agree with David that what I wrote is ‘false’ and rosacea is not ‘baffling’ ? A recent survey sponsored by Galderma/NRS says rosacea is a ‘complicated diagnosis path.’ Note the statement: “The results, which are part of the national educational campaign Rosacea SKINsights sponsored by Galderma Laboratories, also reveal the lengths that women with rosacea would go to if they could get rid of their rosacea forever, and highlight the low awareness and complicated diagnosis path for this common condition.” [12] Some think that rosacea isn’t a complicated diagnosis path at all and would have us believe otherwise and I responded to such remarks in this article you are reading. A rosacea expert, now deceased wrote in a noted paper on rosacea, "Busy doctors who cannot take a detailed history will frequently miss the diagnosis, complicated further by the fact that rosacea is a great mimic of other unrelated disorders that present with a “red face”." [11] What Dr. Kligman wrote is exactly why I started the thread at RF to gather anecdotal reports about this. And many did report that their visit to a dermatologist was quite short. As to what might be considered in diagnosing rosacea it isn’t as simple as some might want to believe. Every week in the rosacea online groups newbies arrive and ask the question, ‘Is this rosacea?’ along with images of their face expecting a simple diagnosis. They are told over and over again that online diagnosis is probably not a good idea and to find a dermatologist to diagnose their condition. The New York Times article quoted above said about this, "Online support groups devoted to rosacea have become a way for the uninitiated to make a diagnosis. (Not a recommended practice.)" [20] To say that rosacea is a simple diagnosis would negate all the work of the NRS ‘expert committee’ who has standardized and classified rosacea. The NRS ‘Expert’ Committee said one of the reasons for standardizing and classifying rosacea is because "the term 'rosacea' has been applied to patients and research subjects with a diverse set of clinical findings that may or may not be an integral part of this disorder.” [13] Rosacea mimics must be differentiated and complicates the diagnosis which is sometimes misdiagnosed. I have been collecting a list of anecdotal reports on the misdiagnosis of rosacea. The NRS ‘expert committee’ had this to say about the nosology of rosacea: “Despite its apparent high incidence, the nosology of rosacea is not well established, and the term “rosacea” has been applied to patients and research subjects with a diverse set of clinical findings that may or may not be an integral part of this disorder. In addition to the diversity of clinical manifestations, the etiology and pathogenesis of rosacea are unknown, and there are no histologic or serologic markers. Therefore, the National Rosacea Society assembled a committee to develop a standard classification system that can serve as a diagnostic instrument to investigate the manifestations and relationships of the several subtypes and potential variants of rosacea. Standard criteria for diagnosis and classification of patients are essential to perform research, analyze results and compare data from different sources, and may further serve as a diagnostic reference in clinical practice. The standard terminology will also facilitate clear communication among a broad range of basic, clinical, and other researchers; practicing dermatologists, primary care physicians, ophthalmologists and other specialists; health and insurance administrators; and patients and the general public. The committee based the standard classification system on present scientific knowledge and morphologic characteristics. This avoids assumptions on pathogenesis and progression, and provides a framework that can be readily updated and expanded as new discoveries are made. As knowledge increases, it is hoped that the definition of rosacea may ultimately be based on causality, rather than on morphology alone.” [13] What the ‘expert committee’ did was to classify rosacea into subtypes and one variant and to help physicians diagnose rosacea better which is now beginning to help. Dermatologists who are aware of this new classification system are better informed than in the past but as the above report acknowledges, this ‘provides a framework that can be readily updated and expanded as new discoveries are made’ and that the “definition of rosacea may ultimately be based on causality, rather than on morphology alone.” [14] And recently there is now a controversy about this classification based on morphology alone. For more info on this controversy, click here. The general direction we are moving towards is a classification based upon phenotype rather than subtypes. [27] The RRDi has now endorsed the phenotype classification of rosacea, being the first non profit for rosacea organization to do this. The NRS has followed this lead over a year later. This is a superior classification over subtypes. Conclusion We are still on the road to understanding this mysterious disorder. Yes there is improvement. For Pascoe to say that the book is closed on rosacea and it is no longer confusing, baffling and mysterious is a disservice to the rosacea community. We need more knowledge and research on rosacea because rosacea is not only a 'widespread but poorly understood facial disorder (Pascoe's own words),' but also 'baffling, mysterious and bewildering (Barrows' own words)', not only to rosacea sufferers but also dermatologists. Not everyone agrees with David Pascoe despite his large following, the websites he owns devoted to rosacea, and his many posts on rosacea. Here are more examples to consider that rosacea is indeed baffling, mysterious and bewildering: The Rosacea Dilemma, which state: “Unfortunately, the pathogenesis of rosacea is still a mystery…..Unfortunately, rosacea tends to wax and wane despite therapy.” [15] and also the article, “We are making progress with both acne and rosacea–but, let’s face it! We still have a long way to go.” [16] “This reveals the high level of misunderstanding and confusion that surrounds rosacea, a chronic disorder primarily of the facial skin, often characterized by flare-ups and remissions.” [17] “Despite being one of the most common skin disorders, its pathogenesis remains unclear and controversial.” [18] A paper written by Rhodes, et.al, discusses the difficulty of diagnosing facial inflammatory dermatoses in early stages. [22] Dr. Jason Rivers, a Vancouver dermatologist and associate editor of The Skin Therapy Letter, "stresses that rosacea is underdiagnosed, misdiagnosed, undertreated and often misunderstood." [23] An interesting thread about this same subject: When a red face isn't rosacea is everyones doctor checking? A report, About some red faces, stated: "Diagnosis is based on different data: date and mode of appearance, characteristics of the erythema, functional signs, and associated systemic manifestations. A case of red face can have an infectious origin, caused by vascular, congenital, or acquired lesions, or be caused by photodermatosis, or be the main location of inflammatory dermatosis or collagenosis, but depending on the clinical context, many other diagnoses can be suggested." Another report mentions "this challenging and often confusing clinical entity." [25] "There is no official standard or universally accepted definition of rosacea and it has been considered to be a cutaneous reaction pattern or typology with case clustering around characteristic clinical features....While the National Rosacea Society Expert Committee diagnosis and classification system have been incorporated into basic, clinical and therapeutic investigations, information on associations between subtypes; the relative prevalence of these features among subtypes; and quantitative and qualitative aspects of these features in rosacea have been sparse..." [26] We have moved from a classification of rosacea into subtypes to a better classification into phenotypes. [27] End Notes [1] RRDi journal Issue 1 Review: an unfortunate mix an editorial by David Pascoe Curiously, Mr. Pascoe had this comment to say when discussing an article about Neurogenic Rosacea: "Is rosacea already complicated enough that another subtype is only going to make diagnosis and care trickier?" Scroll to the bottom of the article, last paragraph before the blog comments, under the subheading, "A Good Idea?" [2] The Rosacea Forum Moderated by Drs. Bernstein and Geronemus [3] Dermilogica [4] skinlaboratory.com [5] Unraveling the mystery of rosacea. Keys to getting the red out. Postgrad Med. 2002 Dec;112(6):51-8, 82; quiz 9. Landow K., University of Southern California School of Medicine, Los Angeles, USA. [6] Possible Causes of Rosacea This Little Understood Skin Disease Is Not Curable, But Treatable [7] Acne Rosacea By Ruth Werner, LMP, NCTMB [8] Nursing Comments [9] Rosacea Care for Clear Skin [10] NRS Untold Millions Suffer Embarrassment of Conspicuous Red-Faced Disorder [10a] NRS, Clues Can Save Millions, Monday, April 4, 2011 [11] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman , M.D., Ph.D. Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A. [12] New Survey Reveals First Impressions May Not Always Be Rosy For People With The Widespread Skin Condition Rosacea Medical News Today [13] Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea [14] Morphology of Rosacea [15] Healthy Aging The Rosacea Dilemma Physicians are still not sure what causes rosacea, requiring them to tailor treatment plans to each symptom. Arisa Ortiz, MD Posted on: July 14, 2009 [16] We are making progress with both acne and rosacea–but, let’s face it! We still have a long way to go. Del Rosso JQ. J Drugs Dermatol. 2010 Jun;9(6):603-4. [17] New Survey Reveals First Impressions May Not Always Be Rosy For People With The Widespread Skin Condition Rosacea [18] The potential role of microorganisms in the development of rosacea. Lazaridou E, Giannopoulou C, Fotiadou C, Vakirlis E, Trigoni A, Ioannides D. J Dtsch Dermatol Ges. 2010 Nov 8. doi: 10.1111/j.1610-0387.2010.07513.x. [19] Clues Can Save Millions Monday, April 4, 2011 [20] Skin Deep - In a Perfect World, Rosacea Remains a Problem The New York Times, April 24, 2008 [21] Rosacea Riddle Now Threatens More Than 16 Million Americans National Rosacea Society News Release April 1, 2010 [22] Outcome of facial rashes with non-specific histological features: a long-term follow-up of 64 cases Lesley E. Rhodes, Richard A. G. Parslew, John Ashworth Journal of Cutaneous Pathology Volume 22, Issue 2, pages 160–163, April 1995 Article first published online: 27 APR 2006 DOI: 10.1111/j.1600-0560.1995.tb01400.x [23] Red in the face Embarrassment, stares and discrimination plague those suffering from rosacea BY MARILYN LINTO ,QMI AGENCY, Toronto Sun, FIRST POSTED: MONDAY, JULY 4, 2011 2:00:01 EDT AM [24] Neurogenic Rosacea: A Distinct Clinical Subtype Requiring a Modified Approach to Treatment Tiffany C. Scharschmidt, MD, John M. Yost, MD, MPH, Sam V. Truong, MD, Martin Steinhoff, MD, PhD, Kevin C. Wang, MD, PhD, Timothy G. Berger, MD ARCH DERMATOL/VOL 147 (NO. 1), JAN 2011 [25] Facial Plast Surg Clin North Am. 2013 Feb;21(1):127-136. doi: 10.1016/j.fsc.2012.11.004. Rosacea: Pathophysiology and Management Principles. Chauhan N, Ellis DA. [26] The British Journal of Dermatology An observational cross-sectional survey of rosacea: Clinical associations and progression between subtypes J. Tan, U. Blume-Peytavi, J.P. Ortonne, K. Wilhelm, L. Marticou, E. Baltas, M. Rivier, L. Petit, P. Martel Note: Quote taken from, Four Kinds of Red in the Face, Rosacea subtypes have significantly different symptoms, May 2, 2013 (dailyRx News) [27] ROSCO Panel Recommends New Approach on Rosacea Diagnosis by Phenotype
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  24. It should be noted that while the four subtypes by their order implies that rosacea gets progressively worse, which sometimes happens, not all rosaceans go through each subtype or progressively in stages. What may add to the confusion on this subject is that most clinical papers on rosacea refer to the 2002 subtype classification or rosacea rather than phenotypes of rosacea, which is a superior classification announced in 2016. “The notion that the erythematotelangiectatic stage generally transforms into the papulo-pustular, inflammatory stage is simply wrong and grossly misleading. Firstly, the papulo-pustular stage mainly occurs in males in whom rosacea is a more serious disease at all stages. The papulo-pustular stage is actually uncommon in females.” [1] “Rosacea is often divided into four stages, according to the progressive nature of the condition. However, the progression is not absolute. For unknown reasons, certain patients may skip a stage. Others experience ocular symptoms as the first manifestation of the condition.” [2] Also, there is controversy on the classification of rosacea into subtypes and variants which is related to this subject, is why the phenotype classification is now used, but many physicians are not keeping up with the current state of the art diagnosis of rosacea. Nevertheless, you can read reports that say this about the older subtype classification: "A small proportion of rosacea subjects may progress between subtypes." [3] End Notes [1] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman , M.D., Ph.D. Department of Dermatology, University of Pennsylvania, Philadelphia, PA, U.S.A. The William J. Cunliffe Lectureship 2003—Manuscript [2] Consult Your Pharmacist Differentiating Between Rosacea and Acne W. Steven Pray, PhD, DPh; Joshua J. Pray, PharmD candidate :U.S. Pharmacist [3] The British Journal of Dermatology. 2013 Apr 21. doi: 10.1111/bjd.12385. [Epub ahead of print] An observational cross-sectional survey of rosacea: Clinical associations and progression between subtypes. Tan J, Blume-Peytavi U, Ortonne JP, Wilhelm K, Marticou L, Baltas E, Rivier M, Petit L, Martel P. Department of Medicine, University of Western Ontario, London, Ontario and Windsor Clinical Research Inc., Windsor, Ontario, Canada.
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