Guide

"For patients with rosacea, phenotype-based treatments should be given for presenting signs and symptoms, according to updated treatment guidelines published online Nov. 12 in the British Journal of Dermatology." Treatment guidelines updated for patients with rosacea, HealthDay This is related to this post

Sent the following question to the RRDi MAC Members (responses will be in this post): RRDi MAC Members, What are your thoughts on this treatment for rosacea: http://irosacea.org/members/forums/topic/3074-ketamine-05-and-amitriptyline-1-for-rosacea/ Responses Amitriptyline is sometime used for treatment of migraine. There is an obvious link between certain rosacea features and migraine. We have in clinic seen some patients with good efficacy of anti-migraine agents (e.g. triptans) for rosacea. We are just now starting trials on this. There may be a similar mode of action, at least for the amitriptyline. Best Alexander Egeberg, MD PhD Gentofte Hospital Department of Dermatology and Allergy Kildegårdsvej 28 2900 Hellerup Denmark --------------------------------------------

Subtypes have been replaced with the phenotype classification of rosacea. The older, outdated subtype classification used four subtypes ETR, Papulopustular, Ocular and Phymatous). The current state of the art classification uses six phenotypes (Flushing, Erythema, Telangiectasia, Papulopustular, Phymatous, and Ocular). Here is the history: The ROSCOE panel in October 2016 was the first to recognized, recommend and endorse the phenotype classification of rosacea. The RRDi endorsed the new Phenotype classification of rosacea in November 2016. Galderma acknowledged the phenotype classification about a year later. In November 2017 the NRS has now moved forward with classifying rosacea into phenotypes with its own published paper following the lead set by the ROSCOE Panel. [1] Medscape has recognized the phenotype classification of rosacea [scroll through this thread to the fifth post]. The RRDi recognized Neurogenic Rosacea as a subtype of rosacea since 2011, but now recognizes Neurogenic Rosacea as a rosacea variant, among thirteen other rosacea variants. There is no consensus with the non profit organizations for rosacea on what constitutes a rosacea variant. Hopefully, someday there may be consensus. We are keeping the subtype classification CATEGORY [Subtypes] in this forum because it has been the standard since 2002 for historical reasons, since much of the past medical papers published in journals and on Pubmed as well as current ones continue to refer to to the old subtype classification However, the RRDi has endorsed a new direction in diagnosing rosacea since the phenotype classification is superior and the subtype classification has been controversial since its inception. Rosacea Variants are another valid classification system and the RRDi has thirteen rosacea variants listed. The subtype classification of rosacea is now history. We are keeping any phenotype updates posted here. Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee

See this post

Please note: There are no confirmed reports that this treatment for Erythromelalgia works for rosacea. There are scant few anecdotal reports of using this treatment for rosacea which are collected in this topic (thread) which seem promising. You should find a doctor who is willing to write you a prescription for this and find a compounding pharmacist. We would ask if you try this treatment to post your results in this thread so others can benefit from your experience. We have gathered together in this thread as much information on this subject as possible. If you can add something please find the reply button and post your comment. An ointment made by Compounding Pharmacists of Ketamine 0.5% and Amitriptyline 1% in a Lipoderm cream used for Erythomelalgia has been reported by Deansm (scroll below) to improve rosacea. "Erythromelalgia is a clinical syndrome characterized by attacks in which the affected limbs become bright red, hot, and excruciatingly painful. The common trigger is heat exposure induced by exercise or increased ambient temperature. As the condition progresses, the limbs become permanently red, hot, and painful....According to various theories, erythromelalgia is a vascular disorder or neuropathic condition. In previous studies, we have shown that both systems are involved, but we do not know which one is affected first. It is plausible that the vascular and neuropathic components differ in each subject depending on the underlying cause....Nonetheless, this strategy offers the flexibility of easy application, no systemic adverse effects, and the possibility of combining it with other treatment options without concern of drug interactions. The combination gel has to be compounded by a pharmacist, which may be a problem for some patients, but it seems to be fairly easy to do and at a much lower cost than for most treatments commonly used." Erythromelalgia is difficult to diagnose and to treat. For more information. The Cutting Edge March 2006 Arch Dermatol. 2006;142(3):283-286. doi:10.1001/archderm.142.3.283 Combination Gel of 1% Amitriptyline and 0.5% Ketamine to Treat Refractory Erythromelalgia Pain A New Treatment Option? Paola Sandroni, MD, PhD; Mark D. P. Davis, MD "Ketamine, sold under the brand name Ketalar among others, is a medication mainly used for starting and maintaining anesthesia. It induces a trance-like state while providing pain relief, sedation, and memory loss. Other uses include for chronic pain and for sedation in intensive care." Wikipedia "Amitriptyline, sold under the brand name Elavil among others, is a medicine used to treat a number of mental illnesses. These include major depressive disorder and anxiety disorder, and less commonly attention deficit hyperactivity disorder and bipolar disorder. Other uses include prevention of migraines, treatment of neuropathic pain such as fibromyalgia and postherpetic neuralgia, and less commonly insomnia. It is in the tricyclic antidepressant (TCA) class and its exact mechanism of action is unclear." Wikipedia "Pharmaceutical compounding (done in compounding pharmacies) is the creation of a particular pharmaceutical product to fit the unique need of a patient. To do this, compounding pharmacists combine or process appropriate ingredients using various tools. This may be done for medically necessary reasons, such as to change the form of the medication from a solid pill to a liquid, to avoid a non-essential ingredient that the patient is allergic to, or to obtain the exact dose(s) needed or deemed best of particular active pharmaceutical ingredient(s). It may also be done for more optional reasons, such as adding flavors to a medication or otherwise altering taste or texture. Compounding is most routine in the case of intravenous/parenteral medication, typically by hospital pharmacists, but is also offered by privately owned compounding pharmacies and certain retail pharmacies for various forms of medication. Whether routine or rare, intravenous or oral, etc., when a given drug product is made or modified to have characteristics that are specifically prescribed for an individual patient, it is known as "traditional" compounding." Wikipedia There is a difference between a pharmacist and a compounding pharmacist. Whether your insurance covers a compounding pharmacist is another matter you will need to investigate. A prescription from a medical doctor is required for the compounding pharmacy to make the prescription. The ointment can be any type the pharmacist has available. This is like the old fashioned pharmacist who has a motar and pestal. Wikipedia Commons Deansm Report Using Ketamine 0.5% and Amitriptyline 1% for Rosacea "Two months ago the GP I am seeing prescribed me an ointment containing Ketamine 0.5% and Amitriptyline 1%. Withing 3 days of using it twice a day the flushing disappered and my skin is white, the same as it was before Rosacea. It has been the same ever since for the last two months. I can eat, excersie, go out in the sun and nothing will bring on a flush. If anyone has this subtye and nothing has worked have a look into this, I have no side affects (the GP said it is very safe as the amount of active ingredients is too low and it's not absored systemically).......The packaging has no branding, it was made in a compounding pharmacy. He said he has found it helpful going back years for patients with Erythromelalgia and it was worth trying for my Rosacea as nothing else worked." Deansm There are other anecdotal reports using this treatment which are shown in this thread by scrolling down to the December 5 and also the December 28 post listing them. Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post.

Thanks MariaSt for the encouragement. Yes, from what I have read from other users it takes months to see improvement. I am willing to try 90 days and if there is improvement I will stick it out longer. But if I keep looking like this, I know how to control my rosacea with sulphur creams and diet. I also take probiotics. So what is your current regimen?

skullmcrex (post #21) recommends "I think all rosacea sufferers should try cleansing milk they're really great. In terms of how I use it, wash my hands, apply to my DRY face, slowly message in outwards circles, and inwards if I feel appropriate (whatever doesn't physically irritate your skin) and then gently rinse off my fave using the technique of putting my hands together, cuping LUKEWARM water and GENTLY pressing it against each cheek and then following up your face, repeating this technique for every other part of your face. Basically what this girl does but when less rigourous/microscopic cleaning with the fingers, and less, but the occasional inwards circle motions too. (Find what annoys your skin the least it's imperative. I'm sure if you don't have the product where you are any "sensitive" cleansing milk would do well. It's been a revelation to me, my skin feels climbed without SLS bombarded and without drying it too much with over application of water. I do a even less vigourous approach to cleansing, less quick/hard but slightly more cleansing. The thing about the pinkies is very interesting too. I don't do everything she says but it's very interesting to me." Watch the video skullmcrex recommends below:

"Using only natural ingredients, researchers have found a way to structure sugar differently. So even when much less is used in chocolate, your tongue perceives an almost identical sweetness to before. The discovery will enable Nestlé to significantly decrease the total sugar in its confectionery products, while maintaining a very natural taste. 'This truly groundbreaking research is inspired by nature and has the potential to reduce total sugar by up to 40% in our confectionery,' said Stefan Catsicas, Nestlé Chief Technology Officer. 'Our scientists have discovered a completely new way to use a traditional, natural ingredient.' " Nestlé has one of the largest R&D capabilities in the food and beverage industry, with 40 R&D locations worldwide and more than 5,000 people working in R&D. Compare original sugar crystals with the new and improved sugar crystals. This will be good news to rosacea sufferers who find that sugar triggers their rosacea. Less sugar, great taste: A scientific breakthrough from Nestle Introducing a new structure for sugar, inspired by nature Marketwired

It has been one month. I apply Soolantra on all my red spots every night. I wash my face in the morning and apply absolutely nothing. I have tried to keep my diet going as best as I can. This past week I did have a couple of Longboard beers. Other than than those two beers, a very healthy high protein diet with some green veggies, lots of water, plenty of exercise (Walk 4.4 miles to the beach about four or five times a week). I haven't seen much improvement in my rosacea, but I will stay on this for three months to see what happens. Basically, after thirty days I am still breaking out with rosacea. I get those little white pustules and they turn into scabs after I remove them. I will stick it out 90 days to see if it improves. It is tough to go through this. Using sulphur creams works for me so to try this regimen isn't for sissies. Here are my photos:

This is an excellent article on demodex mites with photos and explanation of their relationship with rosacea. These Microscopic Mites Live on Your Face, by Lucy Jones, May 8, 2015, BBC Earth

Demodex Density Counts Higher in Rosaceans In many papers on rosacea, demodex density counts are higher than in the normal population. Below are reports about this subject, but the consensus is that five or more demodex mites per square centimeter is when there is an issue with demodectic rosacea. The normal count is 1 to 2 demodex mites per square centimeter for non rosacea subjects or in normal human subjects. One report says, "Studies have found that people suffering from rosacea tend to have more Demodex mites. Instead of 1 or 2 per square centimetre of skin, the number rises to 10 to 20." These Microscopic Mites Live on Your Face, by Lucy Jones, May 8, 2015, BBC Earth "The mean mite count was 49.8 (range 2 to 158) in patients with rosacea and 10.8 (range up to 97) in control subjects (p < 0.001); the highest density of mites was found on the cheeks. A statistically significant increase in mites was found in all subgroups of rosacea, being most marked in those with steroid-induced rosacea." [1] "The mean mite density was 2.03 mites/visual field in the rosacea group (range 0-5, SD = 1.2) and 0.16 mites/visual field (range 0-2, SD = 0.52) in the control group." [2] "A mean density of 0.7 Demodex folliculorum/cm2 was found in controls, 98% of whom had less than five Demodex/cm2. When all clinical types of rosacea were considered collectively, the density of Demodex was significantly higher in patients with rosacea than in controls (mean = 10.8/cm2; P < 0.001). When the various clinical types of rosacea were considered separately, Demodex density was statistically significantly higher than in controls only in the PPR patients (mean = 12.8/cm2; P < 0.001)." [3] "The results of our study revealed that DME [direct microscopic examination] is a more sensitive method for detecting Demodex than SSSB [Standardized skin surface biopsy], especially in patients with diffuse pattern and suspected rosacea type. Further research is needed to confirm this finding." [4] "Every human being carries a colony of 1000 to 2000 Demodex mites." [5] "More than five mites per cm2 are assumed a positive diagnosis of demodicosis. The validity of this optimal threshold is rather artificial and weakly evidence-based." [5] "SSSB and DME were used to measure Demodex mites density (Dd). For SSSB, a standard area of 1 cm2 was drawn on a slide with a waterproof pen. A drop of cyanoacrylic adhesive was then placed on the other side of the slide and the adhesive-bearing surface was applied to the skin for one minute. After allowing the adhesive to dry, the slide was removed gently with surface skin, clarified with one to two drops of immersion oil, and covered with a cover slip. For DME, a 1 cm2 sized affected skin area was squeezed using a comedo extractor. The sample obtained was transferred to a 10% potassium hydroxide drop and covered with a cover slip. Samples obtained using both methods were studied under an optical microscope (×40, ×100)." [6] "Patients with rosacea had significantly higher prevalence and degrees of Demodex mite infestation than did control patients." [7] "The diagnosis of demodicosis was made when compatible clinical manifestations of demodicosis was combined with a high Dd (>5D/cm2) by SSSB, or DME." [6] "High numbers of Demodex induced pro-inflammatory cytokine secretion whereas lower numbers did not. Demodex mites have the capacity to modulate the TLR signalling pathway of an immortalised human sebocyte line. Mites have the capacity to secrete bioactive molecules that affect the immune reactivity of sebocytes. Increasing mite numbers influenced IL8 secretion by these cells." [8] "In the case of cutaneous demodicosis the presence of 5 or more Demodex on 1 cm2 will significantly increase the risk of cutaneous demodicosis." [9] There is evidence that decreasing the mite count improves rosacea. "The present study shows that PDL significantly reduced Dd in facial skin with one session." [10] "To overcome this limitation we evaluated a new quantitative method of evaluating the viability of Demodex mites by using scattered light intensity (SLI)." [11] Demodex Brevis Higher Count Than Demodex Folliculorum in Cylindrical Dandruff Patients "Demodex infestation rates were significantly higher in the rosacea group than acne vulgaris and seborrheic dermatitis groups and controls (p=0.001; p=0.024; p=0.001, respectively)." [14] "Demodex mites may be found on normal skin with a density of <5 mites/cm2. A diagnosis of demodicosis or Demodex infestation is considered when clinical signs/symptoms appear and when more than 5 mites/cm2 are present or when they penetrate into the dermis." [19] In one paper it was shown that the "demodex density was 18.1 ± 10.7 (min: 0 - max: 48, Q1:12 - Q3:22) per cm2 before the pro-yellow laser treatment in the cases of "27 females (79.4%) and 7 males (20.6%)." [21] "Some authors consider the density of > 5 mites per follicle as a pathogenic criterion." [22] Increased Blood Glucose Level Correlates Increase in Demodex Density Count Do the Numbers Matter? The answer to that question according to one report [12], if you use a skin scraping with a light microscope, is no, which the report says, "The severity of the condition does not depend on the quantitative load of the mites in the scrape." Other reports say otherwise. However when using a 'Confocal laser scanning in vivo microscopy', the answer is yes, which this same report concludes, "Confocal laser scanning in vivo microscopy is an effective diagnostic method to detect Demodex mites that does not require preliminary preparation for analysis and allows detecting Demodex mites at the level of the spiky epidermis layer, which is not accessible for scarification, to identify the species belonging to the size of Demodex mites (from 100 up to 200 μm - Demodex brevis, 200 to 400 μm – Demodex folliculorum)." [12] "Comparing the results obtained by light microscopy and confocal laser scanning in vivo microscopy in patients with rosacea and healthy people, in more cases Demodex mites are detected by confocal laser scanning in vivo microscopy, whereas scrape in these patients were negative." [12] "As a result of the study, we found that it is difficult to detect the mite by light microscopy of scrape per 1 cm2 of skin." [12] For more information on how to quantify demodex density go to the subheading, Quantification and Methods for Demodex Density Counts in this article. One study on comparing Standardized skin surface biopsy (SSSB) with Superficial Needle-Scraping (SNS) concluded that "that SNS is a simple and convenient method for assessing Demodex density of pustules in PPR and can be a useful alternative or addition to SSSB for evaluation of Demodex-associated facial papulopustular eruptions." [13] "Statistics on Demodex prevalence in any host are likely to be underestimated, as a single sample may fail to find mites which may be present at other locations on the individual’s skin, or mite population may be below the threshold of detection by molecular methods, resulting in false negatives." [23] Tools to Detect or Quantify Demodex Density Counts Cellophane Tape Method [20] CLSM [Confocal laser scanning in vivo microscopy] [16] DME [direct microscopic examination] Dermoscopy [17] Microscope (simple) RCM [reflectance confocal microscopy] [18] Skin Scraping [potassium hydroxide preparation of skin scrapings] SLI [scattered light intensity] SSSB [standardized skin surface biopsy] SNS [superficial needle-scraping] Supereyes Macro Lens-Disposable Dermatoscope Supereyes Smartphone Microscope Camera Adapter Thumbnail-squeezing method CLSM - did your dermatologist use this device to quantify your demodex density count? According to a Russian study [12], the CLSM in vivo method is the best method of quantifying demodex density counts which needs to be validated by comparing the other tools used. Another paper in Thailand states that SSSB has been 'considered to be the gold standard technique' but after careful investigation that the Skin Scraping technique is just as valid. [15] The paper by Karabay et al shows phots of using SSSB. [19] See also, Methods for Quantifying Demodex Mites. Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] J Am Acad Dermatol. 1993 Mar;28(3):443-8. The Demodex mite population in rosacea. Bonnar E, Eustace P, Powell FC. [2] J Eur Acad Dermatol Venereol. 2001 Sep;15(5):441-4. Increased density of Demodex folliculorum and evidence of delayed hypersensitivity reaction in subjects with papulopustular rosacea. Georgala S, Katoulis AC, Kylafis GD, Koumantaki-Mathioudaki E, Georgala C, Aroni K. [3] Br J Dermatol. 1993 Jun;128(6):650-9. Density of Demodex folliculorum in rosacea: a case-control study using standardized skin-surface biopsy. Forton F, Seys B. [4] Ann Dermatol. 2017 Apr;29(2):137-142 Demodex Mite Density Determinations by Standardized Skin Surface Biopsy and Direct Microscopic Examination and Their Relations with Clinical Types and Distribution Patterns. Yun CH, Yun JH, Baek JO, Roh JY, Lee JR [5] Iran J Parasitol. 2017 Jan-Mar; 12(1): 12–21. PMCID: PMC5522688 Human Permanent Ectoparasites; Recent Advances on Biology and Clinical Significance of Demodex Mites: Narrative Review Article Dorota LITWIN, WenChieh CHEN, Ewa DZIKA, and Joanna KORYCIŃSKA Another paper concluded: "Determination of five or more parasites in 1 cm2 area was considered as positive." Medicina (Kaunas). 2020 Mar; 56(3): 107. Pre-Treatment and Post-Treatment Demodex Densities in Patients under Immunosuppressive Treatments Hacer Keles, Esra Pancar Yuksel, Fatma Aydin, and Nilgun Senturk [6] Ann Dermatol. 2017 Apr; 29(2): 137–142. Published online 2017 Mar 24. doi: 10.5021/ad.2017.29.2.137 PMCID: PMC5383737 Demodex Mite Density Determinations by Standardized Skin Surface Biopsy and Direct Microscopic Examination and Their Relations with Clinical Types and Distribution Patterns Chul Hyun Yun, Jeong Hwan Yun, Jin Ok Baek, Joo Young Roh, and Jong Rok Lee [7] "Twenty-three case-control studies included 1513 patients with rosacea. Compared with the control patients, patients with rosacea were more likely to be infested by Demodex mites [odds ratio, 9.039; 95% confidence interval (CI), 4.827-16.925] and had significantly higher Demodex density (SMD, 1.617; 95% CI, 1.090-2.145). Both erythematotelangiectatic rosacea (SMD, 2.686; 95% CI, 1.256-4.116) and papulopustular rosacea (SMD, 2.804; 95% CI, 1.464-4.145) had significantly higher Demodex density than did healthy control patients." JAAD, September 2017 Volume 77, Issue 3, Pages 441–447.e6 Role of Demodex mite infestation in rosacea: A systematic review and meta-analysis Yin-Shuo Chang, MD, Yu-Chen Huang, MD [8] Demodex mites modulate sebocyte immune reaction: Possible role in the pathogenesis of rosacea.Br J Dermatol. 2018 Mar 12;:Lacey N, Russell-Hallinan A, Zouboulis CC, Powell FC [9] Arch Med Sci. 2018 Mar; 14(2): 353–356. Published online 2016 Jun 17. doi: 10.5114/aoms.2016.60663; PMCID: PMC5868666 The impact of age, sex, blepharitis, rosacea and rheumatoid arthritis on Demodex mite infection Aleksandra Sędzikowska, Maciej Osęka, and Piotr Skopiński [10] J Cosmet Laser Ther. 2018 Jun 08;:1-4 The rapid effect of pulsed dye laser on demodex density of facial skin. Ertaş R, Yaman O, Akkuş MR, Özlü E, Avcı A, Ulaş Y, Ozyurt K, Atasoy M [11] Exp Appl Acarol. 2019 Apr 19;: Evaluation of Demodex mite viability using motility and scattered light intensity. Gatault S, Foley R, Shiels L, Powell FC [12] Dermatol Reports. 2019 Jan 23; 11(1): 7675. Clinical picture, diagnosis and treatment of rosacea, complicated by Demodex mites Alexey Kubanov, Yuliya Gallyamova, and Anzhela Kravchenko [13] J Cosmet Dermatol. 2019 Jul 25. doi: 10.1111/jocd.13082. [Epub ahead of print] A new superficial needle-scraping method for assessing Demodex density in papulopustular rosacea. Huang HP, Hsu CK, Lee JY. [14] An Bras Dermatol. 2020 Feb 12;: Demodex folliculorum infestations in common facial dermatoses: acne vulgaris, rosacea, seborrheic dermatitis. Aktaş Karabay E, Aksu Çerman A [15] Indian J Dermatol Venereol Leprol. 2016 Sep-Oct;82(5):519-22. doi: 10.4103/0378-6323.174423. Skin scrapings versus standardized skin surface biopsy to detect Demodex mites in patients with facial erythema of uncertain cause - a comparative study. Bunyaratavej S, Rujitharanawong C, Kasemsarn P, Boonchai W, Muanprasert C, Matthapan L, Leeyaphan C. [16] Br J Dermatol. 2012 Jun 20. doi: 10.1111/j.1365-2133.2012.11096.x. Non-invasive in vivo detection and quantification of Demodex mites by confocal laser scanning microscopy.Sattler EC, Maier T, Hoffmann VS, Hegyi J, Ruzicka T, Berking C. What is confocal laser scanning microscopy? [17] Dermatol Pract Concept. 2017 Jan; 7(1): 35–38. Published online 2017 Jan 31. doi: 10.5826/dpc.0701a06 PMCID: PMC5315038 Usefulness of dermoscopy in the diagnosis and monitoring treatment of demodicidosis Paula Friedman, Emilia Cohen Sabban, and Horacio Cabo Int J Dermatol. 2010 Sep;49(9):1018-23. Dermoscopy as a diagnostic tool in demodicidosis. Segal R1, Mimouni D, Feuerman H, Pagovitz O, David M. [18] RCM • Distinguishing rosacea from sensitive skin by reflectance confocal microscopy. Skin Res Technol. 2014 Feb 13.Reflectance confocal microscopy vs. standardized skin surface biopsy for measuring the density of Demodex mites.Turgut Erdemir A, Gurel MS, Koku Aksu AE, Bilgin Karahalli F, Incel P, Kutlu Haytoğlu NS, Falay T. What is reflectance confocal microscopy? A paper on RCM states, “In its current form, RCM seems of limited value for noninvasive follow-up of rosacea inclinical practice.” "RCM enables anti-inflammatory effect monitoring of topical ivermectin by determining mite presence. Quantifying exact mite number, and inflammatory and vascular characteristics is challenging due to device limitations. In its current form, RCM seems of limited value for noninvasive follow-up of rosacea in clinical practice." J Dermatolog Treat. 2020 Mar 19;:1-9 Value of reflectance confocal microscopy for the monitoring of rosacea during treatment with topical ivermectin. Logger JGM, Peppelman M, van Erp PEJ, de Jong EMGJ, Nguyen KP, Driessen RJB [19] An Bras Dermatol. 2020 Mar-Apr; 95(2): 187–193. Demodex folliculorum infestations in common facial dermatoses: acne vulgaris, rosacea, seborrheic dermatitis Ezgi Aktaş Karabay and Aslı Aksu Çerman [20] The cellophane tape method (placing tape on the face to stick to the mites) Ubiquity and Diversity of Human-Associated Demodex Mites, paragraph 2 [21] The effect of 577-nm pro-yellow laser on demodex density in patients with rosacea [22] Indian J Dermatol. 2014 Jan-Feb; 59(1): 60–66. Human Demodex Mite: The Versatile Mite of Dermatological Importance Parvaiz Anwar Rather and Iffat Hassan [23] Journal of European Academy of Dermatology and Venereology [Full Text] Demodex: a skin resident in man and his best friend R. Foley, P. Kelly, S. Gatault, F. Powell

Dermata has announced the following treatments in development for rosacea: "DMT210 is our topical gel formulation of DMT200. Due to the wide distribution of GPCRs in the skin we plan to develop DMT210 for the treatment of rosacea, atopic dermatitis and acne vulgaris. Rosacea: DMT210 has demonstrated downregulation of toll-like receptor 2 (TLR2), lowering IL-8 production, which ultimately would reduce erythema associated with rosacea. Moreover, DMT210 also exhibits a reduction in IL-6, which is a powerful inflammatory mediator. Thus, DMT210 has the potential to be the first topical treatment to reduce both the erythema and the inflammation (papules and pustules) of rosacea. DMT220, which is currently being formulated, will be our novel ophthalmic formulation. We plan to develop DMT220 for the treatment of ocular rosacea, because it can be treated by dermatologists. Ocular Rosacea: The ocular surface is also populated with GPCRs, suggesting that a topical ophthalmic formulation using DMT200 could be effective at targeting similar pathways as in the skin. Therefore, since the same inflammatory processes that occur in dermal rosacea are also expressed in ocular rosacea, there is good scientific rationale to develop DMT220 for ocular rosacea." For more info

Ocular Rosacea Phenotype 6 used to be classified as Subtype 4 (red, dry or gritty eyes). "Ocular rosacea is a manifestation of rosacea that affects the eyes and eyelids. Signs and symptoms generally consist of redness, irritation or burning of the eyes. Affected individuals may also feel that there is something, such as an eyelash, in the eye and frequently have redness of the nose and cheeks as well." Wikipedia More Information on Phenotype 6 More Info on Ocular Rosacea (formerly called Subtype 4) Treatment for Phenotype 6 Image courtesy of Wikimedia Commons Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post.

"Phymatous rosacea is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Telangiectasias may be present." Wikipedia Phenotype 5 - Phymatous (Rhinophyma) Phenotype 5 used to be classified as Subtype 3 - [Rhinophyma] (red, enlarged nose). This phenotype responds to treatment very well. Phymatous rosacea is uncommon. The most frequent phymatous manifestation is rhinophyma (known familiarly as "whiskey nose" "brandy nose" or "rum blossom"). In its severe forms, rhinophyma is a disfiguring condition of the nose resulting from hyperplasia of both the sebaceous glands and the connective tissue. Rhinophyma occurs much more often in men than in women (approximate ratio, 20:1), [1] and a number of clinicopathologic variants have been described. [2] Although rhinophyma is often referred to as "end-stage rosacea," it may occur in patients with few or no other features of rosacea. The diagnosis is usually made on a clinical basis, but a biopsy may be necessary to distinguish atypical, or nodular, rhinophyma from lupus pernio (sarcoidosis of the nose); basal-cell, squamous-cell, and sebaceous carcinomas; angiosarcoma; and even nasal lymphoma. [3] Older papers usually mention how rosacea progresses in stages and ends up in subtype 3 (now called Phenotype 5), but recent studies indicate that this is not necessarily true. One can develop subtype 3 without going through any 'stages.' [read this post] One report says, "It can affect nose (rhinophyma), chin (gnatophyma), forehead (metophyma), ears (otophyma) and eyelids (blepharophyma). Rhinophyma is the most frequent location..." [15] For images of phymatous click below: http://goo.gl/BI2lf; 28 Images of Rhinophyma A classic example of Subtype 3 is WC Fields (the rosacea poster boy😞 Another classic example is this painting in the Louvre, "The Old Man and His Grandson" by Ghirlandiao around the year 1480. There are Five Variants of Rhinophyma: Glandular Fibrous Fibroangiomatous Actinic Rhinophymous leishmaniasis This is a great thread to read about what was referred to as Subtype 3 (now called Phenotype 5) Treatment There are a number of different treatments for rhinophyma, including surgery, but it is better to treat the rosacea before it reaches the advance stage of rhinophyma. However, once rhinophyma has developed it can usually be corrected by surgery using either laser, scapel, or dermabrasion. The good thing about rhinophyma is that though this condition is generally regarded as a severe form of rosacea it is a relatively rare disorder involving thickening of the skin on the nose and the presence of many oil glands and this condition can usually can be corrected. Accutane is usually the drug of choice, but your physician may use other prescription drugs such as antibiotics if you have this skin disorder. Other treatment may involve cryosurgery, dermashaving and electrosurgery. "Coblation of rhinophyma is an effective treatment with few side effects." [4] ""...Initially, the mass was thought to be rhinophyma, but biopsy of the mass revealed noncaseating granulomata consistent with sarcoidosis. The mass resolved following several steroid injections..." [5] Radiofrequency is used to treat rhinophyma. [6] Rhinophyma treated with kilovoltage photons {7] Treatment of rhinophyma with ultrasonic scalpel: case report [8] Radiosurgical excision of rhinophyma. [9] "Surgery is indisputably the treatment of choice for rhinophyma." [10] This report said, "Despite many advances in fundamental understanding, surgical techniques, and related technologies, no single method has been universally embraced and employed as the "gold standard." " [11] Smoothbeam laser [13] Surgical Management [14] Another report says, "Both tangential excision and carbon dioxide laser are well-established, reliable procedures for rhinophymaplasty that preserve the underlying sebaceous gland fundi allowing spontaneous re-epithelialization without scarring with similar outcomes and high patient satisfaction. The original nose shape and nearly normal skin surface texture are preserved by quickly removal of the hypertrophic tissue sparing the pilosebaceous tissue. The CO(2) laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs." [16] Another report, which says, "a surgical "gold standard" for treating the distorting phymatous skin alterations has not yet been established," it goes on to state, "the combination of a bovine collagen-elastin with simultaneous autologous non-meshed split-thickness skin grafting" was used in a surgery, and "may ultimately avoid the recurrence of rhinophyma and contribute to a full skin repair leading to satisfactory functional and aesthetic outcome." [17] "This report describes a simple, safe, efficient, and cost-effective approach to the treatment of severe rhinophyma using a scalpel and the electroscalpel, instruments readily available in every operating room." [18] Scalpel Excision and Wire Loop Tip Electrosurgery [19] One reports says, "The CO2 laser is more capital intensive and results in higher fees compared with the simpler cold blade tangential excision. In our experience the ease of use, accuracy and precision of the lasers offer is not justified by the increased costs." [20] "Electrosurgery is one of the simplest and most cost-effective techniques currently available for the treatment of rhinophyma by dermatologists." [21] " It is suspected that many different factors may induce rhinophyma development. In our opinion, mechanical repetitive trauma is one of the most important.: [22] Salicylic acid 30% • Jojoba oil • Glycolic acid 70% • Baking Soda • Dawn Ultra Anecdotal Reports Nose Swelling, big pores, phymous tissue--please post! Another treatment has been reported, coblation. The report says, "A hand-held coblation ‘wand’ emits a slow stream of saline solution – sterilised salt water – from the end that comes into contact with the nose. At the same time, it emits waves of radiofrequency energy to excite the molecules in the solution which ‘sands’ down the tissue. It also uses a low heat to cauterise (clot) any bleeding blood vessels." [12] Fractionated Carbon Dioxide Laser Resurfacing as an Ideal Treatment Option for Severe Rhinophyma: A Case Report and Discussion. End Notes [1] Roberts JO, Ward CM. Rhinophyma. J R Soc Med 1985;78:678-681.[iSI] [Medline] StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jun 15. Rhinophyma. Dick MK1, Patel BC2. [2] J Am Acad Dermatol 2000;42:468-472.[CrossRef][iSI] [Medline] The clinicopathologic spectrum of rhinophyma. Aloi F, Tomasini C, Soro E, Pippione M. [3] J Am Acad Dermatol 1998;38:310-313.[iSI] [Medline] Cutaneous presentation of nasal lymphoma: a report of two cases. Murphy A, O'Keane JC, Blayney A, Powell FC. [4] Coblation of rhinophyma. Timms M, Roper A, Patrick C. J Laryngol Otol. 2011 Apr 27:1-5. [5] Sarcoidosis of the external nose mimicking rhinophyma. Case report and review of the literature. Goldenberg JD, Kotler HS, Shamsai R, Gruber B. Ann Otol Rhinol Laryngol. 1998 Jun;107(6):514-8. [6] Management of mild to moderate rhinophyma with a radiofrequency. Erisir F, Isildak H, Haciyev Y. J Craniofac Surg. 2009 Mar;20(2):455-6. [7] Rhinophyma treated with kilovoltage photons. Skala M, Delaney G, Towell V, Vladica N. Australas J Dermatol. 2005 May;46(2):88-9. [8] Treatment of rhinophyma with ultrasonic scalpel: case report. Tenna S, Gigliofiorito P, Langella M, Carusi C, Persichetti P. J Plast Reconstr Aesthet Surg. 2009 Jun;62(6):e164-5. Epub 2008 Dec 12. [9] Radiosurgical excision of rhinophyma. Somogyvári K, Battyáni Z, Móricz P, Gerlinger I. Dermatol Surg. 2011 May;37(5):684-7. doi: 10.1111/j.1524-4725.2011.01965.x. Epub 2011 Apr 1. Letter: radiosurgical excision of rhinophyma. Niamtu J 3rd. Dermatol Surg. 2012 May;38(5):816-7. doi: 10.1111/j.1524-4725.2012.02383.x. [10] Rhinophyma in rosacea : What does surgery achieve? Sadick H, Riedel F, Bran G. Hautarzt. 2011 Oct 19. [11] Nuances in the management of rhinophyma. Facial Plast Surg. 2012 Apr;28(2):231-7 Authors: Little SC, Stucker FJ, Compton A, Park SS [12] How salt-blasting surgery cured my disfiguring condition called 'drinker's red nose' By ROGER DOBSON Mail Online / Health PUBLISHED: 16:07 EST, 12 May 2012 | UPDATED: 17:23 EST, 12 May 2012 Read more: http://www.dailymail...l#ixzz1uvARY8Et [13] J Dermatolog Treat. 2012 Apr;23(2):153-5. Epub 2010 Oct 22. Moderate rhinophyma successfully treated with a Smoothbeam laser. Chou CL, Chiang YY [14] Conn Med. 2014 Mar;78(3):159-60. Surgical management of rhinophyma: a case report and review of literature. Ferneini EM, Banki M, Paletta F, Ferneini CM. [15] An Bras Dermatol. 2012 Dec;87(6):903-5. Gnatophyma: a rare form of rosacea. Macedo AC, Sakai FD, Vasconcelos RC, Duarte AA. [16] J Craniomaxillofac Surg. 2012 Dec 8. pii: S1010-5182(12)00248-X. doi: 10.1016/j.jcms.2012.11.009. Surgical correction of rhinophyma: Comparison of two methods in a 15-year-long experience. Lazzeri D, Larcher L, Huemer GM, Riml S, Grassetti L, Pantaloni M, Li Q, Zhang YX, Spinelli G, Agostini T. [17] Int J Surg Case Rep. 2012 Nov 10;4(2):200-203. doi: 10.1016/j.ijscr.2012.11.003. [Epub ahead of print] The surgical treatment of rhinophyma-Complete excision and single-step reconstruction by use of a collagen-elastin matrix and an autologous non-meshed split-thickness skin graft. Selig HF, Lumenta DB, Kamolz LP. Aesthetic Plast Surg. 2013 Jan 8. [Epub ahead of print] Optimizing Cosmesis with Conservative Surgical Excision in a Giant Rhinophyma. Lazzeri D, Agostini T, Spinelli G. [18] Aesthetic Plast Surg. 2013 Mar 1. [Epub ahead of print] Management of Severe Rhinophyma With Sculpting Surgical Decortication. Husein-Elahmed H, Armijo-Lozano R. [19] Dermatol Surg. 2013 Apr 5. doi: 10.1111/dsu.12193. [Epub ahead of print] Treatment of Severe Rhinophyma Using Scalpel Excision and Wire Loop Tip Electrosurgery. Prado R, Funke A, Brown M, Ramsey Mellette J. Source Northeast Dermatology Associates, Andover, Massachusetts. [20] J Craniomaxillofac Surg. 2013 Jul;41(5):429-36. doi: 10.1016/j.jcms.2012.11.009. Epub 2012 Dec 8. Surgical correction of rhinophyma: comparison of two methods in a 15-year-long experience. Lazzeri D1, Larcher L, Huemer GM, Riml S, Grassetti L, Pantaloni M, Li Q, Zhang YX, Spinelli G, Agostini T. [21] Actas Dermosifiliogr. 2017 Aug 9. pii: S0001-7310(17)30385-X. doi: 10.1016/j.ad.2017.02.033. [Epub ahead of print] Electrosurgery for the Treatment of Moderate or Severe Rhinophyma. González LF, Herrera H, Motta A. [22] Med Hypotheses. 2020 Jul 15;143:110097 A hypothesis: Role of physical factors in pathophysiology of rhinophyma - Focus on habitual mechanical trauma. Borzęcki A, Turska M

Papules A papule (/ˈpæpjuːl/) is a circumscribed, solid elevation of skin with no visible fluid, varying in size from a pinhead to 1 cm. It can be brown, purple, pink or red in color, and can cluster into a papular rash. Papules may open when scratched and become infected and crusty. Larger non-blisterform elevated lesions may by termed nodules. Papules may have different shapes and are sometimes associated with other features such as crusts or scales. Wikipedia Image - Wikipedia Commons Pustule "Pustule: A pustule is a small elevation of the skin containing cloudy or purulent material (pus) usually consisting of necrotic inflammatory cells. These can be either white or red." Wikipedia Image - Wikipedia Commons Pimple "A pimple, zit or spot is a kind of comedo and one of the many results of excess oil getting trapped in the pores. Some of the varieties are pustules or papules....Some more severe pimples can lead to significant swelling and may appear on the back and chest." Wikipedia Comedo "A comedo is a clogged hair follicle (pore) in the skin. Keratin (skin debris) combines with oil to block the follicle. A comedo can be open (blackhead) or closed by skin (whitehead), and occur with or without acne." Wikipedia Image - Wikipedia Commons Lesion "A lesion is any abnormal damage or change in the tissue of an organism, usually caused by disease or trauma....There is no designated classification or naming convention for lesions. Because the definition of a lesion is so broad, the varieties of lesions are virtually endless. Lesions can occur anywhere in the body that consists of soft tissue or osseous matter, though most frequently found in the mouth, skin, and the brain, or anywhere where a tumor may occur." Wikipedia Lesion counts are discussed in the following post. Cysts (Blood-filled Pimples) Blood-filled pimples (cysts) are usually associated with cystic acne. For more information click here. A collection of pus is called an abscess, not a cyst. Picture of Cystic Acne Abscess An abscess is usually not associated with rosacea but may be a co-existing condition. An abscess is a collection of pus that has built up within the tissue of the body. Wikipedia Five Day Old Abcess - Image courtesy of WikiMedia Commons Differentiation Your dermatologist should differentiate papules, pustules, pimples, comedos, lesions, cysts, and abscesses from milium (plural milia).

Facial flushing in a 22-year-old. Image courtesy of Wikimedia Commons Phenotype 1 Flushing "For a person to flush is to become markedly red in the face and often other areas of the skin, from various physiological conditions. Flushing is generally distinguished, despite a close physiological relation between them, from blushing, which is milder. Generally restricted to the face, cheeks or ears, but also presents in the vagina, specifically in the Vulva and generally assumed to reflect emotional stimulus such as embarrassment, or lovestruck|romantic stimulation. Flushing is also a cardinal symptom of carcinoid syndrome—the syndrome that results from hormones (often serotonin or histamine) being secreted into systemic circulation." Wikipedia Gerd Plewig, MD, says, "there is no direct evidence that rosacea is primarily a vascular disorder. The response of the facial vessels to adrenaline, histamine and acetylcholine is normal, and the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls. In addition, the distribution of rosacea is not identical with the flush area." [1] The controversy about flushing is best described by a noted authority on rosacea, Albert Kligman who wrote, "I, and others, regard rosacea as fundamentally a vascular disorder which ineluctably begins with episodes of flushing, eventuating in the 'red' face." [2] However, another noted authority on rosacea, Dr. Frank Powell "insists that episodes of flushing are not a prerequisite for making a diagnosis of rosacea, and that some patients can develop the full-blown disease without a prior history of frequent flushing. Rebora too, another investigator, says that flushing is not a necessary stage in the sequence leading up to the full-blown 'red face'." [4] Powell in his book wrote a chapter on Flushing and Blushing and confirms what other clinicians have found that while both are seen 'sufficiently often enough' in rosacea patients and both flushing and/or blushing are the 'first features of rosacea to appear in some patients," nevertheless, "flushing and blushing are not necessarily a component of the clinical picture in all patients with rosacea." [5] Flushing is a sign/symptom of rosacea just as telangiectasia, erythema, pustules/papules, ocular manifestations, or rhinophyma, which are the six phenotypes of rosacea. In the old subtype classification flushing was not separated into a subtype. Read this notice about the subtype classification. Flushing is now considered a phenotype of rosacea. However, not all rosacea cases include all six phenotypes. Not all cases of rosacea include the Flushing phenotype. [6] Generally speaking more rosacea sufferers experience flushing than those who report they do not flush. Flushing is associated as a sign/symptom with many conditions. As one report concludes, "flushing [is] associated with fever, hyperthermia, emotions, menopause, medications, alcohol, food, hypersensitivity reactions, rosacea, hyperthyroidism, dumping syndrome, superior vena cava syndrome, and neurologic etiologies. [7] It is important that the physician differentiates rosacea from these other conditions. Treatment for Phenotype 1 Blushing & Flushing Triggers Prescription and Non Prescription Flushing Avoidance List of Anecdotal Reports of Rosaceans Who Report No Flushing End Notes [1] Rosacea: classification and treatment. T Jansen and G Plewig J R Soc Med. 1997 March; 90(3): 144–150. [2] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman, M.D., Ph.D. The William J. Cunliffe Lectureship 2003 –Manuscript [4] Am J Clin Dermatol 2002; 3: 489-496. The management of rosacea. Rebora A [5] Rosacea Diagnosis and Management by Frank Powell with a Contribution by Jonathan Wilkin [6] Anecdotal reports of patients who received a diagnosis of rosacea who report no flushing: Rhea, 4th August 2012 01:58 PM More Info on Flushing [7] J Am Acad Dermatol. 2017 Sep;77(3):391-402. doi: 10.1016/j.jaad.2016.12.031. Etiologies and management of cutaneous flushing: Nonmalignant causes. Sadeghian A, Rouhana H, Oswald-Stumpf B, Boh E.

Erythema (from the Greek erythros, meaning red) is redness of the skin or mucous membranes, caused by hyperemia (increased blood flow) in superficial capillaries. It occurs with any skin injury, infection, or inflammation. Examples of erythema not associated with pathology include nervous blushes. Wikipedia Erythema in rosacea usually involves the Butterfly or T-Zone area of the face. Image - Wikipedia Commons Persistent Facial Erythema (PFE) Dr. Del Rosso points out that if "...persistent facial erythema (PFE) is the pivotal diagnostic feature of cutaneous rosacea, including in both the presence or absence of papulopustular lesions..."that dermatologists"...Consider the role of PFE in essentially all patients with cutaneous rosacea." [1] Erythema used to be designated into one subtype along with telangiectasia: Erythematotelangiectatic Rosacea - Subtype 1 (now separated into Phenotype 2 and Phenotype 3). Read this notice about the subtype classification. Treatment for Phenotype 2 End Notes [1] Journal of drugs in dermatology: JDD June 2019 | Volume 18 | Issue 6 | Editorials | 503 | Copyright © June 2019 What Is “PFE”? It May Just Be Time You Found Out…. Del Rosso Q. James DO JDR Dermatology Research/Thomas Dermatology Las Vegas, NV

To understand why phenotype based treatment is superior to subtype based treatment for rosacea, lets take the case of classifying rosacea as Subtype 1 - Erythematotelangiectatic Rosacea. A rosacean could present clinical features of erythema without any flushing symptoms and be treated with brimonodine. Another rosacean could present with clinical features of teleangiectasia and be treated with laser. These two very different clinical features are classified into one subtype. A third rosacean could present with erythema due to flushing with no telangiectatic signs and treated with anti-flushing drugs. The advantage of a phenotype based treatment is that these three clinical features are separated into (1) Phenotype Flushing, (2) Phenotype Persistent Erythema or (3) Phenotype Telangiectasia and receive totally different treatments determined by this new phenotype based treatment protocol. "The characteristic rosacea symptoms manifest primarily, but not exclusively centrofacially, with forehead, nose, chin and cheeks significantly affected. Based on the various main symptoms a classification of the individual clinical pictures can be performed. However, a classification often does not reflect the clinical reality, since the various symptoms commonly coexist. The present review provides an introduction on pathogenesis and clinical manifestations of rosacea and prefers a symptom-oriented therapy approach." [1] Subtype Classification Overlaps Signs and Symptoms "However, a classification often does not reflect the clinical reality, since the various symptoms commonly coexist. The present review provides an introduction on pathogenesis and clinical manifestations of rosacea and prefers a symptom-oriented therapy approach." [2] Since 2002, "A subtype-directed approach to treating rosacea patients is recommended to dermatologists." Wikipedia The subtype classification has proved wanting and was controversial from the beginning of its inception. "Subtyping of rosacea, a post-hoc means of grouping more common presentations, can be and has been subverted inappropriately to imply strict categories without adequate consideration of the varying phenotypic presentation of individuals and the potential for temporal variation." [3] Phenotype Classification Uses Signs and Symptoms Better Phenotype Classification Distinguishes Signs and Symptoms "The panel agreed on phenotype-based treatments for signs and symptoms presenting in individuals with rosacea." [4] "It’s more important to be categorizing based on patients’ presentation in terms of signs and symptoms,” [5] "The use of a phenotype approach will allow a more accurate and stringent classification of rosacea. New diagnostic tools emerge, and transcriptome analysis has revealed a possible distinct gene profile for each subtype of rosacea. A change in paradigm towards a phenotype classification, which can also easily be combined with newer diagnostic methods, such as transcriptome analysis, is an interesting possibility. The use of more objective criteria will allow those aspects that are most troubling to patients to be better targeted and allow the best treatment to be selected." [6] "For past decade, a subtype classification has been used, but now rosacea experts are advising a move toward a phenotype approach which allows better targeting of treatment." [7] What distinguishes the phenotype classification from the subtype classification? Answer. Conclusion Since 2016, a phenotype-directed approach to treating rosacea was introduced by the ROSCO panel which has proved superior and there is no controversy about this since it takes a symptom oriented approach. In December 2018 a group published in the British Journal of Dermatology concluded, "We present the most current evidence for rosacea management based on a phenotype-led approach." [8] End Notes [1] Pathogenesis and clinical presentation of rosacea as a key for a symptom-oriented therapy. J Dtsch Dermatol Ges. 2016 Dec;14 Suppl 6:4-15 Reinholz M, Ruzicka T, Steinhoff M, Schaller M, Gieler U, Schöfer H, Homey B, Lehmann P, Luger TA [2] J Dtsch Dermatol Ges. 2016 Dec;14 Suppl 6:4-15 Pathogenesis and clinical presentation of rosacea as a key for a symptom-oriented therapy. Reinholz M, Ruzicka T, Steinhoff M, Schaller M, Gieler U, Schöfer H, Homey B, Lehmann P, Luger TA "Most current guidelines are based on the identification of the rosacea subtype to select the appropriate therapy. However, in reality there is often an overlap of clinical features across rosacea subtypes in each patient, requiring several therapeutic strategies for optimal outcome. Thus, there is no single best way to treat all rosacea patients." Dermatoendocrinol. 2017; 9(1): e1361574. Rosacea: Epidemiology, pathogenesis, and treatment Barbara M. Rainer, Sewon Kang, and Anna L. Chien [3] Shortcomings in rosacea diagnosis and classification [4] 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. [5] Phenotype Classification Uses Signs and Symptoms Better [6] Forum for Nord Derm Ven 2017, Vol. 22, No. 1 Rosacea: Time for a New Approach • Rosacea-Time-for-a-New-Approach.pdf CARSTEN SAUER MIKKELSEN, PETER BJERRING, MARGARETA LIRVALL, MARGARETA SVENSSON, HELENE RINGE HOLMGREN, ALEXANDER SALAVA AND THEIS HULDT-NYSTRØM ]7] J Drugs Dermatol. 2019 Sep 01;18(9):888-894 Recognizing Rosacea: Tips on Differential Diagnosis Johnson SM, Berg A, Barr C [8] Br J Dermatol. 2018 Dec 26. doi: 10.1111/bjd.17590. [Epub ahead of print] Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. van Zuuren EJ, Fedorowicz Z, Tan J, van der Linden MMD, Arents BWM, Carter B, Charland L.

Phenotype 3 Telangiectasias /tɛlˌæn.dʒiː.ɛkˈteɪ.zi.ə/ (sometimes called t. langiatasis) also known as spider veins or angioectasias, are small dilated blood vessels near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. Telangiectasias was lumped together into one previous subtype along with erythema - Erythematotelangiectatic Rosacea - Subtype 1 (now separated into Phenotype 2 [Erythema] or Phenotype 3 [Telangiectasias]). Read this notice about the subtype classification. Rosacea Telangiectasis courtesy of BPAC These dilated blood vessels can develop anywhere on the body but are commonly seen on the face around the nose, cheeks, and chin. Wikipedia By Permission of Wikipedia Commons Niamatu Cosmetic Facial Surgery has a photo gallery of nose and cheek spider veins (scroll down to see the photo gallery). Treatment for Phenotype 3 Laser and Radio frequency (keep scrolling below) Tranexamic acid (TXA) Intradermal Microinjections More Treatments Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post.

Nip & tuck with Tracy Mountford: Is there a clever way to calm my red skin? DailyMail

Rosacea Therapeutics Market Is Driven Owing to Rising Awareness Among People Through Smartphone Ownership and Penetration of Internet, Digital Journal

5 Amazing Remedies for Rosacea Skin Problems, DesiBlitz

'I LOOKED LIKE A TOMATO' Beauty blogger ditches gluten and dairy to combat embarrassing rosacea flare ups, The Sun 'My face looked like a tomato': Woman, 32, who suffered from a horrific skin condition reduces her flare-ups by ditching gluten, by Stephen Matthews, DailyMail

Treatment guidelines updated for patients with rosacea, November 21, 2016, Medical Press Phenotype-based treatments recommended for rosacea, Health Day News, Clinical Advisor Expert Panel Provides Recommendations for Rosacea Treatment, MPR

The ROSCO panel has changed the direction of classifying rosacea from subtypes to phenotypes. What is the difference between a phenotype based treatment vs a subtype based treatment? Genetics We have to begin with Genotype which "is the part (DNA sequence) of the genetic makeup of a cell, and therefore of an organism or individual, which determines a specific characteristic (phenotype) of that cell/organism/individual. Genotype is one of three factors that determine phenotype, the other two being inherited epigenetic factors, and non-inherited environmental factors." Wikipedia Genotype-phenotype distinction "The genotype–phenotype distinction is drawn in genetics. "Genotype" is an organism's full hereditary information. "Phenotype" is an organism's actual observed properties, such as morphology, development, or behavior." Wikipedia A phenotype (from Greek phainein, meaning "to show", and typos, meaning "type") is the composite of an organism's observable characteristics or traits, such as its morphology, development, biochemical or physiological properties, phenology, behavior, and products of behavior (such as a bird's nest). Wikipedia Watch this short whiteboard animation on the difference between genotype and phenotype: Phenotype and Subtype in Medicine Phenotype A phenotype in medicine is "the observable properties of an organism that are produced by the interaction of the genotype and the environment." Merriam Webster Medical Dictionary Endotype "An endotype is a subtype of a condition, which is defined by a distinct functional or pathobiological mechanism. This is distinct from a phenotype, which is any observable characteristic or trait of a disease, such as morphology, development, biochemical or physiological properties, or behavior, without any implication of a mechanism. It is envisaged that patients with a specific endotype present themselves within phenotypic clusters of diseases." Wikipedia Disease Entity "The main concept in nosology is the disease entity. Normally there are two ways to define a disease entity: Manifestational criteria and Causal criteria. Manifestational criteria. They are a set of criteria based in signs, symptoms and laboratory findings that define a disease. They define the disease by its symptoms and medical findings. Causal criteria are a causal chain of events that define the disease describing how it develops. They describe the disease by its etiology." Wikipedia Subtype A subtype in medicine is "a type that is subordinate to or included in another type <the blood group subtypes> <subtypes of a disease>." Merriam Webster Medical Dictionary When the NRS 'expert' committee in 2002 began the classification of rosacea into subtypes, they did this based upon good motive. As one paper on this subject put it, "Broadly construed, disease subtyping is the task of identifying subpopulations of similar patients that can guide treatment decisions for a given individual. (When the subtypes have been established to be causally associated with the underlying mechanism, these are also called endotypes) Boland and colleagues describe the concept of a “vero-type” (the Latin word vero means “true”) to represent the true population of similar patients for treatment purposes. What constitutes these vero-types and how they should be discovered remains an open question. An active and growing body of work has explored different approaches for identifying homogeneous patient subgroups ranging from qualitative—based on clinical observations alone—to quantitative models that integrate mea- surements from diverse high-throughput biotechnologies." [1] "Traditionally, disease subtyping research has been conducted as a by-product of clinical experience, wherein a clinician noticed the presence of patterns or groups of outlier patients and performed a more thorough (retrospective or prospective) study to confirm their existence." [1] Subtype Related to Phenotype in Health Records According to the author of the above referenced paper it appears that subtyping is related to 'Electronic Health Records and Phenotyping' and states, "Thus, much research has focused on developing new algorithms for annotating patient records with this information; in the literature, this task of extracting various clinical attributes for each individual is referred to as phenotyping....It is important to remember that phenotyping facilitates cleaner, but still broad, categories of disease....Thus, recent efforts have built on phenotyping work to move away from analysis of broad disease categories and instead provide more descriptive definitions of the disease over time." Why is the phenotype classification superior to the subtype classification? Answer. End Notes [1] AI and Health, Daniel B. Neill, H.J. Heinz III College, Carnegie Mellon University