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Curse of the Celts: tackling rosacea

Rosacea is a common skin disorder that causes redness of the skin. Known as the ‘curse of the Celts’, rosacea is one of the most common skin conditions seen in Irish patients.

People who develop rosacea commonly have a tendency to flush/blush very easily. Key triggers include a change in environmental temperature and consuming hot drinks, alcoholic beverages or spicy foods. Because the redness of rosacea is made worse with alcohol intake, some wrongly attribute the cause of this disorder to alcohol excess. Other key triggers are sunlight exposure and stress.

Epidemiology

According to Prof Frank Powell, Professor Of Dermatology, University College Dublin Charles Institute for Dermatology, and one of Ireland’s leading authorities on rosacea, the condition usually affects people in their 30s or 40s. Both men and women are affected, but rosacea appears to be more common in women, with men generally having more severe disease.

Once rosacea starts, it usually persists, fluctuating in severity over many months or even years. Eventually, rosacea clears or ‘burns itself out’ and it is rarely seen in elderly persons, he notes.

A person who develops rosacea initially notices small red spots on their nose, chin, forehead or the cheeks. There is a slight stinging sensation from these spots, but no real itch, soreness or discomfort. The red spots typically appear in groups of two or three that persist for about 10 days, Prof Powell writes in his booklet ROSACEA: The Curse of the Celts — A Handbook for Patients and the General Public.

These spots gradually flatten and merge into the skin, leaving behind a slight red blotch, like a ‘footprint’ of where they have been. Unlike the lesions of teenage acne, there is no tendency to scarring of the skin.

If no treatment is given, this process continues over many months and gradually gets worse, Prof Powell says. The red blotches become more widespread and blend together so that the rosacea sufferer progressively develops a striking and embarrassing redness at the centre of their face.

According to Prof Powell, a consistent but often overlooked finding in the skin of patients with rosacea is the presence of tiny skin mites called demodex folliculorum. These microscopic creatures live in the oil canals of the face and the eyelids. Patients with rosacea have about four times as many demodex mites in their skin compared with people with clear skin.

Research funded by the Health Research Board (HRB) has helped to determine what the relationship is between these mites and rosacea. This research has shown that the oil in the skin of rosacea patients is different, and possibly conducive to the multiplication of these mites.

While some anti-mite treatments can clear skin lesions in rosacea patients, these treatments have not yet been studied in sufficient detail to ensure they are safe and effective in the long term, he says.

Treatment

While there is no definitive cure for rosacea, the condition can be well managed and there are a number of new topical treatments on the market, as well as improved laser treatment and increased prescription of antibiotics to tackle the root causes.

The symptoms of rosacea can be treated in a number of ways, according to the latest HSE guidance on the condition.

Making lifestyle changes, such as avoiding possible triggers and wearing high-factor sunscreen and avoiding direct sunlight where possible, can be a good way of controlling the symptoms of facial flushing. As strenuous exercise can trigger an outbreak of rosacea, a low-intensity exercise programme, such as walking or swimming, may be better than high-intensity activities, such as running or aerobics.

It may be possible to disguise patches of persistent red skin using specially-designed ‘camouflage’ make-up. GPs or dermatologists can refer to the skin camouflage service and prescribe skin camouflage make-up.

Patients should be advised to avoid using oil-based make-up, scented soaps, alcohol-based skin cleansers or other facial or hair products that contain ingredients that might irritate skin, such as alcohol and fragrances. Skin-care products that are suitable for sensitive skin or non-comedogenic are best for rosacea patients.

A number of treatments are effective in treating the spots and pimples caused by rosacea. GPs can recommend a cream or gel as the first treatment option.

Metronidazole

Metronidazole cream or gel (topical metronidazole) is usually recommended for the treatment of mild-to-moderate spots and pimples.

When applying metronidazole cream or gel, patients should be careful not to get any in their eyes or mouth. They will need to apply topical metronidazole once or twice a day for several months.

Metronidazole does not usually cause any side-effects, although it may irritate skin. Users should avoid exposure to strong sunlight or UV light (used in some lamps and nightclubs).

Azelaic acid

An alternative to topical metronidazole is azelaic acid. Azelaic acid helps to unblock pores and reduce inflammation.

Patients will need to apply azelaic acid cream or gel twice a day and avoid contact with the mouth and eyes. As with topical metronidazole, patients may need to use azelaic acid for several months before they notice any significant improvement in their symptoms.

About a third of people who use azelaic acid will experience side-effects. However, any side-effects are usually short-lived.

The side-effects of azelaic acid can include burning and stinging of the skin, itchiness and dry skin.

Isotretinoin

Isotretinoin is often used to treat severe acne. However, it is also occasionally used to treat rosacea. It can only be prescribed by a dermatologist and not GPs, according to the HSE.

Isotretinoin can cause a number of side-effects, some severe.

Antibiotics

For more serious symptoms of spots and pimples, oral antibiotics may be recommended. In this case, the antibiotics are used for their ability to reduce inflammation of the skin rather than for their ability to kill bacteria.

As with the other treatments, the patient will need to take oral antibiotics for several weeks before they notice a significant improvement in their symptoms. They may need to take oral antibiotics once or twice a day for several months or longer.

The two antibiotics that are most commonly used to treat rosacea are tetracyclines and erythromycin.

Tetracyclines

Tetracyclines are not suitable for women who are pregnant or breast-feeding, as they can cause birth defects in unborn children and interfere with normal bone development in breast-fed children, or for people with a history of kidney disease.

Tetracyclines should be used cautiously in people with a history of liver problems, myasthenia gravis, or systemic lupus erythematosus.

Tetracyclines may cause oral contraceptives to fail during the first few weeks of treatment. Sexually-active women of child-bearing age should use a barrier method of contraception while taking tetracyclines, such as a condom, to avoid becoming pregnant.

Tetracyclines can also make skin more sensitive to the effects of sunlight, so advise patients to avoid exposure to direct sunlight.

Tetracyclines can interact with a number of medications, including warfarin and antacids.

A rare but potentially serious side-effect of tetracyclines is that they can cause an increase in the pressure of the fluid that surrounds the brain, ie, benign intracranial hypertension. The symptoms of benign intracranial hypertension include a severe headache and a disturbance in vision.

If a patient has these symptoms, they should stop taking tetracyclines and contact their GP.

Erythromycin

Erythromycin can be used in women who are pregnant or breast-feeding. It should be used cautiously in patients who have a history of liver or kidney problems, and myasthenia gravis.

Erythromycin can interact with a number of medications, including warfarin and statins.

Visible blood vessels

The symptoms of visible blood vessels associated with rosacea are known as telangiectasia. Treatment for telangiectasia will usually require a referral to a dermatologist.

Laser treatment is one of the most widely-used treatments for telangiectasia. Laser treatment can cause some pain, but most people do not need to have an anaesthetic.

Side-effects of laser treatment are usually mild and can include:

Bruising.

Crusting of the skin.

Swelling and redness of the skin.

Blisters (in rare cases).

Infection (in very rare cases).

These side-effects usually only last a few days and are rarely permanent. An infection will require treatment with antibiotics.

Thickened skin

Thickened skin (rhinophyma) is a symptom of rosacea that often affects the nose. If a patient has severe rhinophyma, the GP may refer to a dermatologist or plastic surgeon.

A number of surgical treatments are available to remove any excess tissue and remodel the nose into a more pleasing shape. This may be done with a carbon dioxide laser or a scalpel.

Ocular rosacea

Rosacea that affects the eyes (ocular rosacea) can lead to a number of eye conditions.

Blepharitis is the most commonly-reported eye condition resulting from rosacea. It can usually be successfully treated by adopting a daily eye-cleaning regimen and by using antibiotic tablets and creams.

Up to one-in-20 people with rosacea may experience symptoms that affect their cornea. This can make eyes bloodshot and watery and cause scarring of the cornea.

In severe cases, if it is not treated, ocular rosacea can lead to vision loss. GPs may refer such patients for treatment to an ophthalmologist.

Standard treatments for ocular rosacea include:

Ocular lubricants. Eye drops or eye ointment can be used to treat dry eyes.

Eye hygiene measures. If a patient has blepharitis, they may need to clean their eyelids with a warm compress (a cloth warmed with hot water) or cotton bud.

Antibiotics such as tetracyclines.

References on request

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