Symptoms of Rosacea

(Taken from their book, Acne and Rosacea, Second Edition, 1993)

Stage I: The erythema (redness) may persist for hours and days, hence the old term erthema congestivum (redness congestion.) Erythema lasting only a few minutes is not early rosacea. Telangiectases becomes progressively prominent, forming sprays on the nose, nasolabial folds, checks, and glabella. Most of these patients complain of sensitive skin that stings, burns, and itches after application of a variety of cosmetics, especially certain fragrances and sunscreens. Trauma from abrasives and peeling agents readily induces long-lasting erythema, thus the facial skin is unusually vulnerable to chemical and physical stimuli.

Stage II: Inflammatory papules and pustules crop up and persist for weeks. Some papules show a small pustule at the apex, justifying the term papulopustular. The lesions are always follicular in origin, mainly in sebaceous follicles but also in the smaller and more numerous vellus follicles. Comedones do not occur. The deeper inflammatory lesions may heal with scarring, but scars are inconspicuous and tend to be shallow. Facial pores become larger and prominent. If there has been much solar exposure over decades, the stigmata of photodamaged skin becomes superimposed, namely yellowed, leathered skin (elastosis), wrinkles and solar comedones. The papulopustular attacks become more and more frequent. Finally, rosacea may extend over the entire face and even spread to the scalp, especially if the patient is balding. Itchy follicular pustules of the scalp are typical. Eventually, the sides of the neck as well as the retroauricular and presternal area may be affected.

Stage III: A small proportion of patients develop more serious expressions of the disease, namely large inflammatory nodules, furunculoid infiltrations, and tissue hyperplasia. These derangements occur particularly on the cheeks and nose, less often on the chin, forehead, or ears. The facial contours gradually become coarse, thickened, and irregular. Curiously, patients may not notice these disfigurements. The deranged appearance becomes evident when photographs from previous years are reviewed. Finally, the patient shows diffusely inflamed, thickened, edematous skin with large pores, resembling the peel of an orange. These coarse features are due to extensively inflammatory infiltration, connective tissue hypertrophy, massive fibrosis and elastosis, diffuse sebaceous gland hyperplasia, and extreme enlargement of individual sebaceous glands forming dozens of yellowish unbilicated papules on the cheeks, forehead, temples, and nose. Thickened folds and ridges may create a grotesque appearance mimicking leonine faces of leprosy or leukemia. The ultimate deformity is the phymas, of which rhinophyma is the prototype.

Telangiectasia (also called spider viens) are red lines that may appear with the progression of rosacea. This effect is due to small blood vessels of the face becoming enlarged and emerge closer to the top of the skin to become most visible and offensive to the rosacea patient. Telangiectasia usually appears on the cheek and nose area and is more noticeable as the rosacea flush subsides. A very small number of dermatogists believe the theory that by searing, sealing, or destroying the vessel by use of lasers will eliminate the telangiectasia. However, the skin needs the blood flow to carry necessary oxygen and nutrients to the skin to stay alive. When these vessels are destroyed, the skin will try to repair itself by creating more arteries and veins to sustain life. And if the skin does not grow more vessels, then necrosis or cell death takes place and the skin dies. So it is most advantageous to have regrowth of the vessels and better yet not to use lasers on skin or any organ unless it is cancerous and the objective is to kill the cancer, or a varicose vein and the object is to kill or strip the vein Also these very same dermatogists believe in the revenue theory also. You will be most challanged to find even 'one' large university medical center anywhere in the world to use laser as a treatment for rosacea as they 'know better.'

These are tiny broken blood vessels that are permanently fixed in the dilated state. These blood vessels take on the appearance of fine red lines coursing through the surface of the facial skin. Telangiectasis is easy to recognize, characterized by the visible presence of capillaries, bright red in color. Diffuse redness frequently precedes the appearance of telangiectasis and is a constant flushed appearance. True diffuse redness is quite different from a localized erythema as seen in cases of sunburn, inflammation or over stimulation. With both telangiectasis and diffuse redness, the redness is not transitory and there generally is not an increase in skin temperature, but particularly there are no alterations in the tissue structure or biochemistry as seen in rosacea. The circulatory network of the skin is extensive and the capillaries are the smallest, most delicate vessels. During normal blood circulation the capillaries undergo constant changes. In between beats the pressure is relieved and the vessels constrict back to their normal size. This return to normal size is accomplished by the natural elasticity in the structure of the capillary. If telangiectasis is present, the capillaries' elasticity is deteriorated so they remain slightly dilated. The constant influx of blood perpetuates this slight dilation. The skin gradually becomes congested and eventually the capillaries become visible through the skin's surface. When it comes to telangiectasis, sometimes a person's lifestyle and habits can be the skin's worst enemy. In a fair, delicate skin predisposed to telangiectasis, a steady diet of hot, spicy food, chronic alcohol consumption, and eating meals too quickly will promote telangiectasis.

Then there's cigarette smoking, which depletes the skin of vitamin C, essential for the formation of collagen, accelerates the crosslinkage of collagen and the hardening of elastin and furthermore creates a trillion free radicals, which destroy the capillary structure. Smoking, which additionally robs the skin of oxygen, is a potent initiator of telangiectasis. Also, the smoker may have a variety of medical problems such as high blood pressure, and mineral deficiencies, which can cause the appearance of telangiectasis.

Papules (PAP yule) are a small, red, solid, elevated inflammatory skin lesion without pus that is minor when the size is of a small measles lesion, moderate when about the size of a pencil eraser, and severe when the papule is the size of a small currency coin or the tip of the little finger. The top of the papule can be flat, pointed, or rounded. Papules are common lesions in acne.

These bumps are caused by vascular flushing. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the skin. These inflammatory cells then migrate toward the surface of the skin, resulting in inflammatory papules. Facial papules are not caused by bacteria or demodex mites.

Facial pustules are small red inflamed, pus-filled, blister-like lesions on the skin surface. These bumps are caused by vascular flushing in areas around sebaceous glands. Over time, flushing results in leakage of inflammatory cells out of the blood vessels and into the skin. These inflammatory cells then migrate towards the sebaceous gland or pore, resulting in inflammatory pustules. The redness can come and go, but eventually it may become permanent. Furthermore, the skin tissue can swell and thicken and may be tender and sensitive to the touch. Note: Pustules are NOT pimples. Pimples have a bacterial component to their pathogenesis and are also mainly localized in and around the hair follicles.

Pustules on the skin surface are relatively common occurrences. Pustules are common in acne and are the yellowish topped, small, pus-filled lesions that adolescents are notorious for picking and squeezing.

Facial pimples are an inflammatory skin condition characterized by superficial skin eruptions around hair follicles also called acne vulgaris and/or cystic acne.

Acne is most common in adolescents, but it can occur at all ages. There seems to be a familial tendency to develop acne. The condition usually begins at puberty and may continue for many years. Three out of four teenagers have acne to some extent, probably caused by hormonal changes that stimulate the sebaceous (oil producing) skin glands. Other hormonal changes can occur with menstrual periods, pregnancy, use of birth control pills, or stress, and also aggravate acne.

Acne is caused when sebaceous glands within the hair follicles (pores) of the skin become plugged, because secretion occurs faster than the oil and skin cells can exit the follicle. The plug causes the follicle to bulge (causing whiteheads), and the top of the plug may appear dark (causing blackheads). If the plug causes the wall of the follicle to rupture, the oil, dead skin cells, and bacteria found normally on the surface of the skin can enter the skin and form small infected areas called pustules (also known as pimples or "zits"). If these infected areas are deep in the skin, they may enlarge to form firm, painful cysts.

Acne commonly appears on the face and shoulders, but may extend to the trunk, arms and legs. Dirt and oil on the face can aggravate the condition. Other factors that increase the chances of acne are hormonal changes, exposure to weather extremes, stress, oily skin, endocrine disorders, certain tumors, and the use of certain drugs (such as cortisone, testosterone, estrogen, and others.) Acne is not contagious. A tendency to have acne may persist through ages 30's to early 40's.

The tendency to develop acne is inherited. Although acne cannot be prevented, careful cleanliness and gentle skin care can help to lessen the effects.

Symptoms of acne vulgaris include a skin rash or lesion on the face, truck (chest), neck, back, or other area, comedones (whiteheads or blackheads), pustules, cysts, papules, nodules, redness (erythema) of the skin lesions or skin around a lesion, inflammation around the skin eruptions, and/or crusting of skin eruptions, scarring of the skin.

Treatment is designed to prevent formation of new lesions and aid the healing of old lesions. Topical medications that dry up the oil and/or promote skin peeling may contain benzoyl peroxide, sulfur, resorcinol, salicylic acid or Vitamin A derivatives (retinoids.) Antibiotics (such as tetracycline or erythromycin) may be prescribed if the skin lesions appear infected. Topical antibiotics (applied to a localized area of the skin) such as clindamycin or erythromycin are also used to control infection. Note: oral tetracycline is usually not prescribed for children until after they have all their permanent teeth, because it can permanently discolor teeth that are still forming. Synthetic Vitamin A analogues (isotretinoin, Accutane) have been shown to be of benefit in the treatment of severe acne. However, pregnant women and sexually active adolescent females should not take this medication! Severe birth defects will occur. Surgical intervention may include professional (chemical) skin peeling, removal of eruptions or scars (dermabrasion), or removal and/or drainage of cysts. A small amount of sun exposure may improve acne. However, excessive exposure to sunlight or ultraviolet rays is not recommended because prolonged exposure increases the risk of skin cancer.

The following suggestions may lessen the effects of acne:

• Clean the skin gently but thoroughly with soap and water, removing all dirt or make-up. Wash as often as needed to control oil, at least daily and after exercising.
• Shampoo hair daily when possible. Use a dandruff shampoo if necessary.
• Comb or pull hair back to keep hair out of the face.
• Don’t squeeze, scratch, pick, or rub lesions. These activities can increase skin damage. Wash your hands before and after caring for skin lesions to reduce the chance of infection.
• Don’t rest your face on your hands. This irritates the skin of the face.
• Identify and avoid anything that aggravates acne. Though no substance is proven to cause acne in everyone, your triggers may include foods, lotions, make-up, and so on. Avoid greasy cosmetics or creams, which can aggravate acne.

Acne usually subsides after adolescence, but may persist indefinitely. Acne generally responds well to treatment after a few weeks, but may flare up from time to time. Acne is not medically dangerous except in severe cases. Scarring may occur if severe acne is not treated.

Acne can be complicated by cyst, skin abscess, permanent facial scars, keloids, skin pigment changes, psychological damage to self-esteem, confidence, personality, social life, side effects of Accutane (including liver damage and damage to the fetus), and /or side effects of other medications. Use of harsh acne topical treatments can lead to a condition known as acne rosacea.

Acne rosacea is a chronic acneiform disorder affecting both the skin and the eye. It is a characterized by both vascular and papulopustular components involving the face and occasionally the neck and upper trunk. Acne rosacea is often described as red, flushed skin with breakouts or papules concentrated on the nose, forehead, and cheeks commonly characterized by dry, flaking skin. Acne rosacea typically results in facial flushing after drinking alcohol, eating hot or spicy foods, or events that increase body temperature.

Clinical findings are usually limited to the sun exposed areas of the face and chest and include mid facial erythema, telangiectasias, papules and pustules, and sebaceous gland hypertrophy. During inflammatory episodes, affected areas of the skin, primarily the convexities of the face, develop swelling, papules, and pustules. The skin lesions are notable for the absence of comedones, which distinguishes this disorder from acne vulgaris.

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

Rhinophyma has been observed from ancient times in Greece but first named by Hebrea in 1845. It comes from the Greek words: Rhis (Greek for nose) and phyyma (Greek for growth).

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

It is a more severe form of acne rosacea. The cause is not really known. Rhinophyma has been associated with many causes such as the over-consumption of alcohol. No consistent causative factor has been identified to date. Men are 12 times more likely to have this problem than women.

Symptoms include overgrowth of the sebaceous (oil making) skin glands, vessel and tissue growth in the deeper layers of the skin, and a thickening of the outer layer of the skin. This can make for a very obvious and prominent nose.

Nonsurgical treatment for rhinophyma is similar to acne care and includes attention to skin hygiene, avoidance of foods that seem to worsen the condition, and the use of antibiotics when small infections are present.

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