Rosacea 101: Includes the Rosacea Diet

Copyright © 2007 by Brady Barrows

All rights reserved. No part of this book may be used or reproduced by any

means, graphic, electronic, or mechanical, including photocopying, recording,

taping or by any information storage retrieval system without the written

permission of the publisher except in the case of brief quotations embodied in

critical articles and reviews.

iUniverse books may be ordered through booksellers or by contacting:

iUniverse

2021 Pine Lake Road, Suite 100

Lincoln, NE 68512

www.iuniverse.com

1-800-Authors (1-800-288-4677)

Because of the dynamic nature of the Internet, any Web addresses

or links contained in this book may have changed

since publication and may no longer be valid.

ISBN: 978-0-595-44426-7 (pbk)

ISBN: 978-0-595-88754-5 (ebk)

CONTENTS

Preface

Chapter I     What is Rosacea?

Chapter 2     Rosacea Mimics

Chapter 3     What Causes Rosacea?

Chapter 4     Is There a Cure?

Chapter 5     treatment

Chapter 6     Rosacea & Psychology

Chapter 7     Demodectic Rosacea A Rosacea Variant

Chapter 8     Steroid-induced Rosacea

Chapter 9     Ocular Rosacea

Chapter 10   Flushing

Chapter 11   Triggers

Chapter 12   Physicians

Chapter 13   Prescriptions

Chapter 14   Non-Prescription—OTC

Chapter 15   Medical Insurance

Chapter 16   Light Devices

Chapter 17   Natural Treatments

Chapter 18   Rosacea Research & Non Profit Organizations

Chapter 19   Recommended Regimen

Chapter 20   Rosacea Research & Development Institute

Chapter 21   Cosmetics

Chapter 22   Lifestyle

Chapter 23   Support

Chapter 24   Rosacea Diet

Chapter 25   Fat Vs. Sugar

Chapter 26   Sugar & Rosacea

Chapter 27   Sugars to Avoid

Chapter 28   Short Term and Long Term Effects of the Rosacea Diet

Chapter 29   30 Grams of Carbohydrate, 30 Days and No Sugar

Chapter 30   Ten Suggestions for the Rosacea Diet

Chapter 31   Omnivores

Chapter 32   Vegetarians

Chapter 33   Post Rosacea Diet

Appendix A   Rosacea Variants

Appendex B   Rosacea Mimics List

Appendix C   Helicobacter Pylori

Appendix D   Other Theories on the Cause of Rosacea

Appendix E   ETS

Appendix F   National Rosacea Society

Appendix G   Reports of Misdiagnosis

Appendix H   Testing for Demodex Mites

Appendix I   Demodicosis

Appendix J   Ivermectin

Appendex K   Research Articles on Demodex and Rosacea

Appendix L   Candida Albicans

Appendix M   Antibiotics

Appendix M-1   Melanotan

Appendex N   Azelaic Acid

Appendix N1   Nitric Oxide (NO)

Appendix O   Rhinophyma

Appendix P   Rosacea & Migraines

Appendix Q   Isotretinoin

Appendex R   Propionibacterium & Rosacea

Appendix S   Angiogenesis & VEGF

Appendix S1   Sunscreen

Appendix T   Pimples, Pustules, and Papules

Appendix T1   Other Rosacea Research

Appendix U   Diet and Acne

Appendix V   Rosacea Defined

Appendix W   The Diet Authority

Appendix X   X Factor

Appendix X-i   Metabolic Syndrome

Appendix X2   Rosacea Alkaline Diet

Appendix X2A   Inflammation Diet

Appendix X3   Nutrition Facts Label

Appendix X4   Glycemic Index

Appendix X5   Protein Synthesis & Gluconeogenesis

Appendix X6   Fiber, Effective Carbohydrate & Sugar Alcohol

Appendix X7   Water

Appendix X8   High Carbohydrate (High Glycemic Load) Vs High Protein Diet Research

Appendix X9   Trans Fats

Appendix X10   Food Pyramids & Percentages

Appendix X11   Glucagon vs. Insulin

Appendix X12   Vitamins & Supplements

Appendix X13   Alcohol

Appendix X14   Athletes

Appendix X15   Lethargy & Headaches

Appendix X16   Weight Gain

Appendix X17   Salt

Appendix X18   Constipation

Appendix Y   Rosacea Diet Comments & FAQs

Appendix Z   Rosacea Diet Poll

Appendix Z1   Glossary

Appendix Z2   What Works for Rosacea Anecdotal Reports

About the Writer

Endnotes

The information contained in this book is not meant to substitute for medical care or treatment. Nothing takes the place of speaking with your doctor or other health care professional. You should consult with your doctor or health care provider before using anything mentioned in this book. You should consult with your doctor or health care provider before changing your current diet or using anything suggested in this book. Your rosacea may take longer than thirty days to control using the Rosacea Diet. Please consult with your doctor or other health care professional before using any drug product discussed within this book. Rosacea seems to be an individual case by case disease, and the Rosacea Diet alone may not control your rosacea and may require additional or other treatment from a qualified physician, including prescription medication, or treatment from a qualified health care practitioner using some other method or treatment. There is no known cure for rosacea, only treatment to control it. There are no statements in this book that the Rosacea Diet cures rosacea. Diet is simply one way to control rosacea.

www.rosacea-101.com

www.rosacea-diet.com

PREFACE

I am a rosacea sufferer, a rosacean. In this book, I frequently use the term rosacean to refer to anyone who suffers from rosacea.

In 1999 I wrote the Rosacea Diet since I discovered that sugar and a high carbohydrate diet feeds the rosacea ‘engine’ and by reducing the fuel that feeds rosacea that this helped control my rosacea. The Rosacea Diet has gone through at least three revisions since then. In 2007 I decided to update my book since I have discovered more about this horrible skin condition that plagues millions of people on planet earth. This book includes the Rosacea Diet, which basically has changed little. What have changed are the myriads of treatments that rosaceans report works for them.

I have updated some basic rosacea information and the goal of this revision is so that you can have in one book what you should know about rosacea, a basic 101 knowledge about rosacea for rosacean newbies. I don’t have any initials behind my name nor am I a health care professional. I am simply a rosacea sufferer who has compiled information on rosacea in one book. The book speaks for itself. I am confident that you will find what you are looking for, which is without a doubt, a way to control your rosacea. I tried my best to cover everything.

While the rosacea beast is one horrible nightmare, you can get control of it and find a regimen that will work for you. May your rosacea knowledge increase by reading this book. Take heart, you will control the rosacea beast.

CHAPTER I

WHAT IS ROSACEA?

Rosacea (pronounced roh-ZAY-sha) comes from the Latin word rosaceus meaning rose colored. Rosacea is a chronic and progressive disorder of the face, characterized by some or all of the following symptoms:

Extremely sensitive skin, blushing, flushing, permanent redness, burning, stinging, swelling, papules, pustules, broken red capillary veins, red gritty eyes (which can lead to visual disturbances) and in more advanced cases, a disfiguring bulbous nose. Men and women of all ages can be affected.¹

If you have no idea what rosacea looks like I suggest you Google it by selecting images in the search.² Rosacea is a common condition that affects people of all races.³

Diseases of seborrhoic origin include rosacea, acne, gram-negative folliculitis, demodex-folliculorum, perioral dermatitis as well as seborrhoic dermatitis.⁴ Seborrhea has to do with sebum. (See Appendix Z1—Rosacea Glossary)

What is confusing about rosacea is that it can be misdiagnosed as another skin condition. One of my favorite statements about this comes from a well-respected physician who stated, Rosacea is probably a collection of many different diseases that are lumped together inappropriately.⁵

I have a whole chapter on what other skin conditions look like rosacea, which you will read about next (Rosacea Mimics). The question is, ‘Who decides whether you have rosacea?’ Answer: Your physician. There is no substitute for a diagnosis by a physician. (See Chapter 12, Physicians) Rosacea is confusing and frustrating enough and self-diagnosis is even more confusing. The docs have a difficult enough job trying to diagnose what skin condition you may be suffering with.

One report says, rosacea is not actually a disease, but rather a chronic dermatologic condition that predominantly affects the convexities of the central aspect of the face.⁶ For example note this report:

Francis Wilkin of the FDA, whose serious studies have given us impressive insights into the nature and mechanisms of flushing, has proposed some concepts, which are inexplicable to most of us. He avers that rosacea is not a disease but a condition. He labels rosacea an ideotype, a cluster of signs and symptoms, apparently not a pathologic entity warranting a specific nosologic status. To be sure, rosacea is a multifac-tional disorder with many different clinical expressions. Nonetheless, it meets all the classical requirements of a pathologic process, most obviously the presence of chronic inflammation, both clinically and histo-logically. Calling rosacea a ‘condition’ downgrades the seriousness of the disorder, perhaps implying that it is only a cosmetic nuisance. Most rosaceans consider rosacea a disease.⁷

Most studies refer to rosacea as a disease. For just one example of a paper that refers to rosacea as a disease, note the following quote:

"Rosacea is a common and chronic disorder characterized by flushing, erythema, papules, pustules, and telangiectasia on the central part of the face. Because the facial skin of individuals with rosacea is particularly sensitive, irritants can trigger a worsening of the signs and symptoms of the disease"⁸

I was stunned when I first heard that rosacea was considered a ‘condition’ rather than a disease and asked the RRDi MAC members to comment on whether rosacea is a condition or a disease. The comments were:

Most words of this type in medicine rooted in Latin from thousands of years ago do not have precise definitions!

The terms disease & condition are often used interchangeably in the literature. . . . this is semantics: disease, affliction or condition all refer to the same meaning.⁹

Once considered a variant of acne, this common skin disorder seems fairly well entrenched as a disease sui generis.¹⁰

To me that is the first confusion that needs to be cleared up. Rosacea is a disease sui generis. The second most confusing matter to clear up is that many people think acne is rosacea since in many scientific papers and books, as well as in the media, rosacea is referred to as acne rosacea. While this description helps us to picture what rosacea looks like, one must be aware that rosacea is not acne.

Acne is technically a condition while rosacea is a disease. Acne vulgaris is a disease different from rosa-cea. According to the American Academy of Dermatology, acne is the term for plugged pores (blackheads and whiteheads), pimples, and even deeper lumps (cysts or nodules) that occur on the face, neck, chest, back, shoulders and even the upper arms. Acne affects most teenagers to some extent, but can also affect adults in the 20s, 30s and 40s.

What is the difference between acne and rosacea?

Answer:

This question is not an easy one to answer since acne looks so much like rosacea. However, there are factors to consider when a physician diagnoses rosacea. You should know about these factors:

(1) Rosacea does not usually present itself with blackheads (comedo formations) that are seen with acne vulgaris.

(2) Acne usually presents itself with plugging of the ducts of the oil glands, resulting in blackheads and pimples on the face and sometimes also the back, shoulders or chest. Rosacea seems to be linked to the vascular network of the central facial skin and causes redness, bumps, pimples and other symptoms that rarely goes beyond the face.

(3) The age of onset, and the location of redness is a clue. Rosacea is commonly an adult disease, and is generally restricted to the nose, cheeks, chin and forehead. However, young ones have been diagnosed with rosacea. Also, one report indicated that some people who have rosacea do not have it on their face at all, but rather on their back or elsewhere¹¹ which adds to the confusion.

(4) Rosacea is usually accompanied with frequent flushing and a persistent redness while acne vulgaris usually doesn’t present itself with flushing.¹² However not all report frequent flushing and flush no more than the general population.¹³

(5) Acne treatments tend to aggravate rosacea leading to a diagnosis of rosacea. Common treatments for acne such as Salicylic Acid, Glycolic Acid, Tretinoin, Retin-A Micro, Avita, Differin, Benzoyl Peroxide, Azelaic Acid, Triclosan, Acne peels, Chemical peels, Topical exfoliants, Toners, Astringents, Witch Hazel and Alcohol tend to aggravate rosacea (but not always). Rosacea sufferers have extremely sensitive skin. Therefore, when a patient doesn’t respond to acne treatment and the acne treatment aggravates the condition it may be diagnosed as rosacea.

(6) Eye symptoms are not associated with acne, so a careful examination for eye symptoms or a finding of ocular pathology will help confirm the diagnosis of rosacea. 50% of rosaceans have ocular rosacea.¹⁴

(7) Unlike acne, rosacea is not driven forward by Propionibacterium, and subsequently should not be treated using acne medications. However, to add more confusion there is a theory that P. acnes may be a potential aggravating factor in rosacea.¹⁵ But before you get excited about this, be sure to read my chapter on What Causes Rosacea?

Just to really add to the confusion it is not uncommon for acne and rosacea to co-exist. Yes, you can have acne and rosacea at the same time! You are beginning to understand the confusion, frustration, mystery, and misunderstanding that rosaceans go through.

While the above factors are not exhaustive, it gives you an idea of what a physician considers to determine a differential diagnosis for rosacea. Besides differentiating rosacea from acne, a physician must also differentiate a host of other rosacea-like skin conditions including rosacea variants and other skin diseases. Self-diagnosis is not a good idea and is discussed in my chapter on physicians. It cannot be over emphasized that a diagnosis from a competent physician who is keeping up with the current research on rosacea be obtained and to avoid the trap of self-diagnosis. You really cannot competently diagnose what skin condition you are suffering with. Read my chapter on physicians before you make an appointment (Chapter 12, Physicians).

Another matter that needs to be cleared up is that rosacea usually tends to effect the face in the ‘T’ zone but sometimes is found on other body parts. The ‘T’ zone is the area shaped like a ‘T’ composed of your forehead, nose and around your mouth. However, as noted in factor number three above, rosacea has been reported to be found on the neck, chest and back of sufferers (rarely). Generally speaking, however, rosacea affects this ‘T’ zone and most rosaceans should understand this zone, which is sometimes called the ‘but-terfly.’¹⁶ (see Figure 1)

Figure 1¹⁷

Classification of Rosacea into Subtypes and Variants

In older literature and research papers discussing rosacea one finds the mention of the ‘stages’ of rosacea into these three:

Stage I—Erythema (redness)

Stage II—Inflammatory papules and pustules

Stage III—Large inflammatory nodules, furunculoid infiltrations, and tissue hyperplasia

These stages sometimes are still mentioned in reading about rosacea even in recent research. However, the National Rosacea Society developed in 2002 a new standard classification system¹⁸ that divides rosacea into four subtypes¹⁹:

Subtype 1: Facial Redness (erythematotelangiectatic rosacea)

Subtype 2: Bumps and Pimples (papulopustular rosacea)

Subtype 3: Skin Thickening (phymatous rosacea)

Subtype 4: Eye Irritation (ocular rosacea)

A fifth subtype has been proposed, Neuropathic Rosacea.²⁰ Whether this subtype ever is recognized by medical professional journals in dermatology and mentioned by dermatologists remains to be seen.

Dr. Dahl says that "Each of the subtypes can be divided further into more specific subgroups. For example, sensory rosacea is an additional subtype that can be recognized and treated."²¹ What sensory rosacea is as a subgroup should be explained so that more can understand what this is.

In 2004 in an article appearing in the Journal of the American Academy of Dermatology, Crawford et al. proposed the concept of glandular rosacea to describe another phenotype distinct from the four subtypes introduced by the expert committee. Glandular rosacea occurs predominantly in males who characteristically have oily skin, large pores, a tendency to rhinophyma, and inflammatory lesions, including papules, pustules and nodulocystic lesions, that extend onto the lateral cheeks and neck.²² Whether phenotypes of rosacea become popular or accepted by medical professionals remains to be seen.

This is a beginning of understanding the classification of rosacea that more informed physicians are beginning to accept. This is the beginning of understanding what we are all talking about so that we can all be on the same page when discussing rosacea. There is also a list of rosacea variants for your consideration at Appendix A—Rosacea Variants.

The Subtypes of rosacea sometimes are referred to as ETR (Subtype 1), Papulopustular (Subtype 2), Phymatous (Subtype 3), and Ocular (Subtype 4).

Figure 2

Phymatous rosacea (Subtype 3) is usually rhinophyma, (see Appendix O—Rhinophyma) which the nose has hypertrophy of the sebaceous tissue resulting in some serious disfigurement. W.C. Fields (see Figure 2). had rhinophyma (see Figures 3) and has become the rosacea poster boy.

However, rhinophyma has been around a long time as noted by a painting by Ghirlandiao (see Figure 4). While alcohol no doubt aggravates rosacea, the problem is simply that untreated rosacea may develop into rhinophyma. There is no evidence that alcohol causes rosacea but it is listed on just about every rosa-cea trigger list as aggravating rosacea or as a trigger. All the phymatous rosacea cases are the end stage of untreated rosacea.²³ There are also other phymas such as gnatophyma (chin), metophyma (forehead), oto-phyma (one or both ears), and blepharophyma (eyelids). The good thing about rhinophyma, if you can say anything good about any rosacea subtype or variant, 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 the best news is this condition can usually be corrected.²⁴

Figure 3

Figure 4

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.

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.²⁵

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.²⁶

History of Rosacea

Rosacea has a long history with treatment options consisting of blood letting, application of leeches, topical mercury, and sulfur and blood salves. The first person known to describe rosacea medically was Dr. Guy

de Chauliac, a French surgeon living in the 14th century, according to an article in the European Journal of Dermatology by Dr. Jean de Bersaques. Dr. de Chauliac talked about red lesions in the face, particularly on the nose and cheeks. He called the condition goutterose (French for pink droplet) or couperose (now a common French term for rosacea).

A 15th Century painting in the Louvre, The Old Man and His Grandson by Domenico Ghirlandiao (see Figure 4) around the year 1480 is an excellent example of Subtype 3, phymatous rosacea. "References to rosacea also did not escape early literature. Chaucer’s Canterbury Tales and Shakespeare’s Henry V include descriptions of men with red faces and enlarged noses.

The first written reference to acne rosacea appeared in an English medical text by Dr. Thomas Bateman in 1812, and noted: The perfect cure of acne rosacea is, in fact, never accomplished. Other 19th century references commonly listed rosacea among the different forms of acne."²⁷

A patient, Margaret (see Figure 5), at the Skin Clinic of the Women’s Medical College is recorded in the 19th Century with an eruption she 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.²⁸

Figure 5

Diagnosis and Assessment

An International Journal of Dermatology report indicates that at present, there are no standard validated tools for assessing the severity of rosacea or its signs or symptoms.²⁹

There are no histological, serological or other diagnostic tests for rosacea. A diagnosis of rosacea must come from your physician after a thorough examination of your signs and symptoms and a medical history.³⁰ However, according to UCSD, A diagnostic test for rosacea can be developed by identifying higher levels of these specific peptides, or the processed forms, in patients suspected of having rosacea, distinguishing it from other dermatological or autoimmune diseases. Currently, rosacea is only diagnosed by clinical symptoms and can be confused with other dermatological diseases such as acne. Preliminary diagnosis can be performed by quantitative immunoblot from tape-stripped skin, or definitively by mass spectrometry.³¹ UCSD is on the cutting edge of linking certain peptides as a possible mechanism for rosacea. (See Theory 5, in Chapter 3, What Causes Rosacea).

According to a recent survey by the National Rosacea Society (NRS), only three-quarters of respondents reported receiving a correct diagnosis the first time they sought treatment for their condition. Eighty-six percent of those surveyed reported that a dermatologist diagnosed their rosacea, while 10% were diagnosed by a general practitioner, and 2% by an ophthalmologist. An additional 2% were diagnosed by another medical specialist (gynecologist, allergist, rheumatologist, and optometrist).³²

This suggests there may be a need for greater awareness of the potential signs and symptoms of rosacea among all health professionals, so more people receive needed treatment, . . . Besides dermatologists, primary care physicians are often the first to see patients with this widespread disorder, and ophthalmologists may also be involved because of its common effects on the eyes.³³ It cannot be overemphasized you need a diagnosis from a physician for rosacea.

Rosacea Variants

There is no universal acceptance of what constitutes a rosacea variant. For example, note this quote:

Debate also continues over whether rosacea conglobata and rosacea fulminans are variants of acne vulgaris or rosacea.³⁴

The NRS expert committee only recognizes at the time of this writing ONE rosacea variant, granulomatous rosacea and that group of experts is the first to classify rosacea into subtypes and variants. ³⁵ However, I have found reports that mention many rosacea variants and you may read about these variants in Appendix A, Rosacea Variants.

Differential Diagnosis

There are many skin conditions that mimic rosacea so that a differential diagnosis is required and is discussed in the next chapter.

Worldwide Rosacean Population

There are no reliable reports on the number of rosaceans worldwide. One estimate puts the number of rosaceans worldwide to be 45 million.³⁶ One report says In the US: More than 10% of the general population exhibits dermatologic characteristics of rosacea…³⁷ The total US population in 2007 is currently over 302,453,619. That would mean there are over 30 million in the US who ‘exhibit dermatologic characteristics of rosacea’ based on this report. The NRS says the number of rosaceans in the US is around 14 million.³⁸ One report says that there are around 30 million Chinese who have ‘red noses,’ not even counting those with rosacea.³⁹ If we used 10% of the world population who ‘exhibit dermatologic characteristics of rosacea’ that number would be over 660 million worldwide. If we use the conservative figure that 1% of the world population has rosacea that would put the number at 66 million rosaceans. The point of all this guesswork is that there is a significant number of rosaceans worldwide without a doubt whatever that figure amounts to.

CHAPTER 2

ROSACEA MIMICS

The next confusing item to consider is the long list of rosacea-like mimics. As Dr. Draelos explains, Rosacea is probably a collection of many different diseases that are lumped together inappropriately.⁴⁰ Dr. Baldwin put it this way: For the task of discussing therapy, rosacea is best viewed as a collection of several conditions with a common name.⁴¹

Diamantis and Waldorf put it this way:

However, rosacea actually represents a spectrum of disease from chronic skin hypersensitivity and flushing to rhinophyma.⁴²

Another report sums it up:

It can be difficult to distinguish acne vulgaris, seborrheic eczema, perioral dermatitis and lupus erythematosus from rosacea.⁴³

This chapter tries to help you understand the concept of a differential diagnosis so that you can at least be educated to what skin condition you might want to ask your physician about. These skin conditions look like rosacea, yet are different skin conditions or diseases. Why is this important?

Here are the reasons:

(1) You may not have rosacea but one of the rosacea variants, skin conditions or diseases listed in this chapter or in Appendix A or B.

(2) You may have rosacea and also one or more of the skin conditions or diseases in this chapter or in Appendix B. Having rosacea and one or more other skin conditions are not uncommon.

(3) You may have been diagnosed with rosacea but later find out that your physician changes the diagnosis to one of the skin conditions or diseases mentioned in this chapter (or Appendix A and B) or you get a second opinion from another physician who says you have been misdiagnosed. Misdiagnosis for rosa-cea is not uncommon.⁴⁴

(4) If you physician explains that you have one or more of the skin conditions or diseases listed in this chapter you won’t be shocked because this is basic Rosacea 101 knowledge. Just imagine the horror you would feel if you have little knowledge of rosacea and you find out later that you were misdiagnosed!

Why do physicians have such a difficult time diagnosing rosacea? This is because since there is no standard test for rosacea and rosacea patients are dependent on a physician’s diagnosis that may be difficult for the physician to differentiate from the rosacea mimics. If you examine the photos of all these different skin conditions and diseases they all look like rosacea.

The number of skin conditions and diseases that look like rosacea is staggering and I have limited this simply because I have exhausted the search due to time constraints. If you keep searching you will no doubt find more rosacea mimics. I cannot overemphasize Dr. Draelos’ quote:

Rosacea is probably a collection of many different diseases that are lumped together inappropriately.⁴⁵ And don’t forget the rosacea variants.⁴⁶ Here are the common rosacea mimics:

1. Perioral Dermatitis

Perioral dermatitis (POD) is a chronic papulopustular and eczematous facial dermatitis. It mostly occurs in women, although a distinct papular variant occurs in children. The clinical and histologic features of the lesions resemble those of rosacea. Patients require systemic and/or topical treatment, an evaluation of the underlying factors, and reassurance.. The etiology of perioral dermatitis is unknown; however, the uncritical use of topical steroids for minor skin alterations of the face often precedes the manifestation of the disease⁴⁷

Histologically, it is indistinguishable from rosacea…⁴⁸

PD is characterized by a skin barrier disorder of facial skin. It differs from rosacea in that it involves a significantly increased TEWL and features of an atopic diathesis. However, it remains disputed as to whether PD is an individual skin disease or a subtype of rosacea in atopic patients.⁴⁹

"Ackerman has stated his belief that, histologically, this condition is the same as rosacea. He says that ‘like rosacea, perioral dermatitis is fundamentally an inflammatory process involving hair follicles. Initially, both conditions are folliculitis that progresses to granulomatous folliculitis and dermatitis.’"⁵⁰

"Perioral dermatitis is a red, bumpy rash around the mouth and on the chin that resembles acne or rosacea.

Perioral dermatitis can be hard to separate from rosacea, but symptoms including tiny blisters and skin scaling can help make the distinction. Other symptoms of rosacea must be present for that diagnosis to be made instead of perioral dermatitis."⁵¹

"Perioral dermatitis (POD) is a chronic papulopustular and eczematous facial dermatitis. It mostly occurs in women, although a distinct papular variant occurs in children. The clinical and histologic features of the lesions resemble those of rosacea… Histologic findings are similar to those of rosacea…"⁵²

You won’t see comedones (whiteheads and blackheads), cysts (boil-like lesions), or scarring, as you would if you have acne, nor will you see the typical flushing of rosacea.⁵³

The cause of perioral dermatitis is unknown. But some dermatologists believe it is a form of rosacea…⁵⁴

Perioral dermatitis (POD) is a chronic papulopustular facial dermatitis found in younger women and children. It appears to be a juvenile form of granulomatous rosacea.⁵⁵

Some authorities consider that perioral dermatitis is a circumscribed variant of rosacea.⁵⁶ Some experts consider this disorder to be a variant of rosacea.⁵⁷

Perioral dermatitis is a distinct entity and not a variant of seborrhoeic dermatitis or rosacea…⁵⁸ Although rosacea papules may appear in the perioral area, as noted earlier, perioral dermatitis without rosacea symptoms cannot be classified as a variant of rosacea. Perioral dermatitis is characterized by such stigmata as microvesicles, scaling, and peeling.⁵⁹

Sodium sulfacetamide, penetrating antibacterial, in combination with hydrocortisone and sulfur, has enjoyed twenty years of remarkable safety, with outstanding efficacy and patient acceptance, in the prescription treatment of pustular acne and severe, refractory seborrheic dermatitis. Recently, this combination has been reported to be highly effective concomitant therapy for perioral dermatitis. Almost paradoxically, it achieves these desired goals without the excessive erythema and discomforting irritation associated with retinoic acid and benzoyl peroxide.⁶⁰

As already mention some clinicians consider perioral dermatitis to be a variant of rosacea.⁶¹ It usually effects young females and results from topical steroid use. My gut feelings nominate perioral dermatitis as a rosacea variant but because of the controversy about this I am listing it as a rosacea mimic. This is another example of the confusion in rosacea among dermatologists. There is no general consensus and much debating.

2. Seborrheic Dermatitis

Seborrheic dermatitis is a common, inflammatory skin condition that causes flaky, white to yellowish scales to form on oily areas such as the scalp or inside the ear. It can occur with or without reddened skin… Seborrheic dermatitis can occur on many different body areas. Typically it forms where the skin is oily or greasy. Commonly affected areas include the scalp, eyebrows, eyelids, creases of the nose, lips, behind the ears, in the external ear, and along skin folds on the middle of the body.⁶²

Experimental studies did not approve an association between rosacea and seborrhoea. Due to the localisation and the effectiveness of isotretinoin some authors suspect that seborrhoea is a factor of rosa-cea, though sebum production is often not increased in rosacea patients (apart of Rosacea fulminans).⁶³ Seborrheic dermatititis and rosacea can co-exist and the two are quite similar. Where rosacea and sebor-rheic dermatitis begins and ends is difficult to distinguish and certainly can be troublesome.

3. Keratosis Pilaris

Keratosis Pilaris is a very common genetic follicular disease manifested by the appearance of rough bumps on the skin. Primarily, it appears on the back and outer sides of the upper arms, but can also occur on thighs and buttocks or any body part except palms or soles. There are several different types of keratosis pilaris, including keratosis pilaris rubra (red, inflamed bumps), alba (rough, bumpy skin with no irritation), rubra faceii (reddish rash on the cheeks) and related disorders.⁶⁴

When keratosis pilaris occurs on the cheeks, the affected area is not only red but it also feels rough. The characteristic reddish aspect of this type of facial keratosis pilaris gives it the clinical name of KP rubra faceii. Keratosis pilaris rubra faceii (KP rubra faceii—KPRF) is characterized by redness (erythema) and the presence of rough bumpiness (follicular spines) which may begin at birth or during childhood or adolescence.⁶⁵

4. Pityrosporum Folliculitis

"Pityrosporum folliculitis is a condition where the yeast, pityrosporum, gets down into the hair follicles and multiplies, setting up an itchy, acne-like eruption. Pityrosporum folliculitis sometimes turns out to be the reason a case of acne isn’t getting better after being on antibiotics for months. It is especially common in the cape distribution (upper chest, upper back) and the pimples are pinhead sized and uniform.

"This yeast is a normal skin inhabitant, different from the yeast that causes thrush and from baker’s or food yeast. Everyone has it on his or her skin but in most cases it causes no problem. The condition affects young to middle-aged adults of either sex. It is associated with a tendency to seborrheic dermatitis or severe dandruff.

Pityrosporum folliculitis is not an infection as such; it is an overgrowth of what is normally there. The yeast overgrowth may be encouraged by external factors and/or by reduced resistance on the part of the host."⁶⁶

These four skin conditions frequently are mentioned in a differential diagnosis for rosacea and reports in the rosacea online forums and groups indicate that sometimes rosacea is misdiagnosed for these four mentioned above and many other skin conditions too numerous to mention here.⁶⁷

Other Rosacea Mimics—See Appendix B.

CHAPTER 3

WHAT CAUSES ROSACEA?

There are many theories on what causes rosacea. No one knows for sure what causes rosacea no matter what you read. Doctors do not know the exact cause of rosacea.⁶⁸

There is absolutely no research paper that proves what causes rosacea no matter what anyone says. One clinician reports:

. there is no histological pattern unique to rosacea.⁶⁹ The pathophysiology of rosacea is still a subject of controversy.⁷⁰

The limited understanding of the pathogenesis of rosacea is a major reason for the slow progression and development of therapeutic agents and modalities.⁷¹

Rosacea presents an enigma to patients and physicians alike. Although new insights and a plethora of therapies provide hope, the underlying etiology remains unknown. This assures a certain amount of frustration as available treatments temporize rather than cure the disease.⁷²

The current thought on what causes rosacea could be broken down to five main theories (and several others mentioned in Appendix D):

Rosacea may be considered a (1) vascular disorder, (2) an inflammatory condition, (3) a disorder provoked by various environmental stimuli, (4) a genetic disorder, or (5) an immune system disorder. Let’s break these down for your consideration.

Theory 1—Rosacea as a Vascular Disorder

Some researchers believe that rosacea is a disorder where blood vessels dilate too easily, resulting in flushing and redness.⁷³

One theory of rosacea’s origin is that the disease may be a component of a more generalized disorder of the blood vessels, which could explain why rosacea sufferers have a tendency to flush.⁷⁴

The dysfunction seems to be a microcirculatory disturbance of the facial angular veins (Vena facialis sive angularis) which are involved in the vascular cooling system of the brain. This may lead to a venous congestion and failure of thermoregulation. The facial angular veins drain the parts of the face which are mostly affected by rosacea including the conjunctiva. This could explain the frequent involvement of the eyes. A vascular dysfunction could also be the reason for the increase of migraine headaches in rosacea patients. Rosacea skin reacts normal to various vasoactive chemicals like caffeine or to chemomediators such as epinephrine, acetylcholine or histamine. Vasoactive intestinal peptide (VIP) and its receptor are important for blood flow regulation. An increased concentration of the receptor was found in rhinophyma and therefore it is suggested that this may contribute to vascular and dermal alterations in rosacea.⁷⁵

When a rosacean believes that this theory is the cause of rosacea then a rosacean frequently becomes obsessed with avoiding flushing at all costs. However, please note this report:

According to Thomas Jansen, MD and Gerd Plewig, MD, there is no direct evidence that rosacea is primarily a vascular disorder… the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls.⁷⁶ Another respected authority on rosacea says, researchers have not found any evidence that a vascular dysfunction causes rosacea.⁷⁷

Dr. Kligman says, "I disagree with these pronouncements. I have seen many hundreds of rosacea patients enrolled in our experimental efforts over the past