The Role Of Metronidazole in The Rosacea Picture

The role of topical metronidazole in the treatment of rosacea.
Wolf JE Jr.
Department of Dermatology, Baylor College of Medicine, Houston, Texas, USA.

Many topical and oral pharmacologic agents have shown well-tolerated efficacy for the treatment of rosacea. Metronidazole was the first topical therapy approved for rosacea and is still considered the foundation therapy by many researchers and dermatologists that are baffled or confused. The efficacy and tolerability of topical metronidazole (formaly a vaginal infection medication) in combination with an oral antibiotic or as monotherapy to maintain remissions have been shown in multiple well-controlled trials for 3 to 4 months before failure to the rosacea sufferer.
PMID: 14959942 [PubMed - indexed for MEDLINE] implement a multifaceted approach to treatment, crafting new treatment combinations to address the unique and evolving features of rosacea in each individual patient.

The Face of Rosacea And Exercise

According to a new survey of 1,261 rosacea patients by the National Rosacea Society, more than 83 percent are affected at least somewhat by exercise. Fortunately, of those who have modified their exercise routine because of this condition, 89 percent said this had reduced their signs and symptoms.

Perhaps because of its popularity, walking was the most commonly reported form of exercise that aggravated rosacea, affecting 36 percent of the respondents. Other common exercise triggers included jogging or running (33.5 percent), aerobics (30.5 percent), weights (16 percent), push-ups or sit-ups (15 percent), and bicycling or spinning (15 percent).

Twenty-four percent of the respondents said they exercise daily, while 48 percent exercise one to three times a week and 16 percent only occasionally. People with rosacea who exercised only occasionally seemed to experience flare-ups more often than others, with 90 percent reporting that their conditions were affected at least somewhat. Interestingly, only 43 percent of those who exercised daily were affected.

"While exercise is important to a healthy lifestyle, people with rosacea should anticipate flare-ups of signs and symptoms, especially with strenuous activity or outdoor heat exposure," said Dr. James Del Rosso, assistant clinical professor of dermatology at the University of Nevada School of Medicine, Las Vegas.

Ways to help reduce the incidence of flare-ups include working out in the early morning or late evening when weather is cooler; working out more frequently but for shorter intervals; keeping cool indoors by running a fan or opening a window; and cooling off by keeping a damp towel on your neck and drinking cold fluids.

The Picture of Rosacea And Dry Skin

Applying moisturizer to your face should not reduce the effectiveness of your topical medication if you are using the products in the right order. First, cleanse your face with a mild cleanser and air dry. Then, apply your topical medication and allow it to dry. After that, you should be able to follow up with any moisturizer or make-up products without interfering with your medical therapy.

Many rosacea patients complain of dry skin. Check with your physician to be sure that you are using the right topical formulation for your skin type. Gel formulations may be best for normal to oily skin, while lotion and cream formulations may be preferable for dry skin. Some physicians prefer that patients do not use a moisturizer, so check with your doctor.

The Winter Picture of Rosacea

The redness of rosacea can be an uninvited guest for the holidays whether you live in icy Minnesota or sun-filled San Diego. From a blast of arctic air to the heat of the kitchen, the winter months pose a host of special conditions that can worsen rosacea symptoms unless precautions are taken.

"Regardless of location, rosacea sufferers need to manage their activities carefully to avoid flare-ups during the winter season," said Dr. Jerome Z. Litt, assistant clinical professor of dermatology at Case Western Reserve University in Cleveland. "This not only applies to skiing or snow shoveling, but to moderating the flurry of activities surrounding the holidays."

In a National Rosacea Society survey of 683 rosacea sufferers on winter rosacea tripwires, exposure to wind was cited as the most common seasonal factor likely to aggravate rosacea, affecting 88 percent of all survey respondents -- including those living in mild and moderate climates as well as areas with severe winter weather. Cold weather affected 72 percent of all respondents, ranging from 80 percent in severe climates to 46 percent in areas where winters are mild.

Conversely, high indoor heat, which can be difficult to regulate in changing weather, had aggravated rosacea in 63 percent of the respondents in mild or moderate areas, while affecting 57 percent of those in severe climates.

One of the least obvious but most common winter tripwires is simple holiday stress, reported to affect 59 percent of rosacea sufferers regardless of weather.

Here are some tips for controlling winter's effect on rosacea symptoms:

Minimize time outdoors in inclement weather, and use a scarf or ski mask to protect the face from wind.

Wear loose, layered clothing to protect from both cold outdoor weather and indoor heat.

Use a sunscreen year round. Sun exposure is the most common rosacea tripwire, and can affect the face even in winter.

Avoid holiday stress. Pace yourself, and do not over-commit to activities.

Take cool-off breaks from holiday baking or cooking.

Limit consumption of heated beverages as well as alcohol, another common rosacea tripwire. Use an ice cube to lower the temperature.

Be sure to continue using rosacea medication consistently, as prescribed by your doctor.

Of the survey respondents who had modified their winter routines to avoid aggravating their rosacea, 93 percent said this had been successful in reducing flare-ups

Rosacea's Holiday Picture

The holidays should be a time of joy and celebration, but avoiding flare-ups during this festive time of year may be a particular challenge for rosacea sufferers. Not only do social, family and financial pressures create stress, but the colder climate and holiday eating can impact your rosacea.

Here are some tips to keep flare-ups to a minimum:

First and foremost, take care of yourself to avoid emotional stress. Stress is most commonly identified by rosacea sufferers as their number one tripwire for flare-ups. Eat right, get plenty of rest, avoid worry and maintain your exercise routine. Try deep breathing and other stress prevention techniques.

If you know what factors trigger your rosacea flare-ups, continue to faithfully avoid them. Enjoy the holiday parties, but limit your intake of alcohol or spicy foods if they affect your rosacea. Also watch out for hot chocolate, cider, coffee, tea and other heated drinks, since many rosacea sufferers report flare-ups from thermally hot beverages.

Cold weather and wind can cause flare-ups for more than one-third of rosacea sufferers. Wear a hat and scarf that protect your face. You also may find it particularly important to use a moisturizer during the cold, dry months.

Finally, keep kitchens cool and well ventilated to avoid becoming overheated when you have hours of holiday cooking to do. Sip a cool drink. Keep a cool, damp towel around to pat your face, and take a break to a cooler room when you can.

Set your own pace and be sure to include some time to pamper yourself.

The Rosacea - Perioral Picture

Often mistaken for rosacea and sometimes occurring with rosacea, Perioral dermatitis is a common facial skin problem in adult women. It rarely occurs in men. Groups of itchy or tender small red spots appear most often around the mouth. They spare the skin bordering the lips (which then appears pale) but develop on the chin, upper lip and cheeks. The skin surface becomes dry and flaky.

Often the skin around the nose is affected too, and sometimes that around the eyes (when it should more correctly be called ‘periocular’, or better still, ‘periorificial’ dermatitis.)

Patients who are susceptible to perioral dermatitis tend to have an oily face, at least in the affected areas.

Perioral dermatitis is probably induced by:

Neglecting to wash the face with soap or preferably a soap-free cleanser and water.

Applying face creams regularly to the area bounded by the cheek folds and chin, or around the eyes in the case of periocular dermatitis. These creams include moisturizers, cream cleansers, make-up foundation, acne medications and sunscreens.

Applying topical steroid creams to the same area. The more potent the steroid cream, the more rapid and severe the perioral dermatitis which may result.

The reason why perioral dermatitis arises is unknown. Recent research suggests it may be related to proliferating bacteria in the hair follicles.

Luckily perioral dermatitis responds well to treatment. Discontinue applying all face creams including topical steroids, cosmetics and sunscreens.

Note: when a steroid cream is discontinued, the rash gets worse for a few days before it starts to improve. Do not apply face creams in the affected areas in the future, as the rash is very likely to reappear. Choose a liquid, gel or light milk sunscreen. Wash the face with warm water alone while the rash is present. When it has cleared up, wash with a non-soap bar or cleanser and water. Your doctor or dermatologist will usually also prescribe a course of oral antibiotics for six to twelve weeks. Normally tetracycline or one of its derivatives is recommended. Antibiotic lotions tend to be less effective.

Perioral dermatitis sometimes recurs when the antibiotics are discontinued, or at a later date. The same treatment can be taken again.

Perioral dermatitis may be aggravated by toothpaste containing tartar-control or fluoride additives, mouthwashes or even some chapsticks.

The Steroid Rosacea Picture

The picture of steroid rosacea defines itself as a rosacea-like condition on the face caused by the use of potent topical steroids. In some cases it can be a variant of perioral dermatitis (also known as periorificial dermatitis).

Steroid rosacea becomes visible after several weeks of applying a topical steroid to the eyelids, cheeks or chin the affected area becomes red (erythematous). The skin can thin and the immune system can become compromised. Small bumps (papules) and pustules appear intermittently, and may paradoxically be especially severe when the topical steroid cream is discontinued.

If the steroid creams are used for months or years, broken capillaries (telangiectasia) may develop.

Steroid rosacea responds well to treatment in most cases although telangiectasia may persist long term.

To treat steroid rosacea, the topical steroids should be discontinued. To minimize severe flare-up, slow withdrawal is recommended by decreasing how often the product is applied and choosing a product that is less potent. If moisturisers are used, these should be non-oily. Oral tetracycline is often prescribed and may be required for several months. The telangiectasia may require treatment with a vascular laser.

THE NATIONAL ROSACEA SOCIETY SUPPORT PICTURE

In a recent letter from the NRS, thanking the RRF supporters, Mr. Sam Huff
has revealed some interesting information about the NRS.

All donations from individuals, either via their web site, or via post are
directed solely towards research funding. This has been the case for several
years. The promotional and support activities of the NRS are funded from
industry and other sources.

This means that everyone is able to directly fund rosacea research by
donating to the NRS.

The letter is here http://rosacea-research.org/pdfs/NRSThankYou.pdf

One of the positive things to emerge of late is the dialogue between the RRF
and the NRS. We have discovered that the NRS is indeed keen to expand its
research funding program. Mr. Huff has also taken the opportunity to
politely respond to public concerns about the operation of the NRS.

We all look forward to what the NRS and rosacea sufferers together can
achieve. Please generously support the NRS now and into the future. It is
only when rosacea sufferers decide to vote with their dollars that our
future will be within our control.

davidp.
--
David Pascoe,