Rosacea Diagnosis and Management by Frank Powell
with a Contribution by Jonathan Wilkin
A Book Review by Brady Barrows
This book is designed with physicians in mind and is full of a wonderful mixture of color illustrations of nineteenth century artists along with the author’s own modern color photographs of his patients. Powell points out the ’great detail that the dermatologists of a former era paid to describing and illustrating this condition.”
Even though this book is not designed for laymen like myself, I found the book fairly easy to understand and insightful and learned a great deal which I will detail in this review. Dr. Powell’s book is, as he says, “not intended to be an in-depth study of this disease,” but to “fill the gap that texbooks leave in the provisions of solutions for individual patients with rosacea who often require their clinicians to be innovative in the approach to the management of their skin conditions.”
Powell confirms how rosacea’s definition has been vague, that the etiology is unknown, yet suggests that ultraviolet light may be the culprit underlying the various pathogenic theories surrounding rosacea. He lauds the new NRS classification of rosacea into subsets and discusses details of rosacea into these subsets using a grading system to select therapies, devoting a chapter on this subject.
One new thought to me is his mention of the ‘lactic acid test’ for skin sensitivity to assess and grade a patient using this tool. A whole chapter is devoted to skin structure and function. His chapter on Flushing and Blushing 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.” He explains the only difference between flushing and blushing are the “different conditions which disparate initiating factors.” Flushing may be initiated by many factors other than emotional or psychological. Blushing is initiated by emotional and psychological factors. He does admit that there are ‘crossovers in the distribution of flushing and blushing’ and that flushing is more widespread. He goes into some detail how Charles Darwin wrote much about the subject of blushing which resulted in the public psyche associating ‘facial reddening and emotions’ leading to ’some curious theories relating to the etiology of rosacea.’
One matter Dr. Powell clears up is the notion that individuals with sensitive skin and who flush frequently should be classified as ‘pre-rosacea.’ He points out that the evidence is lacking for this theory mainly because of the ‘lack of [a] clear definition of both rosacea and the type of facial reaction that constitute[s] facial flushing or blushing.’ Powell makes the point that rosacea may be the result of irritating effects of the environment rather than the effects of frequent flushing.
A whole chapter is devoted on the classification and grading the severity of rosacea. He points out the benefits of clinicians accepting a ‘common recognition of which subtype within the rosacea spectrum’ and how this classificaion also facilitates management of treatment which is ‘largely dictated by which subtype of rosacea’ the patient represents. One clarification worth noting is how he explains that the NRS ‘expert committee’ did not imply ‘a pathogenesis or progression of the disorder through various stages.’
The chapter on Subtype 1 (Erythematotelangiectatic [ETTR] Rosacea) shows the difficulty for differentiating it from rosacea mimics, in particular, heliodermatitis. He says that some clinicians use the terms heliodermatitis and ETTR interchangeably. He thus focuses on differentiating the two conditions. There is much detail also differentiating ETTR with systemic lupus erythematosus (SLE), dermatomyositis, seborrheic dermatitis, atopic dermatitis, other dermatitis, and other rarer conditions. He states that subtype 1 is the most difficult to treat and offers suggestions on its management.
In his chapter on Subtype 2 (Papulopustular [PPR] Rosacea) he says this subtype ‘corresponds most closely to the original concept of rosacea’ and goes into detail about the definition and concludes that this subtype is ‘the easiest type to treat’ and ‘apart from rhinophyma, PPR is the most easily recognized rosacea.’ He gives an interesting short history on past treatments used to treat PPR, for example, ‘reducing the intake of carbohydrates,’ and ‘increasing the quantity of meat.’ He devotes attention to the ‘presence of Demodex folliculorum mites in the facial skin of some patients with rosacea and how ‘these mites are greatly increased in number.’ With many color photos (24 – more than any other chapter) he devotes details about PPR’s clinical features and then spends a third of the chapter discussing ‘differential diagnosis and investigations.’ First he explains rosaceiform dermatitis (RD) in which ‘D. folliculorum mites are found in abundance in some individuals affected with this disorder.’ Sometimes RD can be “seen in persons who have applied potent topical steroid creams to their faces over prolonged periods and is referred to as ’steroid induced rosacea-like dermatitis.’ ” These patients ‘have also been shown to have a major increase in the demodex mite count on heir facial skin using the cyanoacrylate skin biopsy technique.’ Other differential diagnosis is discussed differentiating PPR from acne vulgaris, perioral dermatitis, seborrheic dermatitis, and pityriasis folliculorlum (PF). Dr. Powell goes into some details describing PF. “Pityriasis folliculorum is an often over-looked clinical entity” and cases are ‘mostly female.’ He explains that there is ‘usually a history of rarely using soap or water to cleanse the facial skin but instead using cleansing creams.’ These individuals often apply moisturizers and complain of a burning or itchy sensation. He states that the diagnosis of PF is ‘facilitated by use of dermatoscopy, which shows a distinctive picture of the presence of multiple white keratotic material consisting of keratin encrusted demodex mites protruding upwards from the follicular orifices.’ This condition ’seems to be caused by an over population of mites facilitated by the frequent use of creams and the lack of face washing with soap and water.’
Another discussion focuses on Tinea Faciei and cutaneous sarcoid differentiating these from PPR. A very important note for clinicians is found on the last paragraph of page 82 in his book:
“There is no laboratory test or investigation that will confirm the diagnosis of PPR. Specific investigations may be required to rule out similar appearing conditions (many of which will be identified by listening carefully to the patient’s medical history and examining the skin lesions). These include skin swabs for bacterial culture, skin scrapings for the presence of demodex mites, scrapings for fungal KOH and fungal culture, skin biopsy for histologic examination, (and rarely culture) skin surface biopsy for demodex mite quantification, patch tests, photopatch tests, and very rarely systemic workup wih appropriate blood tests and radiological examinations.”
How many dermatologists do you know do such a detailed history and examination? When you were diagnosed with rosacea, did your physician come close to what is mentioned in the above paragraph? I would suggest buying this book and just having your dermatologist read the above paragraph by handing it to him at the end of your initial visit and insist on getting it back, also suggesting to the physician it is available at amazon and more rosacea patients are going to be walking in who have read this book. It might be an eye opener for some dermatologists. Keeping up with rosacea is what Dr. Powell’s book is all about.
Powell devotes the rest of the chapter with management of PPR with a cool algorithm figure for dermatologists to use.
His chapter on Phymatous (Subtype 3) is also full of photos (14) and notes that while it is a rare malady with a ‘predilection for male patients’ occurs ‘20 times more commonly in male patients.’ He goes into detail abut six different types of rhinophyma and clearly states that while most literature in the past suggests this condition is the end stage of rosacea that this is not true. Rhinophyma can occur with ‘little (or even no) preceding inflammation.’ He ends the chapter with the management of this subtype.
He devotes another chapter on Ocular Rosacea (OR) or Subtype 4. He says that rosacea “is almost unique among the inflammatory dermatoses in that it is often accompanied by ocular inflammation or dysfunction.” This frequency ranges from “20% to 60% depending on whether the findings are being recorded by ‘dermatologists or ophthalmologists.’ “ He goes into great detail with colorful illustrations and photos of the clinical features and makes the point that “most patients do not volunteer any specific complaint related to their eyes when presenting with the skin changes of rosacea. This is because they are usually mild and they do not relate eye symptoms to their skin condition. It therefore behooves the clinician to specifically enquire about ocular symptoms.” He says that dermatologists should refer the patient to an ophthalmologist to rule out any differential diagnosis since that falls into his speciality. Again he finishes with detail management treatment.
In the last chapter, entitled, General Considerations, he suggests asking questions to the patient in taking a history, specifically:
(1) Asking about polycythemia?
(2) Whether the patient has been using a steroid cream?
(3) Any other medication such as niacin or antacids?
(4) Whether there has been any frequent flushing?
(5) Any complementary or alternative medicines, i.e., herbal products?
(6) Eye symptoms?
(7) Any family history of rosacea?
Did your physician ask you any or all these questions? He then goes into some suggestions when taking the physical examination and then some details for applying medications and skin care. For example, his advice is to tell the patient after cleansing with a gentle soap or soap free cleanser to wait 30 minutes before applying the medication and progressively reduce this proceedure as the patient acclimates to the therapy. He emphasizes to tell the patient that ‘drugs have priority – they go on first!’ after sun block or moisturizers. He also encourages going over cosmetic advice with a table of Do’s and Don’ts. He mentions caution to clinicians who treat pregnant patients and also a discussion about the rare patient with skin color (Fiztpatrick’s Skin types 4 – 6) with some suggestions.
One interesting suggestion in this chapter he points out that “it is courteous to discuss with the patient what their concept of rosacea is.” He encourages clinicians to emphasize that rosacea is usually quite controllable and discusses lifestyle factors that may reduce the need for the chronic medication usage by discussing this with the patient. Many rosaceans are concerned about rhinophyma so he mentions it would be good to assure the patient that subtype 3 does not necessarily result from rosacea and this subtype mainly occurs in males which will no doubt relieve female patients. He says it is important to explain to the patient the reason for follow up visits and to reassure the patient that the association of alcohol with rosacea is not valid so as to reduce the stress associated with this misinformation. He concludes with addressing the social stigma of rosacea and the positive outlook that there is with ongoing research and organizations devoted to improve treatment.
If every rosacean were armed with this book when he visits his dermatologist and with a respectful tone suggest that the dermatologist own a copy and read it that this would probably do more for rosacea patient treatment than anything else at this point in time. I highly recommend this book not only for physicians but if you are on a search to find physician treatment for rosacea this is the book that will help you the most. I predict Dr. Powell will become very popular with rosaceans.
Brady Barrows
click on the image below if you want a copy:
