(Acne rosacea; Acne erythematosa; Gutta rosacea)
Definition. A chronic congestion of the face, characterized by flushing, permanent redness, capillary dilatation, secondary once and sometimes by tissue hypertrophy.
Symptoms. Rosacea begins as a temporary congestion or redness of the middle third (flush area) of the face, which recurs at varying intervals. The remissions become shortened as the duration of the disease extends. The color varies from a bright red to a purplish hue; usually the surface is cool, although occasionally it may be noticeably warm to the touch and at times there may be sensations of heat in the affected skin. The congestion, which is at first active, gradually becomes passive and when the color is made to disappear by pressure, it slowly returns. Seborrhea or seborrheic dermatitis is often present, in fact, becomes a part of the rosacea and contributes to the shining and tense appearance of the affected surface, especially the nose. Acne lesions may appear at this stage, differing in no way from the ordinary acne, except in the absence of comedones. Larger lesions, as are found in acne indurata, may mingle with the smaller papules and pustules. Occasionally these lesions appear only in the later stage and rarely may never be present to an appreciable degree. The above description applies to the so-called first or simple stage which may last for months or years with remissions but eventually, unless relieved, develops into a more pronounced type.
In the second stage dilated blood-vessels become visible on the surface, either as fine lines, often numerous and widely distributed, or as larger anastomosing vessels, sometimes tortuous and slightly varicose. These are usually most marked upon the nose, but may form in a less degree upon the cheeks, often giving to the skin a bluish or violaceous tint. During this stage the seborrheal and acnoid features may be more marked or occasionally the surface may be dry, uneven and somewhat scaly. Untreated this type of the disease may continue indefinitely and the third or hypertrophic stage, except in a very moderate degree, is seldom seen.
The third stage consists of a connective tissue growth about the vessels and presents non-inflammatory nodular enlargements at the end and sides of the nose, expanding it longitudinally and laterally (rosacea hypertrophica). In extreme cases the process may continue until the nose is enormously enlarged (rhinophyma), overhangs the mouth and chin, and is more or less covered with deep red nodules and dilated or varicose blood-vessels. Rarely the forehead or cheeks will show hypertrophic changes.
Etiology and Pathology. Rosacea is a common disease representing about 3 per cent. of all cases and usually appears between the thirtieth and fortieth years of life, but not infrequently it may originate before or after that period. Women, up to the age of forty, seem more subject to the disease than men in the proportion of four to one but they seldom develop the hypertrophic form. Locally, acne and seborrhea, the injudicious use of cosmetics, even hot water persistently applied, and exposure to artificial dry heat, wind, sun and extremes of cold are predisposing factors. Rheumatic or gouty diatheses, sedentary living, gastrointestinal disorders, constipation, respiratory catarrhs, ovarian, uterine and genitourinary diseases, a rich or highly seasoned diet and stimulants such as coffee, tea or alcohol, taken in excess, are all well-known predisposing factors. Alcoholism is by no means the sole cause of the disease, as has been generally believed, because many of the extreme cases occur in those of most temperate habits. However, most cases of hypertrophic rosacea do occur in those who combine excessive drinking with constant exposure to the elements.
Pathologically, this disease presents in its initial stage a hyperemia, angioneurotic in some cases, in others due to a seborrheic process. Then, later, dilatation of the vessels, active and passive inflammation, glandular enlargement and in some cases trophic changes in the nature of connective tissue growth, ensue.
Diagnosis may be made from the following: Dermatitis seborrhoica shows more abundant fatty or oily scales and perceptible itching, with a lack of symmetry and no temporary flushing of the face or dilated blood-vessels.
Lupus erythematosus extends by peripheral growth in sharply defined patches with somewhat raised borders. Its scales are more or less dry and adherent and often plug the orifice of the sebaceous ducts. Atrophic scarring invariably follows.
Acne vulgaris begins in younger subjects as papules mingled with comedones. It may occur upon the upper part of the trunk as well as on the face and is never markedly red at the onset.
Tubercular syphilids occurring on the nose might resemble advanced rosacea but the history of development, frequent lack of symmetry, ulceration beneath its crusts or other evidences of syphilitic lesions, past or present, should make the diagnosis clear.
Prognosis. Rosacea in the first and second degrees can always be relieved, if not entirely cured, by appropriate treatment. While the condition is generally persistent and obstinate, it is always cheering to inform the patient that it can, at least, be arrested by the proper measures and this is often equivalent to a cure. Even the hypertrophic or third form may be much relieved and the enlargement reduced by proper surgical measures.
Treatment. Causal and physiological measures are of primary importance and, in this connection, the regulation of the diet to relieve gastrointestinal disorders and constipation, thereby improving nutrition, is absolutely essential. All aggravating local influence such as were mentioned under etiology should be avoided and the various constitutional diseases that may be predisposing should receive specific attention.
The amount of local treatment depends largely upon the measure of relief that can be obtained by removing the predisposing causes. Local treatment embraces the same prescriptions as noted under the treatment for acne, especially the sulphur and milk of magnesia lotion, Kummerfeld’s compound zinc sulphid lotion and Vleminckx’s solution. Occasionally ointments give good results. The formulas suggested for acne are again available. Lotions and ointments are especially serviceable when the acnoid features are pronounced. When capillary dilatation and varicose conditions are most in evidence, physical therapy is the more effective agent. The high-frequency currents are the best in this respect and they may be applied once or twice weekly, using a glass vacuum electrode held a quarter of an inch from the surface. This agent is especially good for cases of the first and many of the second stage. But this latter phase of the disease often responds to the X-rays more quickly and satisfactorily, and to my mind, the X-rays is more valuable here than in the treatment of acne. The Finsen and similar lamps are often effective for general telangiectases and for marked rosacea of small areas.
Massage of the face may be beneficial in the second stage in restoring tone to the weakened vessels. The larger or varicose vessels may be made to disappear by electrolysis, galvanocautery or fulguration. Mild connective tissue hypertrophy can be reduced by scarification, multiple puncture, electrolysis, and solidified carbon dioxide. The larger growths can only be removed by ablation with knife and scissors, followed by skin grafting if necessary. Vaccines, used after the manner described in acne, have benefited a few cases. For internal remedies see Agaricus, Arsenicum, A. brom., A. iod., Belladonna, Caladium, Calcarea phos., Carbo animalis, C. veg., Carbol. acid., Causticum, Coccu. ind., Colchicum, Kali brom., Nux vomica, Phosphorus acid, Rhus tox., Sepia and Silicea.