Other features include tips for managing stressful times, Q&As, a new success story and a new patient survey on the signs of rosacea.

One of the first and most important steps a rosacea patient should take is to ask his or her dermatologist for help in formulating a skin-care plan as early in treatment as possible, Ms. Krupp said. "The average woman spends $100 on beauty products each month, and trial and error is just too expensive." Facial cleansers and makeup often contain additives such as fragrances, peppermint and alcohol, which are frequently cited as rosacea triggers, she said. "But there are plenty of products without these ingredients, so make sure to read the labels before primping."

A variety of makeup brands offer products with a green tint that can help counteract the appearance of redness, Ms. Krupp said. She suggested using gel or cream makeup formulations to create a "dewy" look that hides blemishes and wrinkles. Because many rosacea patients suffer from eye irritation or extremely sensitive skin, Ms. Krupp recommended using eye pencils instead of liquid eyeliner and water-based mascara instead of waterproof mascara for easier removal.

Makeup brushes that are cleaned frequently are a better choice than sponge applicators, and replacing makeup every three to six months will also minimize contaminants, she said. Ms. Krupp noted that clothing can also play a role in helping rosacea patients optimize their appearance. She advised choosing "red-reducing" colors such as yellows and blues and avoiding red, white and black, all of which emphasize a red face. In addition, she emphasized the benefits of long scarves, which can serve double duty as both a fashion accessory and a shield against the wind on wintry days.

A "bad skin day" doesn’t have to turn into a disaster, Ms. Krupp said. "If you have a flare-up despite your commitment to following a rosacea-friendly routine, get over it and treat yourself. I recommend a manicure or pedicure, a massage or even buying a new top."

For more beauty advice, visit Makeup Tips and Rosacea Relief Squad.

"Because the full effects of rosacea tend to vary significantly from one patient to another, medical therapy and other elements of care must be tailored by physicians for each individual case for optimal results," said Dr. Richard Odom, professor of dermatology at the University of California – San Francisco, who chaired the expert committee. "The new standard options should serve as a significant tool in helping doctors provide the best possible outcomes for their rosacea patients."

The new system for managing the disorder builds off of the standard classification and grading systems, previously developed and published by the NRS consensus committee, which identified the four subtypes of rosacea. These include subtype 1 (erythematotelangiectatic) rosacea, characterized by flushing, redness and often visible blood vessels; subtype 2 (papulopustular) rosacea, including bumps and pimples; subtype 3 (phymatous) rosacea, including skin thickening, commonly of the nose; and subtype 4 (ocular) rosacea, involving irritation of the eyes.

"Patients often experience more than one subtype at the same time, and that's one of the reasons good patient-doctor communication can be so important," Dr. Odom said. He noted that the new system begins by advising health professionals to ask patients about possible features of the disorder that might not be visibly evident at the time of their visit.

For example, anyone who has significant flushing should be sure they inform their dermatologist, including how and when it occurs. Patients should also be sure to tell their doctor if they have had long-term extensive sun exposure in their job or lifestyle, as this may lead to redness and visible blood vessels from sun damage.

Beyond its facial symptoms, rosacea can also affect the eyes in some patients, and it may be especially important to note any eye discomfort, such as irritation, burning or stinging, or if the eyes tend to be watery or bloodshot. Although eye symptoms are often mild, in more severe cases they may require treatment by an eye specialist.

Also let your doctor know about any facial burning, stinging or itching, as these factors may then be addressed for your individual case. In addition, because of its effect on personal appearance, remember to be open about the impact rosacea has on your professional or social life, as well as your emotional well-being, in order to help determine the appropriate level of care.

"A wide range of measures are available for managing this potentially complex disorder," Dr. Odom said. "Along with appropriate use of oral or topical therapy, these can include lifestyle changes, surgical procedures such as laser therapy if needed, eye care when called for, proper skin care and effective use of cosmetics."

Reference
1. Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J. Standard management options for rosacea, part 1: Overview and broad spectrum of care. Cutis 2009;84:43-47.

"Studies funded by the NRS research grants program are making an invaluable contribution in identifying the biological mechanisms that may be involved in rosacea, and how future medical therapies might be targeted to bring significant advances in its treatment, prevention or cure," said Dr. Jonathan Wilkin, chairman of the NRS Medical Advisory Board. He noted that further scientific investigations are now under way that may finally unlock the mysteries of this highly prevalent and often baffling disorder.

In a much-heralded study reported in Nature Medicine, widely considered the leading journal on biomedical science, a team led by Dr. Richard Gallo at the University of California-San Diego found a consistently aberrant innate immune response in individuals with rosacea to environmental and emotional triggers. When the normal immune system is faced with any of a broad range of potential dangers -- such as emotional stress, heat or spicy foods -- receptors recognize the potential harm and protect the body by prompting the production of protective molecules known as cathelicidins to neutralize any effects.

Using advanced technology to analyze the biochemical composition of proteins in rosacea patients, the researchers discovered that in rosacea patients, the forms of cathelicidins are different, due to an overabundance of another substance called kallikrein, which can spur dormant cathelicidins into action and lead to skin inflammation. They recently completed the picture when they were able to demonstrate that this process is linked to the actual formation of rosacea signs and symptoms, and are now conducting further NRS-funded research on its implications.

In addition, two new studies building off of this research have been funded by the NRS and are now under way. Dr. Curdin Conrad at the MD Anderson Cancer Center in Houston and Dr. Alexander Navarini at University Hospital of Zurich, Switzerland, are examining the body's immunological process to see whether type I interferon, which can help fight viral infections, and plasmacytoid dendritic cells, which produce interferon, are also present in rosacea. Dr. Joseph Rothnagel and Dr. Manuela Trabi at the University of Queensland, Australia, have noted the involvement of enzymes in Dr. Gallo's work, and are now studying whether other enzymes may also be elevated in rosacea.

Meanwhile, Dr. Martin Steinhoff and Dr. Thomas Luger, Department of Dermatology, University of Muenster in Germany, discovered a biological process involving substances known as proteases that may link flushing with inflammation. The researchers then conducted further investigations to define which proteases may be involved in the inflammatory responses as well as the stinging, burning and itching of rosacea. As part of their research, they recently found that endothelin-converting enzyme (ECE) plays a role, and noted that any substance that inhibits ECE may be effective in the treatment of rosacea.

In other NRS-funded studies, Dr. Robert Walters and Dr. Robert Lefkowitz at Duke University are now investigating the roles of G and beta-arrestin proteins in the flushing triggered by niacin (vitamin B3), a common rosacea trigger, and Dr. Yolanda Helfrich at the University of Michigan is comparing differences between subtype 1 rosacea and the effects of sun exposure.

In a completed study in Ireland, Dr. Noreen Lacey and Dr. Kevin Kavanagh reported that the presence of Bacillus oleronius, found on Demodex mites, produced an immune reaction in rosacea patients but not individuals without rosacea. Demodex are a normal inhabitant of facial skin but are generally present in much greater numbers in rosacea patients.

Reports on completed research can be found here, and summaries of awarded research grants can be seen here.

Other features include tips for avoiding summer flare-ups, Q&As on menopause and whether rosacea is contagious, a new success story and a new patient survey on rosacea and oral antibiotics.

The deadline for submitting applications is November 15, 2009. Grants will be issued following selection by the NRS medical advisory board.

Because the etiology of rosacea is unknown, a high priority in awarding grants will be given to studies relating to such areas as the pathogenesis, progression, mechanism of action, cell biology and potential genetic factors of rosacea. Research in such areas as epidemiology, predisposition, quality of life and relationships with environmental and lifestyle factors may also be funded.

More information on the NRS research grants program may be found in the Research Grants section.

"By exploring the potential inflammatory pathways associated with common triggers of rosacea signs and symptoms, we hope to increase our biological understanding of what causes the disorder and how it progresses," Dr. Granstein said. "Such knowledge can then provide a basis for developing improvements in its treatment and control."

In research funded by the National Rosacea Society, Dr. Granstein and colleagues found that emotional stress, a common rosacea trigger, may activate the sympathetic nervous system with the release of adenosine triphosphate (ATP) from sympathetic nerves running throughout the skin’s blood vessels. In turn, the researchers discovered that ATP can induce a cascade of biochemical events within the body that may play a role in the inflammation of subtype 2 (papulopustular) rosacea.

"ATP may act as a messenger within the nervous system to regulate blood flow to the skin by signaling the dilation of blood vessels after exposure to various rosacea triggers, such as emotional stress," Dr. Granstein said.

He noted that flushing may ultimately be prompted by the nerves surrounding the blood vessels of the skin. These dermal vessels are associated with nerves containing substances such as the calcitonin gene-related peptide (CGRP), which dilate the vessels and thus may be associated with facial redness and the growth of the tiny blood vessels called telangiectasia, both signs of subtype 1 (erythematotelangiectatic) rosacea.

Upon investigating the potential significance of CGRP in prompting subtype 1 signs and symptoms, the researchers found that CGRP may play the opposite role in inflammation -- the bumps and pimples characteristic of subtype 2 rosacea. In recent tests, Dr. Granstein and colleagues observed that CGRP inhibits the stimulated release of certain chemokines (small proteins that recruit inflammatory cells) from the cells lining skin blood vessels (endothelial cells).

These results suggest that while the nerves containing CGRP may be linked to flushing, they may also serve to regulate inflammation by modulating chemokine production by the cells lining the blood vessels.

"Although there is still much work to be done to fully examine and define this complex process, substances that block or enhance the individual components of such pathways may ultimately lead to the effective control or prevention of rosacea," Dr. Granstein said.

In a recent survey of 1,190 rosacea patients conducted by the National Rosacea Society (NRS) and published in Rosacea Review, 85 percent said their rosacea is affected by changes in seasons. Nearly half said their symptoms are at their worst when hot weather arrives, and 46 percent said they have to make the most lifestyle adjustments during this time to reduce the likelihood of a flare-up of signs and symptoms.

"The sun and hot weather are such common rosacea triggers that it should not be surprising that rosacea is often aggravated in the summer," said Dr. Lisa Maier, assistant professor of dermatology at the University of Michigan. "Everyone should minimize sun exposure and use sunscreen during all seasons, but rosacea patients should be even more cautious than most."

In addition to using sunscreen with an SPF of 15 or higher, rosacea sufferers affected by sun and heat are advised to stay in a cool, air-conditioned environment during midday or when the weather is especially hot. Overexertion is also a common rosacea trigger, and sipping a cold drink or chewing on ice chips can help prevent or reduce the facial flushing that often accompanies strenuous activity.

The survey found that cold weather may be problematic for many rosacea sufferers as well. Thirty-five percent of all respondents and 46 percent of those who live in the North said their symptoms are at their worst during cold weather, when raw wind and biting temperatures can irritate already-sensitive facial skin.

Nearly a third of the survey respondents and 44 percent of those in northern areas of the country said they make lifestyle adjustments to ward off rosacea outbreaks during winter, such as covering their face with a scarf before going outdoors or avoiding facial flushing by steering clear of the piping hot beverages often served on chilly days.

The good news is that rosacea flare-ups can often be successfully prevented. The survey found that, regardless of seasonal changes, 87 percent of the respondents said medical therapy and making lifestyle changes had helped reduce their rosacea signs and symptoms.

"If patients notice that their condition tends to worsen during a certain season, they should be on the alert to take whatever seasonal steps may be needed to avoid their personal triggers," Dr. Maier said. "They should also talk to their dermatologist for further guidance on managing their condition."

Rosacea is a chronic disorder that is often characterized by exacerbations and remissions. It typically begins at any time after age 30 as a flushing or redness on the cheeks, nose, chin or forehead that may come and go. Over time, the redness tends to become ruddier and more persistent, and small blood vessels may appear. Without treatment, bumps and pimples often develop, and in severe cases, the nose may become swollen from excess tissue. In many patients, the eyes are also affected, feeling irritated and appearing watery or bloodshot.

Although the cause of rosacea is unknown, its signs and symptoms can be controlled with medical therapy and lifestyle changes to avoid factors that may aggravate the condition. The most common rosacea triggers include hot or cold weather, sun exposure, emotional stress, wind, heavy exercise, alcohol, hot baths, spicy foods, humidity, indoor heat, certain skin-care products and heated beverages.

Other features include tips for handling hurtful comments, Q&As on ocular rosacea and the use of steroids, a new success story and a new patient survey on temperature triggers.

"Whether it's a job interview or simply a social occasion, few things can be more disconcerting for many than developing a red face or blemishes," said Dr. John Wolf, chairman of dermatology at Baylor College of Medicine. "While the initial signs of rosacea may come and go, without proper diagnosis and appropriate medical therapy the disorder can grow progressively more persistent and severe."

Rosacea usually first strikes individuals between the ages of 30 and 60, and may initially resemble a simple sunburn or an inexplicable blush. Suddenly, without warning, a flush comes to their cheeks, nose, chin or forehead. Then just when they start to feel concerned, the redness disappears.
Unfortunately, it happens again and again, becoming ruddier and lasting longer each time -- and eventually, visible blood vessels may appear. Without treatment, bumps and pimples often develop, growing more extensive over time, and burning, itching and stinging are common.

In severe cases, especially in men, the nose may become enlarged from the development of excess tissue. This is the condition that gave comedian W.C. Fields his trademark red, bulbous nose. In some people the eyes are also affected, feeling irritated and appearing watery or bloodshot. Severe cases of this condition, known as ocular rosacea, can result in reduced visual acuity.

Adding to medical concerns, new study results and other factors suggest that rosacea may be substantially more prevalent than is widely believed. Results of an NRS-funded study, recently presented by Dr. Maeve McAleer and colleagues from Mater Misericordiae University Hospital in Dublin, for example, found that 14.4 percent of 1,000 subjects examined in Ireland had rosacea.

"As a chronic condition characterized by flare-ups and remissions, the prevalence of rosacea may appear to be lower because the signs and symptoms are not present at all times in every individual affected by the disorder," Dr. Wolf said. "As a result, the number of people who suffer from rosacea may be substantially higher than has been traditionally reported."

Beyond its physical effects, rosacea often inflicts significant emotional, social and professional concerns because of its intrusive impact on personal appearance.

Compounding the embarrassment is the common myth that rosacea sufferers, who often have a red face and nose, are heavy drinkers. In fact, while alcohol may aggravate rosacea, these symptoms can be just as severe in a teetotaler. Another common misconception is that rosacea is caused by poor hygiene, while in reality it is unrelated to personal cleanliness.

"The good news is that, while rosacea cannot be cured, it can be effectively controlled with medical therapy and lifestyle changes," Dr. Wolf said. Individuals with any of the following warning signs of rosacea are urged to see a dermatologist for diagnosis and appropriate treatment:

• Redness on the cheeks, nose, chin or forehead

• Small visible blood vessels on the face

• Bumps or pimples on the face

• Watery or irritated eyes

In the study, 65 individuals with rosacea and 65 healthy control subjects underwent a facial skin exam, completed a questionnaire, and were measured for height, weight and blood pressure. In general, Dr. Kimball said, the cases of rosacea were moderate to severe.

The researchers found that individuals with rosacea were three times more likely to have a family member with the disease, compared to the control subjects. In addition, rosacea patients had significantly higher rates of blistering sunburns than those without rosacea -- 44 percent versus 5.2 percent.

"Even when we did a more sophisticated analysis of the data controlling for age and gender, we found these findings were statistically significant," said Dr. Kimball. "Although these results are preliminary, they are important for future research as we start to explore their implications in controlling this condition."

The results show that it may be especially important for patients with rosacea to consistently protect against sun exposure and use a sunscreen with an SPF (skin protection factor) of 15 or higher.

While it was not clear whether sunburns contributed to rosacea or patients with rosacea were more likely to sunburn, she said, preventive measures could help lessen rosacea's severity. Sun has been named the top flare-up trigger by 81 percent of patients in a National Rosacea Society survey (NRS), and in another NRS survey nearly 52 percent said someone else in their family had rosacea.

"We are extremely grateful to the thousands of rosacea patients whose donations are used to support this important program," said Dr. Jonathan Wilkin, chairman of the NRS medical advisory board, which reviews and selects grant applications for funding. "The ongoing study results are making significant inroads toward the better understanding and management of rosacea, as well as its potential prevention or cure."

Dr. Robert W. Walters, assistant professor, Division of Dermatology, and Dr. Robert J. Lefkowitz, professor, Department of Medicine, Duke University Medical Center, were awarded $25,000 to study the role of beta-arrestin in cutaneous flushing. The researchers pointed out that niacin, or vitamin B3, long associated with severe flushing, stimulates receptors on skin cells that react by activating both G and beta-arrestin proteins. However, they noted that a recent study has identified niacin-like drugs that can stimulate only the G protein but do not induce flushing, suggesting that it is the beta-arrestins that may regulate flushing. The results of the new project are intended to lead to better understanding of changes in skin blood flow and possible treatments for this significant symptom of rosacea.

Dr. Curdin Conrad, senior postdoctoral research fellow, Department of Immunology, MD Anderson Cancer Center, and Dr. Alexander Navarini, senior postdoctoral research fellow, Department of Dermatology, University Hospital of Zurich, Switzerland, were awarded $21,450 to study the role of plasmacytoid dendritic cells and interferon alpha in rosacea.

They noted that their work is a logical follow-on to the studies by Dr. Richard Gallo and colleagues, also supported by the NRS, which found that in rosacea, antimicrobial peptides such as cathelicidins are involved. Given that these peptides are part of the innate immune system, their work will examine the next steps in the body's immunological process to see whether type I interferon, glycoproteins that help fight viral infections, and plasmacytoid dendritic cells, which produce interferon, are present in rosacea. They noted that these mechanisms contribute to psoriasis, and a similar finding in rosacea could form a sound basis for newer treatment strategies for rosacea.

Dr. Richard Gallo, chief of the division of dermatology at the University of California-San Diego, and Dr. Kenshi Yamasaki of the Veterans Medical Research Foundation were awarded $25,000 to continue their NRS-funded research of how cathelicidins may play a role in the development of subtype 2 (papulopustular) rosacea.

Past support from the NRS has enabled them to show that people with rosacea have too much of a molecule known as cathelicidin, and using mice and artificial cell culture techniques, they showed that this excess leads to rosacea symptoms. They have also shown that the overabundance of cathelicidin is the result of an excess of an enzyme in the facial skin.

In the new study, the researchers will test their hypothesis that the abnormal enzyme is a critical step in the development of rosacea. Too much cathelicidin and too much of this specific class of enzyme may explain its presence, which may in turn suggest a therapy that will inhibit the production or action of these molecules.

Dr. Joseph Rothnagel, associate professor, and Dr. Manuela Trabi, adjunct lecturer, Department of Molecular and Microbial Sciences, The University of Queensland, Australia, were awarded $18,000 for their study, "The role of tissue kallikreins in rosacea." This study will also build from the work of Dr. Gallo and colleagues. They noted that these previous studies reported involvement of the enzyme hK5 and protein CAP18, and hypothesize that at least one other enzyme is also elevated in rosacea. They will study whether proteins known to be crucial for skin integrity are also digested at a higher than normal rate by these enzymes, allowing easier access for pathogens.

Researchers interested in applying for grants may obtain forms and instructions in the research grants section of rosacea.org, or by contacting the National Rosacea Society, 800 South Northwest Highway, Suite 200, Barrington, Illinois 60010, telephone 1-888-662-5874, e-mail rosaceas@aol.com. The deadline for submitting proposals for research grants in 2009 is October 15.

Members of the NRS medical advisory board include Dr. Jonathan Wilkin, former director of dermatologic and dental drug products for the U.S. Food and Drug Administration; Dr. Mark Dahl, chairman of dermatology at Mayo Clinic-Scottsdale and former American Academy of Dermatology (AAD) president; Dr. Michael Detmar, professor of pharmacogenics, Institute of Pharmaceutical Sciences, Swiss Federal Institute of Technology, Zurich, Switzerland; Dr. Lynn Drake, Harvard Medical School and former AAD president; Dr. Marian Macsai, vice chair of ophthalmology at Northwestern University; Dr. David Norris, chairman of dermatology, University of Colorado and former president of the Society for Investigative Dermatology; Dr. Richard Odom, professor of clinical dermatology, University of California-San Francisco and former president of the AAD; Dr. Frank Powell, consultant dermatologist, Regional Centre of Dermatology, Mater Misericordiae Hospital, Dublin, Ireland; Dr. Bryan Sires, clinical associate professor of ophthalmology, University of Washington; and Dr. Diane Thiboutot, professor of dermatology, Pennsylvania State University.

"The early clues to rosacea are confusing for many people because the signs and symptoms often come and go, and are easily mistaken for something else," said Dr. Jonathan Wilkin, chairman of the NRS medical advisory board. "Unfortunately, without medical treatment rosacea usually continues and may become worse, and can have substantial impact not only physically but on an individual's emotional, social and work life."

In NRS surveys, more than 76 percent of rosacea patients said their condition had lowered their self-confidence and self-esteem, and 52 percent reported that it had caused them to avoid public contact or social engagements. Among rosacea patients with severe symptoms, nearly 70 percent said the disorder had adversely affected their professional interactions and nearly 30 percent said they had even missed work because of their condition -- which may be especially harmful in today's economic setting.

The good news is that 80 percent of the survey respondents reported that medical therapy had also improved their emotional, social and professional well being.

During Rosacea Awareness Month, public education activities will be conducted by the NRS to increase awareness and understanding of this widespread disorder, emphasizing its warning signs and urging those who suspect they may have the condition to see a dermatologist or other physician. In addition, bulk quantities of NRS educational materials are available to health professionals for their patients.

Although rosacea varies from one patient to another, its primary signs may include facial flushing or transient erythema (redness), persistent erythema, papules (bumps) and pustules (pimples), and telangiectasia (visible blood vessels), according to the NRS standard classification of rosacea, developed by a consensus committee and review panel of 17 experts worldwide. Secondary features may include burning or stinging, plaques (raised patches on the skin), a dry appearance, edema (swelling), ocular manifestations and phymatous changes, in which the skin thickens.

The standard subtypes of rosacea reflect the most common patterns of signs and symptoms, and characteristics of more than one subtype may occur at the same time. Subtype 1 (erythematotelangiectatic) rosacea is characterized by flushing and persistent redness on the central portion of the face, while subtype 2 (papulopustular) rosacea also features papules and pustules. Subtype 3 (phymatous) rosacea includes thickening of the skin, irregular nodularities and enlargement, especially of the nose. Subtype 4 is ocular rosacea, where the eyes may have a watery or bloodshot appearance, the sensation of a foreign body, burning or stinging, dryness, itching, light sensitivity or a host of other signs and symptoms.

Other features in the issue include tips for surviving holiday cuisine, Q&As on topical medication and the use of lasers, a new success story and a new patient survey on the seasonal effects of rosacea.