Cause of Rosacea?

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Brady Barrows
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Cause of Rosacea?

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What Causes Rosacea?
Editorial by Brady Barrows
Copyright 2005 - All Rights Reserved

There are a number of theories on the cause of rosacea and they may basically be broke down into these popular categories (the numbers are the webmaster's, not by popular vote):

(1) Demodex folliculorum (my editorial on demodex)
(2) A Neuro-vascular disorder (possibly due to genetics) (see this item or read quotes from Dr. Nase below)
(3) Too much Cathelicidin (see this item)
(4) An inflammatory process (see this item
(5) A bacterial infection (see this item)
(6) An immune system disfunction (see this item) (another source)
(7) A combination of genetic predisposition and several types of environmental factors (see this item)
(8) A fungus (see this item)
(9) A psychological disorder (see this item)
(10) Lymphatic vessels (see this item)
(11) Photo Damage, ie., sun (see this item)
(12) Nervous system (see this item)
(13) Helicobacter Pylori (see this item)
(14) Steroid Induced Rosacea (source)
(15) Certain topicals May Trigger Rosacea (source)

None of these theories have been proven nor is this list complete since there are other theories that may be added to this list in the future. As you can see, the jury is still out on what causes rosacea. But depending on which one of the theories you may believe, your belief in the theory will definitely effect what treatment you choose. Just remember that you may be wrong to put your trust in just one theory. Due to not knowing the cause of rosacea there is an X-Factor Phenomenon in controlling rosacea. As the source below so clearly admits, there may even be a 'variety of pathogentic routes' or several different synergistic causes.

"...Rosacea seems to be a reaction pattern to which a variety of pathogenetic routes may lead..."
source

"...rosacea may be thought of as a disease spectrum with 2 primary etiologic components, vascular and inflammatory. The earliest manifestations of the disease are cutaneous vascular dilatory changes with subsequent increased blood flow in the form of telangiectasias and erythema....The later stages of rosacea are marked by inflammatory changes in the form of papules and pustules in the midface, rhinophyma (bullous nose), blepharitis and meibomitis, and corneal vascularization. A type 4, cell-mediated hypersensitivity reaction has been hypothesized as a possible mechanism. Demodex mites also have been implicated as a possible inflammatory stimulus. Additionally, Helicobacter pylori has been postulated to be a causative factor in a subset of patients. Whatever the underlying mechanism, there is a fundamental abnormality in the sebaceous glands of the face and eyelids, which leads to the inflammatory changes exhibited....In the US: More than 10% of the general population exhibits dermatologic characteristics of rosacea..." source > "Occular Rosacea," by J Bradley Randleman, MD, and C Diane Song, MD >
http://www.emedicine.com/OPH/topic115.htm

The X-Factor Phenomenon is why there are so many frustrated rosaceans and is rooted in the cause of rosacea. Whether the cause is genetic, due to the environment, or a combination of both, the X-Factor Phenomenon is not going away until we find the cause and cure of rosacea.

According to Dr. Geoffrey Nase, Ph.D. Microvascular Physiologist, in his book, Beating Rosacea Vascular, Ocular & Acne Forms, A Must-Have Guide to Understanding & Treating Rosacea which is probably one of the most comprehensive work of medical information on rosacea published in book form to date, he lists one of the longest list of some of the proposed triggers (or causes) as follows; "bacteria, yeast, mites, blood vessel damage, nerve dysfunction, systemic infection, gastrointestinal abnormalities, immune system alterations, psychological problems, liver problems, leaky intestines, collagen damage, sun damage, skin irritation, hormonal variations, stress, exercise, facial parasites, blood toxins, sebaceous gland hyperactivity, hair follicle abnormalities, stomach hyperacidity, nervous system defects, cardiovascular abnormalities, food allergies, environmental damage, etc..." However, Dr. Nase discounts the above proposed triggers as causes stating that "rosacea is surrounded by confusion, unproven theories, and erroneous speculation." For instance, he says the H. Pylori theory is only a minimally important rosacea trigger, that there is no evidence that liver problems cause or worsen rosacea, and that the demodex mite plays no real role in the development of rosacea 'except for the odd pustule.' Dr. Nase states in his book that "rosacea is primarily a facial vascular disorder in which the affected blood vessels are functionally and structurally abnormal" and "is a mysterious disorder that continues to receive very little focus by the general medical community." More information on his book can be obtained by ordering his book.

"... Rosacea is a genetic based disorder where there are protein alterations in blood vessels, nerves and the epidermis. This is the heart of rosacea. Everything else is secondary..." Dr. Nase source

"Subject: The Heart of the Rosacea Beast -- Neuro-vascular Alterations at Genetic Level" Dr. Nase - source

"...The problem is that it is the hardest part of the disorder to study and thus has been elusive to pin down the exact neuropeptides, blood vessels and their receptors. But that is where it all starts and progresses..." Dr. Nase source

"...The blood vessels that are dysfunctional are derived in the embryo from a certain cell line common to only the face and eyes. Not to any other organs or blood vessels..." Dr. Nase source

"... Rosacea is primarily a disorder of the facial blood vessels..." Dr. Nase - source

"...Dr. Nase feels as though this is a vascular problem. O.K. A vascular problem that manifests itself on the exterior of the body. But, for heavens sake, what does that mean systemically??? I mean, if we are only seeing the exterior results of a vascular problem......what is it doing to the rest of the vascular system? Also, there doesn't seem to be any coordination between health care providers on this topic. Some people are seeking treatment from opthamologist, some from derms, some from Dr's providing photoderm or laser treatments, some from internists/family practitioners, some even from gastroenterologists. No one knows what the other hand is doing. No continuity of care between them. My theory is that they just do not understand it enough to figure out what to tell us. All the treatment seems to go towards treating the symptoms only, because the cause is unknown" - A nurse's insightful comment on the cause of rosacea > http://groups.yahoo.com/group/rosacea-s ... threaded=1

"...It can be argued that all the stigmata of rosacea are manifestations of an inflammatory process: neutrophilic dermatosis.....The pathophysiology of rosacea is still a subject of controversy. Research suggests that various immune cells and inflammatory mediators play a role in the vascular, inflammatory, and hyperplasia stages of this disorder." The Proposed Inflammatory Pathophysiology of Rosacea: Implications for Treatment, Larry Millikan, MD source > http://groups.yahoo.com/group/rosacea-k ... ssage/1447

"...No one knows for certain what causes rosacea..." International Rosacea Foundation
> http://internationalrosaceafoundation.org/

"...rosacea is characterized by a fragmented understanding of its pathogenesis. Our limited knowledge regarding the pathologic mechanisms and pathways that cause rosacea has been a major barrier, ultimately preventing the development of new treatments..." New Perspectives on Rosacea, Supplement to the October 2003 Skin & Aging
source > http://skinandaging.com/sa/supplements/ ... osacea.pdf

"...While the cause of rosacea is unknown and there is no cure, today medical help is available that can control the signs and symptoms of this potentially life-disruptive disorder..." National Rosacea Society source > http://www.rosacea.org

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, "Doctors do not know the exact cause of rosacea but believe that a combination of genetic predisposition and several types of environmental factors are related to its development. Some researchers believe that rosacea is primarily a disorder of the blood vessels, or vascular system, in which something causes blood vessels to swell, resulting in flushing and redness.

A tiny organism called Demodex folliculorum, a mite that lives in facial hair follicles, may be involved. Some researchers believe that these mites clog the sebaceous gland openings, leading to inflammation. Other investigators have shown a possible link between rosacea and Helicobacter pylori, a bacterium that causes infection in the gastrointestinal system. Also, some research has suggested that the immune system may play a role in the development of rosacea in some people...."
source of article - http://www.nih.gov/niams/healthinfo/rosacea.htm

"The exact cause of rosacea is unknown, although several theories exist. 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. Another theory is that changes in normal skin bacteria or infection of the stomach by Helicobacter pylori may play a role. Other theories suggest that the condition is caused by microscopic skin mites (Demodex ), fungus, a malfunction of the connective tissue under the skin or even psychological factors. None of these possibilities has been proven." > National Rosacea Society source > http://www.rosacea.org/patients/faq.html

"The cause of rosacea is unknown, but it is commonly thought to be of vascular origin because of a clinical association with flushing, development of telangiectasia and tissue swelling, and ultimately, tissue proliferation and rhinophyma (enlargement of the nose)." Postgraduate Medicine source of article -
http://www.postgradmed.com/issues/1999/ ... llikan.htm

"...Pathogenesis is not clearly understood...' -- Thissen MR, Neumann HA., Academisch Ziekenhuis --- source of article > http://www.ncbi.nlm.nih.gov:

"...Currently, neither a specific cause nor a laboratory indicator of rosacea has been suggested...." ---Rosacea: current thoughts on origin. Bamford JT., Department of Family Practice and Community Health, University of Minnesota-Duluth Medical School, MN, USA. [email protected] of article > http://www.ncbi.nlm.nih.gov:

"Etiology The cause of rosacea is poorly understood, although numerous theories have been offered. Hypotheses have included gastrointestinal, psychological, infectious, climatic and immunological causes, although scientific evidence has not substantiated any of these as primary (10). Controlled studies have not demonstrated consistent preponderance of gastrointestinal symptoms in rosacea patients (24). Similarly, neither a distinct psychological abnormality nor one pharmacological mechanism has been isolated in rosacea patients. Perhaps the most commonly touted of the etiologic theories is based on the presence of Demodex folliculorum in patients with rosacea. Demodex folliculorum has been considered a causative agent of rosacea in the past (25,26). The organism feeds on sebum, and in some cases treatment of demodex infestation has noted improvement in the rosacea (14,27). However, in a review of 79 biopsies, Marks noted demodex folliculorum in only 19% of the specimens (28). A bacterial cause for the disease has been hypothesized, but no consistent findings of one bacteria have been demonstrated (5). Climate, specifically exposure to extremes of sun and cold, may have an effect on the course of the disease, but the role of climate in what appears to be a connective tissue disorder is not clear. Finally, an auto immune process has been suggested, and tissue fixed immunoglobulins have been reported in patients with chronic inflammation of rosacea, but no other evidence has been found (29). Recent experimental evidence has suggested this disease may represent a type of hypersensitivity reaction (30)." ----Chapter 41, Acne Rosacea, Marian S. Macsai, Mark J. Mannis, and Arthur C. Huntley - ? 1996 by Lippincott-Raven Publishers
source of article >http://dermatology.cdlib.org/DOJvol1num ... sacea.html

An article in the June 1, 2004 Dermatolgy Times by Rebecca Bryant quotes Michael Detmar, M.D., as saying, "Bacteria are likely involved because what works to some extent as a treatment are antibiotics. Also there appears to be a relationship to photo damage. The nervous system may be involved, because exertion, emotions, and weather trigger the disease, in addition to other triggers such as heat, certain types of food, alcoholic beverages, various topical balms and cosmetics, and various drugs. We're clear that blood vessels are dilated but don't know if that comes first or later. A new area of research suggests that lymphatic vessels are involved." [source]

Based on the theory that rosacea shares the same inflammatory features of acne, a recent study showed that, just as the combination of benzoyl peroxide 1 percent and clindamycin 5 percent gel is a powerful treatment modality for reducing Propionibacterium acnes levels, it also significantly reduces the papules and pustules of rosacea, according to Debra L. Breneman, M.D. ...."Benzaclin, once daily, was found to be well tolerated and effective in the reduction of papules and pustules in patients with rosacea," said Dr. Breneman. "This lends credence to the theory that P. acnes is a potential aggravating factor in rosacea. This gives dermatologists a very effective treatment for rosacea." Source > http://www.dermatologytimes.com

Rosacea Caused by too much Cathelicidin?

An article in the June 1, 2004 Dermatolgy Times by Michelle Stephenson quotes Richard L. Gallo, M.D., Ph.D., who says rosacea may be an 'abnormality in the innate immune system...caused by too much cathelicidin." Dr Gallo says, "if we believe that the disease is caused by too much cathelicidin, we could develop a strategy to block the effects of the cathelicidins by making molecules that mimic that protein but don't have the same effects." source
Brady Barrows
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