Definition And Description

Rosacea, at its commencement, is characterized by the appearance of small reddened macules, or a diffused, reddened patch on the nose or cheeks, or both. The redness gradually ex-rids until after some months, or perhaps years, a considerable part of the face may be involved. The principal characteristic at this stage is a diffused superficial redness without much, if any, infiltration. In this condition the affection may persist indefinitely, and perhaps never go beyond it. More frequently, however, it passes on to the second stage, characterized by the appearance of minute blood-vessels. As the disease progresses, these vessels increase in size, both as to length and breadth, and frequently become tortuous and varicose. At the same time the integument itself thickens, and occasional pustules arise. These are generally seated in the sebaceous glands, and are in reality an acne secondary to the Rosacea. They are rarely, however, a prominent feature of the affection, and should be regarded as accidental complications due to the extension of the morbid action from the surrounding tissues to the glands. This second, or varicose, stage of Rosacea is like the first, of gradual development, often requiring years, but still progressing with slow but steady step. In some cases the affection halts in this stage; in others the morbid action continues, and is accompanied with infiltration of the cutaneous tissues. This may result in very great thickening of the integument, and in severe cases lead to decided hypertrophy and deformation of the nose, which is the part most liable to be the subject of this form of Rosacea. This thickening and hypertrophy may be uniform, or, more frequently, somewhat irregular, budding out in different places into rounded elevations or tubercles. These are not proper acne tubercles, but projections of the general integumentary tissues, including, of course, many sebaceous glands. The large and tortuous veins which characterized the second stage are also present in this, but the red color, so prominent in the earlier periods of the disease, in many cases disappears in great measure as the hypertrophic changes advance. Rosacea may occur at any period of adult life, but, as a rule, does not become developed to any great extent until middle age or later.

Diagnosis

The diagnosis of Rosacea is not difficult. The only affections with which it might by chance be confounded are simple erythema, erythematous eczema, and erythematous lupus. From these it can, as a rule, be readily distinguished by considering the history of the case, and comparing the lesions present with those that accompany the affections just named.

Prognosis

In general the prognosis is favorable, that is, most cases can be greatly improved, and many of them permanently cured. The earlier judicious treatment is adopted, the speedier and more certain the relief. Advanced cases that have reached the second and third stages, however, can be greatly benefited.

Etiology

Rosacea is a reflex affection, and depends, in the majority of cases, on perfectly recognizable causes. These reside, for the most part, in derangements of the alimentary canal, liver, uterus, or ovaries. In considering them it must be remembered that any cause capable of congesting the facial integument, if the cause is repeatedly or continuously in action, is liable to induce Rosacea. Thus, frequent alcoholic stimulation or high living will induce this condition in some. In others, hepatic torpor, while in women it is well known that uterine disturbance greatly influences the facial circulation. The influence of uterine disturbance on the production of Rosacea is denied by some writers, who claim that in the majority of cases questioning the patient fails to elicit any evidence in favor of this view. The fact is that these gentlemen either meet with an exceptional class of cases, or they do not examine them with sufficient persistence and thoroughness.

Hebra's remarks on this point are so judicious and so in harmony with my own experience, that I quote them in full. He says: "Researches, made with care, have demonstrated that women, young or old, who suffer from Acne Rosacea, usually suffer from menstrual disorder, and of the exact nature of the trouble we are often obliged to remain in ignorance, in consequence of the frequent impossibility, or at least difficulty, of making a direct examination of unmarried women, or of obtaining from them a history of any value. I will simply recall, as example, how rare it is to obtain satisfactory replies when you ask a young woman if her menstruation is regular or not, whether it is scanty or profuse, or whether painful or not. According to my experience, she will at first reply that she is all right in that respect, while later, if she is questioned with some persistence, she will admit that it is entirely otherwise. This is quite natural, and should be attributed rather to the manner in which the questions are put, than to a desire on the part of the patient to deceive.

"A question asked in general terms presupposes, if a correct reply is to be given, that the patient herself knows exactly how and when the menstrual epoch should appear, how long the flow should last, and what should be the proper intervals. This is evidently too much to expect of a young girl. The best way is to ask direct and precise questions - for instance, 'When were you unwell last?' 'How many days did the flow continue?' 'After how many days does it usually return?' 'Is it preceded or accompanied with pain?' 'Do you suffer from the whites before, after, or during the interval?' 'What is the quantity, nature, and color of the discharge?' ' When do you next expect to be unwell?' etc. The result of an inquiry pursued in these terms will demonstrate how imperfectly acquainted the generality of women are with these mat-ters, but it is the only means by which we can hope to obtain the in formation we need, and which is so indispensable to their welfare." The fore-going remarks may well be considered by the physician in connection with many other ailments besides the one that now concerns us.

In many cases of Rosacea, however, we will be unable to satisfy ourselves of the presence of any of the causes above mentioned. The patients may be temperate in their habits and not complain of any other bodily discomfort whatever. 18

Treatment

The first step in the management of Rosacea is to ascertain the exciting cause. This done, the next is to remove it, if possible. If the patient is dyspeptic, or suffers from habitual constipation, these conditions must be relieved by measures that need not be here considered.

If the liver seems to be at fault, mild cholagogues, in small doses and long continued, are often of decided service. If spirituous indulgence appear to be the principal cause, it is of course necessary that this should be corrected. If uterine disorder appears to be at the root of the trouble this sometimes requires the special arts of the gynecologist for its removal, at other times may be vastly benefited by a little simple medication. For instance, an amenorrhoea, due to anaemia, may sometimes be removed by the judicious use of iron, sometimes by arsenic; if malarial complications are present, the same drugs, or quinine or eupatorium, may be more advisable. If neither anaemia nor malaria be present, the amenorrhoea may often be relieved by direct uterine excitants. Besides those more generally employed, the writer has used to advantage the less known Caulophyllum and the Leonurus cardiaca. Electricity also should be borne in mind. Dysmenorrhoea, when not due to a mechanical cause, is, if of ovarian origin, frequently controlled by Pulsatilla; if the pains are uterine, Viburnum opulus may be efficient.

These various etiological factors having been provided for, attention may be directed to the local cutaneous difficulty. The use of amyl nitrite in this connection has been considered elsewhere (pp. 16 and 17), and what was there said need not be repeated. I may further add that I have, in a number of instances, vastly improved and sometimes cured Rosacea by internal treatment alone, and without recourse to any external applications whatever. In many cases, however, this can hardly be done, or at least not so quickly as by the judicious use of topical measures in addition. The selection of these, however, will depend in great measure on the stage and condition of the eruption at the time it comes under notice. If acne be present as a complicating lesion, this should be first disposed of in the way indicated elsewhere. This accomplished, we find ourselves face to face with, in the first stage, a chronic congestion of the skin. Local depletion, by scarification, and hot fomentations are of special benefit, as also the method of Hebra, which consists in the use of green-soap or alkaline soap-spirit, followed by lotions containing sulphur. In the second stage, the first thought should be directed to getting rid of the tortuous and varicose veins. This may be most conveniently done by using a fine-pointed gal-vano-cautery, the fine point of a Paquelin cautery, or an ordinary needle, heated to redness, or by electrolysis, as proposed by Hardaway. Scarification and the soap treatment should follow.

In the third or hypertrophic stage, when the skin has acquired an enormous increase in thickness and extent, it may be reduced by excising portions of it, or by electrolysis, or by puncturing it freely with the cauterizing point of either the galvano-or Paquelin cautery. The writer has employed all of these methods, and in addition has obtained very decided shrinkage of hypertrophic noses by the use of the galvanic current. Cheaple (162, July, '74) has obtained good results from the use of the faradic current. By the use of the foregoing means, the great majority, if not all cases of Rosacea, may be cured or greatly benefited, and the disease can no longer be considered as it formerly was, one of the opprobria of the dermatological art.

The following drugs should also be considered: Armoracia, 22; Benzoin, 32; Bismuthi subnitras, 33; Ergota, 52; Hydrarg. C/dor, Corros., 64; Hydrarg. Nitras, 66; Plumbi Oleas, 89; Potassii Acetas, 90; Silica, 105; and Sulphuris lodidum, 109.