By Mark Greener

Medical Journalist and Healthcare Communications Consultant

A quick 2002 quiz. Which is the odd-one out? WC Fields, Rembrandt, Chaucer or Bill Clinton?

If you need a clue, click through to Rembrandt's self-portraits. Or you could try the pictures of WC Fields .

Chaucer is the odd one out. The pictures show that Fields and Rembrandt - like Clinton - have prominent probosces, probably because of late-stage rosacea. Chaucer, like Shakespeare, only wrote about men with red faces and large noses.

Rosacea's been recognised for centuries. Indeed, as a fascinating Lancet article argues, Rembrandt's 1659 self-portrait seems to show many of rosacea's hallmarks: papules and pustules, a spidery tangle of blood vessels and a bulbous nose. (Although not all dermatologists agree with this diagnosis, as a letter to the Lancet indicates). According to about-rosacea.com, Bill Clinton is probably another prominent sufferer.

Despite these high profile patients, rosacea seems to be the largely forgotten skin disease - at least compared to acne, psoriasis or eczema. Indeed, many books and reviews lump rosacea in with acne, a trend - an article in Rosacea Review notes - that began in 1812 with the English clinician Thomas Bateman.

However, while both groups of patients develop papules and pustules, rosacea and acne seem to be distinct clinical entities. (For a comprehensive review of acne, try the Acne Support Group's site. Indeed, some acne treatments can exacerbate rosacea.

Rosacea's low profile is difficult to understand. After all, rosacea isn't a new nosological category. Indeed, the 14th century French surgeon Guy de Chauliac seems to have been the first to describe rosacea medically, the article in Rosacea Review suggests. And it's relatively common. Rosacea accounts for around one in every 63 UK dermatology consultations, for example.

So, in this tour, I hope to raise awareness about this disfiguring disease. And if you want evidence of just how disfiguring rosacea can be, check out the pictures posted on the Dermatology Internet Service.

While men tend to show the hallmark nasal symptoms, rosacea most commonly emerges in Caucasian women, aged between 30 and 50 years. Rosacea usually begins with erythema on the cheeks, nose, chin or forehead. At first, the erythema may wax and wane. But over time, erythema becomes chronic and patients develop telangiectasia (thin, spidery blood vessels) papules and pustules. Finally, connective tissue changes conspire with enlarged, congested sebaceous glands to lead to the bulbous nose (rhinophyma). Many patients suffer ocular symptoms, notably blepharitis (eyelid inflammation), conjunctivitis and a feeling that there is a foreign object in their eye.

Rosacea's pathogenesis is poorly understood. However, spicy food, stress and alcohol are among the factors linked to rosacea exacerbations. (Although they are probably not causes - good news for those pharma executives who live on curries, tight deadlines and G&Ts.)

On the other hand, female hormones and vascular changes might be pathogenic in at least some cases. In addition, some studies implicate Helicobacter pylori in rosacea pathogenesis. But trails of eradication regimens are inconclusive, exemplified by a paper published in the Archives of Dermatology Archives of Dermatology.

To learn more about this forgotten disease, point your browser at National Rosacea Society's site, probably one of the best gateways. Their pages offer more details about rosacea, information on helping patients cope and back copies of the excellent Rosacea Review. The Rosacea Support Group, a site hosted by Bass & Boney, who manufacture a treatment in North America, and, in particular, about-rosacea.com and Dermatology in the Cinema website covers Marilyn Monroe's mole, Morgan Freeman's bumps, and Jimmy Cagney's nose. Like WC Fields, Cagney's craggy countenance may partly have been caused by rosacea.

Currently, there are relatively few specific rosacea treatments, probably because scientists aren't sure about the cause. Almost 200 years ago, Bateman noted that there was no "perfect cure" for rosacea. And even today, management can often prove difficult.

But we've made some advances. The Rosacea Review notes that rosacea sufferers in the middle ages endured blood letting as well as leeches fixed to their nose and other affected areas. At least from the 16th century, patients could swap the leeches for salves.

Today, oral antibiotics are commonly used to resolve some rosacea symptoms, such as inflammatory spots, erythema and, possibly, ocular symptoms. Infoderm.com, sponsored by Galderma offers information about rosacea generally as well as on systemic antibiotics and individual agents. For example, the site suggests that tetracycline and erythromycin, are the commonest oral antibiotics in rosacea. Topical antibiotics - for example, Galderma's metronidazole - offer many patients an effective alternative to oral therapy.

Other studies suggest that the acne drug azelaic acid and retinoids - a group of agents derived from vitamin A and already widely used in dermatology - might be effective in rosacea. However, further studies are needed before either is routinely used. Finally, some aspects of rosacea - for example, rhinophyma - might require cosmetic surgery. In the most common operation, surgeons remove abnormal tissue from the nose. More recently, surgeons began using lasers to treat telangiectasia and for controlled nasal sculpting. About-rosacea.com offers further information on treatment.

So, despite being common and having some high profile sufferers, rosacea is something of a forgotten disease. However, as this tour, I hope, shows, this common and disfiguring disease deserves a higher prominence than it currently attains.

Do you have any comments on this article? Please contact Mark directly at greenermj@aol.com

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