Differential diagnoses: Where is the frontier between acne and rosacea?

Satellite

symposium

ST12. Red face and nxacea:

the largest quantity of emollients there was a 75% reduction in the use of topical steroids. The emollient wet wrapping technique using emollients alone can produce a rapid improvement in the control of atopic eczema using quantities of at least 500g of an emollient cream/ointment per week. Despite the experimental and clinical evidence for the efficacy of emollients, their use in the community is minimal. There is also little clinical trial data indicating the optimum dose of emollients to use. An audit of new patients attending a Paediatric Atopic Eczema clinic in Sheffield revealed that prior to attending the clinic 100% of parents had never been shown how to use any therapy for their child’s eczema and the mean use of emollients/cream/ointments was 50 g per week. The severity of atopic c eczema was recorded at baseline using the SASSAD. All of the topical therapies were then explained and demonstrated by a Specialist Dermatology Nurse. The chiIdren were reviewed three weeks later. In all children there had been a significant reduction in SASSAD and symptoms of pruritus, irritability and sleep disturbance. The mean use of emollient cream/ointment had risen to 500 g/week. In the majority of children the potency of topical steroid required to control their eczema was reduced. Explanation and demonstration of emollient therapy, wet wrapping and the fingertip unit is one of the most important aspects of the management of atopic eczema. Clinical experience and audit indicates that the effect of emollients is proportional to the dose and frequency of application. Clinical trials are needed to further define this dose effect. ST1 l-4

Staphylococcus aureus in atopic dermatitis: Cause or consequence. Practical applications

J.F. Stalder. Hotel Dieu,

CHU

Nantes,

France

Staphylococcus Aureus (SA) constantly colonises not only involved but also non lesional atopic skin (2). Moreover the ratio between Staphylococcus Aureus and Staphylococcus Epidermidis is inversed between atopic and normal patients (4) ; Similarly the 1eveI of SA found in the epidermis of patients with atopic dermatitis (AD) is proportional to the inflammatory score of the lesions (5). If curiously cutaneous infectious manifestations are relatively rare in AD, many arguments point to the implication of SA in the pathogenesis of atopic dermatitis as bacterial adhesion (I), lipids surface abnormalities or superantigen role of SA (3). Under such conditions decreasing the population of SA in one of the objectives of treatment of atopic patients. If the systematic use of topical antiseptics or antibiotics remains contreversial, topical corticosteroids are able to decrease the number of SA on atopic skin. Emollient creams containing essential fatty acid, ceramides and cholesterol are also capable of reducing staphylococaI colonisation. Thus the management of atopic dermatitis patient includes not only the control of inflammatory process but also the decrease of the SA skin colonisation.

Clinical

and practical

s107

aspects

References [I] I. Cole CW, Silverberg NL. The adherence of Staphylococcus aureusto human comeocytes. Arch Dermatol 1986 ; 122 : 166169. [2] 2. Leyden JJ , Marples RR, Kligman AM. Staphylococcus aureus inthe lesions of atopic dermatitis. Br. J. Dermatol. 1974 ; 90 :525-30 131 3. MC Fadden JP, Noble WC, Camp RDR Superantigenic exotoxin -secretingpotential of staphylococci isolated from atopic eczematous skin.Br. J. Dermatol 1993 ; 128 : 63 1-32 [4] 4. Neuber K, Konig W, Ring J. Staphylococcus aureus und atopische Ekzem. H&tarzt 1963,44 : lj5142. [S] 5. Stalder JF, Fleury M, Sourisse M. Rostin M, Pheline F, Lltoux I? Local steroid therapy and bacterial skin flora in atopic dermatitis. Br. 3. Dermatol 1994 ; 13 1 : 536-40.

ST12.

Red face and rosacea:Clinical and practical aspects

ST1 2-1

Epidemiological data, triggering and clinical stages of rosacea

EC. Powell. Regional Dublin,

Centre

of Dermatology

Mater

factors Hospital,

Ireland

The true prevalence of Rosacea is unknown, but may affect 10% or more of the population. In Europe Rosacea accounts for from 0.5% (London) to 3.0% (Dublin) of new referrals to dermatology centres: A genetic predisposition (family history 15%). UV sensitive skin, and precipitating factors (heat, sunlight, hot liquids, stress) are recognised. Clinical variants include papulopustular, odematous, fulminating, rhinophymatous and telangiectatic. Histopathology reveals perifollicular and perivascular orientation of lymphohistocytic cellular infiltrate, with varying degrees of odema, vascular dilatation and sebaceous hyperplasia. The condition known as Rosacea with its polymorphic clinical presentations, may represent more than one entity with differing pathogenic mechanisms. 1ST1 2-2 ] Differential diagnoses: Where is the frontier between acne and rosacea? G. Plewig, T. Jansen. Department Ludwig-Maximillians-University

of Dermatology, of Munich, Germany

Rosacea is a common chronic skin disorder often underdiagnosed in Europe, one of the main reasons probably being the difficulty of differential diagnosis. A variety of conditions has to be considered in differential diagnosis of this disease, including acne vulgaris, seborrheic dermatitis, Demodex folliculitis, perioral dermatitis, sarcoidosis, and lupus erythematosus. Less commonly, rosacea may be confused with dermatomyositis, essential telangiectasia, superior vena caval obstruction, polycythaemia Vera, and Haber’s syndrome. Finally, the listing of flushing disorders such as carcinoid syndrome in the differential diagnosis of rosacea would confuse nosologic categories. Coexisting diseases must also be considered. Rosacea is a common disorder, and by chance alone it should occur with other facial

SlO8

Satellite syuposim ST13. Controversies ou the nmaagemeut of the herpes roster in Eumpe

dermatoses. It is important to recognize that there may be a preceding history of acne leading to a hybrid status in which rosacea coexists with acne. As a rule acne peaks in adolescence, years before rosacea makes its appearance. A positive lupus band test may be present in some patients with rosacea. A thourough evaluation for other evidence of systemic lupus erythematosus is indicated in these cases. The histopathological picture of rosacea is characteristic but not pathognomonic. ST1 2-3

Rosacea: Etiologic hypotheses

animal model and a pausity of human studies. Recent research indicates that photodamage and immune responses may play a hitherto unsuspected role. A second approach is to consider the current effective treatments (metronidazole, tetracycline. or clindamycin) in order to investigate their mechanisms of action. Studies to date have not revealed an insight. Some retinoids, nitric oxide synthetase inhibitors, metronidazole derivatives could be future thempies for rosacea or for a specific clinical stage of the disease.

and pathogenetic

ST13.

A. Reborn. Dept. Dermatology, University of Genoa, Italy Rosacea is a disease which progresses through various phases, but most patients stop at the first two phases, and only a minority proceeds to the third. The research for THE CAUSE of rosacea is, therefore, naive. It is probable, instead, that for each phase there is one or more etiopathogenic factors which are not necessarily the same for all phases. The various hypotheses will be reviewed, divided into the various phases in which they presumably play a major role, that is flushing, erythrosis, papulo-pustular and the phymas. ST1 24

Current management of rosacea and prevention of relapses (drugs, laser therapy, cosmetic products): An update

L.E. Millikan. Tulane University Medical Center. New Orleans, Louisiana, USA Present treatment of Rosacea has been fine tuned to achieve a significant patient improvement in most patients. We are successful with a multi-pronged approach in 90 percent plus of cases. Education - avoidance of triggering factors. Initial topical therapy of newer, more effective agents, including metronidazole, sulfacetamide. Avoidance of topical irritants, especially certain retinoids and benzoyl peroxides. Cover up with cosmefics. Severe/unresponsive patients will usually respond to oral antibiotics including tetracyclines and macrolides - occasionally systemic metronidazole. The physicians role is the proper education and coordination of topical and systemic therapy. Careful follow-up and early treatment am necessary to prevent relapses. Most relapses requite systemic thempy to control prior to returning to the topical regimen. ST124

Rosacea treatment: new in research?

Future trends,

what’s

B. Shroot. Galderma Researclt Inc.. San Diego, California, USA Many different factors contribute to the etiology of Rosacea: triggering factors are now well-known, but a debate still exists concerning the initial mechanism that leads to enhanced flushing, followed by inflammation, and finally talangiectasia. The roles of epidermis, dermis, parasites and bacteria are far from clear. A major research need is to better understand the etiology of the disease. This is hampered by the absence of an

ST13-1

Controversies on the management of the herpes zoster in Europe Pathogenesis of herpes zoster pain and risk factors of postherpetic neuralgia

T.J. Nurmikko. Pain Research Institute, The Walton Ceutre for Neurology and Neurosurgery, Liverpool, UK During acute herpes zoster (AHZ) pain mainly reflects inflammation of the affected spinal root ganglion, nerve, nerve root and sensory projection areas in the dorsal horn, and other spinal cord nuclei. In the affected dermatome(s) quantitative sensory testing reveals slight elevations in the perception thresholds for cold and warm, indicating some dysfunction in the sensory pathways, and reduction of the perception threshold for hot pain. The latter is best explained in terms of sensitisation of pain mediating C-nociceptors. However, some patients may also have an additional central contribution to their pain. MRI and analysis of cerebrospinal fluid show that inflammation reaches the centml nervous system more than 50% of cases. Intensity of the infection, in addition to age and preexisting neuropathy act as risk factors for the development of postherpetic neuralgia F’HN) In PHN, pain is likely to result from damage in various parts of the sensory pathways affected. It has been recently suggested that in PHN there are three different subtypes: (1) peripherally maintained pain with increased sensitivity to heat (irritable C-nociceptor syndrome), (2) pain due to central reorganisation, and (3) pain due to central deafferentation. Recognition of these different subtypes will help to tailor treatment in individual cases. of VZV transmission I ST1 3 2 Prevention E. Bouvet. Hopital Bichat Claude Bernard Paris, France The control of VZV tmnsmission includes: prevention of infection by immunization of receptive persons, isolation precautions for patients with active disease, and protection of susceptible persons after exposure by immunoglobulins, vaccination or antiviral (acyclovir/famciclovir). A policy regarding nosocomial spread of VZV infection is designed in huge part to minimize the possibility of immunocompromised persons becoming infected with VZV. Patients at risk are defined as patients who have primary and acquired immunodeficiency disorders, have neoplastic diseases, have recently received immunosuppressive treatment or are premature newborns of varicella susceptible mothers. Moreover, normal susceptible adults are at risk to develop a more severe disease than children. In hospitals, initial