Matija,

Thank you for posting this link originally.

I just went back and read the journal letter in full.

Had I not seen several derms (a good few years ago now) or heard many
remarks about their standard of treatment, I would be *astonished* at
Dr. Danby's suggestion.

He wants to take us back 5-10 years and re-classify ONLY those
patients with papules and pustules as *true* rosaceans. And here is
the worst bit: Because that is all he can treat effectively! This
is absolutely damning.

With so many patients presenting themselves to him, with symptoms
such as uncontrollable flushing and painful red faces, who he is
unable to satisfactorily treat, one would assume he would be pressing
for BETTER TREATMENTS not a downgrade of expectations. Or worse
still to say that they are "demonstrably genetic"... And therefore
presumably unworthy of treatment?

I am appalled, but not entirely suprised.

Perhaps if Dr. Danby could be transplanted with pure vascular rosacea
for a period of a few days he would, like Dr. Nase has said in the
past, gain a newfound respect for this disorder. Perhaps even a
desire to see his patients better treated.

Andrew.

Appalled from London.

--- In rosacea-support@yahoogroups.com, "Beth Adams" <badams01@r...>
wrote:
>
> Kat,
>
> That is an absolutely brilliant idea, to flood the
> editor with our thoughts. This is the one of the
> most insensitive, condescending, and ignorant
> statements I think I've ever heard a medical
> professional utter regarding Rosacea. And believe
> me, I have seen and spoken to my share of
> derms out of the Stone Age.
>
> Everyone, please, please consider Kat's wonderful
> suggestion to write a letter in response to the
> editor. We want this physician and anyone who
> agrees with him to understand we are not a silent,
> marginal group.
>
> I haven't looked it up yet, but does anyone happen
> to have the email address for the editor?
>
> Fuming but luckily not in flush mode yet,
>
> Beth
>
> ----- Original Message -----
> From: "katwalker1977" <katwalker@j...>
> To: <rosacea-support@yahoogroups.com>
> Sent: Monday, April 04, 2005 4:27 AM
> Subject: [rosacea] Re: Rosacea, acne rosacea, and actinic
telangiectasia
>
>
>
>
>
> "The second problem is what to do about the patients' unreasonable
> expectations." What the hell are our unreasonable expectations? That
> our faces not be fire-engine red? That our faces not itch and burn
> 24/7? That we not have papules and pustles all over our face? That
> we not have icky red eyes? That we be able to lead sem-normal lives,
> such as drinking hot beverages, exercising, and alcohol, without
> bringing on all the previously mentioned symptoms?
>
> I totally get that this guy is being more conservative with the
> diagnosis, stating that some of these symptoms can be due to other
> things and that a proper diagnosis can be complicated by previous
> treatments. But, geez, aren't doctors supposed to "fix" us, to use
> his term? What's the point of paying hundreds to thousands of
> dollars for an expert opinion if it doesn't fix the problem?
> Furthermore, does anyone, aside from those newly diagnosed, really
> expect anything currently out there will "fix" rosacea? I think most
> of us just want something that will provide a reasonable amount of
> symptom relief and know a cure is unrealistic at this point.
>
> I really don't like this guy's attitude towards rosacea patients. I
> think we should flood the journal with responses to his editorial.
>
> -Kat
>
> --- In rosacea-support@yahoogroups.com, "ruizdelvizo"
> <ruizdelvizo@y...> wrote:
> >
> > Hi,
> >
> > I found the article below in the March 2005 issue of the Journal
> of
> > the American Academy of Dermatology. It's a letter from a
> > dermatologist who teaches at Dartmouth University. I think he
> just
> > further confuses and confounds with his definition of rosacea.
> Unless
> > I'm reading this incorrectly, he claims that people who have only
> > papules and pustules along with redness have rosacea. Others
> without
> > p&p's, but with intermittent flushing and constant erythema, may
> not
> > have rosacea at all. Also, he claims that patients are making
> > unreasonable demands to have their rosacea fixed. This guy seems
> like
> > a very bad derm. But it's scary because this is an influential
> > publication.
> >
> > Take care,
> > Matija
> >
> > URL that will break:
> >
> > http://www.eblue.org/scripts/om.dll/serve?
> >
>
action=searchDB&searchDBfor=art&artType=fullfree&id=as019096220402229
> 7
> >
> > Shortcut to above url:
> >
> > http://tinyurl.com/4fgtf
> >
> >
> > Journal of the American Academy of Dermatology
> >
> > March 2005, part 1 . Volume 52 . Number 3
> >
> >
> >
> >
> > Rosacea, acne rosacea, and actinic telangiectasia
> >
> >
> > To the Editor: For the past year or so, dermatologists have been
> the
> > ambivalent recipients of referrals and self-referrals of patients
> who
> > either believe or have been told that they have rosacea. And some
> of
> > them do-the papular and papulopustular disorder known as acne
> rosacea
> > in times past.
> >
> > But many do not. Instead they present with a history of
> intermittent
> > flushing (triggers varying from emotional overload to estrogen
> > depletion) or a background facial erythema (sometimes demonstrably
> > genetic but more commonly actinic) of varying color depth, or
> > telangiectasia of the sun-exposed areas that rosacea favors, or
> all
> > three.
> >
> > Some have already been treated with the metronidazole-containing
> > products that represent the standard of care, making the diagnosis
> a
> > little difficult if the characteristic papules and pustules have
> > disappeared. The problem is that these patients are usually
> > complaining that their rosacea "is still there." By this they mean
> > the background erythema and telangiectasia that, alone or
> together,
> > do not make a diagnosis of acne rosacea even though they are
> common
> > companions of that disorder.
> >
> > We dermatologists are presented with two problems, in addition to
> > sorting out whether the patient actually has (or had) acne
rosacea.
> >
> > The first is education, actually re-education, defining the
> disorder
> > for the patient and pointing out where he or she fits. This is a
> > challenge, because an Expert Committee has recently suggested a
> > change in the criteria for the diagnosis of rosacea (sic) and a
> new
> > disorder, erythematotelangiectatic rosacea, has been included.
> > Details were published in the June issue of the Journal.1 The
> > criteria, also published online at
> > http://www.rosacea.org/class/classystem.html, are such that anyone
> > with persistent central facial erythema (with or without
> > telangiectasia) fits this diagnosis, even though they suffer from
> > nothing more than actinic (ie, sun-induced) erythema, once known
> > simply as "high colour" in the British literature.
> >
> > I make no claim that these features are not part of rosacea, just
> > that the diagnosis cannot hang on the vascular changes alone,
> because
> > these features are quite capable of existing by themselves. I have
> > begun to diagnose such patients as having "pseudorosacea." It
> seems a
> > better fit than "inconstant vasodilatory and actinic
> telangiectatic
> > non-rosacea."
> >
> > The second problem is what to do about the patients' unreasonable
> > expectations. Patients are sent (or come driven by advertising) to
> us
> > in the expectation that we will be able to "fix" them. Well, of
> the
> > six components of rosacea, two (the papules and the pustules) are
> > easily managed in most (but not all) cases by topical
> metronidazole
> > or sulfur/sulfacetamide products, with or without oral
> antibiotics.
> > It is not unreasonable to expect a good outcome here, and of
> course
> > there will be a diminution of some of the erythema as the
> > inflammation associated with these components lessens. That leaves
> us
> > with the need to explain that the two vascular components are
> > manageable only with a vascular laser (there are several) for the
> > telangiectases or an intense pulsed light (IPL) unit for the
> > background erythema, or both. While this presents dermatologists
> who
> > own such equipment with a golden opportunity to market the
> procedure,
> > one can understand that the somewhat suspicious medical public
> will
> > wonder whether they are becoming victims of clever "bait and
> switch"
> > marketing. The fifth component, the famous W. C. Fields
> rhinophyma,
> > now referred to as "phymatous rosacea," will require surgical
> > reduction in one of several ways, usually requiring another
> referral.
> > Sixth and last, if the patient responds to careful questioning
> that
> > an itchy or scratching or gritty feeling in the eyes is part of
> the
> > problem, then a diagnosis of ocular rosacea and a referral to an
> > ophthalmologist should be considered.
> >
> > So how should the front-line primary care practitioner confront
> > suspected rosacea? I would suggest that the presence of papules
> and
> > pustules at a minimum is required for a diagnosis of acne rosacea
> and
> > treatment should be with topicals supplemented as needed with oral
> > cyclines and other anti-inflammatories. Failure to respond should
> > trigger a referral to a dermatologist for consideration of at
> least
> > seven differential diagnoses mentioned in neither the above
> reference
> > nor the above Web site (postadolescent acne, contact dermatitis,
> drug
> > reaction, seborrheic dermatitis, perioral dermatitis, polymorphous
> > light eruption, and facial psoriasis). In the absence of the
> papules
> > and pustules, where only flushing and telangiectasia exist,
> actinic
> > erythema and/or actinic telangiectasia would be better referring
> > diagnoses. The consultant dermatologist should be able to confirm
> the
> > diagnosis, consider the several alternatives, and direct the
> patient
> > to appropriate care, including sun avoidance techniques and truly
> > broad-spectrum sunscreens.
> >
> > One further thought: the concept of marketing actinic
> telangiectasia
> > as a form of rosacea (or pre-rosacea) amenable to topical pre-
> emptive
> > or preventive therapy seems to be part of this whole picture.
> Proof
> > is lacking that the former is a predictor or precursor of the
> latter,
> > making such therapeutic innovations premature at this time. A
> > multicenter phase IV clinical study is underway nevertheless.
> > Meanwhile the predictive diagnosis of prerosacea must remain
> > impossible to make until adequate and tested diagnostic criteria
> are
> > developed. For now it might be fair to accept the diagnosis, but
> only
> > when made retrospectively.
> >
> > In any case, it would be best if the patient were not led to
> believe
> > that the topicals will "cure" the problem, or, in the alternative,
> > that these same topicals have actually failed to do what was
> > expected. Unfulfilled unreasonable expectations tend to breed
> > dissatisfied patients.
> >
> > The Chair of the Expert Committee informs me by letter that he
> > welcomes reports on the usefulness and limitations of these
> criteria.
> > I write in the hope that this contribution will help with both
> > patient care and patient-physician communication.
> >
> > F.W. Danby, MD
> > Section of Dermatology, Department of Medicine, Dartmouth Medical
> > School, Manchester, New Hampshire
> >
> >
> > Reference
> >
> > 1. Wilkin J, Dahl M, Detmar M, Drake L, Liang MH, Odom R. Standard
> > grading system for rosacea: Report of the National Rosacea Society
> > Expert Committee on the Classification and Staging of Rosacea J Am
> > Acad Dermatol 2004;50:907-912.
>
>
>
>
>
>
>
>
> --
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