Medical knowledge | Dermatology » Comorbidity of Rosacea and Alcoholism

COMORBIDITY OF ROSACEA AND ALCOHOLISMCase report Vesna Golik-Gruber1, Marija Buljan2, Ema N. Gruber3 1 Department of Psychiatry, 2 Department of Dermatovenereology, University Hospital “Sestre milosrdnice”, Vinogradska c. 29, 10 000 Zagreb 3 Neuropsychiatry Hospital “Dr. I Barbot”, Popovača Correspondence author: Prim. mr sc Vesna Golik-Gruber Department of psychiatry Clinical Hospital “Sestre Milosrdnice” Vinogradska c. 29, Zagreb e- mail: vgolikgruber@yahoo.com 1 Summary: The classical cutaneous stigmata of rosacea that have been well recognized for over a century are: plethoric face (facial flushing), persistent erythema and teleangiectasia, papules and pustules and specific shape of nose (rhinophyma and tissue hyperplasia). There are various triggering factors associated with rosacea, however, the etiology of rosacea is still unclear. As alcohol is one of the triggering factors, people often inequitably associate rosacea and rhinophyma exclusively to

alcoholism, eventhough, many patients with rosacea neither drink alcohol nor report alcohol as a trigger for their rosacea. However, here we are presenting a case of the fourth stage of rosacea in a male patient alcoholic, showing simultaneous development of rosacea and alcoholism, with ten years history of facial flushing and teleangiectasia appeared and five years history of papules and pustules on the face. The patient had been under dermatological treatment for five years, with no clinical improvement, due to his constant alcohol consumption. During the psychiatric treatment, alcohol abstinence was retrieved, with subsequent normalisation of psychophysical condition and laboratory results. Simultaneously, the patient received dermatological treatment and, after only one month, a remarkable improvement of skin changes was noticed. Key words: rosacea, alcoholism, cutaneous stigmata 2 Introduction: The classical cutaneous stigmata of rosacea are: plethoric face (facial

flushing), persistent erythema and teleangiectasia, papules and pustules and a specific shape of nose (rhinophyma and tissue hyperplasia). Rosacea, a chronic skin disorder, typically affecting the central face, is considered to be a multiphasic disease which is in some cases connected to alcoholism. The presence of such skin changes on the face sometimes inequitably stigmatises patients who are not alcoholics, especially women who are more often affected by rosacea. Case report: A 45-year-old male alcoholic, with cutaneous signs of severe rosacea (Fig.1) turned for medical help because of somatic disorders reveiled during the routine check up, which indicated possible liver cirrhosis. The patient begun alcohol consumption at the age of 15 and, over the past 20 years he daily consumed 1 to 1.5 litre of beer or 1 or 2 litres of vine. On examination, he was in a decreased alcohol tolerance phase, showing distinctive psycho-organic disorders, low criticism and aggressive behaviour during

the periods of drunkness. However, he was unaware of his drinking problem Ten years ago, facial flushing and teleangiectasia appeared and, five years ago, papules and pustules over the central area face, with subsequent development of rhinophyma. The patient received dermatological treatment for the last five years, with no clinical improvement, due to his constant alcohol consumption. On examination, he had moderate withdrawal symptoms and visible signs of severe rosacea on the face. Laboratory results suggested hepatic lesion (GGT 431), an abdominal ultrasound reveiled hepatospleenomegaly, ezophagogastroduodenoskopy showed chronic gastritis, 3 ventricular erosions and oesophageal varicosities of the I/II stage. The diagnosis established by internist indicated diffuse toxic hepatic lesion and possible liver cirrhosis. During the psychiatric treatment, alcohol abstinence was accomplished; patient’s psychophysical condition was improved and laboratory results were normalized. The

patient was treated within the therapeutic groups of treated alcoholics, including individual and group psychotherapy methods, such as cognitive-behavioural psychotherapy, during which he became aware of his alcohol addiction. Simultaneously, the patient received standard local dermatological treatment of rosacea and, after only one month, a remarkable improvement of skin changes was noticed. Discussion: Rosacea is a common skin disorder that can lead to significant facial disfigurement, ocular complications and, severe emotional distress (1). Little is known about the epidemiology of rosacea, but the condition most frequently occurs in people between 30 and 50 years of age and in fair skinned individuals of northern European descent (2,3). Aetiology of rosacea is still in unclear, however, there are various exacerbating factors associated with the disease, including constitutionally weak small blood vessels, disturbances of the vegetative nervous system and, endocrine influence

blood vessels, cold weather, hot beverages, Helicobacter pylori gastric infection, sun exposure, psychogenic factors like stress, anxiety and, alcohol consumption (4-8). The role of alcohol in triggering rosacea can be explained by alcohol-induced easy facial flushing (9). Moreover, alcoholism often coexists with severe anxiety, stress and 4 depression, all of which are considered to be aggravating factors in the developement of rosacea (10). The incidence of rhinophyma, the most obvious stigma of rosacea, is unknown, but it occurs more often in men (11). The third and fourth stages of rosacea are diagnostically clear and noticeable in alcoholics, while in less developed disease we should diagnostically consider other alcohol–associated conditions such as seborrheic dermatitis, as well as the other conditions often found in alcoholics – plethoric face, ethanol-induced vasodilatation, vegetative hyperreactivity and hypertension (12). Insisting on alcohol abstinence during the

treatment of rosacea is one of the major steps in the treatment of this dermatological disorder, therefore making it a preventive function of dermatologist in the field of alcohology. Conclusion: Simultaneous treatment of rosacea and alcoholism very soon results with noticeable improvement of rosacea skin changes, which implies the importance of absolute alcohol abstinence during the treatment and afterwards. Sometimes, the presence of skin “stigmata” of rosacea may indicate or reveal the addiction problem, giving the dermatologist an opportunity for effective intervention regarding the prevention of alcoholism development or maintaining abstinence in alcoholics. 5 References: 1. Quarterman MJ, Johnson DW, Abele DC, Lesher JL, Hull DS, Davis LS Ocular rosacea. Signs, symptoms, and tear studies before and after treatment with doxicicline. Arch Dermatol 1997;133:49-54 2. Berg M, Liden S An epidemiological study of rosacea Acta Derm Venereol 1989;69:419-23. 3. Kligman AM Ocular

rosacea Current concepts and therapy Arch Dermatol 1997;133:89-90 4. Logan RA, Griffiths WAD Climatic factors and rosacea In: Marks R, Plewig G, eds. Acne and Related Disorders London: Martin Dunitz, 1989: 311-5 5. Blount BW, Pelletier AL Rosacea: a common, yet commonly overlooked, condition. Am Fam Physician 2002; 66(3): 435-40 6. Whitlock FA Psychosomatic aspects of rosacea Br J Dermatol 1961;73:137-48 7. Bernstein JE, Soltani K Alcohol-induced rosacea blocked by naloxone Br J Dermatol 1982; 107:59-61. 8. Parish LC, Witkowski JA Acne rosacea and Helicobater pylori bethroted In J Dermatol 1995;34:237-8. 9. Brinnel H, Friedel J, Caputa M et al Rosacea: disturbed defence against brain overheating. Arch Dermatol Res 1989;281:66-72 10. Kaplan HI, Sadock BI Pocket handbook of clinical psychiatry, 3rd ed Lippincott Williams and Wilkins, Phyladelphia, 2001. 11. Wilkin JK Rosacea Int J Dermatol 1983;22:393-400 12. Klatsky AL Blood pressure and alcohol intake In: Laragh JH, Brenner BM,

editors. Hypertensio: Pathophysiology, diagnosis and management 2nd ed New York: Raven Pres, 1995:2649-2667. 6 Sažetak: Klasične stigmatizirajuće promjene u sklopu rozacee, a koje se ponekad vide na koži alkoholičara uključuju crvenilo kože lica, teleangiektazije, papule i pustule te baburasti nos (rinofima). Autori prikazuju slučaj alkoholičara s četvrtim stupnjem rozacee, prikazujući istovremeno tijek alkoholizma i razvoja rozacee. Prije 10 godina kod pacijenta se počinje javljati crvenilo lica, a unazad 5 godina nastaju papule i pustule. Kod dermatologa je bio liječen 5 godina bez poboljšanja, što se može pripisati istodobnom redovitom pijenju alkohola. Tijekom psihijatrijskog liječenja, uspostavlja se apstinencija od alkohola te dolazi do poboljšanja psihofizičkog stanja pacijenta i normalizacije laboratorijskih nalaza. Istodobno, pacijent se liječi kod dermatologa te se već nakon mjesec dana dijagnosticira značajno poboljšanje promjena na koži lica u

sklopu rozacee. Insistiranje na apstinenciji od alkohola u tijeku liječenja rozacee ujedno prevenira i razvoj alkoholizma, odražavajući preventivno djelovanje dermatologa u području alkohologije, bez obzira radi li se o prekomjernom pijenju alkohola ili o već razvijenoj ovisnosti o alkoholu. Ključne riječi: rozacea, alkoholizam, kožna stigma • the work was presented in Psychodermatology Congress in Cavtat, 2004. 7