A personal critique on the state of knowledge of Rosacea.

A Medline search of the world literature turned up over 600 papers published in the last ten years in which the term rosacea appeared in the title. National and international dermatologic meetings have prominently featured symposia on acne vulgaris for more than four decades. It is only in the last decade that rosacea has begun to receive comparable attention on the educational programs. Rosacea, an exceedingly distressing, psychologically devastating, life-long disease, for which there is no cure has finally found a place on the radar screen of medicine. Another welcome development which has recently come onto the scene is the creation of the National Rosacea Society in the USA, a publicly funded group, which publishes brief monthly reports dedicated to the needs of rosacea sufferers. Importantly, it also gives research grants to scientists interested in expanding our knowledge of this still mysterious disorder. This encouragement stands in stark contrast to the indifference of the National Institutes of Health, which with an annual budget of nearly 30 billion dollars, has not seen fit to fund a single grant for the investigation of rosacea. I have been turned down twice, based on the grounds, not directly stated of course, that rosacea is merely a “cosmetic” problem more appropriately funded by the skin care industry. As a result, we have voluminous literature, mainly focused on treatments sponsored by commercial interests; perhaps not the most credible source of unbiased research. My intent in this essay is to take a critical look, admittedly a personal one, on what purports to be our understanding of the diagnosis, treatment, and pathogenesis of rosacea, as described in leading dermatologic texts and in the general literature. What immediately stands out, which may shock the uninitiated, is the striking degree of controversy, conflict, confusion and contradictions, among the thicket of reports from all over the world. The parvenu to rosacea research will likely be puzzled by these quandaries, which may be off-setting to some, but an attraction to those who like to engage in fields where perplexities reign. There are profound disagreements among “experts” who write and talk about rosacea. I state forthrightly that the state of knowledge regarding the classification, pathogenesis, diagnosis and treatment of rosacea is embarrassing, if not scandalous, when compared to the impressive advances in all other fields of dermatologic research. The following topics urgently need to be addressed before we can claim that we know as much about rosacea as we do about acne. It is interesting that the original term for rosacea was "acne rosacea”, which has more features in common with acne than currently realized. If the “acne” portion had been retained in the later works, rosacea might have received much greater investigative attention.