[Reprinted from The Tri-State Medical Journal, St. Louis, September, 1896.] 
ACNE ROSACEA, 
By A. H. Ohmann-Dumesnil, 
Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, 
St. Louis. 
AMONG the more common diseases of the skin acne rosacea may be num- 
bered on account of its frequency as well as the fact that it may be 
seen at different ages and that it is due to so many causes. It is seen 
from early to late adult life. Before puberty it does not occur, as a rule, and 
this is no doubt due to the fact that at this period neither the skin nor its 
appendages, especially the sebaceous glands, have attained their full devel- 
opment. Males and females are affected, but the trouble is not as frequent 
in the latter as in the former. 
Acne rosacea has been divided into three stages, which, if unchecked, 
untreated or permitted to be aggravated by the exciting cause, will natu- 
rally follow each other. However, there are cases observed in which the 
affection does not progress beyond the first or the second stage, seeming to 
assume a chronicity in that particular form. The three different forms of 
the disease which are seen are the hyperemic, the inflammatory and the 
hypertrophic, each one of which presents a marked difference from the others, 
and presents appearances and characteristics which will not only easily lead 
to its recognition but to its differentiation as well. This is an important 
point so far as the method of treatment to choose is concerned and is also 
valuable in the way of formulating prognosis. The forms are rather easy 
to distinguish from one another, as the salient characteristics of each one 
are sufficiently marked to enable even a superficial observer to do this. 
The hyperemic stage is one not infrequently seen and almost as many 
times incorrectly interpreted. In this form, as in the others, it is the nose 
which is principally involved. At times it is the only part which presents 
the objective signs of the disease. The trouble is one easy to recognize 
from the fact that it appears as a more or less diffused redness of the nose, 
which is more marked at the tip. It is not unusual, however, to note this 
heightened color existing over the malar eminences, chin and that part of 
the forehead situated at the root of the nose. Any or all of the localities 
mentioned may be involved, but it is rare to find other areas of the integu- 
ment of the face share in the process, whereas, in erythematous eczema 
the entire face, the ears and the neck are simultaneously the seat of the 
disease. In this form of acne rosacea, frequently called rosacea, to distin- 
guish it from the other forms, more or less seborrhea exists. This latter 
may be of the oily form, or it may be of the dry. When seborrhea sicca 
co-exists it manifests itself in the form of fatty scales, or comparatively 2 
small accumulations of sebum, as shown in Figure 1. In all cases of this 
form the integument is tense and more or less shining, the congestion being 
quite marked. Among the most prominent subjective symptoms complained 
of is a sensation of heat, which is almost always present. This form does 
Fig. I. Acne Rosacea. 
not long continue in men, but in women it is apt to be persistent and con- 
tinue for years, and it produces much anxiety and mental disturbance on 
account of the disagreeable appearance which it presents. The condition 
is a passive hyperemia, somewhat inclined to stasis and accompanied by 
some infiltration and hyperplasia of the tissues. 3 
The second stage of acne rosacea is the inflammatory, and is really that 
to which the name is properly applicable. It is simply the inflammatory 
stage which is naturally the sequence of the hyperemic. It is an exagger- 
ated form, and here we have always a greater generalization of the symp- 
toms. The color is a much brighter red in hue, and the parts involved are 
the nose, cheeks, chin, the space between the eye-brows, and not infre- 
quently the entire forehead. The nose is markedly involved, the tip being 
shiny and often bulbous in form, as well as painful to the touch. Bright 
red branching lines are interspersed through each affected area. They are 
comparatively long and taper away until they are entirely imperceptible to 
the naked eye. They are comparatively subepithelial, and consist of en- 
larged capillaries, whose tendency it is to increase in caliber and thus 
aggravate the inflammatory condition, which has declared itself by bring- 
ing increased quantities of blood to the affected parts. Whilst some cases 
do not progress any farther, in many a distinct eruption of a papular or pus- 
tular character manifests itself. It is the latter form of lesion which pre- 
dominates, giving a distinctly acneic appearance to the face. The diffuse 
and bright redness present, together with the enlarged capillaries, are suf- 
ficient to distinguish a case from acne vulgaris or from sycosis, for either of 
which it might be mistaken by an uninformed observer. 
In the third, or hypertrophic stage,we have the final expression of the 
trouble, but before considering this the etiology and treatment of the forms 
described will be taken up. To begin with, acne rosacea is essentially 
chronic, and this applies with equal truth to all of its stages. The causes 
of acne rosacea are numerous and varied. Among some of these causes the 
following may be mentioned: Indigestion, both intestinal and gastric, as 
well as dilatation of the stomach. A hyper-acid condition of the stomach 
will also act as a causative factor. Excesses in eating or drinking, espe- 
cially indulgence in alcoholics, are prolific causes of acne rosacea. Expos- 
ure to either heat or cold will bring about angio-neurotic changes in the 
integument of the face, which finally culminate in acne rosacea. Uterine 
disorders not infrequently act as causative factors in a very active manner. 
It has been asserted that stricture, or an atonic condition of the male 
urethra, has brought on the trouble, which was relieved by the systematic 
use of steel sounds, but this lacks confirmatory proof at the hands of others. 
There can be no doubt whatever that, as has been pointed out by a number 
of rhinologists, nasal catarrh is often the active causative agent in the pro- 
duction of acne rosacea of the hyperemic type. From the very large list 
of causes, it will easily be seen that the trouble is far from being such a 
simple one as might be supposed. The determination of the etiological 
factors in any given case is a complicated problem, requiring much research 
and careful investigation in order to arrive at a correct and positive conclu- 
sion. Moreover, it must not be forgotten that the determination of any 4 
one single cause is sufficient. It is far from rare to find that several are at 
work which may be interdependent or entirely foreign to one another, and 
yet all conspiring to the same end of producing the cutaneous affection 
which is present. It is very much for this reason that many cases are so 
stubborn to treatment and even apparently incurable. 
It will follow from what has been said that the treatment of the 
trouble should be directed as much to the underlying cause of the disease 
as to the condition which presents itself. It is also as important that the 
general treatment should be carried out in a complete and efficient manner 
if results of a favorable nature are to be expected. The digestive system 
is one which is almost invariably at fault as well as that whose proper per- 
formance of functions is most frequently neglected. A very careful inquiry 
into any deviation from the normal should be made and judicious manage- 
ment employed, more especially in the way of a proper selection of food 
and regulation of diet. But it is unnecessary to enter into any fuller dis- 
cussion of this part of the subject, as it would involve a consideration of too 
many conditions and their treatment, which properly appertain to the 
broader domain of general medicine and to the intricate speculations of a 
number of specialists. 
What concerns us more directly is the consideration of the local meas- 
ures which should be employed. Here, again, we are confronted by a 
quantity of material which attests to the marvelous ingenuity of therapists, 
and, unfortunately, also attests to the fact that no certain method applica- 
ble to all cases has yet been devised. The methods employed are both 
medicinal and surgical. To the former is to be accorded the merit of 
simplicity of application. Pre-eminent in the list of remedies are the reduc- 
ing agents, or such as have a tendency to contract the capillaries and thus 
reduce the supply of blood to the parts, and in that manner aid in subduing 
inflammation by withdrawing from the tissues the pabulum so necessary to 
carry on this process. Sulphur and its various combinations may be in- 
cluded among the most valuable of the reducing agents which we possess, 
and there is no doubt that among those easily prepared we have many 
valuable aids. The facile princeps of all, in my opinion, is without doubt 
that form which seems to be but comparatively little known by practi- 
tioners in general, and which is but rarely prescribed except by those who 
devote particular attention to diseases of the skin. The formula of this 
lotion is as follows: 
Calcis vivae 3SS« 
Sulphuris sublimati §j. 
Aquae 3x. 
M. Coque ad. §vj., divide et filtra. 
The boiling of this must be carefully done over a water bath in a 
graduated vessel. The filtration must also be closely looked after, and the 5 
filtrate should be perfectly clear. If it is not clear the boiling has not been 
thorough or the process of filtration has been imperfect. The color should 
be ruby red. 
This should be applied thin at night and be followed in the morning 
by an ointment. If it be preferred an ointment may be applied both night 
and morning. The ointments may contain any of the following reducing 
agents in varying proportions: Sulphur, ichthyol, resorcin or salicylic 
acid, either alone or in combination. The following formulas are given so 
as to convey an idea of the method of ordering and strengths to employ: 
19 Sulphuris precipit 3ss-3j. 
Ung. aquae rosae 
M. 
fit Sulphuris precipit 3ss. 
Resorcin gr. xv. 
Ung. aquae rosae gj. 
M. 
fit Ichthyol ■ 3j. 
Lauolini puriss. 
Ung. aquae rosae aa. gss. 
M. 
fit Acidi salicylici 9j. 
Ichthyol 3ss. 
Ung. aquae rosae §j. 
M. 
Of course there is no limit to the possible combinations which may be 
made, and the amount of active agent employed must be governed entirely 
by the susceptibility of the skin to its irritating influence, for every one is 
an irritant. On this account the factitious redness produced by the remedy 
must not be confounded with the color due to the disease. 
Whilst these applications will prove sufficient in ordinary cases of acne 
rosacea, others will be found necessitating much more strenuous measures, 
and it is in these that surgical procedures are indicated. Electrolysis will 
be found of the highest value in the destruction of the blood vessels which 
show themselves so prominently in the second stage. The electrolytic 
puncture coagulates the blood in the vessels and not only removes an un- 
sightly appearance, but removes a prominent aid in promoting inflammation. 
Multiple electrolytic punctures are also employed to produce a greater de- 
struction of capillaries and aid in the resorption of effused and hyperplastic 
products of inflammation. Linear and quadrilled scarifications, by means 
of Vidal's scarifier, are also frequently practiced, but one care should 
always be taken, viz., that the scarifier be very thin and that the incisions 
be of a sufficient depth. Another method which has been employed in lieu 
of the electrolytic needle is Unna's microbrenner, an instrument constructed 
on the plan of the Paquelin thermocautery, whose point, however, is prac- 
tically a needle. By means of punctate cauterizations the vessels are de- 6 
stroyed and the thickening of the skin diminished. The disadvantage 
consequent on the nse of this instrument lies in the production of scars. 
The third stage of acne rosacea, which is better known as "rhino- 
plyma," is the hypertrophic condition, which may be constantly met with 
in our streets, and which is popularly known as "rum nose,'' or, as the 
Germans call it, pfundnase. The nose in these cases often assumes enor- 
mous proportions, presenting a tumor-like appearance. A good example 
of the appearance, history and treatment of a marked example is the fol- 
lowing, which I reported to the First Pan-American Medical Congress.* 
Mr. X was about 72 years of age when he applied for treatment. 
He was of a rather robust constitution, and apparently in good health; he 
furthermore stated that he had never been ill. His occupation being that 
of a saloon-keeper, and being of a social disposition, he indulged in alco- 
holics, and, as a result, acne rosacea developed. He did not particularly 
notice the time when his affection began; but he observed an enlargement 
of his nose some six years before he applied for relief. Some little time 
before this last he had seen that the enlargement was progressing rather 
rapidly, and the dimensions were assuming proportions of a rather alarm- 
ing nature to his friends. He, however, paid but little attention to the 
appearance presented, and he would, in all probability, never have sought 
relief had it not been for a circumstance which I do not remember having 
ever heard mentioned in connection with this trouble. It simply consisted 
in the fact that the hypertrophy became so marked and there was so much 
adventitious tissue developed that the weight of the superincumbent mass 
pressed upon his nostrils to a marked degree. This pressure was so great 
that he could no longer breathe comfortably. The weight of the tumor 
was such that it produced stenosis of the nostrils, and, as a result, the pa- 
tient was forced to breathe through his mouth, a condition, which, only un- 
comfortable at first, finally became intolerable. 
The condition presented by the patient, when he applied for relief, 
was as follows: He appeared to be in good health, somewhat inclined to 
be stout. His hair was gray, complexion florid, and skin rather flabby. 
His nose was enormously hypertrophied. The deformity consisted of three 
masses or lobes, one central and two lateral, attached at their bases by 
rather large pedicles, as shown in Figure 2. Each lateral mass somewhat 
pear-shaped, the central one having the appearance of an inverted pyra- 
mid. Taken altogether, the hypertrophied portion would make a large 
handful, and weighed about two pounds. The surface of the integument 
was irregular, the openings of the ducts patulous, and the mass felt hard 
to the touch. It was red and shining, and somewhat nodulated in parts. 
In such a case there seemed to be but one method of procedure to fol- 
low, and it is, on the whole, the best for such cases-to remove the entire 
"Transactions First Pan-American Congress, Vol. II., p. 1,688, et seq. 7 
mass by the knife. No other method can afford any hope of permanent 
relief, and it is, upon the whole, the quickest, best and most thorough 
method. This was accordingly done in the case under consideration in 
the following manner: The lobes of the tumor were removed, leaving a 
small flap of the integument of each in order to cover the surface denuded. 
Fig. II. Rhinophyma-Before Operation. 
The flap in each case was derived from the lower part and laid np in such 
a manner as to bring the line of stitches at that part of the nose which 
corresponds to the sulcus of each ala. In the case of the middle lobe, the 
line of sutures naturally lay directly across the nose. In the dissection of the 
skin flaps care was taken to make as thin an integument as was consistent 
with the preservation of the nutrition of the tissue. Healing took place 8 
per primam, the dressing used being iodoform collodion. The final result 
was a most excellent one, as maybe seen in Figure 3. The only ontoward 
circumstance, and this is hardly noticeable, is, that the nostrils are possi- 
bly a little more open than they should be, but this could hardly be avoided 
in such an extensive operation. This slight tilting up of the nares was 
no doubt due to the cicatricial contraction which took place at the site of 
the sutures. This amounted to but little, although it points to the neces- 
sity of allowing for contraction both of the skin and of the scar in such 
cases. In plastic operations of this character, however, it is a most diffi- 
cult matter to estimate exactly the amount of skin required, and there can 
be no doubt that a little too much economy is to be preferred to generosity in 
Fig. III. Rhinophyma-Afer Operation. 
view of the fact that any redundant tissue is prone to take on the hyper- 
trophic process rapidly. 
In rhinophyina we have a distinct hypertrophy of fibrous tissue, the 
density of the structure being marked. The skin covering the growth is 
thin, retention cysts of sebaceous matter appearing in the substance of the 
growth. In the case detailed a large retention cyst nearly half an inch 
in diameter was observed. Enlarged vessels were observed, the papillae 
were atrophied, and some portions of the structure seemed to point to the 
presence of a degenerative process. 
The subject of rhinophyma is one which possesses much interest, and 
is deserving of much more study than has been devoted to it up to the 
present time.