Several months ago, when Lloyd A. Coombs, 61, a retired machinist from Springfield, was rushed to the hospital with congestive heart failure, he was surprised to find the person in charge of his care would not be his primary doctor but one he’d never heard of with a title he’d never come across: hospitalist.

Actually, he says “it was fine.” The hospitalist, Dr. Winthrop F. Whitcomb, director of inpatient medical service at Mercy Hospital in Springfield, kept his regular doctor informed, and best of all, was on the scene whenever Coombs needed him.’

“I liked it because I could see him every day, sometimes twice, three times a day. He corresponded with my family and everything,” says an enthusiastic Coombs, who now feels well.

In the old days, when care wasn’t so “managed” and patients stayed in the hospital longer, a primary care physician would often stop by to see his hospitalized patients early in the morning and maybe later as well. In between, he’d try to coordinate things as best he could from his office.

The plus was the continuity of the bond between patient and doctor. The negatives were the hours wasted as the primary doctor and hospital specialists chased each other by phone, not to mention the primary doctor’s disgruntled patients waiting to be seen in the office.

Now, hospital stays are so short that a doctor who might once have had 10 hospitalized patients a day may now have only two or three, sometimes even at different locations, making it less efficient to drive all over town to visit them while trying to take care of office patients as well.

In theory, the answer to that dilemma is hospitalists – a term coined in 1996 to refer to internists who, instead of seeing private patients of their own, spend all day in the hospital overseeing the care of other doctors’ patients.

There are now 3,500 such physicians in American hospitals, say Whitcomb and Dr. John Nelson, a hospitalist at the North Florida Regional Medical Center in Gainsville, who co-founded the National Association of Inpatient Physicians in 1997. The group now has 800 members and is gaining 100 new ones a month.

Though the hospitalist movement is growing fastest in California and the Southeast, hospitalists now practice in many Massachusetts hospitals, adds Whitcomb.

There’s not enough evidence yet to say how well hospitalist programs are working, but there is some:

• A 1998 study of nearly 10,000 Pennsylvania patients published in the Annals of Internal Medicine found that costs were about 15 percent less for patients seen by hospitalists compared to those whose hospital care was managed by their primary care doctors. Although length of stay decreased in all comparison groups, the decline was greatest in the hospitalist model. Hospitalists’ patients also needed fewer readmissions.
• A 1998 study of 1,623 California patients published in the Journal of the American Medical Association showed that a hospitalist model reduced length of stay and did not affect mortality or readmission rates or patient satisfaction.
• Hospitalists also cut length of stay and costs at the Park Nicollet Clinic in St. Louis Park, Minn., according to an observational analysis in the February 16, 1999 issue of Annals.
• On the other hand, an analysis of 16 Kaiser Permanente hospitals in California, also published in the February 16 Annals, found that although length of stay decreased, costs increased with hospitalist care. Researchers couldn’t explain this trend but speculate that patients may have been sicker.

Still, some observers say the advantages are many.

At Brigham and Women’s Hospital in Boston, for instance, a survey showed that patient satisfaction with hospitalists is as good or better as with traditional care, says Dr. Andrew Halpert, who runs one of the Brigham’s two hospitalist programs and heads inpatient care for Harvard Vanguard Medical Associates, a group practice in Boston.

And 30-day readmission rates dropped about 25 percent among patients seen by Harvard Vanguard hospitalists, he says.

Because patients in the hospital are sicker than those seen in office settings, hospitalists may be better at managing complex cases, proponents say.

“You get good at what you do all the time, and a hospitalist does inpatient care all the time,” says Nelson. “Last year, I cared for nearly 1,000 hospitalized patients. A doctor with my same training who practices mostly in the office and a little in the hospital has done hospital care a lot less.”

Still, there’s so little data that “we’re flying blind,” cautions Dr. John Eisenberg, administrator of the Agency for Health Care Policy and Research, the lead government agency for researching medical cost and quality issues.

“I like the idea of voluntary hospitalists – if I’m a doctor and I need to have someone [ else] care for a patient in the hospital and the patient agrees,” he says. “What I don’t like is mandatory hospitalists, if I think I could provide better care and I’m not allowed to.”

Dr. Harold Sox, chairman of the department of medicine at Dartmouth-Hitchcock Medical Center, agrees, noting in an Annals article that mandatory “hand-offs” of patients to hospitalists “threatens the internist’s identity as the physician who can care for the sickest patients in any venue. . .”

In Texas and Florida, the issue of mandatory versus voluntary hospitalists is becoming a legislative battle; managed care companies are urging laws to mandate the practice and doctors are generally opposed to it. The hospitalists’ association sides with primary care doctors, saying that the hospitalist system should be voluntary.

“I’m not sure this model is for everybody,” concedes Whitcomb of Springfield. “Some patients really want to see their doctor when they’re in the hospital, and some physicians want to retain their hospital responsibilities.”

But so far, “patients are telling us it’s okay,” says Nelson of Florida. “They’re willing to trade a familiar doctor and in turn get a more available doctor.”

The idea may increasingly appeal to more primary care doctors. So long as a doctor is kept in the loop, having someone else in the hospital all day to chat with patients and make sure lab tests get read is a boon, adds Nelson.

“And it eliminates the need to practice telephone medicine.”

Information

For more information on hospitalists, contact:

• The National Association of Inpatient Physicians at 1-800-843-3360 or on the Web at www.naiponline.org
• You can also read the February 16, 1999 supplement to the journal, “Annals of Internal Medicine.”

Blame it on Aristotle, who believed that watching tragic plays led to a healthy catharsis of emotions like pity and fear.

Or on Freud, who, at least in his early days, also took the hydraulic view — that pent-up feelings, like steam in a pressure cooker, need release lest they cause hysteria or phobia.

Or on self-help gurus urging that anger be vented by yelling, pounding pillows or bopping people with hollow, plastic bats.

Wherever its provenance, the idea that vigorously expressing anger — even getting carried away with it — is both helpful and healthy has persisted for centuries, despite a stunning lack of evidence that it is.

Now, there’s a series of elegant studies that “ought to be a stake through the heart of the notion that every time you are angry, it’s better to let it all out,” says Dr. Redford Williams, director of the behavioral medicine research center at Duke University.

The research, published recently in the Journal of Personality and Social Psychology, shows that catharsis — verbal or physical venting — is “worse than useless,” says the lead author, Iowa State University psychologist Brad J. Bushman. “Expressing anger produces harmful effects — it increases aggression.”

Now, before you slam down the paper and mutter unprintable things about the mental health profession, take a deep breath. There’s also solid research showing that anger should be expressed, but in ways that are constructive — not destructive. Take a look, for instance, at the following:

– Road rage. One 30-year old New York lawyer, a patient of Raymond Chip Tafrate, a Connecticut psychologist, was a chronic tailgating, fist-shaking, horn-beeping driver. He’d leap out at lights and get into fist fights with other drivers. In therapy, he learned not to act on his anger by changing his thinking and understanding that most drivers who enraged him had not done so intentionally, and that he shouldn’t take it personally.

– Workplace wrath: A verbally abusive businessman with his own company went to Colorado psychologist Jerry Deffenbacher in distress. He was a big, loud man — intimidating by his presence but even more so by his outbursts. Two of his most senior people told him they were thinking of leaving because of his behavior.

In therapy, he learned to rate his rising anger on a scale of zero to 100, and when it hit 60, to tell whoever he was about to blow up at that he didn’t want to say things he shouldn’t and that he needed a “time out.” He then went into his office for 10 minutes, not just to cool down, but to rehearse mentally how to get his message across without being abusive.

He also invented an unusual trick that helped. An arch-conservative, he hated Bill Clinton. He promised himself that whenever he lost his temper, he’d wear a Clinton button for 30 minutes. Amazingly enough, it helped keep his anger from running away with him.

The new studies nail down the case against indulging anger.

In the first, psychologist Bushman used 360 male and female college students. Half were chosen randomly to read a fake newspaper article touting the benefits of catharsis; the other half read an anti-catharsis article. All were then asked to write an essay on abortion — pro or con, depending on their beliefs.

Students were then selected randomly to receive either a positive response to their essays, with comments such as “No suggestions, great essay!” or negative ones like “This is one of the worst essays I have ever read.” The negative responses were geared to making the students angry.

Finally, all the students were asked to rank a list of 10 activities, including hitting a punching bag, that they would like to do later. (In this part of the experiment, they didn’t get a chance to.)

The results were stunning: If people were not angered, they didn’t want to hit the punching bag, regardless of whether they were primed to believe in catharsis or not. If they were angered, those who had read the pro-catharsis article were twice as likely as those who’d read the anti-catharsis article to want to hit the bag, suggesting that “media messages can persuade people to vent anger,” Bushman says.

In the second study, Bushman’s team randomly assigned 600 college students, male and female, to read a pro-catharsis article, an anti-catharsis one or a neutral story. All were angered with negative comments about their essays and then given the chance to hit a punching bag.

Seven women declined, but all the others hit it. Each subject was then paired with an “opponent” (an experimenter) for a competitive task that offered the opportunity for aggression — blasting the opponent with a loud, unpleasant noise.

The students who read the pro-catharsis article were twice as aggressive as the others “and the more they liked hitting the bag, the more aggressive they were,” says Bushman. This is the opposite of what catharsis theory predicts — that venting should dissipate anger.

“People expect catharsis to work, they expect relief,” says Bushman. “But it never happens. In fact, people lash out more and more as if trying to get that relief.”

In yet another twist, the psychologists then took 100 students, primed them all to believe in catharsis and made them all angry. But this time, they were told to sit quietly for two minutes, instead of hitting the bag, before getting the chance to be aggressive in the competitive task. With just this two-minute time out, they ended up being much less aggressive than students in the previous experiment who had had the chance to hit the bag.

So what do these studies prove?

Just what many researchers, including social psychologist Carol Tavris, author of “Anger: The Misunderstood Emotion,” has been saying for years: Venting doesn’t work.

“The biggest, fattest cultural myth, the elephant in our living room . . .is that catharsis is good for you,” she says. “All you have to do is go to another country and realize that the kind of excess we take for granted is considered loss of face in Japan, childish in France and rude and selfish in England.”

What yelling and punching pillows does is let a person “rehearse” anger, she says, which only encourages more anger. It’s not much of a stretch, in other words, to imagine that rehearsing anger — like writing violent threats on a Web site — could contribute to the murders that tore apart Columbine High School in Colorado recently.

And mere venting means you never get to the bottom of things. Anger is often a “defense against feelings of helplessness and depression,” says psychologist Anne Alonso, clinical professor of psychiatry at Harvard Medical School. “So when you encourage the defense, you put a greater distance between the real problem and the patient’s ability to deal with it.”

Furthermore, indulging your anger can be bad for your health, especially if you’re male, notes Williams of Duke. While some data suggest that women who hold their anger in may be at higher risk of death from all causes, other data show that men who express it outwardly have higher death rates, he says.

Growing evidence, in fact, shows that anger, like other strong emotions, can directly trigger heart attacks, says Dr. Murray Mittleman, director of cardiovascular epidemiology at the Institute for the Prevention of Cardiovascular Disease at Beth Israel Deaconess Medical Center in Boston.

In 1995, Mittleman’s study of more than 1,600 heart attack survivors, male and female, showed that in the two-hour period after someone feels intense anger, heart attack risk more than doubles. Admittedly, this is a small effect because the baseline risk of a heart attack in a healthy 50-year old man is one in a million in any given hour; anger raises this to two in a million.

Another study of more than 1,300 male veterans showed that the most hostile had a three-fold higher risk of heart attacks than mellower men.

The bottom line, says psychologist Bushman, is to cool it. “Counting to 10 is good advice. If you are really angry, count to 100.”

Venting, in other words, “does not reduce the buildup of anger. Expressing anger only leads to further anger.”

SIDEBAR:

Coming to grips with taming anger:

People often think there are only two ways to deal with anger: venting or bottling it up. Neither works long term.

But there are things that do, says clinical psychologist Raymond Chip Tafrate of Central Connecticut State University, who has pooled and analyzed data on 18 studies of anger treatment, and by summer, will have analyzed data on 50.

The research clearly shows, he says, that catharsis not only doesn’t work but “may actually be harmful.”

“There is a kernel of truth in the expressive school,” says Jerry Deffenbacher, a Colorado State University psychologist. Some inhibited, overcontrolled people may be helped by learning to be “more noisily expressive,” especially in therapy, and to learn that their anger will not make the world crumble. But then they must move on and deal with their anger constructively.

For that, several methods — notably relaxation and cognitive-behavioral therapy — have been proven effective in studies.

Some relaxation approaches are modelled on treatments for anxiety, says Deffenbacher. The idea is to practice relaxation, then imagine an angering situation with increasing intensity until you can counteract your arousal with relaxation.

In the heat of an angry moment, he adds, the tried and true remedies of counting to 10, taking deep breaths and simply relaxing your muscles can also help.

In cognitive therapy, you learn to defuse anger “by thinking about your thinking,” says psychologist Albert Ellis, head of the Albert Ellis Institute for Rational Emotive Behavior Therapy in New York, and co-author, with Tafrate, of the 1997 book, “How to Control Your Anger Before it Controls You.”

Say that a co-worker frustrates you. If you think, “I don’t like this. She really frustrates me,” you’ll feel mildly angry. But if you keep fuming, “She is screwing up my entire life,” you’ll fan the flames and make anger last longer.

The problem really, Ellis believes, is an irrational belief that the world owes you something and that the other guy is “no good as a human being” because he’s not doing “what I consider the right thing.”

While many people who are chronically angry may have shaky self-esteem, that’s not always the case. Some research, in fact, suggests it’s grandiosity — inflated self-esteem and sensitivity to criticism — that causes chronic anger.

And what of anger that once had a concrete trigger — like childhood sex abuse — but becomes a crippling way of life? The trick here, psychologists say, is to acknowledge the anger, but to move on with your life and not get stuck in the anger forever. Still mad at your parents after 40 years? The tough-to-accept reality is that you may well have reason to be, but you’re only keeping your own life on hold if you focus on that, not forward motion.

Sometimes, of course, anger “is a signal that you need to act,” notes Dr. Redford Williams, director of the behavior medical research center at Duke University and author, with his wife, Virginia Williams, of the 1997 book, “Life Skills.”

If she hadn’t acted appropriately on her anger, he says, “Rosa Parks would still be riding in the back of the bus.”

With summer — and tick season — fast approaching, there’s a new weapon available to reduce your chances of catching Lyme disease: a vaccine called LYMErix, approved by the Food and Drug Administration late last year.

Now, the bad news. The vaccine isn’t approved for kids under 15 or people over 70. It protects about 80 percent of the people who get it, and that’s if you get three shots, which, according to current FDA licensing, must be taken over 12 months. If you get only two shots, a month apart, there’s only a 50 percent chance you’ll be protected. And no one knows how long the protection will last.

Moreover, even if the vaccine were 100 percent effective, you’d still have to take the usual precautions — wearing long sleeves and pants and using tick repellents and removing attached ticks — if you live, work or play in woodsy or marshy areas. That’s because ticks that carry Lyme can also infect you with babesiosis and erlichiosis, other tick-borne infections for which there are no vaccines.

But there’s a promising new wrinkle in all this. Last fall, the vaccine manufacturer, SmithKline Beecham, reported that it’s possible to compress the timetable for the three immunizations into six months or even two and still get the same degree of protection as with the year-long schedule.

The company is not pushing this timetable — yet — because it’s still in the process of seeking FDA approval for it. But since there’s justification for accelerating the shots, it’s worth talking to your doctor about it if you’re at high risk.

Lyme disease is a nasty, though rarely fatal, illness that is both often-missed and overreported. It strikes about 12,000 to 16,000 Americans a year, mostly in the Northeast, but also in the upper Midwest, Pacific Northwest and elsewhere.

It starts with a bite from the deer tick, Ixodes scapularis. If you get the ticks off your skin within 36 to 48 hours, you’re probably safe because it takes this long for the disease to be transmitted, says David Weld, executive director of the American Lyme Disease Foundation in Somers, N.Y.

The bite causes a rash that often looks like a “bull’s eye” and flu-like symptoms — fever, chills, headache and fatigue — as well as occasional facial weakness and heart disturbances. Some people may have chronic arthritis or neurologic problems even months or years later.

In fact, scientists from Boston reported this month at an international conference that they have found a neurotoxin made by the Lyme bacterium.

The toxin “may explain memory problems and why nerves get stimulated so that they fire off and you get pain, numbness or tingling,” says Dr. Sam Donta, the lead researcher and a Lyme disease specialist at Boston Medical Center and the Boston VA Medical Center.

‘The evidence is accumulating,” he says, “that this is a subtle, chronic infection, but we have a long way to go.”

If you catch Lyme disease quickly — while you still have the rash — antibiotics often work. But not always. New evidence also presented at the conference showed that even after receiving antibiotics, some dogs with Lyme disease still harbored the bacteria that causes it, Borrelia burdorferi.

Complicating the decision about whether to get vaccinated this year (other vaccines are in the pipeline for future seasons) is the fact that scientists are unsure as to whether this tick season will be worse than usual. Some say it will be, but much of this is guesswork is based on the complicated life cycle of ticks.

Adult ticks mate in the fall on the bodies of large mammals, chiefly deer.

No disease is transmitted at this point, but after feeding on deer blood, pregnant female ticks drop off and bury themselves in leaves. Each female lays about 3,000 eggs, which then hatch — as larvae — the following summer.

The larvae are harmless at first. But they feed on mice or other rodents, and if those animals carry the Lyme bacteria, the larvae become infected, too. After feeding on mice, the larvae huddle in the ground for the winter, then emerge the following spring as nymphs that can potentially infect humans.

But a number of things can affect how many ticks there are in any given area in any year. A mild winter and a wet spring, for instance, can boost the tick population — and may this year.

So can a bumper crop of acorns two years before the ticks appear, says Rick Ostfeld, an ecologist at the Institute of Ecosystem Studies, a private nonprofit research organization in Millbrook, N.Y.

“There are two pathways by which acorns have an effect,” he says. Deer love acorns, so when there’s a bumper crop of acorns, it lures deer deep into oak forests. Mice love acorns, too.

So lots of acorns means lots of mice survive the winter, which means that “two summers after a good acorn fall you have lots of infected nymphs,” he says. Since there were bumper acorn crops in 1997 and in 1998, Ostfeld predicts “a pretty bad summer for Lyme disease in 1999 and worse in 2000.”

Dr. Ned Hayes, an epidemiologist at the Centers for Disease Control and Prevention who specializes in bacterial diseases transmitted from animals to humans, is less convinced about this year’s forecast: “I wouldn’t make any predictions.”

But he and other Lyme specialists, among them, Dr. Bela Matyas, medical director of epidemiology at the Massachusetts Department of Public Health, say that if you’re at risk for Lyme disease, you should talk to your doctor soon about getting the vaccine.

The vaccine works by stimulating the immune system to make antibodies to a protein called OspA, which is found on the surface of the bacteria in the tick’s gut. The vaccine does not attack the tick itself. But when the tick sips a person’s blood, it sucks in the antibodies, which then kill the bacteria.

This process is not foolproof, however. If bacteria enter the body despite vaccination, they quickly stick a different protein called OspC on the surface. The vaccine doesn’t work against this protein, which means that if the first line of defense fails, you may still get infected.

Next month, the Advisory Committee on Immunization Practices, a group of experts that advises the CDC on vaccine issues, is expected to recommend that anyone at high risk of Lyme disease because of frequent or prolonged exposure to tick-infested habitats should consider being vaccinated.

For people with less frequent or less prolonged exposure, it’s unclear how much added benefit a vaccine provides over standard anti-tick precautions.

People with minimal exposure to tick-infested areas need not get the vaccine.

People who have uncomplicated arthritis from a prior Lyme disease infection and are at high risk should consider getting the vaccine, the committee is expected to say. But those who have Lyme disease that has not responded to treatment should not, because the vaccine could make things worse. In healthy people, however, initial data indicate that there are no serious side effects.

The bottom line is to discuss vaccination with your doctor and remember that it takes a while for the vaccine to kick in, it doesn’t work for everyone, and even when it does, it doesn’t protect against other tick-borne illnesses. This means you still have to take precautions to avoid ticks — forever.

• Look for the deer tick on your skin or clothing after walking in fields or woods. The tick – a dark speck the size of a poppy seed – is most likely to bite in the nymph stage.
• If you can’t avoid areas where ticks thrive – woods, marshy areas, high grass and bush – wear long-sleeved shirts, long pants tucked into socks, and closed-toe shoes. Light colors make it easier to spot ticks on your clothes.
• Use insect repellants. Permethrin kills ticks on contact, but it can be irritating, so spray it on your clothes, not your skin. You can use DEET (diethyltoluamide) on your skin and clothes. State guidelines vary, but in Massachusetts and some other states, health officials say you should not use DEET on infants, and don’t use products with more than 15 percent DEET on children. Adults should use products with no more than 30 to 35 percent DEET. High concentrations of DEET may cause severe allergic reactions and seizures.
• When you get home from a tick-infested area, shower or bathe and remove any ticks with tweezers within 24-48 hours.
• If pets have been in tick-infested areas, check them, too, as well as areas where they sit or lie.
• If you become infected – you should notice a rash and flu-like symptoms – call your doctor; antibiotics are often effective if given early, but not always.

For more information, contact:

• The Lyme Disease Foundation, 1-800-886-LYME (or 1-800-886-5963) or on the Web, www.lyme.org.
• American Lyme Disease Foundation, 914-277-6970 or on the Web, www.aldf.com.

Lyme disease in Massachusetts

The original column in the Boston Globe contained a photo and a chart. The Photo Caption read:

• With summer — and tick season — fast approaching, there’s a new weapon available to reduce your chances of catching Lyme disease: a vaccine called LYMErix, approved by the Food and Drug Administration late last year. Now, the bad news. The vaccine isn’t approved for kids under 15 or people over 70. It protects about 80 percent of the people who get it, and that’s if you get three shots, which, according to current FDA licensing, must be taken over 12 months. If you get only two shots, a month apart, there’s only a 50 percent chance you’ll be protected. And no one knows how long the protection will last.

The chart data is available at the Boston Globe on Microfilm.

What Allison Taylor hates most about rosacea, the skin problem that turns faces red and makes people look like they’ve had a few too many, is the chronic embarrassment.

“I wear a lot of makeup because I’m so self-conscious,” says Taylor, 35, who manages a medical practice in Boston. “I always look sunburned. People ask me if I don’t feel well.”

For others, like a 44-year old Cape Cod psychologist who asked that her name not be used, it’s the complications of rosacea, like eye irritation, that are unattractive and make wearing contact lenses impossible. “It’s not like I won’t go out of my house,” she says. But it’s a “major pain in the neck.”

Rosacea is an unglamorous problem. It won’t kill you. It won’t even really make you sick. But emotionally, it can make life miserable for the 13 million Americans who have it. Some hate to go to work; others, like Taylor, dread parties because some foods and alcohol make you “get redder and redder.”

Rosacea is a chronic condition that first strikes in one’s 30s and 40s, though many people suffer for years before they’re properly diagnosed. Famous faces with rosacea have included Rembrandt, W.C. Fields, and Princess Diana. President Clinton also suffers from the ailment.

Initially, rosacea is just excessive flushing and blushing caused by dilation of blood vessels on the cheeks, nose, chin or forehead, says Dr. Arthur Sober, associate chief of dermatology at Massachusetts General Hospital.

Nobody is sure why this happens, but it may be an abnormal response to temperature changes. In fact, researchers have shown it’s the heat in hot coffee or tea, not the caffeine, that triggers flushes. Other triggers include stress – notably anger and embarrassment – sun, wind, hot showers, coughing, spices, chocolate, tomatoes, and even exercise.

When a healthy person exercises hard, he may get red, “but this usually calms down in about 15 minutes,” says Dr. Mark V. Dahl, chairman of dermatology at the University of Minnesota Medical School. When someone with rosacea exercises, his face may stay red for an hour or two.

Chronic flushing leads to the appearance of broken blood vessels, or telangiectasia. “If you have a constantly increased blood flow to the skin, it creates new blood vessels. They may look broken but they’re not,” says Dr. Steven J. Ugent, a dermatologist at Boston Medical Center. But these vessels are treatable with lasers – “perhaps the most gratifying cosmetic procedure one can perform because it works so well and there’s so little risk,” says Dr. Robert Stern, a Beth Israel Deaconess Medical Center dermatologist.

In many people, though, rosacea doesn’t end with flushing and blushing but progresses to inflammation, in which the face breaks out with papules (little red bumps) and pustules (pus-filled pimples) that may look like acne.

Some think this may be caused by skin mites called Demodex folliculorum, though it’s unclear which comes first, the mites or the rosacea. The mites may trigger inflammation, but they may also flock to sites of rosacea and take up residence.

Others blame Helicobacter pylori, the bacteria that causes stomach ulcers. One recent study of more than 200 people, however, found that the prevalence of H. pylori is no higher in people with rosacea than in those without it, says Dr. Kenneth Arndt, chief of dermatology at Beth Israel Deaconess. And treatment of H. pylori doesn’t seem to get rid of rosacea.

What does work for inflammatory rosacea is the antibiotic metronidazole (Flagyl), applied as a cream or gel, with or without tetracycline, another antibiotic taken in pill form.

“Antibiotics work tremendously well,” says Dahl of Minnesota, though researchers still aren’t sure whether it’s because the drugs – often taken for months or longer, at low doses – actually kill microbes or simply quell inflammation.

In some cases, rosacea progresses to a third phase, called rhinophyma – or W.C. Fields nose – in which the nose becomes bulbous as oil glands become enlarged and the layer of skin called the dermis becomes thicker.

“This is women’s greatest fear,” says Dr. Joseph Bikowski, clinical associate professor of dermatology at the University of Pittsburgh. In reality, women “rarely, if ever” get rhinophyma, he adds, though men often do.

If the nose gets so big it interferes with vision, surgery is necessary to resculpt tissues. In cases where rhinophyma is caught early, a drug called Accutane may work, though it can’t be taken by women who are pregnant or who might become pregnant because it causes birth defects.

In some people, like the Cape Cod psychologist, rosacea can attack the eyes. She’s been taking low dose antibiotics for years, which helps, though she still can’t wear eye makeup.

But for most people with rosacea, it’s the embarrassment, not the medical problems, that hurts most, especially the assumption that rosy faces are a sign of alcoholism.

“People assume that people with rosacea are drinkers, when that is not the case,” says Ugent of Boston Medical Center. “You can have rosacea and never touch alcohol.”

“People tend to trivialize it because it’s a skin disease,” adds Dahl of Minnesota. But “for some people, it’s life-destroying.”

Triggers of rosacea

A number of foods, drinks, skin care products and other factors can cause flare-ups of rosacea, including these:

Foods:

• Certain cheeses, chocolate, soy sauce, vinegar, citrus fruits, spicy and thermally hot foods.
• Beverages: Alcohol, especially red wine, beer, bourbon, gin, vodka or champagne. Any thermally hot drink.
• Emotional factors:
• Stress, anxiety, embarassment, anger.
• Skin Care Products and Medications:
• Cosmetics and hair sprays, especially those containing alcohol, acetone, witch hazel or fragrances.
• Topical steroid creams.
• Any product that causes redness or stinging.
• Vasodilators (used to lower blood pressure).

Thermal factors: 

• Saunas, hot baths, excessively warm environments.

Weather:

• Sun, strong wind, cold, humidity.

Exercise:

• Any workout that raises body temperature and increases blood flow to the face, such as aerobic exercise.

Medical conditions and behavioral factors:

• Menopause, chronic cough, caffeine withdrawal, smoking.

For more information, contact the National Rosacea Society on the web at www.rosacea.org/ or by telephone, 1-888-NO-BLUSH.