Medical history of the representation of rosacea

in the 19th century

Bernard Cribier, MD, PhD
Strasbourg, France

Throughout the 1800s, clinical illustrations helped to formalize what was then the recently developed field
of dermatology. Knowledge of skin diseases was given new dimension as artists and clinicians alike strove
to accurately document the physical characteristics of numerous dermatoses. Introduction of novel
processes and refined techniques advanced the clinical use of disease images. The increasingly superior
quality of these images aided in the early distinction between rosacea and acne. This article highlights these
illustrative contributions in dermatology, and includes key images that serve as a road map to early clinical
understanding of skin diseases. ( J Am Acad Dermatol 2013;69:S2-14.)

Key words: acne; art; illustrations; papules; pustules; rosacea.

D ermatology emerged as a science in the 19th
century, and the images published during
this period of prodigious medical progress
provided the fundamental basis for categorization,
description, and education concerning major skin
diseases. The advent of color illustrations had con-
siderable impact on the growing understanding of
skin diseases, particularly between 1800 and 1850.
The impact was most significant for facial dis-
eases, with the most spectacular manifestations of
dermatoses receiving the most exposure in illustra-
tions. Yet, although the pioneers of dermatology
were confronted with numerous and severe cases of
lupus vorax, monstrous tumors, and spectacular
infectious diseases, they did not neglect acne and
rosacea in their discussions and representations.
During this time, improvements in the quality of
images helped to refine diagnostic capabilities, clar-
ifying the differences between rosacea and acne.
One of the oldest representations of rosacea is
found in a famous painting by Ghirlandaio that can
now be admired in the Louvre.1 It shows an afflicted
elderly man leaning tenderly toward his grandson.
The artist was not a physician, but this rendering of
rhinophyma in the year 1480 has a precision that was
unparalleled in medical literature 400 years later.
This article presents the evolution of medical
representations of rosacea, and the pictorial ele-
ments that have allowed for the gradual distinction of
rosacea from acne. It begins with the color illustra-
tions of Bateman and culminates with Radcliffe
Crockers work in London, 1903. Historical discus-
sions of medical rosacea are also included.2,3
THE GREAT PIONEERS: WILLAN AND
BATEMAN
Robert Willan (1757-1812) was head of the Carey
Street Public Dispensary in London and is the first
Western physician to have published an illustrated
treatise on dermatology.4 His book included numer-
ous illustrations (hand-colored copper etchings), a
great novelty in medicine at the time. The works of
Willan are particularly celebrated, including a fa-
mous color representation of elementary lesions
introduced earlier by Joseph Jacob Plenck (1735-
1807) in Austria. In the 4 earliest volumes, which
were published in English and rapidly translated to
other languages, the illustrations are not very repre-
sentative for acne or rosacea. Although there are
much older engravings that show venereal disease
(dating to the Renaissance), an illustrated dermatol-
ogy text similar to Willans had yet to be published.
Willan was aware of the limitations of his colored
engravings, which did not adequately express the
different degrees of coloration in raised colored
lesions or pustules, or more subtle changes of the
skin.

From the Faculty of Medicine, Dermatology Clinic, University of
Strasbourg and University Hospital of Strasbourg.
Publication of this article was supported by a grant from
Galderma International. Editorial support provided by
Galderma International.
Conflicts of interest: None declared.
Accepted for publication April 21, 2013.
Reprint requests: Bernard Cribier, MD, PhD, Clinique
Dermatologique, H^ opitaux Universitaires de Strasbourg, 1,
place de lH^opitaleBP 426, F-67091 Strasbourg Cedex, France.
E-mail: bernard.cribier@chru-strasbourg.fr.
0190-9622/$36.00
2013 by the American Academy of Dermatology, Inc.
http://dx.doi.org/10.1016/j.jaad.2013.04.046

S2
J AM ACAD DERMATOL Cribier S3
VOLUME 69, NUMBER 6

Thomas Bateman (1778-1821) was a student and symptomatology, but this is quite hard to recognize
devoted associate of Willan who took up the study of in the illustration. It should be noted that for Willan,
skin diseases after Willans death. Bateman, a mem- these etchings served as adjuncts to the descriptions,
ber of the Royal College of Physicians and an and the images were not intended to accurately show
assistant at the Carey Street Public Dispensary, the number or size of the lesions.
became the primary specialist in skin diseases after As will be discussed in more detail, Pierre Louis
Willan. He completed some of the illustrations Alphee Cazenave (1795-1877) refined Willans de-
started by Willan, and it is scriptions of different forms
in his work that we find of acne as follows: These
the illustration that truly CAPSULE SUMMARY species appear to relate to
marks the beginning of acne different states of the same
d Early illustrations were used early to help
and rosacea representation disease. It occurs in a super-
formalize the science of dermatology.
(Fig 1).5,6 ficial follicular lesion with
It should be noted that d During the 19th century, high-quality signs of inflammation, this
there are other early images illustrations promoted distinction would be acne simplex;
of nasal deformities relating between acne and rosacea. where the inflammation is
to rosacea, most notably the d
Modern imaging techniques often greater and accompanied by
etching in Paulus Barbette3 sacrifice quality in favor of objective greater swelling, this would
(1623-1666); however, the il- information. be acne indurata; or again a
lustration in Fig 1 is the first state of truly congested in-
that clearly shows acne rosa- fected dots, characterized by
cea. It is taken from a German translation published bright red coloring, this would be acne rosacea.3,7
in 1830 containing 40 plates, where several drawings The idea of inflammation is what should be
are sometimes grouped together on the same remembered from these illustrations. Raised lesions,
plate.2,6 Fig 1 shows illustration 34 and contains 3 scabs, papules, or pustules all have a more artificial
figures showing successively acne simplex, acne look. Regardless of the fact that the author classifies
rosacea, and acne indurata. The image of rosacea all of these diseases in the same group, acne rosacea
has been truncated, but a larger version of the same seems distinct from the other 2. The absence of
painting showing the entire profile also exists in the comedones is quite clear, but we can see many
original English publication. Bateman explained that lesions in Fig 1 and a few in Fig 2. There are also
the etching was based on a drawing from Willans other elements in the illustration that can be inter-
own collection. preted as closed comedones.
Two forms of acne that could be considered Throughout the 19th century, this image of rosa-
polymorphic and conglobata, according to modern cea was reproduced in such works as that of Ludwig
standards, are represented using images of facial August Struve (1795-1828). His 1829 publication,
profiles. The features are not distinct, but seem entitled Ubersicht der Hautkrankheiten nach ihren
youthful. Although the lesions lack realistic clarity, Classen, Gattunge, Arten und Variet aten,8 is consid-
comedones, papules, and nodules can be discerned. ered the first German book to explore the subject of
As Willan indicated, representing a pustule is diffi- dermatology. Plate 1 of Struves book shows (among
cult. Facial acne indurata can be seen, surrounded by 17 vignettes) a copy of the image of acne rosacea by
purplish erythema. It is worth noting that the colors Bateman, but it is curiously titled acne indurata,
vary greatly from one book to the next because they Gutta rosea.8
are painted by hand and fare differently over time.
Regarding the image of rosacea (Fig 1), the
portion of the illustration included in Batemans ROSACEA IN ALIBERTeTHE INGENIOUS
book was centered on the nose and seen in profile. DEVICE OF THE BRUSH AND CHISEL
The anatomic representation is minimal and the In his famous book, Description des maladies de
picture focuses on the background erythema. What la Peau Observees a  lH^opital Saint-Louis (1825),9
can be seen of the rest of the face is limited. The artist Alibert gives a description of scab pustular rosacea
has also focused on telangiectasias, which appear that is accompanied by a beautifully illustrative
branched as if they all come from a single larger engraving (Fig 2). In this 36-year-old patient of
source. The other lesions portrayed are even less sanguine temperament, the disease began with a
realistic; they seem to be sitting on top of the skin and small eruption of the back of the nose that spread
range in color, from blue to dark violet. One could over the cheekbones, forehead, and chin; Alibert
guess that the lesions are pustules, because of known states the skin swelled, became rough, masked
S4 Cribier
Fig 1. From left, acne simplex, acne rosacea, and acne indurata. From Bateman 1830.6
spots rosacea, and took in a word all the character of
rosacea.9
The artist has represented the front facial aspect,
with diffuse erythema that is convincing enough. On
this background, lesions appear in relief, mainly
pustules, which Alibert described as buttons (.)
about the size of a pinhead and [that] contain a
yellowish fluid.9 The location of the lesions is very
accurately rendered, as is its color, which is a little
darker and purplish on the nose without involving
the periphery of the eyes and mouth. Again, the
author and the artist do not seek the perfect imitation
of reality. Instead, Alibert wants by frightening
colors of the painter, to educateeas it wereethe
sight by sight, to highlight and contrast the charac-
teristics of skin diseases (.) in a word hit the senses
of my readers.9 This method therefore relied on the
exaggeration of the figure, both the color and the
forms. There was no need to have a representation of
the facial condition that was perfectly realistic. The
illustration was simply staged to see, or rather feel,
the skin lesions.
The original illustration is a very large picture and
truly a portrait of the disease; the subjects clothes were
stylish and not colored, to better highlight the lesions,
and the face is completely expressionless, with empty
eyeseartistic techniques that contrasted with the color
intensity to focus the attention on the desired areas. In
his next book, Clinique de lh^ opital Saint-Louis ou
J AM ACAD DERMATOL
DECEMBER 2013
Traite Complet des Maladies de la Peau, published in
1833, the same plate is included (Fig 3), but the lesions
have changed, suggesting that the first image was a
model for the second.10
The purplish color of the nose has been greatly
exaggerated and erythema of the face is less finely
represented. Everything here seems rougher, further
accentuating the desire to impress the reader. Note
that the number of papulopustular lesions increased
significantly in the decades that separate these 2
books! The pustules of varus gutta rosea extend
over the entire face, and strongly irritate the skin.10
The accentuation of the color of the nose is justified by
the swelling that occurs there, and Alibert states, What
contributes above all to make so many deformities is
the sort of swelling that occurs in various parts of the
face, by the development and progress of the rosacea.
Often the nose swells in all its dimensions, and the
forehead skin and fatty tissue of the cheeks and lips are
involved. The book Clinique de lh^opital Saint-Louis
was published during the pinnacle of Aliberts career.
However, the quality of the representation and de-
scription of rosacea in the 1825 publication are supe-
rior to those done in 1833 (Fig 2).9
RAYER, WORCESTER, AND PUSTULES
Pierre Francois Olive Rayer (1793-1867) pub-
lished a theoretical treatise on skin diseases in
1826, which was reissued in 1835 and accompanied
J AM ACAD DERMATOL Cribier S5
VOLUME 69, NUMBER 6

Fig 2. Lesions of pustular rosacea. From Alibert 1825.9 Fig 3. Varus gutta rosea. From Alibert 1833.10

by an atlas.11 The objective of this publication was
very different from the oversized books of Alibert. To
reduce the cost of publication, Rayers book in-
cluded multiple representations on a single plate; the
illustrations were smaller, allowing readers to ob-
serve many lesions. In the fourth plate, which was
dedicated to pustules (Fig 4, A), is a representation of
rosacea (upper right), called here couperose. The
artist uses the same frame as in the work of Bateman,
that is to say a fragment of a face in profile, centered
on the nose. It shows a clear improvement compared
with the English work, the realism of lesions of
erythema is not knife cut but more diffuse (Fig 4,
B). The legend includes the following explanation:
Rosacea, pustules, tubercles, skin redness and di-
lated veins. The pictured spider veins are more
realistic, although still not truly rendering the ap-
pearance of vascular lesions. However, the pustules
are represented with the utmost care and are easily
identifiable here. There are also dark-red papules
occurring on this diffuse erythema. What can be
interpreted as comedones are seen at the left side.
Finally, note that this representation of rosacea is
much more realistic than the sebaceous flow and
follicular bumps at the bottom of the plate, which
poorly reflect the reality of acne. The illustration of
back acne is more realistic, although there it contin-
ued to be difficult to represent inflammatory
papules and nodules. Rayer made much of pustules
interpreted as chronic inflammation of the follicles of
the face and considered branching veins to be a
consequence of pustules.11
This image was reproduced identically in the first
American treatise on dermatology, published by
Noah Worcester (1812-1847)12; however, the quality
was inferior. The author did not maintain the orga-
nization of Rayers plate, but instead issued a total of
61 small illustrations that were juxtaposed on the
page with no real sense. The following diagnoses
coexisted in the same plate: acne rosacea, sycosis
menti, pemphigus diutinus, and purulent scabies.
Three small images of acne without further specifi-
cation are found at the bottom of the page, but are
not comparable with Rayers.
THE LESSONS OF ACNE ROSACEA:
CAZENAVE
By mid-century, Cazenave published a very
expensive book featuring Aliberts large-format pain-
tingsewith plates measuring 34 3 53 cm.7 The
S6 Cribier J AM ACAD DERMATOL
DECEMBER 2013

Fig 4. A, Pustules. B, Close-up view of couperose. From Rayer 1835.11

J AM ACAD DERMATOL
VOLUME 69, NUMBER 6
Fig 5. Acne rosacea. From Cazenave, 1856.7
exceptional image quality in Cazenaves Lecons sur
les maladies de la peau7 makes it the finest book of
French dermatology. Published for the first time in
1845, this book contains a portrait depicting male
acne rosacea; Fig 5 reproduces the illustration from
the 1856 edition. The face is not the most successful
image in the book, but it shows a young man, of fair
skin and blue eyes, with pustules and includes the
commentary by Cazenave that rosacea in men (.)
mostly affects the pustular character.7 The drawing
illustrates the Celtic phenotype. The diagnosis is not
absolutely clear, however, as the artist is often ham-
pered by the exact representation of pustules, which
always appear somewhat artificial. The blank back-
ground is missing a bit of realism and the man looks a
little absenteseemingly unaffected by his illness.7
Very soon after, Erasmus Wilson (1809-1884)ethe
most famous English dermatologist of the mid-
centuryepublished his book Portraits of Diseases of
the Skin.13 These portraits include a very beautiful
image of a woman with papulopustular rosacea
(acne rosacea); this is the first major portrait of
rosacea that is also a very successful artistic rendition.
The brunette patient looks sad and distant, yet her
hairstyle is fashionable. The lace collar of the dress
and the lighting are well rendered despite the slightly
artificial appearance of the pustules. The lesions are
in the foreground and seem quite accurate.
Cribier S7
Fig 6. Acne rosacea. From von Hebra, 1869.14
By mid-century, portraiture was actively wel-
comed and encouraged in dermatology texts, and
an artistic culmination was reached in the atlas of von
Hebra.14 It is this perfect blend between artistry and
accuracy in the portraiture of symptomatology that
makes this period of the 1850s the richest and most
interesting period in dermatology-related medical
representation.
THE ATLAS OF VON HEBRA AND
ROSACEA IN VIENNA
The most beautiful portraits ever published in
dermatology are those in the extraordinary atlas of
Ferdinand von Hebra (1816-1880).14 This book was
published between 1856 and 1876 and is presented
in large-format plates that are unrelated, but grouped
thematically into booklets and put in large folders.
Plate 7 includes acne and rosacea. Von Hebra
worked with several painters who were also physi-
cians, including Carl von Rzehaczek, Anton Elfinger,
and brothers Carl and Julius Heitzmann.
Carl Heitzman (1836-1896), who was himself a
dermatologist and also a pathologist, created por-
traits of acne and rosacea that were painted from
life and lithographed. The results are stunning. Figs
6 and 7 show 2 representations of rosacea that are
well known; the first image is a perfect example of
papulopustular rosacea (No. 5 in von Hebras book,
S8 Cribier
Fig 7. Acne rosacea. From von Hebra, 1869.14
Fig 6 here). Nothing is missing; the portrait includes
centrofacial erythema that extends to the middle of
the forehead and papules and pustules that are
extremely realistic.14
The second of these wonderful portraits illustrates
rhinophyma (No. 6 in von Hebras book, Fig 7 here).
The artist chose to represent a monstrous form,
which was not uncommon at that time. All authors
of the time reported rhinophyma by exaggerating its
proportions and providing detailed descriptions.
Seen here is a man with light eyes, nose entirely
replaced by a lobulated mass on which can clearly be
seen red papules and gaping follicular orifices. The
remainder of the face displays a typical papulopus-
tular rosacea; and the drawing of pustules is abso-
lutely perfect, especially on the forehead.
In both cases, the model is dressed elegantly;
Heitzmann has deliberately painted the coat and tie
as in other portraits. Patients with facial lesions
extending to the neck or chest are represented with
open-necked garments. Achieving that level of pre-
cision required both artistic talent and the clinical
observations of a practicing dermatologist.
The precision is somewhat diminished in plate
1 of the same book, which shows a case of acne
disseminata vulgaris. The patients age and her SPECTACLE OF RHINOPHYMA
blue eyes could suggest a diagnosis of rosacea.
However, the portrait includes distinct comedones,
which recalls that von Hebra was the first to say that
acne and rosacea are 2 separate entities that can be
differentiated based on the presence or absence of
J AM ACAD DERMATOL
DECEMBER 2013
Fig 8. Couperose hypertrophique. From Besnier et al
1897.17
comedones. In addition to the images that were
presented in the atlas, there are also original water-
colors in Vienna of these physician artists who
contributed so much to the splendor of Viennese
dermatology in the late 19th century.
A book published in a series by Fatovic-Ferencic15
includes a beautiful portrait of man with monstrous
rhinophyma painted by Carl von Rzehaczek (1816-
1897). The artist or his master in 1841 chose an
example of rhinophyma, spectacular because of its
very large size. It is only slightly smaller than that of
the model used for plate 6 of von Hebras atlas. The
artist has added features, such as pustules touching
the hairless scalp, showing a clear indication of
rhinophyma in context of papulopustular rosacea.15
BARETTA AND MOULAGE (CASTS): THE
The tradition of wax moulage in medicine began
with Renaissance anatomic studies, long before the
first representations of syphilis and other skin dis-
eases. According to Schnalke,16 the first skin mou-
lages probably date from the early 19th century work
J AM ACAD DERMATOL
VOLUME 69, NUMBER 6
Fig 9. Acne rosacea. From Hallopeau and Lerrede, 1900.19
of Franz Heinrich Martens (1778-1805) in Jena,
Germany. Facial moulages were cast from wax and
then painted colorfully and augmented by the addi-
tions of hair and glass eyes. The famous poet Goethe
aided Martens in his short career as a doctor and an
artist by helping him to get a professorship at the
University of Jena. Not long after, the first large
collection of dermatologic moulages was created by
Joseph Towne (1806-1879) in London. This medical
illustrator and creator of moulages is thought to have
cast more than 550 individual moulages. Several of
his moulages were sold and can now be found in
collections in the United States, Russia, and India.16 A
third center of moulage development emerged in
Vienna in the mid-century, when Anton Elfinger
(1821-1864) began creating moulages for von Hebra
in addition to watercolor paintings.
By the time artist Jules Baretta (1833-1923) arrived
at the Hospital Saint-Louis in Paris, representations of
skin diseases in moulages were quite well estab-
lished as an educational resource. Baretta collabo-
rated with dermatologist Charles Lailler to create
moulages over a long and fruitful period. Barettas
work and the Parisian collection are arguably the
best known in the moulage tradition and ultimately
grew to include more than 3500 dermatologic casts,
thus constituting the largest collection in the world.
Cribier S9
Fig 10. Rhinophyma. From Jacobi, 1904.20
Most of these moulages are still preserved at the
Museum Moulage Collection of the Hospital Saint-
Louis. A huge effort has been made to photograph
and catalog these works of medical art. Now one can
admire them without moving through the library of
the Paris Descartes University, which put the first
3000 into digital format, making them available for
perusal online (www.bium.univ-paris5.fr). At the
museum in Paris, there are over 20 moulages of
rosacea cases.
Baretta did the first castings in 1867, and the series
of rosacea began in 1870 with the representation of
the entire face of a 69-year-old man (moulage186).
Rhinophyma in this case had become a spectacular
and highly skewed mass, masking the mans mouth;
the case is recorded as Acne hypertrophic nose.
Syn. Rhinophyma variety elephantiasis. The choice
to represent these nonstandard subjects raises some
S10 Cribier J AM ACAD DERMATOL
DECEMBER 2013

Fig 11. Acne rosacea. From Hardy and de Montmeja, Fig 12. Rosacea. From Fox, 1880.23
1882.22

doubt as to the educational purpose of these cast-

ings. The number of monstrous cases being repre-
sented between 1870 and 1894 is striking (moulages
239, 773, 1259, 1736, 1780). Thus, the story seems to
outweigh the medical aspect. However, it must be
admitted that the moulages include very accurate
details of symptomatology, such as dilated follicular
orifices of the nose and blackheads.
Baretta then beautifully represented other forms
of rosacea, including profuse pustular forms (molds
342, 583, 663, 818), sometimes with crusted lesions
(342, 583, 818), which is often seen in patients who
are severely affected. Telangiectasia of the nose
appear in a nasal mold from 1880 (cast 650), and
again on the upper half of a face (cast 852). There are
also casts of more normal forms. This includes the
1905 moulage of a moderate rhinophyma compli-
cated by a basal cell carcinoma of 2 cm created from
the face of an 85-year-old man (cast 2437).
The most interesting works are a series of casts
from a patient treated with radiotherapy for his
rhinophyma. They were created a few months apart
in 1909 and 1910; therapy for this patient resulted in a
nasal shape that reverted almost to normal (2653 and
2662). Surprisingly, only men were represented in Fig 13. Rosacea. From Van Haren Noman, 1900.24
this series of 20 cases, revealing that these spectac-
ular representations do not capture the classic
J AM ACAD DERMATOL
VOLUME 69, NUMBER 6
Fig 14. Acne rosee. From Besnier et al, 1897.18
spectrum of the disease. Moulages are also limited to
showing purely macular disease lesions, which may
explain the lack of female role mode.
Fig 8 shows moulage 1237, the upper aspect of the
face of an elderly man with an enlarged forehead. A
reproduction of this molding was published in the
Muse e de lH^ opital Saint-Louis17 as a detachable
plate. The text accompanying the photograph shows
the same patient in black and white. Fig 8 also
illustrates another limitation of moulagesethe aspect
of a death mask for facial castsebecause living
patients are forced to close their eyes to make the
plaster casts.
THE IMAGE OF THE IMAGE: THE
2-DIMENSIONAL MOULAGE
The vogue of castings from the 1870s is such
that some books on skin diseases have lithographs
that are no longer painted from nature but are
only reproduction of casts. This is obviously the ROSACEA IN PHOTOGRAPHY: 1840 TO
case with all illustrations of the book known as the
Musee de lH^ opital Saint-Louis,17 which included
detachable color plates so that the images could be
disseminated beyond the borders of the Parisian
medical community.17 These illustrations do not
adequately retain the genius of the original
Cribier S11
Fig 15. Acne rosacea. From Duhring, 1876.25
moulages. The image is often very flat and trivial,
like the blotches in La Pratique Dermatologique,18
which shows the upper aspect of the face of
inanimate diffuse erythema with centrofacial areas
and telangiectasia of the nose. A good example is
the reproduction of mold 852, which is dull and
has no particular interest, nearing the appearance
of a death mask. Another example of an illustra-
tion from a cast of St Louis is present in the book
of Francois Henri Hallopeau (1842-1919) and
Emile Leredde (1866-1926) that shows a very
pustular rosacea (exhibit 663 in the book, Fig 9
here).19
A distinct contrast is evident in the German works
of Eduard Jacobi (1862-1915) and Ludwig Albert
Neisser (1855-1916). The work of Jacobi in rendering
rosacea with rhinophyma is absolutely stunning
(Fig 10).20
1900
The earliest medical photographs date from 1845
and many early daguerreotypes show skin diseases,
one of them illustrating rhinophyma associated with
pustules that was typical around 1860.21 Various
techniques were used at the same time, including
S12 Cribier
Fig 16. Rhinophyma. From Radcliffe Crocker, 1903.27
stereoscopic images. In France, Alfred Hardy
(1811-1893) published the first atlas of dermatologic
photographs in 1868, with images produced by a
keen-eyed photographer, A. de Montm eja.22 This is
the very same Hardy who went on to build the
famous photographic laboratory of the Hospital
Saint-Louis. Fifty images were published and repub-
lished several times in a book entitled Clinique
Photographique des Maladies de la Peau.22 Fig 11
shows a case of rosacea. The photographs were
pasted on cardboard and colored by hand. Some
traces of original color can be seen in this version
from 1882. Note that the image is not excellent and
the print quality declined with successive editions.
This can be considered the beginnings of medical
illustration photography, and the representation is
still very imprecise when compared with the mou-
lages of the same era or the lithographic plates of von
Hebra.
After the rare historical photographs from the
book by H. G. Piffard (1842-1910), the first derma-
tology book illustrated with numerous photographs
in the United States was that of George Henry Fox
(1846-1937), published in 1880.23 Fox uses for the
first time the technique of photogravure, which was
invented in 1876. There is a beautiful portrait illus-
trating rosacea in a woman (Fig 12). This image is
striking because of the sad and dark mien of the
patient. Again, there was coloring by hand to high-
light the lesions.
J AM ACAD DERMATOL
DECEMBER 2013
It was not until 1900 that a book emerged that had
black-and-white photographs of high quality; this
book was authored by van Haren Noman
(1854-1896), a Dutch physician.24 The text was
written in English, French, and German and the
book was distributed rapidly throughout the medical
world of the early 20th century. It lacks the color here
to show details of the symptomatology of rosacea,
but the photograph is very accurate (Fig 13). Rosacea
here can be compared with cases of acne and the
differences seen.
From that date, photography became increasingly
common in the literature of dermatology, including
La Pratique Dermatologique,18 the first encyclopedia
of dermatology, which combines photographs and
lithographs in black and white. However, for the
representation of rosacea, the watercolor remained
superior because of its ability to reproduce color in
high quality (Fig 14).18
THE LAST DAYS OF LITHOGRAPHY
The advent of photography in the middle of the
19th century did not immediately replace the role for
artists in medical representation because of its ob-
jective nature. On the contrary, quality reproduc-
tions did not rapidly enable a simple and massive
dissemination of this new process. Thus, there were
several important books illustrated primarily with
color lithographs until the 1920s. The latter were
often illustrations of rare diseases. Nevertheless,
J AM ACAD DERMATOL
VOLUME 69, NUMBER 6
there are beautiful pictures of rosacea in the book by
Duhring (1845-1913), published in 1876.25 As shown
in Fig 15, the rosacea representation was a beauti-
fully illustrated portrait of a sad-eyed young woman,
obviously very affected by the numerous pustules
and redness of her skin. The artist here is very much
instrumental in illustrating the symptomatology of
rosacea, perilesional erythema. The image is of high
quality, with the aim of a true portrait and an
attention to detail.25 One can see some contrast in
a photographic image presented by Isidor Neumann
(1832-1906) in an 1890 publication26; compared with
the lithograph below, Neumanns photograph is
much more artificial and does not capture the
nuances of rosacea. The image is not successful on
an artistic or educational levelethe visual informa-
tion is not fulfilling its role: a clinician simply could
not recognize rosacea after seeing the picture. The
quality is far from that achieved by the dermatolo-
gists/painters of the Viennese school.
In 1903, Radcliffe Crocker (1845-1909) published
the last large-format atlas with large plates that could
be detached and displayed.27 The plate devoted to
rosacea shows an elderly man in 3/4 profile with
rhinophyma. This is quite original in dermatology
(Fig 16). A detail shows only the nose in profile. The
portrait is beautiful and informative; rhinophyma is
clearly associated with diffuse redness of the area,
centrofacial and forehead, dotted with pustules.
Curiously, the author includes on the same board a
case called acne rosacea that seems far less con-
vincing as the lesions appear more erythematous,
scaly.28
IMAGERY IN THE 20TH CENTURY
The early 20th century saw the flowering of
smaller works, with illustrations of various kinds,
blending black-and-white photographs, old litho-
graphs, and moulages, as is the case in La Pratique
Dermatologique but also in subsequent publications
by Louis-Anne-Jean Brocq (1856-1928) and then
Ferdinand-Jean Darier. From 1900 most books in-
clude images of skin histopathology, often photomi-
crographs, and sometimes drawings. The oldest of
these micrographs is probably the one showing a
picture of rhinophyma in the atlas of Joseph
Meissner.28 It was not until the 1950s that the pho-
tographs completely replaced all other forms of
illustrations in dermatology. After this time, color
images occur in all books and with increasing
frequency in periodicals. Artists have disappeared
from the world of dermatology. In the mid-20th
century, some lucky hospital departments had pro-
fessional photographers dedicated to dermatology,
which was a supreme luxury. Quality slides from the
Cribier S13
1950s and 1960s marked the peak of photography.
But since the widespread use of digital photographs,
the quality has declined as catalogers take multiple
photographs and quality is not always the ultimate
objective. In 2004, photographs of rosacea were
published in series to grade the severity of the
disease, and were then arranged according to clinical
forms.29 These images were intended to help the
clinician to give an overall severity score, which is
sometimes a tricky business. Regardless of the type
of image, a representation is only an imperfect
reflection of clinical reality, never the true goal.
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DECEMBER 2013
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