drnase
16th January 2006, 11:22 PM
IowaDavid wrote:
I'm all for doing what helps.
For the record: My subtype and nervous-system wiring doesn't respond to aspirin or ibuprofen. I take ibuprofen fairly regulary, and I haven't noticed any real change.
When I take clonidine or klonopin--that gives me a recognizeable effect.
I take supplements to slow down the progress of my disease.
I do have a very flush-oriented manifestation of rosacea (subtype 1 hardcore). I'm going to venture a guess and say that the various subtypes of rosacea require different treatment modalities.
I'm only posting about this as, after reading Dr. Nase's book, I got the impression: IPL is the answer within 5 treatments. Also, if you combine that with the various meds recommended, you're going to be back to normal. That is the major problem, that I've seen, with Dr. Nase's book: It gives _Very_ good advice to treat rosacea; however, it also does not qualify its recommendations properly.
To make an analogy~it's like George Tenet's quotation, "It's a slam dunk."
False hope is a cruel trick. I'm only asking that potential remedies be qualified by a) Their cost, b) Their efficacy for all manifestations of the disease, and c) Their proven help for rosacea sufferers.
Frankly, I feel cheated by the language in Dr. Nase's first book--just get 3-5 IPL and you're good to go! That sounds like a photorejuvenation spa advertisement.
This is not to say Dr. Nase isn't a very helpful source of information regarding this disease--his writings have helped me tremendously. What I DO think is unhealthy is this Kim Jong Il sort of personality cult loyality. It's not helpful, it can cause conflicts, and, at the worst, it causes people believe and use treatments that are harmful, or, at best, costly and benign.
David
Hello David,
I understand that you are a little frustrated with me because I do not support LED for rosacea. That’s fine and such is life. You usually write in a very objective, down to earth style, but not since I have warned that many Type I Rosacea Sufferers will worsen with LED because its main mechanism of action is increasing blood flow. Now you have lost much of the objectiveness that I knew of the old David and in fact state that my "false hope is a cruel trick". You also state quite aggressively that my book is like a "Photofacial Advertisement" Wow, where is that old David? Just because I dont endorse something that harms more people than it helps does not mean that you get to take pop shots at me. My biggest problem is that I am nobodies' "Yes Man". When you and Peter put up 6 or 7 great testimonials from LED and I get 100 to 125 emails about how it hurt individuals, I will not blindly endorse your product.
You dont have to respond to this post as this is my first and last post to this board. It is a perfect post to end on because it shows the arrogant pathology that is thrown up by some people with agendas.
Now, you have just suggested that in my 332 page textbook that I indicate that 3 – 5 laser treatments is a near cure for the disorder. I cannot tell you how wrong that statement is – this is why these boards have been so destructive lately -- You make an erroneous accusation that is not backed up by any facts. In fact, your statement could not be more wrong. I back these up by facts in my book. Exact quotes taken from my book. Its time to step back David and re-evaluate whether your loss of objectivity is now hurting people.
This is my only post and my last post to this group because it clearly demonstrates the clear pathology in these boards and the animosity that a few rosacea sufferers exhibit when they dont have to face the person in real life.
1. The very first part of laser treatment indicates what symptoms lasers are generally effective on and clearly states their limitations. Right off the bat this is made clear:
Effect on rosacea symptoms:
• Extremely effective at reducing chronic facial inflammation, generalized redness, swelling, and telangiectasia
• Moderately effective at reducing facial papules, burning sensations, rhinophyma and many forms of facial flushing
• Minimally effective at reducing facial pustules
2. To my knowledge, I am the only laser researcher in the world who states that “at least 20% of rosacea sufferers do not respond to laser treatment – they are laser resistant.”
3. I clearly state that, “Many rosacea sufferers should know before hand that they may need 10 to 12 treatments to get significant clearance”.
4. I dedicate an entire chapter on why rosacea must be treated with multiple methodologies and not just laser.
Medical experts indicate that facial nerves are responsible for some of the most common and intense forms of rosacea flushing. (1-3) Common triggers for neural flushing include overheating, physical activity, embarrassment, anger, mental concentration, certain foods and beverages, stress, hormonal surges, exhaustion, and spontaneous. Below are listed three therapies for reducing neural flushing, and one combination approach for rosacea sufferers with more advanced cases.
1. Photoderm or Laser Therapy: Laser therapy can reduce many forms of neural flushing. For best clearance and long-lasting results, it is recommended that physicians treat the entire facial flush zone several times. It is also important that the physician target different blood vessel types of the face: (1) Superficial, thin-walled vessels near the epidermis, (2) Superficial, thick-walled thermoregulatory shunt vessels, and (3) Deep thick-walled feed vessels in the middle dermis. Realistic goals for this therapy include reducing the intensity and duration of mild to moderate neural flushing. Rosacea sufferers should be warned that there is significant variation between laser physicians in their ability to treat facial flushing. Please do your homework first and only proceed with laser specialists who have experience in treating rosacea and facial flushing.
2. Oral Antihypertensive Medications (Clonidine, Rilmenidine, or Moxonodine): Oral antihypertensive medications such as clonidine, rilmenidine, and moxonodine are able to reduce the intensity and duration of neural flushing in many rosacea sufferers. Currently, clonidine is the most popular oral medication used for neural flushing.
3. Oral Antihypertensive Medications (Beta Blockers such as Nadolol or Propranolol): Oral beta-blocker treatment is able to reduce the intensity and duration of neural flushing in a significant number of rosacea sufferers.
4. Combination of Laser Therapy and Oral Antihypertensive Medications: Rosacea sufferers with severe neural flushing may require a combination of laser therapy and low-dose antihypertensive medications in order to achieve adequate reductions in neural flushing.
2. FACIAL FLUSHING:
SKIN IRRITATION
Topical skincare products such as facial cleansers, moisturizers, sunscreens, anti-acne products, anti-aging products, and general cosmetics can cause facial irritation and flushing in many rosacea sufferers. (4) Below are listed two therapies for skin irritation flushing, and one combination therapy for sufferers with more severe cases.
1. Photoderm or Laser Therapy: Laser treatment of damaged, hyper-reactive blood vessels near the surface of the skin can decrease skin reactivity in most rosacea sufferers. In addition to laser therapies’ direct actions on dermal blood vessels, treatment may also help to normalize the epidermal structure, (5-7) resulting in a better protective barrier to irritants. Laser therapy for hyper-reactive skin is one of the newest and exciting indications for vascular lasers. This therapy may allow rosacea sufferers to finally use a gentle cleanser, moisturizer, and sunscreen, without facial flushing. For skin irritation flushing, physicians should selectively target superficial, thin-walled blood vessels (the hairpin capillary loops near the epidermis). For best results, laser treatment should be performed several times over the rosacea sufferer’s entire facial flush zone.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of irritating topical products, and active treatment with soothing, protective skincare products. Basic starting points include:
• Stop using topical products that thin and weaken the protective skin barrier. The two most important in this respect are topical steroids and topical irritants (i.e., harsh cleansers, toners, anti-acne products, exfoliators, etc.). By just removing these two groups of skincare products, rosacea sufferers may notice significant reductions in facial skin reactivity and flushing within 3 to 6 weeks.
• Start using skincare products with moderate concentrations of micronized zinc oxide (4% or higher), and dimethicone. These ingredients are very effective anti-irritants that moisturize, protect, and soothe. (8, 9)
• Start using topical metronidazole-based products such as noritate or metrogel to decrease skin inflammation.
3. Combination of Laser and Skincare Therapy: The best approach for moderate to severe sufferers is to combine a series of laser treatments with proper skincare therapy.
3. FACIAL FLUSHING:
ENVIRONMENTAL
(SUN, HEAT, COLD & WIND)
Environmental insults such as sun, heat, cold and wind can cause facial flushing in most rosacea sufferers. (10-13) Below are listed two therapies for environmental flushing, and one combination therapy for more advanced cases.
1. Photoderm or Laser Therapy: Laser treatment can reduce facial flushing to moderate environmental insults. For best clearance of environmental flushing, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals for this therapy include returning to normal outdoor activities in mild to moderate environmental conditions.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of products that thin or weaken the epidermis, and active treatment with protective skincare products.
• Stop using topical products such as steroids and irritants that decrease the thickness of the protective skin barrier.
• Start using skincare products with moderate concentrations of micronized zinc oxide (at least 8%), and dimethicone. Both of these ingredients are excellent skin protectors. These skin protectants can reduce environmental flushing by shielding facial blood vessels from sunlight, heat, cold, and mechanical aggravation (wind). Realistic expectations for this therapy include returning to normal outdoor activities in mild to moderate environmental conditions.
3. Combination of Laser and Skincare Therapy: The best approach for moderate to severe sufferers is to combine a series of laser treatments with proper skincare therapy.
4. FACIAL FLUSHING:
PHYSICAL ACTIVITY
Any form of physical activity, from simple walking to strenuous exercise, can cause a rosacea sufferer’s face to flush. (4, 12) Below are listed three therapies for physical activity flushing, and one combination therapy for the more serious cases.
1. Photoderm or Laser Therapy: Proper laser therapy can reduce facial flushing to mild or moderate physical activity. For best clearance of physical activity flushing, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals for this therapy include eliminating facial flushing to everyday non-strenuous physical activity, and reducing facial flushing to mild or moderate physical activity.
2. Oral Antihypertensive Medications (Nadolol, Clonidine, Rilmenidine, or Moxonodine): Low-dose antihypertensive medications may alleviate physical activity flushing by reducing the bodies’ cardiovascular and neural response to physical exertion.
3. Combination of Laser Therapy and Oral Antihypertensive Medication: Rosacea sufferers who experience frequent or intense flushing to physical activity may require a combination of laser therapy and low-dose antihypertensive medications in order to achieve satisfactory reductions in this flushing reaction.
4. Ice Chip Therapy: Rosacea experts have found that exercise-induced flushing can be reduced by ice chip therapy. (14) With ice chip therapy, the patient is instructed to hold shaved ice chips in the mouth for several minutes at a time without chewing or swallowing. While this may be inconvenient, some rosacea sufferers may be able to return to strenuous aerobic exercise with this therapy.
5. FACIAL FLUSHING:
FOOD & BEVERAGE
Certain foods and beverages can cause facial flushing in rosacea sufferers. (15) Below are listed two therapies that may reduce facial flushing to foods and beverages.
1. Photoderm or Laser Therapy: Proper laser therapy can effectively reduce some forms of food- and beverage-induced flushing. For best clearance and long-lasting results, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals of this therapy include reducing the intensity and duration of mild to moderate triggers. It is exciting to note that this therapy may totally eliminate some minor food and beverage triggers for long periods of time.
2. Oral Medications such as Antihistamines or Aspirin Prior to Ingestion of Certain Foods, Supplements, and Beverages: Taking an antihistamine about two hours before a meal that contains foods high in histamine, or an aspirin about an hour before eating foods high in niacin, may be helpful to rosacea sufferers. (16) Foods that contain histamine or release histamine in the body include processed beef, cheeses, canned fish, vinegar, tomatoes, spinach, eggplant, cheese, chocolate, chicken livers, citrus fruits, bananas, raisins, figs, avocados, yogurt, sour cream and certain alcoholic beverages. Foods high in niacin include lean meats, poultry, seafood, eggs, beans, nutritional supplements, liver, and fortified cereals.
6. FACIAL FLUSHING:
MENOPAUSE
Menopause, which usually starts to affect women in their late 40’s to middle 50’s, is defined as a permanent cessation of menstruation when the ovary stops producing egg cells and female sex hormones such as estrogens. During the course of menopause, women frequently experience hot flashes. Menopausal hot flashes can cause intense facial flushing in female rosacea sufferers. These flushing attacks can worsen all rosacea symptoms including facial redness, inflammation, swelling, burning sensations, papules, and pustules. (14) This can push a mild female sufferer into severe rosacea. Below are listed three individual therapies for menopausal flushing, and one combination therapy for more severe cases.
1. Hormone Replacement Therapy: Oral hormone replacement therapy is very effective at decreasing the number, duration, and intensity of hot flashes. (17, 1 Hormone replacement therapy varies considerably among individuals so proper treatment must be prescribed by the patient’s physician.
2. Clonidine: Oral clonidine has been shown to decrease the number, intensity, and duration of hot flashes in a significant number of clinical studies. (17, 1
3. Black Cohosh: Black cohosh (Cimicifuga racemosa) is the most thoroughly studied natural approach to reducing menopausal hot flashes. (19) Dr. Michael Murray, an internationally recognized naturopathic physician, highly recommends this supplement to his female patients. (19) He recommends that black cohosh be taken in standardized tablets that contain 1 mg of triterpenes, calculated at 27-deoxyactein per tablet. In a recent article, “Black Cohosh Versus Hormone Replacement Therapy in Menopause”, Dr. Murray reviewed 4 major clinical studies on the effectiveness of black cohosh in treating menopausal hot flashes: (19)
• A large open study employing 131 doctors and 629 female patients found that after 6 weeks of black cohosh therapy, the number and intensity of hot flashes improved considerably in 86.6% of the patients. In this study, 43.3% reported that they did not experience any hot flashes during black cohosh treatment.
• A controlled study of black cohosh vs. hormone replacement therapy (premarin) in 60 patients demonstrated that black cohosh treatment of hot flashes was superior to premarin treatment. Black cohosh treatment was found to be free of side effects.
• A double blind, placebo-controlled study of black cohosh vs. premarin in 80 patients demonstrated that black cohosh was much more effective than premarin in reducing the number of daily hot flashes. The number of hot flashes experienced each day decreased from 5 to 1 in the black cohosh-treated group, vs. 5 to 3.5 in the premarin-treated group.
• A double-blind study of black cohosh vs. placebo in 110 women demonstrated that black cohosh was extremely effective at relieving the number and duration of hot flashes.
Recent medical reviews in (1) Advances in Therapy: Therapeutic Efficacy and Safety of Cimicifuga Racemosa for Gynecologic Disorders, and in (2) The Journal of Women’s Health: A Review of the Effectiveness of Cimicifuga Racemosa for the Symptoms of Menopause, are consistent with the above clinical findings. (20, 21) Both medical reviews conclude that black cohosh shows very good to excellent therapeutic effectiveness in the treatment of hot flashes without significant side effects.
4. Combination of Oral Medications and Laser Therapy: Female sufferers who experience frequent or intense hot flashes, may require a combination of laser therapy with oral medications/supplements in order to achieve satisfactory reductions in this flushing reaction.
Important: Laser Therapy and Facial Flushing
As the reader can see from above, I consider laser therapy to be one of the best available treatments for facial flushing. No matter what the underlying cause, laser treatment of facial blood vessels is the most direct approach to flushing disorders. Over the last two years, vascular laser specialists have made significant advancements in the treatment of facial flushing. Technological advancements in laser systems, and more aggressive treatment protocols have resulted in much better clearance of facial blood vessels with longer-lasting results. This is an exciting area of rosacea treatment that continues to improve.
Now, with the above said, the reader must understand that photoderm or laser therapy is not a cure for facial flushing. The rosacea sufferer and the laser practitioner should have realistic goals and expectations.
Realistic Goals & Expectations:
• Eliminate most mild forms of facial flushing for significant periods of time (i.e., two to three years on average).
• Reduce the frequency and intensity of moderate to severe facial flushing for significant periods of time (i.e. one to two years on average).
Those sufferers who have severe rosacea with frequent flushing, or who continually push their vascular disorder to the limit, will need laser touchups periodically to maintain their clearance. Right now this is not perfection, but because laser therapy can: (1) Eliminate mild facial flushing, (2) Reduce the intensity and duration of many forms of moderate flushing, (3) Reduce superficial rosacea symptoms such as facial redness, telangiectasia, and papules, (4) Decrease uncomfortable burning sensations, (5) Decrease the need for oral medications, and (6) Allow a return to a near-normal lifestyle; this therapy must be placed at the top of the treatment list.
FACIAL REDNESS
Chronic facial redness is the most common rosacea symptom. Below are listed three therapies for reducing chronic facial redness.
1. Photoderm or Laser Therapy: Laser therapy can eliminate or reduce permanent facial redness in most rosacea sufferers. Laser therapy is the single best treatment for facial redness. Laser specialists can clear facial redness by at least 80% in most sufferers. For best clearance and long-lasting results, this therapy must be performed several times over the entire facial flush zone.
2. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel can reduce chronic facial redness in mild to moderate cases.
3. Very-Low-Dose Oral Isotretinoin: For rosacea sufferers with moderate to severe facial redness, very-low-dose isotretinoin can be extremely effective in reducing redness, with long-lasting results. (22-2 In most cases, very-low-dose isotretinoin should be taken for 6 months or longer in order to ensure long-lasting results. (27, 29) Caution: patients should not undergo any form of laser surgery while on isotretinoin due to adverse skin reactions. Patients are usually instructed to wait at least 4 to 6 months after stopping isotretinoin before undergoing any type of laser therapy.
FACIAL PAPULES AND PUSTULES
Facial papules (small, red inflammatory lesions), and pustules (red inflammatory lesions with pus) are seen in many rosacea sufferers. (12) Below are listed four therapies for reducing rosacea papules and pustules.
1. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually quite effective on rosacea papules and pustules.
2. Very-Low-Dose Oral Isotretinoin: For rosacea sufferers with moderate to severe inflammatory papules and pustules, very-low-dose isotretinoin is the single most effective therapy. (22-2 In most cases, very-low-dose isotretinoin should be taken for 6 months or longer in order to ensure long-lasting results. (27, 29)
3. Photoderm or Laser Therapy: Proper laser therapy can result in substantial improvement in inflammatory papules. (30, 31) Please note that laser therapy is not usually effective on facial pustules.
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), and Novacet (Medicis) are extremely effective on rosacea papules and pustules. These are quick-acting topical medications that penetrate deeply into the skin. Rosacea sufferers with ultra-sensitive skin must be careful though, because these products may cause facial irritation.
FACIAL BURNING
Facial burning sensations are reported by a large number of rosacea sufferers in the moderate to severe stages. (22, 28, 29, 32) Below are listed five therapies for reducing facial burning sensations, and one near-future therapy.
1. Photoderm or Laser Therapy: Laser therapy often results in dramatic reductions in facial burning sensations. Currently, I do not know of any better therapy for facial burning sensations. The ability of laser therapy to reduce physical burning sensations is often the most gratifying to laser experts.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of known irritants, and active treatment with topical anti-inflammatory medications. Basic starting points include:
• Stop using topical products that cause burning, stinging, or flushing reactions. The first group of products to discontinue is topical steroids. Physicians state that with topical steroid use, “Patients experience exquisite sensitivity of the involved skin to the slightest irritant; itching, burning, and intense redness being major complaints.” (32) Other medical experts find that some rosacea patients on topical steroids experience intense bouts of facial burning that “May become disabling”. (33) The second group of products to discontinue is known topical irritants. By removing these two groups of skincare products, rosacea sufferers may notice significant improvement in burning sensations within 6 to 8 weeks.
• Start using topical metronidazole-based products such as noritate or metrogel to decrease skin inflammation.
3. Very-Low-Dose Oral Isotretinoin: In a clinical study on 18 rosacea patients, very-low-dose isotretinoin significantly decreased facial burning sensations in all rosacea sufferers. (22)
4. Oral Non-Steroidal Anti-inflammatory Medications: Physicians have reported success with non-steroidal anti-inflammatory medications (naproxen or cox-2 inhibitors) in the treatment of rosacea burning. (29, 34)
5. Oral Elavil (Zeneka): Certain antidepressants possess analgesic actions that may alleviate symptoms of inflammatory skin disorders. Older tricyclic antidepressants such as elavil (amitriptyline) may be helpful in treating sensory burning and stinging sensations. (35)
6. Topical Strontium Nitrate (near-future treatment): Topical strontium nitrate may give rosacea sufferers considerable relief from facial burning and stinging sensations. Clinical studies have recently demonstrated that when strontium nitrate is applied to the facial skin, it significantly reduces skincare-induced burning, stinging, and facial redness. (36-3 This inhibitory action takes place within seconds and is long-lasting. (37, 3
In a recent medical study, Dr. Gary Hahn performed a series of exciting clinical experiments to determine the effect of strontium nitrate on irritant-induced burning, stinging, and flushing reactions. (39) In this double blind, placebo-controlled study on 24 subjects with sensitive facial skin, Dr. Hahn demonstrated that pretreatment with strontium nitrate significantly decreased sensory irritation to topical lactic acid (a known irritant). He also demonstrated that addition of strontium salts directly into the lactic acid solution had the same calming actions. Furthermore, strontium nitrate significantly reduced sensory irritation (burning, stinging, and itching) to 70% glycolic acid, depilatory-induced irritation, and aluminum chloride-induced irritation. In this study, skin flushing induced by a strong irritant (aluminum/zirconium solution) was almost completely blocked by treatment with strontium salts. Although the exact mechanism of strontium nitrate in decreasing sensory irritation has not been elucidated, it is speculated that strontium inhibits activation of sensory pain fibers by interfering with calcium-dependent pathways and/or by altering ion permeability within these nerve fibers. (39)
In a more recent clinical study on 24 female subjects with hypersensitive skin, strontium nitrate (500 mM) blocked facial burning and stinging sensations to topical salicylic acid by approximately 50%. (3
Dr. Gary Hahn is a licensed physician in California and serves as an assistant clinical professor in the Department of Pediatrics at the University of California, San Diego. Dr. Hahn is also the president of Cosmederm Technologies, a skincare research and development company where water-soluble strontium salts have been tested and incorporated into skincare products. Dr. Hahn states, “Simple water-soluble strontium salts have proved to be potent and selective inhibitors of chemically induced sensory irritation in humans and do not produce numbness or loss of other tactile sensations. The addition of strontium salts to formulations of topical products can significantly reduce the signs and symptoms of irritant contact dermatitis, which is a significant problem for many people who use cosmetics, personal care products, and topical drugs.” (39) Furthermore, he states, “At this point there are no limitations on product usage, it literally can be used in any class of products, including most acid products, and on base products such as depilatories. The compound is the result of five years of intense investigation into the mechanisms of the skin; we took the opposite approach to skincare - not ingredients, but the biochemical mechanisms in the skin and nervous system.”
These findings are very important to rosacea sufferers who frequently experience facial burning sensations to topical skincare products, and environmental insults such as wind, sun, heat, and cold. I am very excited about the potential of this substance for rosacea-related burning and stinging sensations. I have had several in-depth communications with Dr. Hahn pertaining to the use of this substance for rosacea. Currently, most of the products with strontium salts are off limits for rosacea sufferers (they are used in chemical peels, and alpha- and beta-hydroxy acids). In personal communication with Dr. Hahn, he stated that he was very interested in incorporating strontium salts into gentle moisturizing creams and lotions to evaluate its potential for suppression of rosacea-related burning sensations. He mentioned that they are already working on alcohol-free toners and moisturizers that could be used to reduce uncomfortable burning sensations. In addition to formulating their own product lines, Cosmederm Technologies also distributes the active ingredient (strontium nitrate) to other skincare companies. At the time of this writing, Dr. Hahn was personally developing several different formulas of strontium nitrate (1%, 5%, and 10% hydrogel formulations) for my personal testing. Strontium nitrate shows great promise for rosacea sufferers; it holds the potential to decrease rosacea burning to topical skincare products, and environmental insults such as wind, heat, sun, and cold.
FACIAL SWELLING
Facial flushing is often accompanied by bouts of swelling. In some cases, facial swelling is minor and transient; however, in moderate to severe cases, swelling can become severe and permanent. Below are listed three therapies for reducing facial swelling.
1. Photoderm or Laser Therapy: Laser therapy can effectively reduce mild to moderate facial swelling. (31) In rosacea sufferers with extensive swelling, physicians should proceed with caution; laser specialists should treat these patients with low energy settings, multiple pulses, and long pulse durations, so that the patient experiences minimal post-laser swelling.
2. Very-Low-Dose Oral Isotretinoin: Multiple clinical studies indicate that oral isotretinoin is moderately effective at decreasing rosacea swelling. (40-43)
3. Oral Enzyme Therapy: Systemic proteolytic enzyme therapy (Wobenzyme N) may offer hope to rosacea sufferers with mild to moderate swelling. This enzyme therapy has significant anti-swelling and anti-inflammatory actions. (44 - 47)
RHINOPHYMA
Over the years I have been evaluated and treated by dozens of physicians. In general, most of my experiences with these physicians were very good. Many spent quality time reviewing my case, some spent extra time with me after my appointments, a few faxed me important medical articles concerning potential treatments, while others gathered together in small groups to try to come up with better solutions for my rosacea. However, when it came to the discussion and treatment of rhinophyma, my experience with medical physicians was frustrating and depressing. Over a span of two years I saw seven general dermatologists and five plastic surgeons for my rhinophyma. My rhinophyma was growing at an alarming rate and based on my familial history of rhinophyma (a great uncle with severe rhinophyma), I wanted to aggressively treat this disfiguring disorder. However, each physician gave me no real hope or constructive medical suggestions. Not a single physician offered me any form of active treatment. The only suggestion made to me was to wait until my nose had grown 75% to 100% larger and then they would cut the mass of tissue back down with a scalpel or tissue laser. Yikes! They were satisfied to let my nose turn bright red and grow to almost twice its size! Do you know how depressing and frustrating that medical advice is to a young man in his mid-to-late 20’s? All 12 physicians stated that there was nothing else that could be done.
Thankfully, I came across articles by medical experts that discussed cutting-edge treatment approaches for rhinophyma. These physicians understood our plight and recommended a pro-active approach to treating rhinophyma. They recommended a two-pronged attack: (1) Treat the underlying inflammation, swelling, and sebaceous gland hyperactivity with oral isotretinoin, and (2) Aggressively treat the blood vessels of the nose with a series of vascular laser treatments. This approach, although lengthy, usually yields very good to excellent results. Below are detailed treatment therapies for mild, moderate, and severe rhinophyma.
Mild to Moderate Rhinophyma:
Actively Treat It
1. Low-dose, Long-term Isotretinoin: Low-dose, long-term isotretinoin is an excellent form of treatment for mild to moderate rhinophyma. (29, 43, 48-51) In most cases, oral isotretinoin treatment results in remarkable reductions in the entire disease process (shrinking rhinophyma and decreasing nose swelling, inflammation, sebaceous gland abnormalities, redness, and burning sensations). (29, 43, 48-51) After the initial treatment period, some rhinophyma sufferers may need periodic pulse dosing with isotretinoin to maintain clearance. For details on these medical findings, please refer to Chapter 10, “Oral therapy with Isotretinoin”.
2. Photoderm or Laser Therapy: Laser treatment of blood vessels supplying the nose can reduce and reverse mild to moderate rhinophyma. (31, 52) Experts indicate that because the underlying problem in rhinophyma is vascular in nature, treatment of rhinophyma with vascular lasers can not only reduce the size and severity of rhinophyma, but, “Often prevents further development of the condition.” (52)
3. Combination of Oral Isotretinoin and Laser Therapy: Rhinophyma is progressive in nature and usually requires aggressive treatment. In many cases, rhinophyma sufferers will need a two-pronged attack: (1) Treat the inflammation, swelling, and sebaceous gland abnormalities with oral isotretinoin, and (2) Treat the underlying vascular disorder with a series of vascular laser treatments. Caution: patients should not undergo any form of laser surgery while on isotretinoin due to adverse skin reactions. Patients are usually instructed to wait at least 4 to 6 months after stopping isotretinoin before undergoing any type of laser therapy.
My Personal Experience with Isotretinoin and Laser Therapy: The combination of photoderm therapy and oral isotretinoin worked wonders on my rhinophyma. This combination therapy reversed and completely normalized my disorder. This approach was a true godsend for my condition. Rhinophyma sufferers do not have to wait until grotesque disfigurement sets in before starting treatment.
Severe Rhinophyma:
Surgical Techniques for Physical
Removal of Excess Nose Tissue
In severe rhinophyma, the nose can grow to enormous sizes (sometimes interfering with nasal breathing and eating). At this stage, surgical treatment is required to physically remove the newly formed tissue and sebaceous gland abnormalities. Below are listed six treatments for severe rhinophyma, and one combination treatment for the most advanced cases.
1. Dermabrasion or Surgical Scalpel: Some physicians recommend simple shaving with a surgical scalpel or dermabrasion for rhinophyma. (53) The main drawback to these techniques is that excessive bleeding usually occurs during these procedures.
2. Electrosurgery with Cautery Knives or Loops: Some physicians use electrosurgery with cautery knives and loops to control tissue removal and reduce bleeding. (53) Electrosurgery usually gives good to excellent results in reshaping the nose. The other benefit of electrosurgery is that it is relatively inexpensive. The main drawback to this surgery is that it allows for heat dispersion into the tissue, which may cause mild hypertrophic scarring in a small percentage of patients. (54)
3. Newer Heated Scalpels: The heated Shaw scalpel is composed of surgical steel and coated with Teflon. This special scalpel is much more “accurate” than most other forms of heated scalpels. (53)
4. The Ultrasonic Scalpel: This surgical scalpel incorporates ultrasonic vibration, resulting in more ‘sharpness’ of the blade and even less bleeding than other treatment modalities. (53)
5. The Carbon Dioxide (CO2) Laser: The CO2 laser has been used with great success to treat most forms of rhinophyma. (53) Experts indicate that the CO2 laser is the preferred tool for the treatment of rhinophyma. (53) The CO2 laser selectively destroys the excess tissue in a very controlled fashion, without bleeding.
6. Surgery with Skin Grafts: For large rhinophyma, surgery followed by simple skin grafts can give the patient very good to excellent results.
7. Combination of Surgery and Oral Isotretinoin: Rhinophyma can be treated surgically by scalpels, electrosurgery, dermabrasion, and laser. However, recurrence of rhinophyma can occur after any form of surgical treatment. (55) Drs. Rodder and Plewig of the Department of Dermatology, University of Dusseldorf, recommend surgical removal of excess tissue, followed by long-term, very-low-dose isotretinoin. These physicians usually treat their rhinophyma patients with 0.2 mg/kg of isotretinoin for the first several months, followed by 0.1 mg/kg per day for 2 years. Patients have remained in full remission for 2 to 2.5 years following cessation of this treatment protocol. (55)
STEROID-INDUCED ROSACEA
Steroid-induced rosacea is still quite common because well-meaning physicians routinely use topical steroids to treat facial redness and inflammation. Topical steroids of any concentration should never be used to treat rosacea sufferers or patients who show pre-rosacea symptoms (i.e., facial flushers and blushers). With continued use, topical steroids thin the epidermis, weaken the blood vessels, and worsen facial flushing. One of the most important first steps that rosacea sufferers can take is to wean themselves off topical steroids.
The major problem with discontinuing topical steroids is that rosacea sufferers usually get worse before they get better. They almost always experience rebound flares that cause their faces to become more red, inflamed, and sensitive. (33) Under normal conditions, this can take weeks to reverse, and months for the skin to fully heal itself. (33) To decrease this rebound flare and speed up the healing process, medical experts now recommend a very effective four-step approach to weaning off topical steroids:
1. First Step – begin treatment with oral anti-inflammatory medications: Physicians recommend that rosacea sufferers begin treatment with oral anti-inflammatory medications one to four weeks prior to weaning off topical steroids. This pre-treatment therapy can help decrease inflammation, and reduce the intensity of steroid-withdrawal flares. Popular oral anti-inflammatory medications being used to decrease the rebound inflammation include:
• Clarithromycin – 250 milligrams twice a day. (56, 57)
• Minocycline – 100 milligrams twice a day. (5
• Very-low-dose isotretinoin – Drs. Plewig and Klingman recommend isotretinoin at 5 milligrams per day. (59)
2. Second Step – reduce the amount of topical steroid applied to the facial skin: After the initial oral anti-inflammatory therapy, rosacea sufferers are instructed to start weaning off topical steroids. During the first week, rosacea sufferers should simply reduce the amount of cream that they apply to their faces (i.e., use less cream and less applications per day).
3. Third Step – decrease the strength of the topical steroid: Over the next two to four weeks rosacea sufferers should decrease the strength of the topical steroid in a stepwise fashion. Rosacea sufferers should wean themselves down to 0.5% over-the-counter hydrocortisone.
4. Fourth Step – slowly replace the steroid with topical anti-inflammatory creams: Eventually, rosacea sufferers will be able to permanently replace the steroid with metronidazole-based creams such as noritate or metrogel. Some physicians also recommend topical zinc oxide for healing steroid-induced rosacea. (60)
Note: Most rosacea sufferers would be wise to stay on oral anti-inflammatory medications throughout the entire withdrawal process until the skin and blood vessels normalize.
Important: Proper Use of Topical Steroids
Rosacea sufferers should never use any form of topical steroid to treat rosacea on a daily or weekly basis. Topical steroids will make rosacea sufferers worse in the long run. For in-depth discussion on this extremely important topic, please refer to Chapter 5, “Topical Steroids”.
Now with the above warning posted, it should be pointed out that topical hydrocortisone can be used sparingly by rosacea sufferers under certain conditions. If used wisely, topical hydrocortisone (1%) can be used to reduce major skin flare-ups that occur periodically. (61) In those rosacea sufferers who have self-control, topical hydrocortisone can be used for 2 to 3 days in order to reduce facial inflammation caused by skin irritation or bad bouts of flushing. Topical hydrocortisone treatment should be stopped after 2 to 3 days, and should not be repeated for at least 14 to 17 days. So, under these conditions, topical hydrocortisone is not being used to treat rosacea per se, but is being used to reduce facial inflammation caused by bad flare-ups.
Rosacea sufferers also need to be aware that many over-the-counter topical hydrocortisone preparations contain harsh ingredients such as drying alcohols, emulsifiers, cetyl and steryl alcohols, and emulsifying wax. These ingredients can be detrimental to rosacea skin. For those rosacea sufferers with self-control, I can highly recommend a new 1% hydrocortisone cream (Dermarest Dricort 1% Hydrocortisone Cream, by Del Pharmaceuticals, Inc.) that contains an extremely gentle base consisting of colloidal silicon dioxide.
ROSACEA FULMINANS
Rosacea fulminans is a rare, devastating disease of unknown origin. It occurs exclusively in young women. All women are reported to be flushers and blushers. (62, 63) This form of rosacea has a rapid onset and can cause severe facial inflammation with nodular lesions. Drs. Jansen, Plewig and Klingman describe the onset of rosacea fulminans and its treatment: “Rosacea fulminans is an explosive process. Suddenly, without warning, in a matter of a week, severe facial affliction strikes like lightning. Sadly, nothing is really known about this form of rosacea. It is usually confined to the center of the face (nose, cheeks and chin), and presents as deep erythema, with crops of severe papules, pustules and nodules. Early and aggressive treatment is warranted: in some cases, hospital treatment is required. The optimum treatment consists of oral contraceptives (anti-androgen type), isotretinoin, and oral and topical steroids (this is the only form of rosacea in which steroids are indicated in order to relieve the patient of severe inflammation and extreme facial discomfort). If left untreated, it will usually leave widespread pitted and linear scars. However, early treatment, especially with isotretinoin results in excellent clearance and for some unknown reason, recurrence is rarely ever seen.” (62)
ROSACEA AND EXTENSIVE
SUN DAMAGE
Some rosacea sufferers have extensive sun damage. It is extremely important for rosacea sufferers to be warned that most forms of treatment for facial sun damage are strong irritants to rosacea. Laser resurfacing, chemical peels, and anti-aging products can all worsen the underlying flushing disorder. Sadly, one of the most common reports that I receive from rosacea sufferers is that they have innocently turned their mild rosacea into moderate rosacea with intense flushing and burning sensations, after treatment for facial sun damage. Please be very careful. At this time, I can only safely recommend one form of treatment for rosacea with extensive sun damage.
1. Photoderm or Laser Therapy: Photoderm and vascular lasers can effectively treat signs of sun damage such as facial wrinkles and solar elastosis. (64, 65) Vascular laser therapy effectively removes disrupted collagen fibers of the face, and stimulates the formation of new, healthy fibers. (64, 65) This is known as “sub-surfacing” because these lasers “remodel” or “rebuild” damaged collagen deep within the skin without harming the outer layer of facial skin. Recently, photoderm has been shown to remodel collagen deep within the middle dermis (66) and stimulate the formation of pro-collagen, collagen I, collagen III, and elastin. (67)
Please note that skin resurfacing lasers such as the CO2 laser are not the same as photoderm or vascular lasers. Skin resurfacing lasers destroy skin tissue and blood vessels; while photoderm and vascular lasers only destroy blood vessels. Rosacea sufferers should be very careful with skin resurfacing lasers because they can permanently aggravate the underlying vascular beast. Rosacea experts do not recommend the use of skin resurfacing lasers for anything other than severe rhinophyma.
ROSACEA AND PERIORAL DERMATITIS
Some rosacea sufferers also have perioral dermatitis, a rash-like dermatitis around the mouth area. Although the exact cause of perioral dermatitis is unknown, it is considered to be an inflammatory skin disorder with vascular origins. (6 The main symptoms include persistent redness around the mouth area, and inflammatory papules or pustules. Many cases of perioral dermatitis are exacerbated by topical steroids. (69) Below are listed five therapies for treating perioral dermatitis.
1. Discontinue Topical Steroids: If a patient is using topical steroids on a daily or weekly basis, then discontinuing the steroid will result in substantial improvement in all symptoms. (69)
2. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually quite effective in reducing most symptoms of perioral dermatitis. (69)
3. Low-Dose Oral Isotretinoin: For those cases of perioral dermatitis that do not respond adequately to topical and oral antibiotics, low-dose oral isotretinoin has been shown to have dramatic, long-lasting effects. (70)
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), or Novacet (Medicis) are extremely effective on inflammatory papules and pustules around the mouth area, and in some cases may also decrease skin redness. (69) Rosacea sufferers with ultra-sensitive skin should be cautious with these products because they can cause irritation.
5. Photoderm or Laser Therapy: Laser specialists often report dramatic improvement in perioral dermatitis after a series of laser treatments. This should not be surprising as biopsies of perioral dermatitis often demonstrate marked dilation of blood vessels with moderate swelling. (6
ROSACEA AND ACNE
Some rosacea sufferers also have co-existing skin problems such as whiteheads, blackheads, large pores, and excess facial oil. This usually presents a problem because most anti-acne preparations are too harsh for rosacea skin. Rosacea sufferers must be very cautious when trying to treat skin problems such as acne, oily skin, or enlarged pores. Let me fully warn the reader -- rosacea sufferers can innocently turn a cosmetic case of rosacea into one with debilitating flushing and burning sensations after the use of topical irritants. Please be smart and listen to your face! Rosacea sufferers will be their own best judge as to whether a particular anti-acne product makes their vascular disorder worse. For detailed information on the most common anti-acne preparations to avoid, please read the section on “Skin Irritation: Topical Irritants”, in Chapter 5. Below are listed some of the “safer” anti-acne treatments for rosacea sufferers:
1. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually somewhat effective on acne symptoms. This is usually a good, safe starting point.
2. Klaron Lotion 10% (Dermik Laboratories, Inc.): This is an elegant, water-based, alcohol-free lotion that contains 10% sodium sulfacetamide (a penetrating antibacterial). Based on numerous physician and patient reports that I have received, this seems to be one of the gentler topical anti-acne products. This is a good choice for rosacea sufferers with acne. (29)
3. Cleocin T Gel (Upjohn Company): This popular anti-acne medication contains clindamycin phosphate in an elegant, alcohol-free gel. This also seems to be a popular choice for rosacea patients with sensitive skin.
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), or Novacet (Medicis) are extremely effective on facial whiteheads and blackheads. Rosacea sufferers with ultra-sensitive skin should be cautious because these topicals can cause facial irritation.
3. Very-Low-Dose Oral Isotretinoin: Rosacea sufferers with moderate to severe acne may have to treat their acne from the inside (i.e., oral pills). Under these conditions, very-low-dose oral isotretinoin is an excellent choice.
ROSACEA AND
SEBORRHEIC DERMATITIS
Some rosacea sufferers also have seborrheic dermatitis, an inflammatory skin disorder that is caused by abnormal number or activity of Pityrosporum Ovale, a facial skin yeast. (71, 72) Seborrheic dermatitis primarily affects areas of the facial skin that are rich in sebaceous glands such as the center of the face, eyebrows, scalp, and eye lid edges. Most patients with seborrheic dermatitis tend to have oily skin. The skin in these areas is often red with yellowish flakes.
Seborrheic dermatitis is a chronic condition that has no known cure, however it is controllable with treatment. It is imperative that rosacea sufferers treat their seborrheic dermatitis because if seborrheic dermatitis is left untreated, facial skin may become hyper-reactive to all topical skincare products and medications. It is equally important that rosacea sufferers find a treatment therapy that does not involve chronic use of topical steroids (even 1% hydrocortisone), as these steroids will make rosacea worse. Below are listed three therapies for treating seborrheic dermatitis.
1. Topical Nizoral 2% Cream (Janssen): Nizoral cream contains a powerful antifungal ingredient (2% ketoconazole) that is very effective in the treatment of seborrheic dermatitis. Medical experts highly recommend topical ketoconazole for rosacea patients with yeast-related skin disorders. (73)
2. Topical Sulfur/Sulfacetamide Preparations: Preparations with sulfur and sodium sulfacetamide are very useful in the treatment of seborrheic dermatitis. (58, 74-76, 76, 77) Two popular brands are Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), and Novacet (Medicis). Rosacea sufferers with ultra-sensitive skin should be cautious though because these topicals may cause facial irritation. Patients with ultra-sensitive skin may have greater success with specially formulated sulfur/sulfacetamide topicals that contain lower concentrations of the active ingredients, and are placed into non-irritating base creams or gels. Some private practice physicians report great success with:
• 2.5% micronized colloidal sulfur + 5% sodium sulfacetamide compounded into Noritate.
• 2.5% micronized colloidal sulfur + 5% sodium sulfacetamide compounded into Metrogel.
3. Oral Antifungals: Ketoconazole (Nizoral Tablets, Janssen), Fluconazole (Diflucan Tablets, Pfizer), or Itraconazole (Sporanox Capsules, Janssen): For those rosacea sufferers who have ultra-sensitive skin or severe seborrheic dermatitis, oral antifungals such as ketoconazole, fluconazole or itraconzaole may be a god-send in treating their condition. (73)
• Treatment with oral ketoconazole can have a dramatic effect on yeast-related skin disorders (i.e., seborrheic dermatitis). (71) Short courses of oral ketoconazole (200 milligrams per day for 28 days) may reduce the disease to such an extent that remission can be maintained easily with the periodic use of gentle topical medications. (71) This may also break the vicious inflammatory cycle, allowing rosacea sufferers to use topical products that they were not able to use in the past.
• Dr. Faergmann at the Dept. of Dermatology, Central Hospital, Sweden, routinely uses oral ketoconazole to treat patients with yeast-related skin disorders. (7 In moderate to severe cases, he uses oral ketoconazole to achieve clearance of the disease (3 to 6 weeks of daily treatment), and then uses 200 milligrams, 2 times a month to maintain clearance.
• Other medical experts also use monthly pulse dosing with ketoconazole to maintain clearance in moderate to severe cases. (79) Dr. Jones reports excellent success using a “Two Saturday” treatment protocol where he treats his patient with 400 milligrams of ketoconazole on one Saturday and then repeats it 1 week later (this is followed by a one-month break and then re-treatment).
ROSACEA AND DEPRESSION/ANXIETY
It is quite common for rosacea sufferers to go through bouts of depression and/or anxiety. Depression and anxiety can be caused by any number of reasons, including cosmetic disfigurement, painful skin sensations, decreased quality of life, and avoidance of triggers that are associated with the disorder. It must be stressed that depression or anxiety under these conditions is quite normal and can occur in the most emotionally sound people. It does not mean that a person is “weak” or “mentally unfit”. It must also be emphasized that depression and anxiety are usually caused by the chronic illness, and that the chronic illness is not caused by the depression or anxiety. (80)
While depression and anxiety do not cause rosacea, they both can increase the frequency and intensity of facial flushing by activating complex neural and hormonal pathways this, in turn, can worsen rosacea symptoms. Therefore, it is very important that rosacea patients address depression and anxiety.
Depression and anxiety are caused in part by an imbalance in chemical messengers in the brain. There are a variety of medications and herbs that are now available to treat depression and anxiety. These medications/herbs primarily work by normalizing the chemical imbalance in the brain.
1. Antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRI’s): The newer nontricyclic antidepressants such as fluoxetine (Prozac, Eli Lilly and Company), sertraline (Zoloft, Pfizer), and paroxetine (Paxil, SmithKline Beecham), are very effective anti-depressants that generally have mild, transient side effects. (81) Paxil is also approved for the treatment of social phobia and anxiety. Several dozen anecdotal reports from physicians and rosacea sufferers suggest that paxil may help to decrease the frequency and intensity of some forms of neural-mediated flushing.
2. St. John’s Wort: For mild to moderate depression or anxiety, this natural herb may be worth a try. Recent clinical trials have demonstrated that Saint John’s Wort (Hypericum perforatum) has significant antidepressant and anti-anxiety actions. In some cases, Saint John’s Wort seems to be as effective as synthetic antidepressants. In other cases, its effects are barely noticeable until the patient realizes that things that used to aggravate them, no longer affect them the way they once did.
For anyone contemplating Saint John’s Wort (SJW), I highly recommend reading “St. John’s Wort Extract” by Dr. Michael T. Murray. (82) This 4-page pamphlet is an excellent source of information on SJW. He details numerous clinical studies demonstrating the effectiveness of SJW in treating mild to moderate forms of depression (83-87) In two of the clinical studies cited, SJW demonstrated anti-anxiety actions comparable to those of valium (diazepam). Dr. Michael T Murray recommends a standardized 0.3% hypericin at 300 milligrams, three times daily. (82) This is the exact dosage that is used in most clinical studies.
In the British Medical Journal (1996), Dr. Klaus Linde and colleagues thoroughly reviewed all of the studies reported in the medical literature on the effectiveness and safety of SJW. (8 Based on data from 1,008 patients, the results clearly showed that SJW extracts were very effective in the treatment of mild to moderate depression. In addition, six medical studies found that SJW was as effective as synthetic antidepressants but with fewer side effects. In a more recent 1999 review by Drs. Josey and Tackett of the University of Georgia, College of Pharmacy, they reported on 4 controlled studies that indicate, “St. John’s Wort is as effective as other antidepressant medication and more effective than placebo, as the clinical symptoms of depression greatly decreased upon administration of Hypericum. The side effect profile of Hypericum at this time appears to be superior to any current US approved antidepressant medication.” (89)
3. Anti-Anxiety Drugs: While anti-anxiety medication is not a long-term solution for rosacea, short-term treatment can help rosacea sufferers get back on their feet again. (81) When administered under the supervision of a physician who is treating the entire rosacea spectrum, anti-anxiety medication may help rosacea sufferers break through the vicious flush cycle. (81) In the medical article, “Psychological Aspects of Rosacea”, rosacea experts indicate that for temporary treatment of situational stress that may occur in rosacea, Alprazolam (Xanax, Parmacia and Upjohn Company) is the treatment of choice due to its quick mode of action and complete elimination before the next dose. (81) However, if the patient requires long-term therapy for anxiety, buspirone (Buspar, Bristol-Myers Squibb) is recommended because it is not addicting or sedating. (81) However, the therapeutic effect of Buspar is not achieved for at least 2 weeks and thus cannot be taken on an “as-needed” basis. (81)
REFERENCES
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8. Draelos, Z.D. New developments in cosmetics and skincare products. Adv Dermatol 12: 3-17, 1997.
9. Nichols, K., N. Desai, and M.G. Lebwohl. Effective sunscreen ingredients and cutaneous irritation in patients with rosacea. Cutis 61: 344-346, 1998.
10. Haxthausen, H. "Changes in the skin vessels from protracted action of climatic factors and their significance in various skin diseases". Br J Dermatol Syp 105-125, 1930.
11. Landthaler, M., D. Haina, W. Waidelich, and O. Braun-Falco. Laser therapy of venous lakes (Bean-Walsh) and telangiectasias. Plast Reconstr Surg 73: 78-83, 1984.
12. Gratton, D. The many faces of rosacea. J Cutan Med Surg 2 Suppl 4: S4-S4, 1998.
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15. Guarrera, M., A. Parodi, C. Cipriani, C. Divano, and A. Rebora. Flushing in rosacea: a possible mechanism. Arch Dermatol Res 272: 311-316, 1982.
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17. Tulandi, T. and S. Lal. Menopausal hot flush. Obstet Gynecol Surv 40: 553-563, 1985.
18. Walsh, B. and I. Schiff. Vasomotor flushes. Prog Clin Biol Res 320: 71-87, 1989.
19. Murray, M.T. "Black cohosh versus hormone replacement therapy in menopause". In: Ask the Doctor, Vital Communications, Inc, 1998, p. 1-3.
20. Lieberman, S. A review of the effectiveness of Cimicifuga racemosa (black cohosh) for the symptoms of menopause. J Womens Health 7: 525-529, 1998.
21. Liske, E. Therapeutic efficacy and safety of Cimicifuga racemosa for gynecologic disorders. Adv Ther 15: 45-53, 1998.
22. Erdogan, F.G., P. Yurtsever, D. Aksoy, and F. Eskioglu. Efficacy of low-dose isotretinoin in patients with treatment-resistant rosacea. Arch Dermatol 134: 884-885, 1998.
23. Ertl, G.A., N. Levine, and A.M. Kligman. A comparison of the efficacy of topical tretinoin and low-dose oral isotretinoin in rosacea. Arch Dermatol 130: 319-324, 1994.
24. Vogt, E. and H.C. Friederich. Oral 13-cis-retinoic acid therapy in adenoma sebaceum symmetricum and the most severe forms of acne and rosacea. Z Hautkr 58: 646-667, 1983.
25. Turjanmaa, K. and T. Reunala. Isotretinoin treatment of rosacea. Acta Derm Venereol 67: 89-91, 1987.
26. Jansen, T. and G. Plewig. Rosacea: classification and treatment. J R Soc Med 90: 144-150, 1997.
27. Baker, B. "Low-dose, pulsed oral isotretinoin may clear resistant rosacea". Skin & Allergy News 30(12): 23, 1999.
28. Tackett-Fletcher, W. and K. Roberts. Rosacea. Geriatr Nurs 20: 44, 47, 1999.
29. Hooper, B.J. and M.P. Goldman. "Rosacea". In: Primary Dermatologic Care, edited by B. Bowlus. St. Louis: Mosby, 1999, p. 48-50.
30. Lowe, N.J., K.L. Behr, R. Fitzpatrick, M. Goldman, and J. Ruiz-Esparza. Flash lamp pumped dye laser for rosacea-associated telangiectasia and erythema. J Dermatol Surg Oncol 17: 522-525, 1991.
31. Laughlin, S.A. and D.K. Dudley. Laser therapy in the management of rosacea. J Cutan Med Surg 2 Suppl 4: S4-S9, 1998.
32. Greaves, M.W. "Flushing, flushing syndromes, rosacea and perioral dermatitis". In: Textbook of Dermatology, edited by R.H. Champion, J.L. Burton, and et al. Malden: Blackwell Science, 1998, p. 2099-2112.
33. Rapaport, M.J. and V. Rapaport. "Eyelid dermatitis to red face syndrome to cure: Clinical experience in 100 cases". J Am Acad Dermatol 41: 435-442, 1999.
34. White, J.W. "Tips from the experts". Dermatol Clin 6: 649-667, 1988.
35. Koo, J. and C. Gambla. Cutaneous sensory disorder. Dermatol Clin 14: 497-502, 1996.
36. Zhai, H., W. Hannon, G. Hanha, A. Pelosi, R. Harper, and H. Maibach. Strontium nitrate suppresses chemically-induced sensory irritation in humans. Contact Dermatitis 42: 98-100, 2000.
37. Hahn, G.S. Modulation of neurogenic inflammation by strontium. In: Biochemical modulation of skin reactions: Transdermals, topicals and cosmetics, edited by A.F. Kydonieus and J.J. Wille. New York: CRC Press, 2000, p. 261-272.
38. Hahn, G.S. Anti-irritants for sensory irritation. In: Handbook of cosmetic science and technology, edited by A. Barel, M. Paye, and H. Maibach. To be published, 2000, p. 1-24.
39. Hahn, G.S. "Strontium is a potent and selective inhibitor of sensory irritation". Dermatol Surg 25: 689-694, 1999.
40. Harvey, D.T., N.A. Fenske, and L.F. Glass. Rosaceous lymphedema: a rare variant of a common disorder. Cutis 61: 321-324, 1998.
41. Nikolowski, J. and G. Plewig. Oral treatment of rosacea with 13-cis-retinoic acid. Hautarzt 32: 575-584, 1981.
42. Plewig, G., J. Nikolowski, and H.H. Wolff. Action of isotretinoin in acne rosacea and gram-negative folliculitis. J Am Acad Dermatol 6: 766-785, 1982.
43. Hoting, E., E. Paul, and G. Plewig. Treatment of rosacea with isotretinoin. Int J Dermatol 25: 660-663, 1986.
44. Duskova, M. and M. Wald. Orally administered proteases in aesthetic surgery. Aesthetic Plast Surg 23: 41-44, 1999.
45. Korpan, M.I. and V. Fialka. Wobenzyme and diuretic therapy in lymphedema after breast operation. Wien Med Wochenschr 146: 67-72, 1996.
46. Gordon, G. "Systemic enzyme therapy: aspirin vs enzymes". The Doctor's Prescription for Healthy Living 2: 1998.
47. Ransberger, K. "Oral enzyme therapy". Total Health 20: 1-3, 1998.
48. Shalita, A.R., W.J. Cunningham, J.J. Leyden, P.E. Pochi, and J.S. Strauss. "Isotretinoin treatment of acne and related disorders: an update". J Am Acad Dermatol 9: 629-638, 1983.
49. O
Geoffrey
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Dr. Geoffrey Nase
Ph.D. Neuro-Vascular Physiologist
Rosacea Specialist and Consultant
http://www.drnase.com
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I'm all for doing what helps.
For the record: My subtype and nervous-system wiring doesn't respond to aspirin or ibuprofen. I take ibuprofen fairly regulary, and I haven't noticed any real change.
When I take clonidine or klonopin--that gives me a recognizeable effect.
I take supplements to slow down the progress of my disease.
I do have a very flush-oriented manifestation of rosacea (subtype 1 hardcore). I'm going to venture a guess and say that the various subtypes of rosacea require different treatment modalities.
I'm only posting about this as, after reading Dr. Nase's book, I got the impression: IPL is the answer within 5 treatments. Also, if you combine that with the various meds recommended, you're going to be back to normal. That is the major problem, that I've seen, with Dr. Nase's book: It gives _Very_ good advice to treat rosacea; however, it also does not qualify its recommendations properly.
To make an analogy~it's like George Tenet's quotation, "It's a slam dunk."
False hope is a cruel trick. I'm only asking that potential remedies be qualified by a) Their cost, b) Their efficacy for all manifestations of the disease, and c) Their proven help for rosacea sufferers.
Frankly, I feel cheated by the language in Dr. Nase's first book--just get 3-5 IPL and you're good to go! That sounds like a photorejuvenation spa advertisement.
This is not to say Dr. Nase isn't a very helpful source of information regarding this disease--his writings have helped me tremendously. What I DO think is unhealthy is this Kim Jong Il sort of personality cult loyality. It's not helpful, it can cause conflicts, and, at the worst, it causes people believe and use treatments that are harmful, or, at best, costly and benign.
David
Hello David,
I understand that you are a little frustrated with me because I do not support LED for rosacea. That’s fine and such is life. You usually write in a very objective, down to earth style, but not since I have warned that many Type I Rosacea Sufferers will worsen with LED because its main mechanism of action is increasing blood flow. Now you have lost much of the objectiveness that I knew of the old David and in fact state that my "false hope is a cruel trick". You also state quite aggressively that my book is like a "Photofacial Advertisement" Wow, where is that old David? Just because I dont endorse something that harms more people than it helps does not mean that you get to take pop shots at me. My biggest problem is that I am nobodies' "Yes Man". When you and Peter put up 6 or 7 great testimonials from LED and I get 100 to 125 emails about how it hurt individuals, I will not blindly endorse your product.
You dont have to respond to this post as this is my first and last post to this board. It is a perfect post to end on because it shows the arrogant pathology that is thrown up by some people with agendas.
Now, you have just suggested that in my 332 page textbook that I indicate that 3 – 5 laser treatments is a near cure for the disorder. I cannot tell you how wrong that statement is – this is why these boards have been so destructive lately -- You make an erroneous accusation that is not backed up by any facts. In fact, your statement could not be more wrong. I back these up by facts in my book. Exact quotes taken from my book. Its time to step back David and re-evaluate whether your loss of objectivity is now hurting people.
This is my only post and my last post to this group because it clearly demonstrates the clear pathology in these boards and the animosity that a few rosacea sufferers exhibit when they dont have to face the person in real life.
1. The very first part of laser treatment indicates what symptoms lasers are generally effective on and clearly states their limitations. Right off the bat this is made clear:
Effect on rosacea symptoms:
• Extremely effective at reducing chronic facial inflammation, generalized redness, swelling, and telangiectasia
• Moderately effective at reducing facial papules, burning sensations, rhinophyma and many forms of facial flushing
• Minimally effective at reducing facial pustules
2. To my knowledge, I am the only laser researcher in the world who states that “at least 20% of rosacea sufferers do not respond to laser treatment – they are laser resistant.”
3. I clearly state that, “Many rosacea sufferers should know before hand that they may need 10 to 12 treatments to get significant clearance”.
4. I dedicate an entire chapter on why rosacea must be treated with multiple methodologies and not just laser.
Medical experts indicate that facial nerves are responsible for some of the most common and intense forms of rosacea flushing. (1-3) Common triggers for neural flushing include overheating, physical activity, embarrassment, anger, mental concentration, certain foods and beverages, stress, hormonal surges, exhaustion, and spontaneous. Below are listed three therapies for reducing neural flushing, and one combination approach for rosacea sufferers with more advanced cases.
1. Photoderm or Laser Therapy: Laser therapy can reduce many forms of neural flushing. For best clearance and long-lasting results, it is recommended that physicians treat the entire facial flush zone several times. It is also important that the physician target different blood vessel types of the face: (1) Superficial, thin-walled vessels near the epidermis, (2) Superficial, thick-walled thermoregulatory shunt vessels, and (3) Deep thick-walled feed vessels in the middle dermis. Realistic goals for this therapy include reducing the intensity and duration of mild to moderate neural flushing. Rosacea sufferers should be warned that there is significant variation between laser physicians in their ability to treat facial flushing. Please do your homework first and only proceed with laser specialists who have experience in treating rosacea and facial flushing.
2. Oral Antihypertensive Medications (Clonidine, Rilmenidine, or Moxonodine): Oral antihypertensive medications such as clonidine, rilmenidine, and moxonodine are able to reduce the intensity and duration of neural flushing in many rosacea sufferers. Currently, clonidine is the most popular oral medication used for neural flushing.
3. Oral Antihypertensive Medications (Beta Blockers such as Nadolol or Propranolol): Oral beta-blocker treatment is able to reduce the intensity and duration of neural flushing in a significant number of rosacea sufferers.
4. Combination of Laser Therapy and Oral Antihypertensive Medications: Rosacea sufferers with severe neural flushing may require a combination of laser therapy and low-dose antihypertensive medications in order to achieve adequate reductions in neural flushing.
2. FACIAL FLUSHING:
SKIN IRRITATION
Topical skincare products such as facial cleansers, moisturizers, sunscreens, anti-acne products, anti-aging products, and general cosmetics can cause facial irritation and flushing in many rosacea sufferers. (4) Below are listed two therapies for skin irritation flushing, and one combination therapy for sufferers with more severe cases.
1. Photoderm or Laser Therapy: Laser treatment of damaged, hyper-reactive blood vessels near the surface of the skin can decrease skin reactivity in most rosacea sufferers. In addition to laser therapies’ direct actions on dermal blood vessels, treatment may also help to normalize the epidermal structure, (5-7) resulting in a better protective barrier to irritants. Laser therapy for hyper-reactive skin is one of the newest and exciting indications for vascular lasers. This therapy may allow rosacea sufferers to finally use a gentle cleanser, moisturizer, and sunscreen, without facial flushing. For skin irritation flushing, physicians should selectively target superficial, thin-walled blood vessels (the hairpin capillary loops near the epidermis). For best results, laser treatment should be performed several times over the rosacea sufferer’s entire facial flush zone.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of irritating topical products, and active treatment with soothing, protective skincare products. Basic starting points include:
• Stop using topical products that thin and weaken the protective skin barrier. The two most important in this respect are topical steroids and topical irritants (i.e., harsh cleansers, toners, anti-acne products, exfoliators, etc.). By just removing these two groups of skincare products, rosacea sufferers may notice significant reductions in facial skin reactivity and flushing within 3 to 6 weeks.
• Start using skincare products with moderate concentrations of micronized zinc oxide (4% or higher), and dimethicone. These ingredients are very effective anti-irritants that moisturize, protect, and soothe. (8, 9)
• Start using topical metronidazole-based products such as noritate or metrogel to decrease skin inflammation.
3. Combination of Laser and Skincare Therapy: The best approach for moderate to severe sufferers is to combine a series of laser treatments with proper skincare therapy.
3. FACIAL FLUSHING:
ENVIRONMENTAL
(SUN, HEAT, COLD & WIND)
Environmental insults such as sun, heat, cold and wind can cause facial flushing in most rosacea sufferers. (10-13) Below are listed two therapies for environmental flushing, and one combination therapy for more advanced cases.
1. Photoderm or Laser Therapy: Laser treatment can reduce facial flushing to moderate environmental insults. For best clearance of environmental flushing, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals for this therapy include returning to normal outdoor activities in mild to moderate environmental conditions.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of products that thin or weaken the epidermis, and active treatment with protective skincare products.
• Stop using topical products such as steroids and irritants that decrease the thickness of the protective skin barrier.
• Start using skincare products with moderate concentrations of micronized zinc oxide (at least 8%), and dimethicone. Both of these ingredients are excellent skin protectors. These skin protectants can reduce environmental flushing by shielding facial blood vessels from sunlight, heat, cold, and mechanical aggravation (wind). Realistic expectations for this therapy include returning to normal outdoor activities in mild to moderate environmental conditions.
3. Combination of Laser and Skincare Therapy: The best approach for moderate to severe sufferers is to combine a series of laser treatments with proper skincare therapy.
4. FACIAL FLUSHING:
PHYSICAL ACTIVITY
Any form of physical activity, from simple walking to strenuous exercise, can cause a rosacea sufferer’s face to flush. (4, 12) Below are listed three therapies for physical activity flushing, and one combination therapy for the more serious cases.
1. Photoderm or Laser Therapy: Proper laser therapy can reduce facial flushing to mild or moderate physical activity. For best clearance of physical activity flushing, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals for this therapy include eliminating facial flushing to everyday non-strenuous physical activity, and reducing facial flushing to mild or moderate physical activity.
2. Oral Antihypertensive Medications (Nadolol, Clonidine, Rilmenidine, or Moxonodine): Low-dose antihypertensive medications may alleviate physical activity flushing by reducing the bodies’ cardiovascular and neural response to physical exertion.
3. Combination of Laser Therapy and Oral Antihypertensive Medication: Rosacea sufferers who experience frequent or intense flushing to physical activity may require a combination of laser therapy and low-dose antihypertensive medications in order to achieve satisfactory reductions in this flushing reaction.
4. Ice Chip Therapy: Rosacea experts have found that exercise-induced flushing can be reduced by ice chip therapy. (14) With ice chip therapy, the patient is instructed to hold shaved ice chips in the mouth for several minutes at a time without chewing or swallowing. While this may be inconvenient, some rosacea sufferers may be able to return to strenuous aerobic exercise with this therapy.
5. FACIAL FLUSHING:
FOOD & BEVERAGE
Certain foods and beverages can cause facial flushing in rosacea sufferers. (15) Below are listed two therapies that may reduce facial flushing to foods and beverages.
1. Photoderm or Laser Therapy: Proper laser therapy can effectively reduce some forms of food- and beverage-induced flushing. For best clearance and long-lasting results, physicians must treat both superficial and deep facial blood vessels over a series of laser treatments. Realistic goals of this therapy include reducing the intensity and duration of mild to moderate triggers. It is exciting to note that this therapy may totally eliminate some minor food and beverage triggers for long periods of time.
2. Oral Medications such as Antihistamines or Aspirin Prior to Ingestion of Certain Foods, Supplements, and Beverages: Taking an antihistamine about two hours before a meal that contains foods high in histamine, or an aspirin about an hour before eating foods high in niacin, may be helpful to rosacea sufferers. (16) Foods that contain histamine or release histamine in the body include processed beef, cheeses, canned fish, vinegar, tomatoes, spinach, eggplant, cheese, chocolate, chicken livers, citrus fruits, bananas, raisins, figs, avocados, yogurt, sour cream and certain alcoholic beverages. Foods high in niacin include lean meats, poultry, seafood, eggs, beans, nutritional supplements, liver, and fortified cereals.
6. FACIAL FLUSHING:
MENOPAUSE
Menopause, which usually starts to affect women in their late 40’s to middle 50’s, is defined as a permanent cessation of menstruation when the ovary stops producing egg cells and female sex hormones such as estrogens. During the course of menopause, women frequently experience hot flashes. Menopausal hot flashes can cause intense facial flushing in female rosacea sufferers. These flushing attacks can worsen all rosacea symptoms including facial redness, inflammation, swelling, burning sensations, papules, and pustules. (14) This can push a mild female sufferer into severe rosacea. Below are listed three individual therapies for menopausal flushing, and one combination therapy for more severe cases.
1. Hormone Replacement Therapy: Oral hormone replacement therapy is very effective at decreasing the number, duration, and intensity of hot flashes. (17, 1 Hormone replacement therapy varies considerably among individuals so proper treatment must be prescribed by the patient’s physician.
2. Clonidine: Oral clonidine has been shown to decrease the number, intensity, and duration of hot flashes in a significant number of clinical studies. (17, 1
3. Black Cohosh: Black cohosh (Cimicifuga racemosa) is the most thoroughly studied natural approach to reducing menopausal hot flashes. (19) Dr. Michael Murray, an internationally recognized naturopathic physician, highly recommends this supplement to his female patients. (19) He recommends that black cohosh be taken in standardized tablets that contain 1 mg of triterpenes, calculated at 27-deoxyactein per tablet. In a recent article, “Black Cohosh Versus Hormone Replacement Therapy in Menopause”, Dr. Murray reviewed 4 major clinical studies on the effectiveness of black cohosh in treating menopausal hot flashes: (19)
• A large open study employing 131 doctors and 629 female patients found that after 6 weeks of black cohosh therapy, the number and intensity of hot flashes improved considerably in 86.6% of the patients. In this study, 43.3% reported that they did not experience any hot flashes during black cohosh treatment.
• A controlled study of black cohosh vs. hormone replacement therapy (premarin) in 60 patients demonstrated that black cohosh treatment of hot flashes was superior to premarin treatment. Black cohosh treatment was found to be free of side effects.
• A double blind, placebo-controlled study of black cohosh vs. premarin in 80 patients demonstrated that black cohosh was much more effective than premarin in reducing the number of daily hot flashes. The number of hot flashes experienced each day decreased from 5 to 1 in the black cohosh-treated group, vs. 5 to 3.5 in the premarin-treated group.
• A double-blind study of black cohosh vs. placebo in 110 women demonstrated that black cohosh was extremely effective at relieving the number and duration of hot flashes.
Recent medical reviews in (1) Advances in Therapy: Therapeutic Efficacy and Safety of Cimicifuga Racemosa for Gynecologic Disorders, and in (2) The Journal of Women’s Health: A Review of the Effectiveness of Cimicifuga Racemosa for the Symptoms of Menopause, are consistent with the above clinical findings. (20, 21) Both medical reviews conclude that black cohosh shows very good to excellent therapeutic effectiveness in the treatment of hot flashes without significant side effects.
4. Combination of Oral Medications and Laser Therapy: Female sufferers who experience frequent or intense hot flashes, may require a combination of laser therapy with oral medications/supplements in order to achieve satisfactory reductions in this flushing reaction.
Important: Laser Therapy and Facial Flushing
As the reader can see from above, I consider laser therapy to be one of the best available treatments for facial flushing. No matter what the underlying cause, laser treatment of facial blood vessels is the most direct approach to flushing disorders. Over the last two years, vascular laser specialists have made significant advancements in the treatment of facial flushing. Technological advancements in laser systems, and more aggressive treatment protocols have resulted in much better clearance of facial blood vessels with longer-lasting results. This is an exciting area of rosacea treatment that continues to improve.
Now, with the above said, the reader must understand that photoderm or laser therapy is not a cure for facial flushing. The rosacea sufferer and the laser practitioner should have realistic goals and expectations.
Realistic Goals & Expectations:
• Eliminate most mild forms of facial flushing for significant periods of time (i.e., two to three years on average).
• Reduce the frequency and intensity of moderate to severe facial flushing for significant periods of time (i.e. one to two years on average).
Those sufferers who have severe rosacea with frequent flushing, or who continually push their vascular disorder to the limit, will need laser touchups periodically to maintain their clearance. Right now this is not perfection, but because laser therapy can: (1) Eliminate mild facial flushing, (2) Reduce the intensity and duration of many forms of moderate flushing, (3) Reduce superficial rosacea symptoms such as facial redness, telangiectasia, and papules, (4) Decrease uncomfortable burning sensations, (5) Decrease the need for oral medications, and (6) Allow a return to a near-normal lifestyle; this therapy must be placed at the top of the treatment list.
FACIAL REDNESS
Chronic facial redness is the most common rosacea symptom. Below are listed three therapies for reducing chronic facial redness.
1. Photoderm or Laser Therapy: Laser therapy can eliminate or reduce permanent facial redness in most rosacea sufferers. Laser therapy is the single best treatment for facial redness. Laser specialists can clear facial redness by at least 80% in most sufferers. For best clearance and long-lasting results, this therapy must be performed several times over the entire facial flush zone.
2. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel can reduce chronic facial redness in mild to moderate cases.
3. Very-Low-Dose Oral Isotretinoin: For rosacea sufferers with moderate to severe facial redness, very-low-dose isotretinoin can be extremely effective in reducing redness, with long-lasting results. (22-2 In most cases, very-low-dose isotretinoin should be taken for 6 months or longer in order to ensure long-lasting results. (27, 29) Caution: patients should not undergo any form of laser surgery while on isotretinoin due to adverse skin reactions. Patients are usually instructed to wait at least 4 to 6 months after stopping isotretinoin before undergoing any type of laser therapy.
FACIAL PAPULES AND PUSTULES
Facial papules (small, red inflammatory lesions), and pustules (red inflammatory lesions with pus) are seen in many rosacea sufferers. (12) Below are listed four therapies for reducing rosacea papules and pustules.
1. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually quite effective on rosacea papules and pustules.
2. Very-Low-Dose Oral Isotretinoin: For rosacea sufferers with moderate to severe inflammatory papules and pustules, very-low-dose isotretinoin is the single most effective therapy. (22-2 In most cases, very-low-dose isotretinoin should be taken for 6 months or longer in order to ensure long-lasting results. (27, 29)
3. Photoderm or Laser Therapy: Proper laser therapy can result in substantial improvement in inflammatory papules. (30, 31) Please note that laser therapy is not usually effective on facial pustules.
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), and Novacet (Medicis) are extremely effective on rosacea papules and pustules. These are quick-acting topical medications that penetrate deeply into the skin. Rosacea sufferers with ultra-sensitive skin must be careful though, because these products may cause facial irritation.
FACIAL BURNING
Facial burning sensations are reported by a large number of rosacea sufferers in the moderate to severe stages. (22, 28, 29, 32) Below are listed five therapies for reducing facial burning sensations, and one near-future therapy.
1. Photoderm or Laser Therapy: Laser therapy often results in dramatic reductions in facial burning sensations. Currently, I do not know of any better therapy for facial burning sensations. The ability of laser therapy to reduce physical burning sensations is often the most gratifying to laser experts.
2. Skincare Therapy: Skincare therapy involves discontinuing the use of known irritants, and active treatment with topical anti-inflammatory medications. Basic starting points include:
• Stop using topical products that cause burning, stinging, or flushing reactions. The first group of products to discontinue is topical steroids. Physicians state that with topical steroid use, “Patients experience exquisite sensitivity of the involved skin to the slightest irritant; itching, burning, and intense redness being major complaints.” (32) Other medical experts find that some rosacea patients on topical steroids experience intense bouts of facial burning that “May become disabling”. (33) The second group of products to discontinue is known topical irritants. By removing these two groups of skincare products, rosacea sufferers may notice significant improvement in burning sensations within 6 to 8 weeks.
• Start using topical metronidazole-based products such as noritate or metrogel to decrease skin inflammation.
3. Very-Low-Dose Oral Isotretinoin: In a clinical study on 18 rosacea patients, very-low-dose isotretinoin significantly decreased facial burning sensations in all rosacea sufferers. (22)
4. Oral Non-Steroidal Anti-inflammatory Medications: Physicians have reported success with non-steroidal anti-inflammatory medications (naproxen or cox-2 inhibitors) in the treatment of rosacea burning. (29, 34)
5. Oral Elavil (Zeneka): Certain antidepressants possess analgesic actions that may alleviate symptoms of inflammatory skin disorders. Older tricyclic antidepressants such as elavil (amitriptyline) may be helpful in treating sensory burning and stinging sensations. (35)
6. Topical Strontium Nitrate (near-future treatment): Topical strontium nitrate may give rosacea sufferers considerable relief from facial burning and stinging sensations. Clinical studies have recently demonstrated that when strontium nitrate is applied to the facial skin, it significantly reduces skincare-induced burning, stinging, and facial redness. (36-3 This inhibitory action takes place within seconds and is long-lasting. (37, 3
In a recent medical study, Dr. Gary Hahn performed a series of exciting clinical experiments to determine the effect of strontium nitrate on irritant-induced burning, stinging, and flushing reactions. (39) In this double blind, placebo-controlled study on 24 subjects with sensitive facial skin, Dr. Hahn demonstrated that pretreatment with strontium nitrate significantly decreased sensory irritation to topical lactic acid (a known irritant). He also demonstrated that addition of strontium salts directly into the lactic acid solution had the same calming actions. Furthermore, strontium nitrate significantly reduced sensory irritation (burning, stinging, and itching) to 70% glycolic acid, depilatory-induced irritation, and aluminum chloride-induced irritation. In this study, skin flushing induced by a strong irritant (aluminum/zirconium solution) was almost completely blocked by treatment with strontium salts. Although the exact mechanism of strontium nitrate in decreasing sensory irritation has not been elucidated, it is speculated that strontium inhibits activation of sensory pain fibers by interfering with calcium-dependent pathways and/or by altering ion permeability within these nerve fibers. (39)
In a more recent clinical study on 24 female subjects with hypersensitive skin, strontium nitrate (500 mM) blocked facial burning and stinging sensations to topical salicylic acid by approximately 50%. (3
Dr. Gary Hahn is a licensed physician in California and serves as an assistant clinical professor in the Department of Pediatrics at the University of California, San Diego. Dr. Hahn is also the president of Cosmederm Technologies, a skincare research and development company where water-soluble strontium salts have been tested and incorporated into skincare products. Dr. Hahn states, “Simple water-soluble strontium salts have proved to be potent and selective inhibitors of chemically induced sensory irritation in humans and do not produce numbness or loss of other tactile sensations. The addition of strontium salts to formulations of topical products can significantly reduce the signs and symptoms of irritant contact dermatitis, which is a significant problem for many people who use cosmetics, personal care products, and topical drugs.” (39) Furthermore, he states, “At this point there are no limitations on product usage, it literally can be used in any class of products, including most acid products, and on base products such as depilatories. The compound is the result of five years of intense investigation into the mechanisms of the skin; we took the opposite approach to skincare - not ingredients, but the biochemical mechanisms in the skin and nervous system.”
These findings are very important to rosacea sufferers who frequently experience facial burning sensations to topical skincare products, and environmental insults such as wind, sun, heat, and cold. I am very excited about the potential of this substance for rosacea-related burning and stinging sensations. I have had several in-depth communications with Dr. Hahn pertaining to the use of this substance for rosacea. Currently, most of the products with strontium salts are off limits for rosacea sufferers (they are used in chemical peels, and alpha- and beta-hydroxy acids). In personal communication with Dr. Hahn, he stated that he was very interested in incorporating strontium salts into gentle moisturizing creams and lotions to evaluate its potential for suppression of rosacea-related burning sensations. He mentioned that they are already working on alcohol-free toners and moisturizers that could be used to reduce uncomfortable burning sensations. In addition to formulating their own product lines, Cosmederm Technologies also distributes the active ingredient (strontium nitrate) to other skincare companies. At the time of this writing, Dr. Hahn was personally developing several different formulas of strontium nitrate (1%, 5%, and 10% hydrogel formulations) for my personal testing. Strontium nitrate shows great promise for rosacea sufferers; it holds the potential to decrease rosacea burning to topical skincare products, and environmental insults such as wind, heat, sun, and cold.
FACIAL SWELLING
Facial flushing is often accompanied by bouts of swelling. In some cases, facial swelling is minor and transient; however, in moderate to severe cases, swelling can become severe and permanent. Below are listed three therapies for reducing facial swelling.
1. Photoderm or Laser Therapy: Laser therapy can effectively reduce mild to moderate facial swelling. (31) In rosacea sufferers with extensive swelling, physicians should proceed with caution; laser specialists should treat these patients with low energy settings, multiple pulses, and long pulse durations, so that the patient experiences minimal post-laser swelling.
2. Very-Low-Dose Oral Isotretinoin: Multiple clinical studies indicate that oral isotretinoin is moderately effective at decreasing rosacea swelling. (40-43)
3. Oral Enzyme Therapy: Systemic proteolytic enzyme therapy (Wobenzyme N) may offer hope to rosacea sufferers with mild to moderate swelling. This enzyme therapy has significant anti-swelling and anti-inflammatory actions. (44 - 47)
RHINOPHYMA
Over the years I have been evaluated and treated by dozens of physicians. In general, most of my experiences with these physicians were very good. Many spent quality time reviewing my case, some spent extra time with me after my appointments, a few faxed me important medical articles concerning potential treatments, while others gathered together in small groups to try to come up with better solutions for my rosacea. However, when it came to the discussion and treatment of rhinophyma, my experience with medical physicians was frustrating and depressing. Over a span of two years I saw seven general dermatologists and five plastic surgeons for my rhinophyma. My rhinophyma was growing at an alarming rate and based on my familial history of rhinophyma (a great uncle with severe rhinophyma), I wanted to aggressively treat this disfiguring disorder. However, each physician gave me no real hope or constructive medical suggestions. Not a single physician offered me any form of active treatment. The only suggestion made to me was to wait until my nose had grown 75% to 100% larger and then they would cut the mass of tissue back down with a scalpel or tissue laser. Yikes! They were satisfied to let my nose turn bright red and grow to almost twice its size! Do you know how depressing and frustrating that medical advice is to a young man in his mid-to-late 20’s? All 12 physicians stated that there was nothing else that could be done.
Thankfully, I came across articles by medical experts that discussed cutting-edge treatment approaches for rhinophyma. These physicians understood our plight and recommended a pro-active approach to treating rhinophyma. They recommended a two-pronged attack: (1) Treat the underlying inflammation, swelling, and sebaceous gland hyperactivity with oral isotretinoin, and (2) Aggressively treat the blood vessels of the nose with a series of vascular laser treatments. This approach, although lengthy, usually yields very good to excellent results. Below are detailed treatment therapies for mild, moderate, and severe rhinophyma.
Mild to Moderate Rhinophyma:
Actively Treat It
1. Low-dose, Long-term Isotretinoin: Low-dose, long-term isotretinoin is an excellent form of treatment for mild to moderate rhinophyma. (29, 43, 48-51) In most cases, oral isotretinoin treatment results in remarkable reductions in the entire disease process (shrinking rhinophyma and decreasing nose swelling, inflammation, sebaceous gland abnormalities, redness, and burning sensations). (29, 43, 48-51) After the initial treatment period, some rhinophyma sufferers may need periodic pulse dosing with isotretinoin to maintain clearance. For details on these medical findings, please refer to Chapter 10, “Oral therapy with Isotretinoin”.
2. Photoderm or Laser Therapy: Laser treatment of blood vessels supplying the nose can reduce and reverse mild to moderate rhinophyma. (31, 52) Experts indicate that because the underlying problem in rhinophyma is vascular in nature, treatment of rhinophyma with vascular lasers can not only reduce the size and severity of rhinophyma, but, “Often prevents further development of the condition.” (52)
3. Combination of Oral Isotretinoin and Laser Therapy: Rhinophyma is progressive in nature and usually requires aggressive treatment. In many cases, rhinophyma sufferers will need a two-pronged attack: (1) Treat the inflammation, swelling, and sebaceous gland abnormalities with oral isotretinoin, and (2) Treat the underlying vascular disorder with a series of vascular laser treatments. Caution: patients should not undergo any form of laser surgery while on isotretinoin due to adverse skin reactions. Patients are usually instructed to wait at least 4 to 6 months after stopping isotretinoin before undergoing any type of laser therapy.
My Personal Experience with Isotretinoin and Laser Therapy: The combination of photoderm therapy and oral isotretinoin worked wonders on my rhinophyma. This combination therapy reversed and completely normalized my disorder. This approach was a true godsend for my condition. Rhinophyma sufferers do not have to wait until grotesque disfigurement sets in before starting treatment.
Severe Rhinophyma:
Surgical Techniques for Physical
Removal of Excess Nose Tissue
In severe rhinophyma, the nose can grow to enormous sizes (sometimes interfering with nasal breathing and eating). At this stage, surgical treatment is required to physically remove the newly formed tissue and sebaceous gland abnormalities. Below are listed six treatments for severe rhinophyma, and one combination treatment for the most advanced cases.
1. Dermabrasion or Surgical Scalpel: Some physicians recommend simple shaving with a surgical scalpel or dermabrasion for rhinophyma. (53) The main drawback to these techniques is that excessive bleeding usually occurs during these procedures.
2. Electrosurgery with Cautery Knives or Loops: Some physicians use electrosurgery with cautery knives and loops to control tissue removal and reduce bleeding. (53) Electrosurgery usually gives good to excellent results in reshaping the nose. The other benefit of electrosurgery is that it is relatively inexpensive. The main drawback to this surgery is that it allows for heat dispersion into the tissue, which may cause mild hypertrophic scarring in a small percentage of patients. (54)
3. Newer Heated Scalpels: The heated Shaw scalpel is composed of surgical steel and coated with Teflon. This special scalpel is much more “accurate” than most other forms of heated scalpels. (53)
4. The Ultrasonic Scalpel: This surgical scalpel incorporates ultrasonic vibration, resulting in more ‘sharpness’ of the blade and even less bleeding than other treatment modalities. (53)
5. The Carbon Dioxide (CO2) Laser: The CO2 laser has been used with great success to treat most forms of rhinophyma. (53) Experts indicate that the CO2 laser is the preferred tool for the treatment of rhinophyma. (53) The CO2 laser selectively destroys the excess tissue in a very controlled fashion, without bleeding.
6. Surgery with Skin Grafts: For large rhinophyma, surgery followed by simple skin grafts can give the patient very good to excellent results.
7. Combination of Surgery and Oral Isotretinoin: Rhinophyma can be treated surgically by scalpels, electrosurgery, dermabrasion, and laser. However, recurrence of rhinophyma can occur after any form of surgical treatment. (55) Drs. Rodder and Plewig of the Department of Dermatology, University of Dusseldorf, recommend surgical removal of excess tissue, followed by long-term, very-low-dose isotretinoin. These physicians usually treat their rhinophyma patients with 0.2 mg/kg of isotretinoin for the first several months, followed by 0.1 mg/kg per day for 2 years. Patients have remained in full remission for 2 to 2.5 years following cessation of this treatment protocol. (55)
STEROID-INDUCED ROSACEA
Steroid-induced rosacea is still quite common because well-meaning physicians routinely use topical steroids to treat facial redness and inflammation. Topical steroids of any concentration should never be used to treat rosacea sufferers or patients who show pre-rosacea symptoms (i.e., facial flushers and blushers). With continued use, topical steroids thin the epidermis, weaken the blood vessels, and worsen facial flushing. One of the most important first steps that rosacea sufferers can take is to wean themselves off topical steroids.
The major problem with discontinuing topical steroids is that rosacea sufferers usually get worse before they get better. They almost always experience rebound flares that cause their faces to become more red, inflamed, and sensitive. (33) Under normal conditions, this can take weeks to reverse, and months for the skin to fully heal itself. (33) To decrease this rebound flare and speed up the healing process, medical experts now recommend a very effective four-step approach to weaning off topical steroids:
1. First Step – begin treatment with oral anti-inflammatory medications: Physicians recommend that rosacea sufferers begin treatment with oral anti-inflammatory medications one to four weeks prior to weaning off topical steroids. This pre-treatment therapy can help decrease inflammation, and reduce the intensity of steroid-withdrawal flares. Popular oral anti-inflammatory medications being used to decrease the rebound inflammation include:
• Clarithromycin – 250 milligrams twice a day. (56, 57)
• Minocycline – 100 milligrams twice a day. (5
• Very-low-dose isotretinoin – Drs. Plewig and Klingman recommend isotretinoin at 5 milligrams per day. (59)
2. Second Step – reduce the amount of topical steroid applied to the facial skin: After the initial oral anti-inflammatory therapy, rosacea sufferers are instructed to start weaning off topical steroids. During the first week, rosacea sufferers should simply reduce the amount of cream that they apply to their faces (i.e., use less cream and less applications per day).
3. Third Step – decrease the strength of the topical steroid: Over the next two to four weeks rosacea sufferers should decrease the strength of the topical steroid in a stepwise fashion. Rosacea sufferers should wean themselves down to 0.5% over-the-counter hydrocortisone.
4. Fourth Step – slowly replace the steroid with topical anti-inflammatory creams: Eventually, rosacea sufferers will be able to permanently replace the steroid with metronidazole-based creams such as noritate or metrogel. Some physicians also recommend topical zinc oxide for healing steroid-induced rosacea. (60)
Note: Most rosacea sufferers would be wise to stay on oral anti-inflammatory medications throughout the entire withdrawal process until the skin and blood vessels normalize.
Important: Proper Use of Topical Steroids
Rosacea sufferers should never use any form of topical steroid to treat rosacea on a daily or weekly basis. Topical steroids will make rosacea sufferers worse in the long run. For in-depth discussion on this extremely important topic, please refer to Chapter 5, “Topical Steroids”.
Now with the above warning posted, it should be pointed out that topical hydrocortisone can be used sparingly by rosacea sufferers under certain conditions. If used wisely, topical hydrocortisone (1%) can be used to reduce major skin flare-ups that occur periodically. (61) In those rosacea sufferers who have self-control, topical hydrocortisone can be used for 2 to 3 days in order to reduce facial inflammation caused by skin irritation or bad bouts of flushing. Topical hydrocortisone treatment should be stopped after 2 to 3 days, and should not be repeated for at least 14 to 17 days. So, under these conditions, topical hydrocortisone is not being used to treat rosacea per se, but is being used to reduce facial inflammation caused by bad flare-ups.
Rosacea sufferers also need to be aware that many over-the-counter topical hydrocortisone preparations contain harsh ingredients such as drying alcohols, emulsifiers, cetyl and steryl alcohols, and emulsifying wax. These ingredients can be detrimental to rosacea skin. For those rosacea sufferers with self-control, I can highly recommend a new 1% hydrocortisone cream (Dermarest Dricort 1% Hydrocortisone Cream, by Del Pharmaceuticals, Inc.) that contains an extremely gentle base consisting of colloidal silicon dioxide.
ROSACEA FULMINANS
Rosacea fulminans is a rare, devastating disease of unknown origin. It occurs exclusively in young women. All women are reported to be flushers and blushers. (62, 63) This form of rosacea has a rapid onset and can cause severe facial inflammation with nodular lesions. Drs. Jansen, Plewig and Klingman describe the onset of rosacea fulminans and its treatment: “Rosacea fulminans is an explosive process. Suddenly, without warning, in a matter of a week, severe facial affliction strikes like lightning. Sadly, nothing is really known about this form of rosacea. It is usually confined to the center of the face (nose, cheeks and chin), and presents as deep erythema, with crops of severe papules, pustules and nodules. Early and aggressive treatment is warranted: in some cases, hospital treatment is required. The optimum treatment consists of oral contraceptives (anti-androgen type), isotretinoin, and oral and topical steroids (this is the only form of rosacea in which steroids are indicated in order to relieve the patient of severe inflammation and extreme facial discomfort). If left untreated, it will usually leave widespread pitted and linear scars. However, early treatment, especially with isotretinoin results in excellent clearance and for some unknown reason, recurrence is rarely ever seen.” (62)
ROSACEA AND EXTENSIVE
SUN DAMAGE
Some rosacea sufferers have extensive sun damage. It is extremely important for rosacea sufferers to be warned that most forms of treatment for facial sun damage are strong irritants to rosacea. Laser resurfacing, chemical peels, and anti-aging products can all worsen the underlying flushing disorder. Sadly, one of the most common reports that I receive from rosacea sufferers is that they have innocently turned their mild rosacea into moderate rosacea with intense flushing and burning sensations, after treatment for facial sun damage. Please be very careful. At this time, I can only safely recommend one form of treatment for rosacea with extensive sun damage.
1. Photoderm or Laser Therapy: Photoderm and vascular lasers can effectively treat signs of sun damage such as facial wrinkles and solar elastosis. (64, 65) Vascular laser therapy effectively removes disrupted collagen fibers of the face, and stimulates the formation of new, healthy fibers. (64, 65) This is known as “sub-surfacing” because these lasers “remodel” or “rebuild” damaged collagen deep within the skin without harming the outer layer of facial skin. Recently, photoderm has been shown to remodel collagen deep within the middle dermis (66) and stimulate the formation of pro-collagen, collagen I, collagen III, and elastin. (67)
Please note that skin resurfacing lasers such as the CO2 laser are not the same as photoderm or vascular lasers. Skin resurfacing lasers destroy skin tissue and blood vessels; while photoderm and vascular lasers only destroy blood vessels. Rosacea sufferers should be very careful with skin resurfacing lasers because they can permanently aggravate the underlying vascular beast. Rosacea experts do not recommend the use of skin resurfacing lasers for anything other than severe rhinophyma.
ROSACEA AND PERIORAL DERMATITIS
Some rosacea sufferers also have perioral dermatitis, a rash-like dermatitis around the mouth area. Although the exact cause of perioral dermatitis is unknown, it is considered to be an inflammatory skin disorder with vascular origins. (6 The main symptoms include persistent redness around the mouth area, and inflammatory papules or pustules. Many cases of perioral dermatitis are exacerbated by topical steroids. (69) Below are listed five therapies for treating perioral dermatitis.
1. Discontinue Topical Steroids: If a patient is using topical steroids on a daily or weekly basis, then discontinuing the steroid will result in substantial improvement in all symptoms. (69)
2. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually quite effective in reducing most symptoms of perioral dermatitis. (69)
3. Low-Dose Oral Isotretinoin: For those cases of perioral dermatitis that do not respond adequately to topical and oral antibiotics, low-dose oral isotretinoin has been shown to have dramatic, long-lasting effects. (70)
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), or Novacet (Medicis) are extremely effective on inflammatory papules and pustules around the mouth area, and in some cases may also decrease skin redness. (69) Rosacea sufferers with ultra-sensitive skin should be cautious with these products because they can cause irritation.
5. Photoderm or Laser Therapy: Laser specialists often report dramatic improvement in perioral dermatitis after a series of laser treatments. This should not be surprising as biopsies of perioral dermatitis often demonstrate marked dilation of blood vessels with moderate swelling. (6
ROSACEA AND ACNE
Some rosacea sufferers also have co-existing skin problems such as whiteheads, blackheads, large pores, and excess facial oil. This usually presents a problem because most anti-acne preparations are too harsh for rosacea skin. Rosacea sufferers must be very cautious when trying to treat skin problems such as acne, oily skin, or enlarged pores. Let me fully warn the reader -- rosacea sufferers can innocently turn a cosmetic case of rosacea into one with debilitating flushing and burning sensations after the use of topical irritants. Please be smart and listen to your face! Rosacea sufferers will be their own best judge as to whether a particular anti-acne product makes their vascular disorder worse. For detailed information on the most common anti-acne preparations to avoid, please read the section on “Skin Irritation: Topical Irritants”, in Chapter 5. Below are listed some of the “safer” anti-acne treatments for rosacea sufferers:
1. Oral and Topical Antibiotics: The combination of oral antibiotics and topical noritate or metrogel is usually somewhat effective on acne symptoms. This is usually a good, safe starting point.
2. Klaron Lotion 10% (Dermik Laboratories, Inc.): This is an elegant, water-based, alcohol-free lotion that contains 10% sodium sulfacetamide (a penetrating antibacterial). Based on numerous physician and patient reports that I have received, this seems to be one of the gentler topical anti-acne products. This is a good choice for rosacea sufferers with acne. (29)
3. Cleocin T Gel (Upjohn Company): This popular anti-acne medication contains clindamycin phosphate in an elegant, alcohol-free gel. This also seems to be a popular choice for rosacea patients with sensitive skin.
4. Topical Sulfur/Sulfacetamide Preparations: Preparations such as Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), or Novacet (Medicis) are extremely effective on facial whiteheads and blackheads. Rosacea sufferers with ultra-sensitive skin should be cautious because these topicals can cause facial irritation.
3. Very-Low-Dose Oral Isotretinoin: Rosacea sufferers with moderate to severe acne may have to treat their acne from the inside (i.e., oral pills). Under these conditions, very-low-dose oral isotretinoin is an excellent choice.
ROSACEA AND
SEBORRHEIC DERMATITIS
Some rosacea sufferers also have seborrheic dermatitis, an inflammatory skin disorder that is caused by abnormal number or activity of Pityrosporum Ovale, a facial skin yeast. (71, 72) Seborrheic dermatitis primarily affects areas of the facial skin that are rich in sebaceous glands such as the center of the face, eyebrows, scalp, and eye lid edges. Most patients with seborrheic dermatitis tend to have oily skin. The skin in these areas is often red with yellowish flakes.
Seborrheic dermatitis is a chronic condition that has no known cure, however it is controllable with treatment. It is imperative that rosacea sufferers treat their seborrheic dermatitis because if seborrheic dermatitis is left untreated, facial skin may become hyper-reactive to all topical skincare products and medications. It is equally important that rosacea sufferers find a treatment therapy that does not involve chronic use of topical steroids (even 1% hydrocortisone), as these steroids will make rosacea worse. Below are listed three therapies for treating seborrheic dermatitis.
1. Topical Nizoral 2% Cream (Janssen): Nizoral cream contains a powerful antifungal ingredient (2% ketoconazole) that is very effective in the treatment of seborrheic dermatitis. Medical experts highly recommend topical ketoconazole for rosacea patients with yeast-related skin disorders. (73)
2. Topical Sulfur/Sulfacetamide Preparations: Preparations with sulfur and sodium sulfacetamide are very useful in the treatment of seborrheic dermatitis. (58, 74-76, 76, 77) Two popular brands are Sodium Sulfacetamide 10% and Sulfur 5% Lotion (Glades Pharmaceuticals), and Novacet (Medicis). Rosacea sufferers with ultra-sensitive skin should be cautious though because these topicals may cause facial irritation. Patients with ultra-sensitive skin may have greater success with specially formulated sulfur/sulfacetamide topicals that contain lower concentrations of the active ingredients, and are placed into non-irritating base creams or gels. Some private practice physicians report great success with:
• 2.5% micronized colloidal sulfur + 5% sodium sulfacetamide compounded into Noritate.
• 2.5% micronized colloidal sulfur + 5% sodium sulfacetamide compounded into Metrogel.
3. Oral Antifungals: Ketoconazole (Nizoral Tablets, Janssen), Fluconazole (Diflucan Tablets, Pfizer), or Itraconazole (Sporanox Capsules, Janssen): For those rosacea sufferers who have ultra-sensitive skin or severe seborrheic dermatitis, oral antifungals such as ketoconazole, fluconazole or itraconzaole may be a god-send in treating their condition. (73)
• Treatment with oral ketoconazole can have a dramatic effect on yeast-related skin disorders (i.e., seborrheic dermatitis). (71) Short courses of oral ketoconazole (200 milligrams per day for 28 days) may reduce the disease to such an extent that remission can be maintained easily with the periodic use of gentle topical medications. (71) This may also break the vicious inflammatory cycle, allowing rosacea sufferers to use topical products that they were not able to use in the past.
• Dr. Faergmann at the Dept. of Dermatology, Central Hospital, Sweden, routinely uses oral ketoconazole to treat patients with yeast-related skin disorders. (7 In moderate to severe cases, he uses oral ketoconazole to achieve clearance of the disease (3 to 6 weeks of daily treatment), and then uses 200 milligrams, 2 times a month to maintain clearance.
• Other medical experts also use monthly pulse dosing with ketoconazole to maintain clearance in moderate to severe cases. (79) Dr. Jones reports excellent success using a “Two Saturday” treatment protocol where he treats his patient with 400 milligrams of ketoconazole on one Saturday and then repeats it 1 week later (this is followed by a one-month break and then re-treatment).
ROSACEA AND DEPRESSION/ANXIETY
It is quite common for rosacea sufferers to go through bouts of depression and/or anxiety. Depression and anxiety can be caused by any number of reasons, including cosmetic disfigurement, painful skin sensations, decreased quality of life, and avoidance of triggers that are associated with the disorder. It must be stressed that depression or anxiety under these conditions is quite normal and can occur in the most emotionally sound people. It does not mean that a person is “weak” or “mentally unfit”. It must also be emphasized that depression and anxiety are usually caused by the chronic illness, and that the chronic illness is not caused by the depression or anxiety. (80)
While depression and anxiety do not cause rosacea, they both can increase the frequency and intensity of facial flushing by activating complex neural and hormonal pathways this, in turn, can worsen rosacea symptoms. Therefore, it is very important that rosacea patients address depression and anxiety.
Depression and anxiety are caused in part by an imbalance in chemical messengers in the brain. There are a variety of medications and herbs that are now available to treat depression and anxiety. These medications/herbs primarily work by normalizing the chemical imbalance in the brain.
1. Antidepressants such as Selective Serotonin Reuptake Inhibitors (SSRI’s): The newer nontricyclic antidepressants such as fluoxetine (Prozac, Eli Lilly and Company), sertraline (Zoloft, Pfizer), and paroxetine (Paxil, SmithKline Beecham), are very effective anti-depressants that generally have mild, transient side effects. (81) Paxil is also approved for the treatment of social phobia and anxiety. Several dozen anecdotal reports from physicians and rosacea sufferers suggest that paxil may help to decrease the frequency and intensity of some forms of neural-mediated flushing.
2. St. John’s Wort: For mild to moderate depression or anxiety, this natural herb may be worth a try. Recent clinical trials have demonstrated that Saint John’s Wort (Hypericum perforatum) has significant antidepressant and anti-anxiety actions. In some cases, Saint John’s Wort seems to be as effective as synthetic antidepressants. In other cases, its effects are barely noticeable until the patient realizes that things that used to aggravate them, no longer affect them the way they once did.
For anyone contemplating Saint John’s Wort (SJW), I highly recommend reading “St. John’s Wort Extract” by Dr. Michael T. Murray. (82) This 4-page pamphlet is an excellent source of information on SJW. He details numerous clinical studies demonstrating the effectiveness of SJW in treating mild to moderate forms of depression (83-87) In two of the clinical studies cited, SJW demonstrated anti-anxiety actions comparable to those of valium (diazepam). Dr. Michael T Murray recommends a standardized 0.3% hypericin at 300 milligrams, three times daily. (82) This is the exact dosage that is used in most clinical studies.
In the British Medical Journal (1996), Dr. Klaus Linde and colleagues thoroughly reviewed all of the studies reported in the medical literature on the effectiveness and safety of SJW. (8 Based on data from 1,008 patients, the results clearly showed that SJW extracts were very effective in the treatment of mild to moderate depression. In addition, six medical studies found that SJW was as effective as synthetic antidepressants but with fewer side effects. In a more recent 1999 review by Drs. Josey and Tackett of the University of Georgia, College of Pharmacy, they reported on 4 controlled studies that indicate, “St. John’s Wort is as effective as other antidepressant medication and more effective than placebo, as the clinical symptoms of depression greatly decreased upon administration of Hypericum. The side effect profile of Hypericum at this time appears to be superior to any current US approved antidepressant medication.” (89)
3. Anti-Anxiety Drugs: While anti-anxiety medication is not a long-term solution for rosacea, short-term treatment can help rosacea sufferers get back on their feet again. (81) When administered under the supervision of a physician who is treating the entire rosacea spectrum, anti-anxiety medication may help rosacea sufferers break through the vicious flush cycle. (81) In the medical article, “Psychological Aspects of Rosacea”, rosacea experts indicate that for temporary treatment of situational stress that may occur in rosacea, Alprazolam (Xanax, Parmacia and Upjohn Company) is the treatment of choice due to its quick mode of action and complete elimination before the next dose. (81) However, if the patient requires long-term therapy for anxiety, buspirone (Buspar, Bristol-Myers Squibb) is recommended because it is not addicting or sedating. (81) However, the therapeutic effect of Buspar is not achieved for at least 2 weeks and thus cannot be taken on an “as-needed” basis. (81)
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49. O
Geoffrey
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Dr. Geoffrey Nase
Ph.D. Neuro-Vascular Physiologist
Rosacea Specialist and Consultant
http://www.drnase.com
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