More is Better vs Less is More

[Guide]

There are basically two schools of thought when it comes to treating rosacea, the 'more is better' philosophy, and the 'less is more' thought.

+ = √  More is Better
Generally, the 'more is better' philosophy treatment plan is what rosaceans prefer, based upon anecdotal reports of what a typical rosacean is using to treat rosacea. This is usually because their physician recommends an oral systemic treatment, either low dose, timed released doxycycline as well as a topical ivermectin (Gold Standard). Old school dermatologists continue to prescribe a high dose oral doxycycline and a metronidazole topical. These are just two examples of multiple treatments for rosacea, and there are other examples too numerous to list. Anecdotal reports of rosaceans using over the counter products for rosacea usually range from two or more treatments at the same time. Physicians use multiple approaches in treating rosacea. For example, a patient with severe rosacea phenotype 2 and 4 was treated with multiple treatments. 

Rosaceans typically will think that if this little treatment improves my rosacea then 'more is better' and while on occasion this may be the case, i.e., Carvedilol (Coreg) to treat flushing, the dosage may actually need to be increased if the physician recommends, this is not always the case, when it comes to using multiple, concurring rosacea treatments. Furthermore, when taking more than one drug for rosacea, there are drug interactions to consider (synergism).  

- = + Less is More
Of course, not every decision you make about rosacea treatment means 'less is more,' but in the number of concurring treatments, this should be a chief concern. The less is more approach simply means to use just one rosacea treatment at a time to see if it improves the rosacea. If you think the treatment is working to improve your rosacea, then stop the treatment to see if the rosacea comes back or gets worse. If it does come back or gets worse, it usually indicates the treatment worked. The best way to prove it does work is then again use the one treatment again after you have stopped the treatment and see if your rosacea improves again. Voila!  Eureka!  This rosacea treatment has proved to work and if the treatment is stopped my rosacea returns or gets worse. 

Then if you still feel you need to add another treatment along with the one that is working for you, add another or second treatment for rosacea and notice if it gets better or gets worse. If it gets worse, stop the treatment and see if you return to your baseline (how your skin was before you started the second treatment). If you return to baseline then if you want to completely convince yourself you could try it again to see the results. If the same, surely this is enough convincing. If not, then experiment.

If the second treatment improves your rosacea along with the first treatment, then wondeful!  To convince yourself, remove the second treatment to see what happens? If removing the second treatment your rosacea gets worse, then you know. Try using the second treatment again and see if it improves again. Convinced? 

You could then even add a third or fourth rosacea treatment, but do so in this systematical, one at a time approach or 'less is more.'

You can do this simple approach of 'less is more' using the above method since you can clearly know if a rosacea treatment is for you or not.

Multiple Treatments for Rosacea Can Cause Confusion
If you are taking multiple treatments for rosacea, this can create a quagmire of confusion. Lets take a typical example to show you.

Lac_77 at RF [post no 4] replied to a thread about Mirvaso rebound with the following post dated April 29, 2020 at  01:58 PM:

"I had the same reaction to you only a few weeks ago After only 5 days of using it it sent my skin crazy. I stopped using it and the symptoms persisted for about another 5 days, then returned back to how it was previously thankfully (still terrible though). I hope that is the same for you."

Lac_77 [post no 1] started a thread on the very same day (April 29 at 02:07 PM) just a few minutes after posting the initial post mentioned above about "seriously intense flushing constantly" due to his five month course of accutane. So, his experience using Mirvaso, pales into insignificance when you consider five months of accutane at 20 mg/day.

To conclude the Mirvaso for his flushing issue would be tantamount to a blatant injustice. How can anyone figure out what causes 'permanent' damage in these cases of concurring rosacea treatment which blurs into confusion. Also when someone uses photo dynamic therapy, i.e., IPL, Laser, etc., there are reports that these devices all cause skin damage as well and the difficulty of sorting through what has caused 'permanent' damage is a maze of spider webs, not to mention what are the systemic oral treatments doing to the issue as well, since most rosaceans are taking oral medication treatment at the same time, i.e., antibiotics, anti-flushing drugs, etc. and possibly other topicals all at the same time! Other factors to consider that may have a bearing on the damage is the environment, i.e., sun, chemicals, activities, heat, cold, etc., which can further aggravate the damage, since they should also be ruled out.  

To conclude, multiple treatments for rosacea not only confuse but also blur treatment decisions. A 'less is more' approach would resolve this. 

One Treatment at a Time - Less is More
That is why using ONE treatment at a time is so much better than taking multiple rosacea treatments since it is so difficult to figure out what is helping and what is causing damage in multiple treatments for rosacea which is common among rosaceans who figure 'more is better' rather than a simplified approach. 'Less is more' is a better approach.

The typical example above with Lac_77 who has damaged his skin with accutane treatment taking high dose for five months and then he tries Mirvaso on already damaged skin, what do you think would happen? This is an example of multiple treatments confusing the issue and how the more is better approach can really cause damage and further confusion.

Less is More in Medicine
The less is more approach in medicine is particularly advocated in homeopathic medicine. The JAMANetwork has a page dedicated to this concept. Jessica A. Otte, MD, has a website and a blog devoted to this subject. Joan Stephenson, PhD, Contributing Writer for MedPage Today, wrote an article on a movement concerning this topic stating, "Whatever changes are needed to move the less-is-more movement forward, the idea has staked its claim in the culture of medicine." 

"In dermatology, doctors are opting to order the medicines they want, without the inactive ingredients they don’t, at the dosage they need, and dispensing these medicines directly to patients at the point of care. These doctors are taking control of how they are treating their patients." [1]

“It is an art of no little importance to administer medicines properly; but it is an art of much greater and more difficult acquisition to know when to suspend or altogether omit them” [2]

"In our collective enthusiasm to diagnose and treat disease, a growing body of evidence indicates that we may often be doing too much of a good thing." [3]

Rocky Bilhartz, MD wrote an article, stating, "You can always do less in medicine, but you’re amiss by thinking that less is always more. What’s good for the group is not always good for the individual." [4] So not every rosacea treatment decision warrants a 'less is more' approach. 

A significant number of articles on the 'less is more' in medicine focuses on economic waste and reducing costs. One article is typical, "As 2017 ended, the influential writer and cardiologist Lisa Rosenbaum challenged the tenets of the less-is-more movement in the New England Journal of Medicine....Rosenbaum concluded that "Mitigating waste is imperative," but she argued that doing so means considering the nuances of complex medical decisions and that what may be perceived as a greed for dollars may reflect a hunger for information." [5]

Conclusion
Whether you choose a 'more is better' or a 'less is more' approach in your treatment decisions with your rosacea will without a doubt have consequences. There really are treatments that work with either method and you, the rosacea patient, has the decision to decide which is the best one to use for your rosacea. Always, the remember the customer (the rosacean) is always right. The customer is coming to the medical provider (the seller) for advice and counsel which the customer (the rosacean) is paying for. Whatever the customer decides is always right (including consequences, risks and benefits). 

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End Notes

[1] When Less Is More in Medicine, Sep 23, 2019, Physician's Weekly

[2] Healthc Policy. 2016 Feb; 11(3): 6–7.
De-prescribing: When Less Is More in Healthcare
Jennifer Zelmer, PhD, Editor-in-chief

[3] Learning More from ‘Less is More’ Medicine
By  Carla Berg | September 13, 2017, Society for Participatory Medicine

[4] The problem of “less is more” in American health care, Rocky Bilhartz, MD, KevinMD.com

[5] In Defense of Less-Is-More, John Mandrola, MD, Commentary, MedScapehttps://www.medscape.com/viewarticle/891091#vp_1