Guide

Laser is one of the older light devices used for treating rosacea and is included in the category of Photo Dynamic Therapy (PDT) for the treatment of rosacea. Here are the most common lasers mentioned: Pulsed dye laser (595 nm, yellow) Smoothbeam laser [4] Safe and effective for the treatment of port-wine stains for patients of all ages, including infants and children Highest degree of success on the head and neck Less success on extremities and torso Minimal risk of scarring or pigment alteration Some models utilize a dynamic cooling system to decrease pain and epidermal injury Lighter skinned patients respond quicker, due to deeper penetration of the laser energy Newer models may produce less bruising Treatment of choice for port-wine stains and facial erythema in rosacea Other indications include hemangiomas, spider angiomas, telangiectasias, venous lakes, scars, and warts Pulsed Nd:YAG (KTP) green laser (532 nm, green) Suited to treat superficial vessels Little or no bruising seen Most effective for lighter skinned patients, tanned skin may lead to increased incidence of skin injury Skin cooled through contact cooling and/or cooling gels Indications include telangiectasias, adult port-wine stains, cherry angiomas, spider angiomas, and venous lakes Intense pulsed light source (515-1200 nm) Multiple wavelengths delivered simultaneously Bruising occurs with treatment and correlates with response to treatment Useful for port-wine stains, telangiectasias, hemangiomas [1] While there are some positive reports that laser works for rosacea there are a number of reports indicating otherwise. For instance Banshee's report that she no longer recommends laser. [2] Jenn is another one who reports a bad reaction to laser. [3] There are many reports posted about laser treatment for rosacea, some good and many otherwise. The excel V+ laser platform is considered one of the top of the line machines. What you need to understand is anyone with a lot of money can purchase a top of the line racing car like a Lotus Formula One but its the driver that really counts. The same is true with these high end laser machines, it is the dermatologist or the operator using the laser that make the difference. light devices available in the RRDi affiliate store. End Notes [1] Skin Therapy Letter Written for dermatologists by dermatologists. Indexed by the US National Library of Medicine. [2] Banshee's full report [3] Jenn's report [4] J Dermatolog Treat. 2012 Apr;23(2):153-5. Epub 2010 Oct 22. Moderate rhinophyma successfully treated with a Smoothbeam laser. Chou CL, Chiang YY.

Note: Some LED devices are available for your browsing in the RRDi affiliate store. Low level, light emitting diode therapy has been reported to help rosacea in some of the anecdotal reports in internet rosacea groups. Some rosaceans even build home made devices while others receive therapy from well established cosmetic and dermatological treatment centers. LED is just one of the many Photo Dynamic Therapies (PDT) for rosacea. "LED photomodulation treatment may accelerate the resolution of erythema and reduce posttreatment discomfort in IPL-treated patients with photodamage." [1] "Several lamps that generate visible light, many of them using light-emitting diodes (LEDs), have recently found their way to the dermatologic armamentarium. Claims of their value in the treatment of a variety of conditions ranging from cosmetic (antiwrinkle) to acne, rosacea, and skin cancer are made to market them.... ...Blue light (407-420 nm) and red light (633- 660 nm) are promoted for the treatment of acne. They work by exciting high amounts of intracellular porphyrins naturally generated by Propionibacterium acnes (P. acnes).....Blue light and blue-red combinations have demonstrated efficacy in mild to moderate inflammatory acne, having a physical modality comparable to treatment with topical clindamycin but inferior to benzoyl peroxide plus clindamycin....Red light (633 nm) may aid in effectively healing long-term torpid ulcers and may enhance angiogenesis in the rabbit ear chamber model...." [2] There are many rosaceans who have reported building their own LED devices for rosacea. There are red, blue, and yellow LED devices and possibly other colors. You should consider Twickle Purple's post when going this route. [3] "Coupled blue and red light-emitting diodes therapy "could represent an effective, safer, and well-tolerated approach for the treatment of such conditions." [4] There are LED devices listed in our store. Instructions for building your own red light unit from IowaDavid Anecdotal Reports ladycappuccino [post no 3] - "If your only problem is flushing, then I would opt for a red light therapy. It knocked off my flushinh, made it practically non existent." End Notes [1] J Cosmet Dermatol. 2008 Mar;7(1):30-4. Use of light-emitting diode photomodulation to reduce erythema and discomfort after intense pulsed light treatment of photodamage. Khoury JG, Goldman MP. [2] SKINmed. 2005; 4 (1): 38-41. ©2005 Le Jacq Communications, Inc. Light Emitting Diode-Based Therapy William Abramovits, MD; Peter Arrazola, BA; Aditya K. Gupta, MD, PhD, FRCP© [3] Twickle Purple's Post on LED Research [4] J Med Case Rep. 2020 Jan 28;14(1):22 Coupled blue and red light-emitting diodes therapy efficacy in patients with rosacea: two case reports. Sorbellini E, De Padova MP, Rinaldi F

IPL is one of the Photo Dynamic Therapies (PDT) for rosacea. Some IPL devices are available in the RRDi affiliate store. Intensity Pulsed Light (IPL) Therapy is one of the hottest treatment for rosacans. Reports have indicated successful cosmetic improvement for rosacea. However the side effects include skin peeling, potential loss of facial hair and pain. Many have reported having to return after some time (months or years) for more treatment. Rosacea: significant results with a significant reduction in vessel number and size and a complete disappearance of papules have been achieved after 4 IPL sessions. Figure 1. One report says: "IPL significantly reduces erythema and telangiectasia of rosacea and this is sustained for at least 6 months." [1] Another report: "As demonstrated by truly objective and quantitative means, intense pulsed light is effective for reducing rosacea-associated blood flow, telangiectasia, and erythema." [2] Not everyone reports that IPL helps. Belinda reports, "I had three IPL treatments with a highly respected laser specialist doctor. After the third I experienced scars appearing accross my face, facial fat loss which has left me looking guant and aged, increased redness and MORE broken cappillaries. For the first few weeks my skin looked great, put then the scars, dents, fat loss and increased redness appeared over the next few months. It was incredibly traumatic and upsetting." [3] Mistica reports some "Possible unwanted effects of IPL." Steve reports that he is "Still Red After 12 Luminus One IPL Sessions." There are many reports that IPL doesn't work for many rosaceans. However, there are other reports that it works for them. One anecdotal report says that after the first treatment with IPL herpes broke out on the face. [4] There is evidence that IPL kills demodex mites. [5] "About 2.5 years ago I began having the debilitating burning you all speak of. It was so bad that I had to take time off of work. I went to a plastic surgeon and supposed laser specialist. He conducted about 5 aggressive IPL sessions. It completely took away the burning however it left me with some skin damage (I am positive). THis doc told me that IPL is the gold standard in treatment of burning and veins from rosacea. I was so totally vulnerable that I took his word as God and did what he said. Plus I was desperate for relief. When I felt that I began to notice little lines connecting on my face I brought it up with him. He of course denied it completely. I could not touch IPL after that, except for on my nose to help breakdown the vasculature. I have nose swelling and I hate it." [6] "Although rosacea is difficult to treat, we believe that IPL can be therapeutically useful in such cases." [7] IPL for Meibomian Gland Dysfunction "To conclude, treatment with 540 nm-IPL improved facial telangiectasia in late-stage rosacea that remained after sequential anti-mite therapy and effectively reduced the recurrence of rosacea." [8] Warnings IPL Burns from Perth Home Operator January 23rd, 2012, by David Pascoe | in the news, IPL IPL - Warning to others - don't do this long term !! - The Taff 21st October 2012 Support Groups IPL and Laser Damage Support Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post. End Notes [1] Treatment of rosacea with intense pulsed light: significant improvement and long-lasting results. Papageorgiou P, Clayton W, Norwood S, Chopra S, Rustin M. Department of Dermatology, Royal Free Hampstead NHS Trust, London NW3 2QG, U.K. Br J Dermatol. 2008 Sep;159(3):628-32. Epub 2008 Jun 28. [2]Objective and quantitative improvement of rosacea-associated erythema after intense pulsed light treatment. Mark KA, Sparacio RM, Voigt A, Marenus K, Sarnoff DS. Department of Dermatology, New York University School of Medicine, New York, USA. Dermatol Surg. 2003 Jun;29(6):600-4. [3] Belinda's full report [4] jdubbed's report • A later report says it was a 'heat rash.' [5] Improves acne, rosacea Intense Pulsed Light Eradicates Demodex Mites Timothy F. Kirn Sacramento Bureau [6] wendykay post no 8 [7] J Dermatol. 2018 Jun 28;: Successful treatment of erythematotelangiectatic rosacea with intense pulsed light: Report of 13 cases. Tsunoda K, Akasaka K, Akasaka T, Amano H [8] Exp Ther Med. 2020 Jun;19(6):3543-3550 Improved telangiectasia and reduced recurrence rate of rosacea after treatment with 540 nm-wavelength intense pulsed light: A prospective randomized controlled trial with a 2-year follow-up. Luo Y, Luan XL, Zhang JH, Wu LX, Zhou N

Gram negative folliculitis is an inflammation of follicles caused by a bacterial infection that can result from long-term antibiotic treatment. Patients who are being treated with antibiotics for severe acne may develop Gram negative folliculitis. Image - Wikipedia Commons The word “Gram” refers to a blue stain used in laboratories to detect microscopic organisms. Certain bacteria do not stain blue and are called “Gram negative. [1] Gram-negative folliculitis is an acne condition caused by Gram-negative organisms. Usually people who had Gram-negative folliculitis are they who had complication with acne vulgaris and rosacea, and also develops in patients who have received systemic antibiotics for prolonged periods. http://media.clinicaladvisor.com/Images/2009/10/23/feature1004-acne_fig3_76081.jpg Image - media.clinicaladvisor.com Gram-negative folliculitis occurs in patients who have had moderately inflammatory acne for long periods and have been treated with long-term antibiotics, mainly tetracyclines, a disease in which cultures of lesions usually reveals a species of Klebsiella, Escherichia coli, Enterobacter, or, from the deep cystic lesions, Proteus. [2] Images of Gram-negative Folliculitis by DermIS H Pylori, a gram negative bacteria, has been implicated in many rosacea research papers as being a factor in rosacea. This controversy continues to be debated. An interesting thread to read on this was started by Rory. http://www.rosaceagroup.org/The_Rosacea_Forum/showthread.php?30120-Gram-negative-Perioral-Dermatitis End Notes [1] Acnenet American Academy of Dermatology [2] Wikipedia

This variation of Rosacea is relatively rare and is sometimes referred to in medical literature as Rosacea Fulminans or in certain cases as Halogen Rosacea.

The Classic Butterfly of Rosacea and the T - Zone In discussing rosacea the 'butterfly' or T - Zone usually comes up. Butterfly Here is a graphic of the classic butterfly in rosacea: Image - Wikipedia Commons The facial butterfly is usually associated with rosacea but can also be found in lupus patients. "In the case of lupus, the butterfly or malar rash can appear on other parts of the body, aside from the face. For instance, it could appear on the arms, legs, or trunk." [1] "The prototypical butterfly-shaped skin lesion of SLE, which has also led many of the patient organizations to identify with the butterfly, has in essence retained its position over time. Defined as 'fixed erythema, flat or raised, over the malar eminences, tending to spare the nasolabial folds', it sometimes poses problems in differential diagnosis, mainly against rosacea and occasionally against dermatomyositis." [2] RRDi Logo The RRDi uses the butterfly as part of its logo. What is the butterfly effect in rosacea? T - Zone The T - Zone can be clearly seen in this graphic: Image - bellasugar.com [1] Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] Bel Marra Health [2] Curr Rheumatol Rep. 2020; 22(6): 18. New Criteria for Lupus Martin Aringer, Nicolai Leuchten, Sindhu R. Johnson

Pyoderma Faciale (PF) is also known as Rosacea Fulminans

There are reports that may indicate migraine headaches may be associated with rosacea. For instance, one report says, "Studies have found possible associations between rosacea and the face mite Demodex folliculorum, Helicobacter pylori infection, and migraine headaches. [1] Another report says, "the association of rosacea with migraine headaches suggests an inherent vascular lability in individuals with rosacea." [2] The NRS reports that "women with rosacea may be more likely to experience migraine headaches than those without rosacea, according to findings reported in the medical journal Dermatology." This same report says "the authors speculated that changes in vascular reactivity caused by age-related modifications in sexual hormones might be the reason for this finding." [3] "We observed a slightly increased risk for female migraineurs to develop rosacea, particularly in women with severe migraine aged 50 years or older." [4] "One case-controlled study of 53,927 rosacea patients who were identified using a UK database between 1995 and 2009, showed that women (but not men) were significantly more likely to develop rosacea if they had previously experienced migraines." [5] "So the research team analyzed 172 oral samples and nearly 2,000 fecal samples taken from the American Gut Project, and sequenced which bacteria species were found in participants who suffered migraines versus those who did not. And it turns out, the migraineurs have significantly more nitrate-reducing bacteria in their saliva than those who don’t suffer these headaches. And it turns out, the migraineurs have significantly more nitrate-reducing bacteria in their saliva than those who don’t suffer these headaches. Having too many nitrates in the body, which can aid cardiovascular health in best case scenarios, has been linked to migraines for unlucky folks. Now this new research suggests that’s because having too much oral nitrate-reducing bacteria, which converts nitrates into nitric oxide in the body, leads to the pounding headaches." [6] The above quote is related to the article, Do You Have A Gut Feeling About Your Rosacea? "We found a significantly higher prevalence and risk of incident migraine especially in female patients with rosacea. These data add to the accumulating evidence for a link between rosacea and the central nervous system." [7] "Our meta-analysis confirmed an association in occurrence of migraine and rosacea." [8] "Male subjects with rosacea have increased risk for migraine: A population-based study." [9] Notes [1] Rosacea: A Common, Yet Commonly Overlooked, Condition B. WAYNE BLOUNT, M.D., M.P.H., and ALLEN L. PELLETIER, M.D. University of Tennessee Health Science Center, Memphis, Tennessee American Family Physician, August 1, 2002 [2] Rosacea: a reaction pattern associated with ocular lesions and migraine? Ramelet AA., PMID: 7979452 [PubMed - indexed for MEDLINE] [3] The Proposed Inflammatory Pathophysiology of Rosacea from SKINmed Dermatology for the Clinician Rosacea Linked with Increase in Migraine Rosacea Review, Winter 1998 Postmenopausal female rosacea patients are more disposed to react with migraine. Berg M, Liden S, Dermatology. 1996;193:73-74. Study Finds Association Between Rosacea & MigraineNRS Posted: 01/03/2017 [4] J Am Acad Dermatol. 2013 May 1. pii: S0190-9622(13)00308-3. doi: 10.1016/j.jaad.2013.03.027. Migraine, triptans, and the risk of developing rosacea: A population-based study within the United Kingdom. Spoendlin J, Voegel JJ, Jick SS, Meier CR. [5] Rosacea and Migraine by By Dr Ananya Mandal, MD [6] This is why some foods trigger migraines BY NICOLE LYN PESCE, NEW YORK DAILY NEWS Wednesday, October 19, 2016 [7] Prevalence and risk of migraine in patients with rosacea: A population-based cohort study. J Am Acad Dermatol. 2016 Nov 3; Egeberg A, Ashina M, Gaist D, Gislason GH, Thyssen JP [8] The relationship between migraine and rosacea: Systematic review and meta-analysis. Cephalalgia. 2017 Jan 01;:333102417731777 Christensen CE, Andersen FS, Wienholtz N, Egeberg A, Thyssen JP, Ashina M [9] Male subjects with rosacea have increased risk for migraine: A population-based study

Ivermectin (Stromectol) is a drug used in the USA for the eradication of mites in animals. It was announced at a yahoo r-s group on October 20, 2004 that this drug may give significant relief to some rosaceans. Here is a quote: "... Oral Ivermectin (Stromectol) is making a huge difference in these sufferers facial symptoms and flushing triggers (yes, I said flushing triggers). Ivermectin is an anti-mite drug that is related to the macrolide antibiotics. It has a very good safety profile and less side effects than most antibiotics (and not one major side effect)..." [1] Another report: "Demodex is a saprophyte parasite in mammals. In Man, it is associated with differing clinical profiles (rosacea-like dermatitis, folliculitis and blepharitis). We report a case of demodecidosis in an HIV-infected patient that was successfully treated with ivermectin. CASE REPORT: A man from Laos, infected by HIV and treated for glandular tuberculosis, presented with a prurigenous eruption on the face and the pre-sternal and interscapular areas. Direct examination of scraped product and histopathological examinations confirmed the diagnosis of demodecidosis. Clinical cure was obtained after 2 single cures of ivermectin a one month's distance. DISCUSSION: The features of demodecidosis are often similar to those of rosacea. In immunodeficient patients, the semiology remains the same but the eruption is more abundant. During HIV-infection, demodecidosis occurs at the AIDS stage or with a CD4 count lower than 200/mm3. Many anti-dust mite molecules are used to treat the disease but frequently lead to irritation. Administration of a single cure of ivermectin, repeated if necessary, appears to be an interesting alternative to contact anti-dust mite agents." [2] Another report: "...Oral or topical ivermectin may also be useful in such cases..." [3] This topic has raised a number of questions and comments at the r-s yahoo group where all this originated. One clinical study in Germany says Ivermectin was ineffective and oral metronidazole was better. [4] Galderma has applied for a patent using ivermectin and hydrocortisone "for treating skin conditions and afflictions, and especially for treating rosacea (formerly known as acne rosacea." [5] Anecdotal Reports Ivermectin for Demodex Thread at RF More info More info on Demodex Mites and Rosacea. Galderma Releases Soolantra Galderma received FDA approval for Soolantra Ivermectin cream in December 2014. More Information Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] Rosacea Support Group post Wed Oct 20, 2004 [2] Demodecidosis in a patient infected by HIV: successful treatment with ivermectin Clyti E, Sayavong K, Chanthavisouk K. [3] The Management of Rosacea. Rebora, A.. American Journal of Clinical Dermatology, 2002, Vol. 3 Issue 7, p489, 8p; [4] Demodex abscesses: clinical and therapeutic challenges. Schaller M, Sander CA, Plewig G. J Am Acad Dermatol. 2003 Nov;49(5 Suppl):S272-4. [5] AVERMECTIN/HYDROCORTISONE COMPOSITIONS FOR TREATING AFFLICTIONS OF THE SKIN. E.G., ROSACEA

* Atopic Dermatitis (Eczema) is a rosacea mimic that can be quite confusing to differentiate from rosacea since if you click on Google images of eczema, it certainly looks like rosacea, so be sure to rule out atopic dermatitis (eczema). Eczema can be anywhere on the body but if it on your face, it is a rosacea mimic. Furthermore, you may have rosacea along with atopic dermatitis, therefore exczema can be a co-existing condition with rosacea. Medline Plus says, "Eczema is a term for several different types of skin swelling. Eczema is also called dermatitis. It is not dangerous, but most types cause red, swollen and itchy skin. Factors that can cause eczema include other diseases, irritating substances, allergies and your genetic makeup. Eczema is not contagious." [1] Click here for an image of eczema. Eczema is due to a hypersensitivity reaction (similar to an allergy) in the skin, which leads to long-term inflammation. The inflammation causes the skin to become itchy and scaly. Long-term irritation and scratching can cause the skin to thicken and an have a leather-like texture. One report shows a hypersensitivity to gluten. [2] Nummular Eczema "Staphylococcus aureus plays an important role in skin and soft tissue infections and contributes to the pathophysiology of complex skin disorders such as atopic dermatitis." [3] Allergic Eczema, aka Contact Dermatitis "Allergic eczema, also known as contact dermatitis, is a skin condition that occurs when a person's skin comes into contact with an allergen." [4] This could be any allergic reaction that manifests on the facial area which looks like rosacea, i.e., countdracula's post about an allergic reaction to onions and garlic. "Our results showed that there may be an association between nickel sensitivity and rosacea. Nickel sensitivity may be one of the underlying pathology or a triggering factor of the rosacea." [5] Treatment "Today, topical agents like emollients and corticosteroids are the mainstay of AD therapy, and patients with lesions that are resistant to optimally administered topical treatment can also receive phototherapy or systemic therapy with ciclosporin. Dr Fougerousse discusses her hopes for the future of AD therapy with the recent development of biologicals like dupilumab, which may provide improvements in clinical outcomes and quality of life for patients with moderate-to-severe AD. In the next few years, the therapeutic arsenal for AD will likely expand to include more systemic therapies providing sustained symptom control." [6] Pimecrolimus Dupilumab Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post. End Notes *Allergic Dermatitis image courtesy of WikiMedia Commons [1] Medline Plus [2] Cutaneous hypersensitivity to gluten. Tammaro A, Narcisi A, De Marco G, Persechino S. Dermatitis. 2012 Sep;23(5):220-1. [3] Case Rep Dermatol. 2017 May-Aug; 9(2): 19–25. Published online 2017 May 22. doi: 10.1159/000473872 PMCID: PMC5465516 Successful Treatment of Chronic Staphylococcus aureus-Related Dermatoses with the Topical Endolysin Staphefekt SA.100: A Report of 3 Cases Joan E.E. Totté, Martijn B. van Doorn, and Suzanne G.M.A. Pasmans [4] Everything you need to know about allergic eczema, MedicalNewsToday Last reviewed Mon 18 June 2018 By Rachel Nall, RN, BSN, CCRN Reviewed by Debra Sullivan, PhD, MSN, RN, CNE, COI [5] Endocr Metab Immune Disord Drug Targets. 2019 Jan 01;: Nickel Sensitivity In Rosacea Patients: A Prospective Case Control Study. Çifci N [6] Dermatol Ther (Heidelb). 2021 Feb 1 : 1–8. doi: 10.1007/s13555-021-00489-w At the Dawn of a Therapeutic Revolution for Atopic Dermatitis: An Interview with Dr Anne-Claire Fougerousse Anne-Claire Fougerousse

Keratosis pilaris rubra faceii [KPRF] is characterized by redness (erythema) and the presence of rough bumpiness (follicular spines) which may begin at birth or during childhood or adolescence. You can see how confusing this would be to differentiate from rosacea. KPRF can also be a co-existing condition. If you do a google image search it looks just like rosacea. "If it is possible to get rosacea on your arms, it would be incredibly unusual. Keratosis pilaris might be the more likely culprit, since keratosis pilaris usually affects the arms. (Keratosis pilaris is a very common skin condition in which keratin protein forms hard plugs within hair follicles). Keratosis pilaris can get red, dry and irritated (usually from scratching it), it is commonly misdiagnosed as rosacea on the face....Another possibility is eczema that can crop up anywhere, and one of the common areas is top of the arms. Eczema also goes misdiagnosed quite commonly as rosacea." Does rosacea only affect the face? ZocDoc Click here for an example of KPRF. Individual with KPRF World of Felton photo of KP DermIS Images Keratosis pillars 101 KPRF is listed also as a co-existing condition Treatment KP Elements KP Elements Treatment Cream and Scrub Combo Pack Oraser Body Emulsion Plus by ZO® Skin Health [1] Differin Gel, according to Wikipedia, contains "Adapalene [which] is a third-generation topical retinoid primarily used in the treatment of mild-moderate acne, and is also used off-label to treat keratosis pilaris as well as other skin conditions." Anecdotal Reports mcinnis' report on misdiagnosis Bowthy's 'cure' JonathanB's chemical peels poppe says to take Selective serotonin reuptake inhibitors (SSRIs) at post no 3 in this thread. Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. If you never heard about this topic and you learned about it here first, wouldn't it be a gracious act on your part to show your appreciation for this topic by registering with just your email address and show your appreciation with a post? And if registering is too much to ask, could you post your appreciation for this topic by finding the START NEW TOPIC button in our guest forum where you don't have to register? We know how many have viewed this topic because our forum software shows the number of views. However, most rosaceans don't engage or show their appreciation for our website and the RRDi would simply ask that you show your appreciation, please, simply by a post. End Notes [1] KERATOSIS PILARIS, Dr Sarah Norman BM BS BMedSci (Hons) DRCOG MRCGP MEWI MBCAM, Aesthetic Medicine • May 2016 aesthetic-medicine-article.pdf

image courtesy of Wikimedia Commons Erysipelas produces a rash that is red, slightly swollen, very defined (well demarcated), warm, and tender to the touch. This individual has infection in the skin on both sides of the face, however, bilateral (both side) involvement is infrequent. [1] Erysipelas may produce symptoms that affect the entire body (systemic) such as fever and chill. Erysipelas is a rosacea mimic. Click here for more info. Click here for images of erysipelas. End Notes [1] Image of individual with erysipelas

Accutane (Isotretinoin) has been used for many years to treat acne rosacea in higher doses so if you are taking high dose Accutane (20-40 mg or higher daily) you should read this Accutane Article. Low Dose Isotretinoin (2.5 mg to 10 mg) Please post your comments on isotretinoin in this thread by clicking on the REPLY button. Low dose isotretinoin has been successfully used to treat recalcitrant cases of rosacea: "Low-dose isotretinoin was an effective therapeutic option for difficult-to-treat papulopustular rosacea." A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-Treat Papulopustular Rosacea Presented in part at the Journées Dermatologiques de Paris Congress, Paris, 7–11 December 2010. Emilie Sbidian, Éric Vicaut, Henri Chidiack, Elie Anselin, Bernard Cribier, Brigitte Dréno6, Olivier Chosidow ________________________________________________________ "As previously discussed, isotretinoin is a viable alternative for recalcitrant cases of rosacea. In a large-scale, placebo-controlled, randomized, 12-week, multicenter study, Gollnick et al demonstrated complete remission in 24% and marked improvement in 57% of patients with isotretinoin 0.3 mg/kg therapy daily, in contrast with remission in 14% and marked improvement in 55% of patients treated with doxycycline 100 mg daily for 14 days, then 50 mg daily. Patients treated with isotretinoin rated treatment results at the end of the study as “excellent improvement” more frequently, at 32.6% in comparison with 24.2% for patients treated with doxycycline." Clin Cosmet Investig Dermatol. 2015; 8: 159–177. Published online 2015 Apr 7. doi: 10.2147/CCID.S58940 PMCID: PMC4396587 PMID: 25897253 Update on the management of rosacea Allison P Weinkle, Vladyslava Doktor, and Jason Emer ------------------------------------------------------------------------------------ "For severe cases of inflammatory papules and pustules or for inflammatory papules and pustules that do not respond to oral antibiotics or that recur after the discontinuation of oral antibiotics, treatment with low-dose oral isotretinoin (0.25 to 0.30 mg per kilogram of body weight per day) for 12 to 16 weeks has been shown to be effective in two randomized, controlled trials." N Engl J Med 2017; 377:1754-1764DOI: 10.1056/NEJMcp1506630RosaceaNovember 2, 2017, Esther J. van Zuuren, M.D. ========================================================== "Continuous “microdose” isotretinoin (CMI) treatment (0.04–0.11mg/kg/day) has been shown to be sufficient to control persistent adult acne vulgaris....Oral isotretinoin was then reduced to an individual continuous minimal dose, which ranged from 0.03 to 0.17mg/kg/day (mean, 0.07mg/kg/day). Group 2 had different grades of untreated rosacea....Available data suggests that oral isotretinoin may be used in selected cases of recalcitrant PPR, with a suggested daily dose of 0.3mg/kg." J Clin Aesthet Dermatol. 2011 Sep; 4(9): 54–61. Use of Oral Isotretinoin in the Management of RosaceaHyunhee Park, DO and James Q. Del Rosso, DO, FAOCD ============================================================== "Low-dose isotretinoin was an effective therapeutic option for difficult-to-treat papulopustular rosacea." A Randomized-Controlled Trial of Oral Low-Dose Isotretinoin for Difficult-To-Treat Papulopustular Rosacea Presented in part at the Journées Dermatologiques de Paris Congress, Paris, 7–11 December 2010. Emilie Sbidian, Éric Vicaut, Henri Chidiack, Elie Anselin, Bernard Cribier, Brigitte Dréno6, Olivier Chosidow --------------------------------------------------------------------------------- "Very low-dose isotretinoin (e.g., 10–20 mg once to five times a week, equivalent to 5 mg/day) is an effective treatment for mild to moderate papulopustular rosacea and is well tolerated." Australasian Journal of Dermatology, DOI: 10.1111/ajd.12522 Very low-dose isotretinoin in mild to moderate papulopustular rosacea; a retrospective review of 52 patients Marius Rademaker, DM. ------------------------------------------------------------------------------- "Using isotretinoin for 1-2mg/kg/day for 3-4 months produces 60%-95% clearance of inflammatory lesions in patients with acne. Doses as low as 0.1mg/kg/day have also proven successful in the clearance of lesions. Encouraging results have also been seen in small numbers of patients with rosacea, Side effects affecting the mucocutaneous system and raised serum triglyceride levels occur in most patients receiving isotretinoin." Profiles Drug Subst Excip Relat Methodol. 2020;45:119-157 Isotretinoin. Khalil NY, Darwish IA, Al-Qahtani AA 2.5 mg Generic Isotretinoin Anecdotal Reports on Low Dose Isotretinoin for Flushing Avoidance patrick33 reports that his flushing is completely gone after taking low dose (2.5 mg 'for the first month followed by 2.5mg every other day for the following three months'). We may hear more reports about this since most rosaceans who want flushing avoidance may try this route. Weekly 20 to 40 mg Low Dose Isotretinoin One report indicates that using a low dose 20 to 40 mg weekly of isotreionoin results in "an effective treatment for papulopustular rosacea, including among patients with severe disease." This is considered low dose because it is taken WEEKLY not daily. The DAILY dosage is calculated at dosage of 0.3-1 mg/kg/day. Low-dose isotretinoin vs. minocycline in the treatment of rosacea Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post.

Coffee is Not a Rosacea Flareup Trigger First off just remember that whenever you hear about rosacea triggers that usually the list of triggers has not been substantiated in any clinical studies and most of the triggers are simply anecdotal reports based upon surveys or polls. However, one trigger has been substantiated that should be removed from the list and this trigger is coffee. It is not a rosacea trigger and coffee lovers can rejoice. The NRS lists coffee as a trigger [1] and as a result many physicians believe this and pepetuate this misconception by telling their patients to avoid coffee or caffeine.[2] As a result rosaceans believe that coffee is a rosacea trigger when it is not. Actually the NRS says that the trigger is HOT beverages such as coffee. It would be just as valid to add to the NRS list HOT WATER! But thankfully the confusion is cleared up due to the only known rosacea trigger that has ever been actually discussed in a clinical paper (1981) which reports hot coffee is no more a rosacea trigger than hot water so what you need to be careful about is drinking HOT beverages to avoid a flush (a rosacea flareup is different than a rosacea flush). [2] Coffee May Be Good for Your Skin There is no evidence that coffee or caffeine causes a rosacea flareup. In fact, one study concluded the converse: "Increased caffeine intake from coffee was inversely associated with the risk of incident rosacea. Our findings do not support limiting caffeine intake as a means to prevent rosacea. Further studies are required to explain the mechanisms of action of these associations, to replicate our findings in other populations, and to explore the relationship of caffeine with different rosacea subtypes." [3] The New York Times commented on this study and reports, "Yet another reason to drink coffee: A new study suggests it can be good for the complexion." [4] Difference Between a Rosacea Flareup Trigger and a Flushing Trigger There is a difference between a rosacea flareup trigger and a flushing trigger. To understand the difference read this article. Coffee May Be a Flushing Trigger There is evidence that coffee may be a flushing trigger. Rosacea LTD IV has a page, Your Red Face May be Caused by Caffeine Intoxication. However, there is no clinical paper that has established that coffee causes a flushing trigger in every rosacea sufferer. So no need to give up coffee yet. You need to experiment if coffee triggers a flush in you. It may be simply the the heat from your coffee and you should try drinking COLD coffee to see if causes you to flush. If so, just don't drink HOT coffee. File This Under Unfair: Your Coffee Habit May Be Causing Your Hot Flashes, Prevention, By CAROLINE PRADERIO What are the Side Effects of Caffeine?, verywell, By Elizabeth Hartney, PhD states, "Flushed Face -- a red face at work might make you look embarrassed, and can be embarrassing!" "Hot coffee is the most problematic source of hot flashes because you are dealing with two triggers, a hot beverage and caffeine." Caffeine & Hot Flashes by DORIE KHAN, Livestrong What You Add to Your Coffee May be the Culprit What most rosaceans have no clue about is what you add to your coffee may the culprit that is actually triggering your rosacea and not the coffee. For example if you add sugar to your coffee, sugar is a rosacea trigger, just as valid a trigger as spicy food or wine. Experiment with drinking coffee without any additives. The tough drink black coffee. Try it. You may find black coffee doesn't trigger rosacea at all. Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] See the NRS 'Official' Trigger List lists coffee under Beverages > Hot Drinks > Coffee : http://www.rosacea.org/patients/materials/triggers.php See Screen Shot: [2] Oral thermal-induced flushing in erythematotelangiectatic rosacea. Wilkin JK; J Invest Dermatol. 1981 Jan;76(1):15-8. ---------------------------- The effects of caffeine and coffee, agents widely alleged to provoke flushing in patients with erythematotelangiectatic rosacea, were investigated. Neither caffeine nor coffee at 22 degrees C led to flushing reactions. Both coffee at 60 degrees C and water at 60 degrees C led to flushing reactions with similar temporal characteristics and of similar intensities. It is concluded that the active agent causing flushing in coffee at 60 degrees C is heat, not caffeine. [3] JAMA Dermatol. 2018 Oct 17. doi: 10.1001/jamadermatol.2018.3301. Association of Caffeine Intake and Caffeinated Coffee Consumption With Risk of Incident Rosacea In Women. Li S, Chen ML, Drucker AM, Cho E2,5,6, Geng H, Qureshi AA, Li WQ. ----------------------------- A typical example of a physician stating that caffeine is a rosacea trigger is a video from Stanford University below: [4] Coffee May Tame the Redness of Rosacea, Nicholas Bakalar, The New York Times JAMA Dermatol. 2018 Dec 1;154(12):1385-1386. doi: 10.1001/jamadermatol.2018.3300. Full Article One More Reason to Continue Drinking Coffee-It May Be Good for Your Skin. Wehner M, Linos E.

Obtaining a diagnosis for rosacea may seem to be fairly straight forward but considering that there are reports of misdiagnosis it would be good for rosaceans to be educated on this subject so that if one experiences a misdiagnosis it will not be a surprise and will understand better how a diagnosis is obtained. A survey by Galderma/NRS says that the results [of a unique digital perception survey] “highlight the low awareness and complicated diagnosis path for this common condition.” Are you aware of how a diagnosis of rosacea is obtained? Generally, one diagnostic differentiator is when treatments for acne exacerbate the problem, this is used as an indicator in a diagnosis of rosacea. Rosacea is sometimes referred to as 'adult acne' in older papers, later called 'acne rosacea' and because it looks like acne. Rosacea is generally adult onset, and older adults obtaining a rosacea diagnosis is common. However, there are now reports of children receiving a diagnosis of rosacea. [24] First and foremost is that diagnosis is the sole prerogative legally and ethically of a physician, not obtained in rosacea social media groups. So the information in this editorial is not meant to substitute or replace a physician’s diagnosis but is simply for a rosacea sufferer to understand the subject of a rosacea diagnosis for educational purposes. Knowing what is involved in obtaining a diagnosis of rosacea is quite helpful in basic Rosacea 101 which is a subject I am quite familiar with and wish to pass on this information freely to those who wish to increase their rosacea knowledge. When you read in rosacea social media groups the common question, 'IS THIS ROSACEA?' asked to a group of rosacea sufferers by posting photos of your face, do you really think that this group is qualified to differentiate rosacea from this list? However, learning how a diagnosis of rosacea is obtained by a physician can be rewarding and help you better to ask pertinent questions to your dermatologist. The NRS Classification System (2002) into subtypes and one variant is the first clearly defined proposal to identify and classify rosacea. [2] It is of interest to note that this classification system is based on morphology rather than causality. Understanding this classification and variant system was the beginning of a better understanding for this disease, however, it has been controversial from the beginning. Dermatologists who are still using the subtype classification system are somewhat able to better diagnose rosacea and it may be that your physician is familiar with this old classification, however, some physicians are not keeping up with this latest classification system, the phenotype classification, and may be relying on past knowledge on this subject when referring to subtypes. If your physician is still referring to subtypes, you may want to point out the next paragraph to your physician. Phenotype Classification of Rosacea The new direction of classifying rosacea is a phenotype based treatment. "Because rosacea can encompass a multitude of possible combinations of signs and symptoms, the following updated classification system is based on phenotypes—observable characteristics that can result from genetic and/or environmental influences—to provide the necessary means of assessing and treating rosacea in a manner that is consistent with each individual patient's experience. The phenotypes and diagnostic criteria are largely in agreement with those recommended by the global rosacea consensus panel in 2016, and at least 1 diagnostic or 2 major phenotypes are required for the diagnosis of rosacea." [15] Physical Examination, History & Tests Does rosacea spread beyond the facial region? There are no generally accepted histological, serological or other diagnostic tests for rosacea, therefore, a diagnosis is simply arrived at by a patient history and physical examination. [1] However, rosaceans have been shown to have high serum zonulin levels. [14] [17] Some clinical tests may be done, i.e., blood tests, skin biopsies, scans, etc., to rule out rosacea mimics or other diseases, not to mention ruling out other co-existing conditions. One report recommends thyroid tests. [19] Frank Powell, MD, who served on the NRS ‘expert committee‘ that classified rosacea says in his book, “There is no laboratory test or investigation that will confirm the diagnosis of PPR. Specific investigations may be required to rule out similar appearing conditions (many of which will be identified by listening carefully to the patient’s medical history and examining the skin lesions). These include skin swabs for bacterial culture, skin scrapings for the presence of demodex mites, scrapings for fungal KOH and fungal culture, skin biopsy for histologic examination, (and rarely culture) skin surface biopsy for demodex mite quantification, patch tests, photopatch tests, and very rarely systemic workup with appropriate blood tests and radiological examinations.” [3] There are now certain devices recommended to be more objective in diagnosing rosacea, i.e., non-invasive imaging and measurement tools. [12] To rule out demodectic rosacea “Potassium hydroxide examination, standardized skin surface biopsy, skin biopsy, or a combination of these are essential to establish the diagnosis.” [4] However, some researchers state that if you use a skin scraping with a light microscope, there may be no reliable data on demodex density counts. However when using a 'Confocal laser scanning in vivo microscopy', there is a significantly more reliable data to count on simply using a skin scraping with a microscope. [11] In some cases to rule out rosacea mimics such as lupus and scleroderma it is suggested that obtaining an ANA blood test and other blood tests might be considered. [5] Another test you might consider having is the Autologous serum skin test (ASST) to rule out chronic uticaria. One report says it is necessary to perform individual bacterial cultures and antibiograms on rosacea patients. [6] Another report suggests testing mucin to differentiate lupus. [7] Another test to consider is to rule out Grave’s disease with blood tests. According to Ladonna, “…my husband took me to the dermatologist and she said it was Rosacea and couldnt be anything but….So he took me to many doctors, and finally a wonderful doctor took a shot in the dark blood test and discovered my problem. Later more involved tests and scans confirmed it. I was Hyperthyroid…specifically Graves Disease…” So from the above tests it shows that a five minute visit to your dermatologist who simply diagnoses you with rosacea and doesn’t take any of the tests mentioned above to differentiate other rosacea mimics might mean you could receive a misdiagnosis. There is anecdotal evidence that many rosaceans report a quick diagnosis in five minutes or less. Galderma has patented a diagnostic test for rosacea. "Facial erythema, the most common primary feature of all subtypes of rosacea, has been described as a mandatory diagnostic feature and is thus the predominant mark of patients with rosacea, especially in the ETR and PPR subtypes, but it can also be present in PhR and OR." [13] Serum Zonulin Level have been shown high in rosacea patients. [17] "abnormally high facial skin levels of cathelicidin and the trypsin-like serine protease kallikrein 5 (KLK5)" [18] GPSkin® Barrier Device One report recommends thyroid tests and states, "Our findings indicate that thyroid blood tests, including thyroid autoantibodies, should be tested and thyroid ultrasounds should be performed in patients diagnosed with rosacea." [19] "Erythema, burning, dryness and itching are the characteristics of papulopustular rosacea, which makes it different from acne vulgaris. The epidermal barrier function was damaged in papulopustular rosacea patients while not impaired in that of acne vulgaris patients." ]21] "Recent research has confirmed the increased presence of bacterial genera like Acidaminococcus and Megasphera in the intestinal microbiome and Rheinheimera and Sphingobium in the blood microbiome of rosacea patients." [22] "five accurate CNNs-based evaluation system (FACES)" [25] There are a number of other skin diseases that mimic rosacea and should be ruled out in a Differential Diagnosis Of Rosacea. Taking a Patient History and Biopsies In Powell’s last chapter, [3] entitled, General Considerations, he suggests asking questions to the patient in taking a history, specifically: (1) Asking about polycythemia? (2) Whether the patient has been using a steroid cream? (3) Any other medication such as niacin or antacids? (4) Whether there has been any frequent flushing? (5) Any complementary or alternative medicines, i.e., herbal products? (6) Eye symptoms? (7) Any family history of rosacea? Biopsies to rule out demodectic rosacea is another important consideration. One report suggests a biopsy to rule out Morbus Morbihan. If you physician neglects to ask any of the above questions you might simply bring the above questions to his attention in a respectful tone so that a proper diagnosis of your skin condition can be obtained. Not knowing the answers to the above questions may hinder a proper diagnosis. Rosaceanet (ADD) has 15 questions to ask you and then recommends something to you if you would like more info on a diagnosis. [8] If you note the disclaimer it says, "This questionnaire does not provide medical advice. It should not be used to diagnose rosacea. Only a medical doctor such as a dermatologist can make this diagnosis. The purpose of this questionnaire is to help you seek medical care if you believe that you may have rosacea. A dermatologist can provide you with a diagnosis and proper treatment." "Central facial redness affects many adults and can be an indicator of the chronic inflammatory disease rosacea. Rosacea is a clinical diagnosis based on the patient’s history, physical examination, and exclusion of other disorders." [16] Dermoscopy and Other Tools to Detect or Quantify Demodex Density Counts Dermoscopy may prove useful according to this source: "Dermoscopy, in addition to its well-documented value in evaluation of skin tumours, is continuously gaining appreciation also in the field of general dermatology." [9] "The dermoscopic hallmark of rosacea is represented by the presence of linear vessels characteristically arranged in a polygonal network (vascular polygons) {click for image}." [10] Scroll down to the subheading, Tools to Detect or Quantify Demodex Density Counts, in the post, Demodex Density Count - What are the Numbers? Polarized Light Dermoscopy to test for Rosetts "There are also isolated reports of the presence of rosettes in a lesion of discoid lupus erythematosus and in papulopustular rosacea." [20] Non-Invasive Object Skin Measurement A study recommends a more objective skin measurement for erythema, demodex density counts, rosacea severity, etc, using certain device tools. [12] Serum Zonulin Level Measurement The serum zonulin levels were found to be significantly higher in patients with acne rosacea. [14] Skin Hydration Sensor (SHS) A device to assist dermatologists which "measures volumetric water content (up to ~1 mm in depth) and wirelessly transmits data to any near-field communication–compatible smartphone." [23] Whether this device assists in diagnosing rosacea remains to be seen. Etcetera Tests to Differentiate Rosacea Diagnosing Rosacea In Five Minutes Or Less Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] National Rosacea Society, Answer to Question 5 http://www.rosacea.org/patients/faq.php#test "There is no appropriate and reliable method of evaluating and monitoring severity in rosacea." Nailfold capillaroscopy as a diagnostic and prognostic method in rosacea. Fonseca GP, Brenner FM, Muller CD, Wojcik AL. An Bras Dermatol. 2011 Feb;86(1):87-90. [2] Classification of Rosacea http://www.rosacea.org/class/classysystem.php [3] Rosacea Diagnosis and Management by Frank Powell with a Contribution by Jonathan Wilkin [4] Demodicosis: a clinicopathological study. Hsu CK, Hsu MM, Lee JY. J Am Acad Dermatol. 2009 Mar;60(3):453-62 [5] Scroll to Alba’s Post #6 about ANA Blood Tests [6] Necessary to perform individual bacterial cultures and antibiograms in rosaceans? A new study on acne and rosacea patients concluded these findings: CONCLUSIONS: 1. In the cases of acne vulgaris the majority of isolated bacteria from conjunctival sac included Streptococcus spp., Staphylococcus spp. and Enterobacteriaceae. 2. In the severe cases of rosacea the main bacteria found in conjunctival sac were S. aureus, S.pyogenes, P.aeruginosa, E. faecalis, A. baumanii, P. fluorescens. 3. Because of changeable drug-sensitivity of bacterial strains, it seems to be necessary to perform individual culture and antibiogram in every patient with inflammatory lesions, in particular in clinically severe and resistant to therapy cases of acne vulgaris and rosacea. 4. The higher frequency of the bacterial colonisations in the conjunctival sac in patients with acne vulgaris and rosacea can be a potential source of ocular infections in the cases of local and systemic disorders of protective mechanisms. 5. Estimation of bacterial flora and antibiotic sensitivity of bacteria isolated from conjunctival sac, the skin of the eyelids and skin lesions should be perform, especially when patients are prepared for eye surgery. Source of the above information [7] Mucin is not a rare finding in rosacea is the title of a research study done by A. Fernandez-Flores at the Service of Cellular Pathology, Clinica Ponferrada in Spain. http://www.ncbi.nlm.nih.gov/pubmed/20191122?dopt=Abstract http://www.clinicaponferrada.com/ Mucins are a family of high molecular weight, heavily glycosylated proteins (glycoconjugates) produced by epithelial tissues in most metazoans. They are being investigated for their potential as diagnostic markers. http://en.wikipedia.org/wiki/Mucin The study concluded "that: 1. mucin is a common finding in granulomas of rosacea; 2. this mucin is probably not related to any progression to the mucinous variant of rhinophyma; 3. since discoid erythematosus lupus is a clinical differential of rosacea, it is important to be aware of the fact that mucin is a common finding in the granulomas, in order not to misdiagnose both entities." Here is another potential diagnostic marker to differentiate rosacea from lupus. [8] Rosaceanet American Academy of Dermatology Could I Have Rosacea? [9] J Eur Acad Dermatol Venereol. 2013 Mar 12. doi: 10.1111/jdv.12146. [Epub ahead of print] Dermoscopic patterns of common facial inflammatory skin diseases. Lallas A, Argenziano G, Apalla Z, Gourhant JY, Zaballos P, Di Lernia V, Moscarella E, Longo C, Zalaudek I. [10] Dermatol Ther (Heidelb). 2016 Dec; 6(4): 471–507. Published online 2016 Sep 9. doi: 10.1007/s13555-016-0141-6 PMCID: PMC5120630 Dermoscopy in General Dermatology: A Practical Overview Enzo Errichetti, Giuseppe Stinco [11] Russian Study on Demodex Mites and Rosacea Illuminating [12] Br J Dermatol. 2019 May 23;: Non-invasive objective skin measurement methods for rosacea assessment: a systematic review. Logger JGM, de Vries FMC, van Erp PEJ, de Jong EMGJ, Peppelman M, Driessen RJB [13] ebcd2834a10dd16de29012a02f3129a9a92f.pdf [14] J Dermatolog Treat. 2020 Apr 15;:1-13 Measurement of the serum zonulin levels in patients with acne rosacea. Yüksel M, Ülfer G [15] Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee [16] Recognizing Rosacea: Tips on Differential Diagnosis September 2019 | Volume 18 | Issue 9 | Original Article | 888 | Copyright © September 2019 Sandra Marchese Johnson MD FAAD, Andrew Berg PA, Chelsea Barr MPAS PA-C ebcd2834a10dd16de29012a02f3129a9a92f.pdf [17] J Dermatolog Treat. 2020 Apr 23;1-4. doi: 10.1080/09546634.2020.1757015. Measurement of the Serum Zonulin Levels in Patients With Acne Rosacea Mavişe Yüksel, Gözde Ülfer [18] Exp Dermatol. 2014 Jul 21; Endoplasmic reticulum stress: key promoter of rosacea pathogenesis. Melnik BC [19] Dermatol Ther. 2020 Dec 05;: investigation of thyroid blood tests and thyroid ultrasound findings of patients with rosacea. Gönülal M, Teker K, Öztürk A, Yaşar FY [20] An Bras Dermatol. 2020 Nov 16;S0365-0596(20)30297-X. doi: 10.1016/j.abd.2020.05.010. PubMed Rosettes in T-cell pseudolymphoma: a new dermoscopic finding Rodrigo Gomes Alves, Patricia Mayumi Ogawa, Mílvia Maria Simões E Silva Enokihara, Sergio Henrique Hirata [21] Pak J Med Sci. Nov-Dec 2016;32(6):1344-1348. doi: 10.12669/pjms.326.11236. Clinical characteristics and epidermal barrier function of papulopustular rosacea: A comparison study with acne vulgaris Maosong Zhou, Hongfu Xie, Lin Cheng, Ji Li [22] Acta Microbiol Immunol Hung. 2021 Jan 29;: Interactions between immune system and the microbiome of skin, blood and gut in pathogenesis of rosacea. Joura MI, Brunner A, Nemes-Nikodém É, Sárdy M, Ostorházi E [23] Skin Hydration Sensor (SHS) The device is "a soft, battery-free, noninvasive, reusable skin hydration sensor (SHS) adherable to most of the body surface. The platform measures volumetric water content (up to ~1 mm in depth) and wirelessly transmits data to any near-field communication–compatible smartphone. The SHS is readily manufacturable, comprises unique powering and encapsulation strategies, and achieves high measurement precision (±5% volumetric water content) and resolution (±0.015°C skin surface temperature)." The article does mention rosacea once here: "Key results include clinical use of the SHS on n = 13 patients with a wide range of inflammatory skin conditions (e.g., AD, psoriasis, urticaria, xerosis cutis, and rosacea), with benchmarks against standard tools to quantitatively characterize the diseased locations." Whether this device can be used to assist dermatologists with rosacea remains to be seen. Sci Adv. 2020 Dec; 6(49): eabd7146. Reliable, low-cost, fully integrated hydration sensors for monitoring and diagnosis of inflammatory skin diseases in any environment Surabhi R. Madhvapathy, Heling Wang, Jessy Kong, Michael Zhang, Jong Yoon Lee, Jun Bin Park, Hokyung Jang, Zhaoqian Xie, Jingyue Cao, Raudel Avila, Chen Wei, Vincent D’Angelo, Jason Zhu, Ha Uk Chung, Sarah Coughlin, Manish Patel, Joshua Winograd, Jaeman Lim, Anthony Banks, Shuai Xu, Yonggang Huang, John A. Rogers [24] PubMed RSS Feed - -Deciphering Childhood Rosacea: A Comprehensive Review [25] PubMed RSS Feed - -FACES: A Deep-Learning-Based Parametric Model to Improve Rosacea Diagnoses

Cathelicidin and Richard Gallo have almost become synonomous in the rosacea world. Richard Gallo is doing research on cathelicidin's role in rosacea. Alarmins are "antimicrobial peptides (AMPs) such as defensins and cathelicidins [1], which not only kill microbes but also trigger host-tissue responses, including leukocyte chemotaxis, angiogenesis, expression of extracellular matrix components, and inflammation." Abnormal levels of cathelicidin LL37 in the skin have been linked to rosacea. There has been much excitment concerning cathelcidin's pathogenic role in rosacea along with kallikrein 5 (KLK5). Kallikrein 5 (KLK5) is a serine protease expressed in the epidermis, actually a subgroup of serine protease. More info on KLK5 A report in JAAD in 2010 concluded that "because an excess of KLK5 and cathelicidin has been hypothesized to contribute to the development of rosacea, finding that an effective treatment for rosacea can decrease expression of these molecules further supports the involvement of KLK5 and cathelicidin in the pathogenesis of this disease." [1] The above journal reports that Finacea was effective in treating rosacea and the report was sponsored by Intendis, the manufacturer of Finacea. In August 2007 major newspapers across the country said scientists have found the cause of rosacea. For instance the Los Angeles Times, the Washington Post, and Medical News Today all had headlines discussing this subject. Here is the actual abstract from Nature Medicine. Does it claim that the cause of rosacea has really been found? Many rosaceans would like to think so. Richard L. Gallo and colleagues noticed that patients with rosacea had elevated levels of cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Cathelicidin antimicrobial protein is an antimicrobial protein found in specific granules of polymorphonuclear leukocytes (PMNs). Stratum Corneum Tryptic Enzyme (SCTE) is part of the the kallikrein family protease. Antibiotics have been used in the past to treat rosacea, but antibiotics may only work because they inhibit some SCTEs. ----------------------Begin Abstract Increased serine protease activity and cathelicidin promotes skin inflammationin rosacea Kenshi Yamasaki, Anna Di Nardo, Antonella Bardan, Masamoto Murakami, Takaaki Ohtake, Alvin Coda1, Robert A Dorschner1, Chrystelle Bonnart, Pascal Descargues, Alain Hovnanian, Vera B Morhenn & Richard L Gallo Nature Medicine, 5 August 2007 | doi:10.1038/nm1616 Acne rosacea is an inflammatory skin disease that affects 3% of the US population over 30 years of age and is characterized by erythema, papulopustules and telangiectasia1, 2, 3. The etiology of this disorder is unknown, although symptoms are exacerbated by factors that trigger innate immune responses, such as the release of cathelicidin antimicrobial peptides4. Here we show that individuals with rosacea express abnormally high levels of cathelicidin in their facial skin and that the proteolytically processed forms of cathelicidin peptides found in rosacea are different from those present in normal individuals. These cathelicidin peptides are a result of a post-translational processing abnormality associated with an increase in stratum corneum tryptic enzyme (SCTE) in the epidermis. In mice, injection of the cathelicidin peptides found in rosacea, addition of SCTE, and increasing protease activity by targeted deletion of the serine protease inhibitor gene Spink5 each increases inflammation in mouse skin. The role of cathelicidin in enabling SCTE-mediated inflammation is verified in mice with a targeted deletion of Camp, the gene encoding cathelicidin. These findings confirm the role of cathelicidin in skin inflammatory responses and suggest an explanation for the pathogenesis of rosacea by demonstrating that an exacerbated innate immune response can reproduce elements of this disease. 1. Division of Dermatology, University of California, San Diego, and VA San Diego Health Care System, 3350 2. La Jolla Village Drive, San Diego, California 92161, USA. 3. Department of Dermatology, Asahikawa Medical College, Asahikawa 078-8510, Japan. 4. Department of Medicine, Asahikawa Medical College, 2-1-1-1 Midorigacka Hidashi, Asahikawa 078-8510, Japan. 5. INSERM, U563, Toulouse F-31000, France. Université Paul-Sabatier, Toulouse F-31000, France. 6. CHU Toulouse, Department of Genetics, Place du Dr. Baylac, Toulouse F-31000, France. --------------------End Abstract It appears that this team of scientists may be on to something, but as for finding the cause of rosacea, this appears to be a bit premature, but of course, most rosaceans are excited and hopeful about this research. According to one report by Jen Christensen of WHOI, "skin samples and biopsies from rosacea patients had significantly higher levels of cathelicidin. In addition, the cathelicidin found in rosacea patients was a different form than that found in people without rosacea. Researchers also found patients had higher levels of an enzyme called stratum corneum tryptic enzyme (SCTE). This enzyme appears to convert the cathelicidin into another peptide that triggers rosacea symptoms. Dermatologist Richard Gallo, M.D., Ph.D., says the findings explain why tetracycline, a type of antibiotic, reduces symptoms in some patients with rosacea. Tetracycline inhibits the enzymes that convert the cathelicidin into an inflammatory peptide. But it doesn’t work for everyone. In the future, Gallo would like to see the development of medications that specifically target the enzyme or the proteins and prevent the onset of rosacea symptoms. The JAAD report explains that Gallo and his team are now reporting in 2010 that Finacea may be the treatment they are looking for. [2] Here is another report on this subject that needs further explanation: Dermatology 2008;217:7-11 (DOI: 10.1159/000118506) The Epidermal Vitamin D System and Innate Immunity: Some More Light Shed on This Unique Photoendocrine System? Siegfried Segaert, Thierry Simonart Department of Dermatology, University Hospital Leuven, Leuven, and Department of Dermatology, Hôpital Universitaire Erasme, Brussels, Belgium Click here for some explanation of the above report. "Skin biopsies of patients with rosacea and normal controls were compared, and the rosacea samples had elevated cathelicidin based on immunostaining and analysis of cathelicidin mRNA....Rosacea samples had elevated abundance of SCTE compared with normal skin samples, and protease activity was also elevated based on in situ zymography. To ascertain whether the elevated active cathelicidin peptides could contribute to the rosacea symptoms, the most abundant peptides, LL-37 and FA-29, from the rosacea samples were added to cultured human keratinocytes or injected subcutaneously into mice. These rosacea-enriched peptides stimulated interleukin-8 production from the keratinocytes and caused erythema, vascular dilation, neutrophil infiltration, thrombosis, and hemorrhage in the injected skin." [3[ Vitamin D and Cathelicidins "Current studies have unexpectedly identified vitamin D3 as a major factor for the regulation of cathelicidin expression. This finding may provide new strategies in the management of infectious and inflammatory diseases of the skin by targeting control of the expression and function of cathelicidin and other AMPs." [4] End Notes [1] Cathelicidins are small cationic peptides that possess broad-spectrum antimicrobial activity. These gene-encoded 'natural antibiotics' are produced by several mammalian species on epithelial surfaces and within the granules of phagocytic cells. Since their discovery over a decade ago, cathelicidins have been speculated to function within the immune system, contributing to a first line of host defense against an array of microorganisms. Consequently, cathelicidins have captured the interest of basic investigators in the diverse fields of cell biology, immunology, protein chemistry and microbiology. A burgeoning body of experimental research now appears to confirm and extend the biological significance of these fascinating molecules. This article reviews the latest advances in the knowledge of cathelicidin antimicrobial peptides, with particular emphasis on their role in defense against invasive bacterial infection and associations with human disease conditions. [2] J Am Acad Dermatol 2009;60:AB1. Abstract P103, American Academy of Dermatology, 68th Annual Meeting, March 5–9, 2010, Miami, Florida (JAAD Poster Abstracts, March 2010 / Volume 62 / Number 3) [3] Sci. STKE, 14 August 2007, Vol. 2007, Issue 399, p. tw290 [DOI: 10.1126/stke.3992007tw290] Hyperactive Antimicrobial Response Produces Rosacea Nancy R. Gough Science's STKE, AAAS, Washington, DC 20005, USA [4] Dtsch Med Wochenschr. 2009 Jan;134(1-2):35-8. Epub 2008 Dec 17. Cathelicidins: multifunctional defense molecules of the skin. Peric M, Koglin S, Ruzicka T, Schauber J. Go to subheading, Vitamin D, in the post below: Gallo's theory and resources Scand J Infect Dis. 2003;35(9):670-6. Cathelicidins and innate defense against invasive bacterial infection.Nizet V, Gallo RL. Department of Pediatrics, Division of Infectious Diseases Universityof California, San Diego, La Jolla 92093, USA PMID: 14620153 [PubMed - indexed for MEDLINE] Antimicrobial peptides and the skin immune defense system Jürgen Schauber, MDa and Richard L. Gallo, MD, PhDb J Allergy Clin Immunol. 2008 August; 122(2): 261–266. Published online 2008 April 25. doi: 10.1016/j.jaci.2008.03.027. This thread has an enormous amount of research on this subject. ** "The term "alarmins" has been used to describe antimicrobial peptides (AMPs) such as defensins and cathelicidins, which not only kill microbes but also trigger host-tissue responses, including leukocyte chemotaxis, angiogenesis, expression of extracellular matrix components, and inflammation. Rosacea, an inflammatory skin disease, exhibits many of these resultant characteristics. Thus, Yamasaki and colleagues recently identified altered levels and post-translational processing of cathelicidin in skin from rosacea patients. When cultured with human keratinocytes, abnormal cathelicidin peptides resulted in erythema and vascular dilatation. Deletion of the cathelicidin gene in a mouse model of skin irritation resulted in significantly less inflammation than in wild-type animals. In addition, increases in the activity of serine proteases that lead to activation of cathelicidin were implicated in inflammatory changes associated with rosacea. Thus, manipulation of antimicrobial peptides and their postsecretory processing may be a focus for the development of effective therapeutic strategies for rosacea." Editorial Journal of Investigative Dermatology (2007) 127, 2493. doi:10.1038/sj.jid.5701133 Autoimmune disease: Skin deep but complex Nicole Baumgarth1 & Charles L. Bevins Nature 449, 551-553 (4 October 2007) | doi:10.1038/449551a; Published online 3 October 2007 Rosacea May Be Caused by Immune Response, Not Bacteria Neil Osterweil, Senior Associate Editor, MedPage Today Published: August 06, 2007 Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine. There is evidence that Vitamin D is "a major regulator of the expression of the cationic antimicrobial peptide cathelicidin."

If only we had a dream team like this to differentiate rosacea from the list below! Differential Diagnosis of Rosacea Authoritative Resource Guide Below is a list with sources showing differential skin disease(s) to consider in diagnosing rosacea when patients present with erythema, telangiectasia, or flushing. Can you see why a dermatologist is better qualified to differentiate the list below, rather than asking a social media group of rosacea sufferers, i.e., Facebook or Reddit, the question, 'IS THIS ROSACEA?' ! "The aetiology of facial rash is diverse, and the diagnosis is not always straightforward." [19] Just because a patient presents with erythema, pimples/pustules, telangiectasia or flushing doesn't mean it is rosacea and should be differentiated from this list below, which by the way, is not an exhaustive list and will keep growing as we learn of new ones which we add to the list below with authoritative sources. If we have missed one, why not find the reply to this topic button and let us know about it. That is what rosaceans helping rosaceans is all about. A new approach on differentiating rosacea from other skin diseases is the Gate Recurrent Unit. Acne @ Acne Agminata ** [22] Acne Venenata* Acne Vulgaris* [17] Actinic folliculitis Actinic Reticuloid ^ Acute cutaneous lupus erythematosus [19] Adenoma Sebaceum [27] Allergic Conjunctivitis @ Amyloidosis [23] Anaphylaxis ! Ataxia–telangiectasia Atopic dermatitis $ Autosensitization dermatitis [5] Basal Cell Carcinoma + Bloom's syndrome [23] Bromoderma ** Calcinosis [24] Carcinoid Syndrome # [6] [17] [23] Cardiac Disease [23] Cellulitis Chalazions [8] Chronic discoid lupus erythematosus (CDLE) # [7] Chronic Topical Corticosteroid Therapy ^ Crohn’s disease @@ Climacterum ! Colon Cancer @@ Contact and photocontact dermatitis $ [19] Corticoid Damage* CREST Syndrome [24] Cutaneous adverse drug reactions (ADRs) [10] Cutaneous Angiosarcoma Cutaneous Coccidioidomycosis [25] Cutaneous Lymphoma [17] Cutaneous Lupus Erythematosus (CLE) [7] Cutaneous Rosai-Dorfman [1] Demodicidiosis* Dermatomyositis* [17] [19] [24] Discoid Lupus Erythematosus (DLE) [7] Disseminated Idiopathic T-Cell Pseudolymphoma [27] Drug Allergies [23] Drug eruptions (particularly from iodides and bromides) % Eosinophilic pustular folliculitis (EPF) [2] Epidermal Growth Factor Receptor Inhibitor Drug Eruptions [17] Erysipelas ^ Erythema Infectiosum * Erythema perstans faciei [24] Erythromelagia (EM) Exophiala oligosperma Extranodal Rosai-Dorfman [11] FACE syndrome @@ Follicular mucinosis [9] Folliculitis [14] Fractional Microneedling Radiofrequency Induced Rosacea Gram-negative Folliculitis* Growth Factor Receptor Inhibitor “acne” + Haber's syndrome # Hyperpigmentation (PIH) [18] Idiopathic facial aseptic granuloma (IFAG) Indeterminate cell histiocytosis (ICH) Infectious diseases [23] Jessner's lymphocytic infiltrate of the skin (JLIS) [27] Kaposi varicelliform eruption (eczema herpeticum) Keratinization [23] Keratosis Pilaris [4] Keratosis Pilaris Atrophicans Faciei (KPAF) Iatrogenic Rosacea [12] Lichen Spinulosus [4] Iododerma ** Lupoid leishmaniasis Lupus Erythematosus ^ [6] Lupus Miliaris Disseminatus (Faciei)* [17] Lupus Vulgaris ** Lymphoma [23] Malar rash Malassezia folliculitis MARSH Syndrome [26] Mast cell activation syndrome Mastocytosis Syndrome @ Measles Virus [15] Medications $ Medication-induced facial erythema (eg topical or systemic corticosteroids) [19] Medullary Carcinoma of the Thyroid ! Melkerrson-Rosenthal syndrome [3] Mitral Valve Incompetence ** Mixed Connective Tissue Disease [6] Morbihan´s Disease* Mycosis fungoides (MF) [29] Neoplasia [23] Netherton syndrome [16] Pancreatic cell tumor ! Pellagra Perioral Dermatitis* Periocular Dermatitis* Pheochromocytoma ! Photodermatitis # Photosensitivity diseases Photosensitive Eruption [6] Physical erythema $ Pityriasis folliculorum Pityrosporum Follicultis Poikiloderma [20] Polycythemia Vera [6] Polymorphous light eruption # [17] [27] Polymyositis % Porphyrias [23] Post-Inflammatory Erythema (PIE) [18] Pregnancy @@ Primary cutaneous marginal zone lymphoma (PCMZL) Prosopitis Granulomatosa* Pseudolymphoma [27] Pustular Folliculitis** Pyoderma faciale & Renal Carcinoma ! Rhinophyma* Rosaceiform Dermatitis [13] Rosai-Dorfman disease (extranodal) Rubeosis Diabeticorum* Sarcoidosis ** [23] Sarcoidosis, Small Nodular Type* Sarcoidosis (papular) [27] Sebaceous Gland Carcinoma % Seborrheic Blepharokeratoconjunctivitis % Seborrheic Dermatitis* [17] Secondary Lues* Sensitive Skin Skin Granulomas % Sterile Eosinophilc Pustulosis* Steroid rosacea @@ Subacute Cutaneous Lupus Erythematosus SCLE* Sweet syndrome Syphilis ^ Systemic Lupus Erythematosus @ [17] Systemic Mastocytosis [6] Tinea Faciei [19] Topical Steroid–Induced Acne [17] Trichoblastoma [28] Trichodysplasia spinulosa (TS) [4] Tuberculosis ^ Tyrosinase Kinase Inhibitor Drug Eruptions [17] Ulcerative Colitis @@ End Notes *DermIS # Journal of the Royal Society of London, Vol. 90, March, 1997, p.247 @ American Family Physician, August 1, 2002 $ Diagnosis and Treatment of Rosacea, Aaron F. Cohen, MD, and Jeffrey D. Tiemstra, M, J Am Board Fam Pract 2002;15:214 –7.) % Treatment of Acne Rosacea Reviewed CME/CE, Laurie Barclay, MD, Charles Vega, MD, FAAFP, MedscapeCME Clinical Briefs ^ Acne Rosacea, Marian S. Macsai, Mark J. Mannis, and Arthur C. Huntley, 1996 by Lippincott-Raven Publisher ** Rosacea: Differential Diagnoses & Workup, Agnieszka Kupiec Banasikowska, MD, Saurabh Singh, MD, eMedicine from WebMD + Rosacea, Guy F. Webster, MD, PhD, Medical Clinics of North America - Volume 93, Issue 6 (November 2009) ! The flushing patient: Differential diagnosis, workup, and treatment, Leonid Izikson, MD, Joseph C. English III, MD, Matthew J. Zirwas, MD. Journal of the American Academy of Dermatology - Volume 55, Issue 2 (August 2006) & DermNet NZ @@ Rosacea: A Review, Brittney Culp, BA and Noah Scheinfeld, MD, P&T, 2009 January; 34(1): 38–45. [1] Cutaneous Rosai-Dorfman disease presenting as a granulomatous rosacea-like rashs. Shi XY, Ma DL, Fang K. Chin Med J (Engl). 2011 Mar;124(5):793-4. [2] J Dermatol. 2013 Mar 12. doi: 10.1111/1346-8138.12125. Clinical and histopathological differential diagnosis of eosinophilic pustular folliculitis. Fujiyama T, Tokura Y. Infection. 2020 Nov 25;: Eosinophilic pustular folliculitis (EPF) in a patient with HIV infection. Kanaki T, Hadaschik E, Esser S, Sammet S [3] Diagn Pathol. 2013 Nov 13;8(1):188. Melkerrson -Rosenthal syndrome, a rare case report of chronic eyelid swelling. Kajal B, Harvey J, Alowami S. Allergy Asthma Clin Immunol. 2019 Jan 5;15:1. doi: 10.1186/s13223-018-0316-z. eCollection 2019. Melkersson-Rosenthal Syndrome: A Case Report of a Rare Disease With Overlapping Features Mauro Cancian, Stefano Giovannini, Annalisa Angelini, Marny Fedrigo, Raffaele Bendo, Riccardo Senter, Stefano Sivolella Dermatol Online J. 2020 Jun 15;26(6): Morbihan disease: a case report and differentiation from Melkersson-Rosenthal syndrome. Kuraitis D, Coscarart A, Williams L, Wang A [4] "The differential diagnosis of TS can be broad, including keratosis pilaris and related disorders, lichen spinulosus, sarcoidosis, rosacea, and perforating disorders." JAAD Case Rep. 2019 Apr; 5(4): 352–354. Published online 2019 Apr 5. doi: 10.1016/j.jdcr.2019.02.001 PMCID: PMC6453831 Widespread keratosis pilaris–like eruption in an immunocompromised child Alice Frigerio, MD, PhD, Tuna Toptan, MD, PhD, Yuan Chang, MD, James Abbott, MD, Sarah D. Cipriano, MD, and Anneli R. Bowen, MD [5] JAAD Case Rep. 2019 May; 5(5): 410–412. Autosensitization dermatitis: A case of rosacea-like id reaction Sarah D. Ferree, BA, Connie Yang, BA, and Arianne Shadi Kourosh, MD, MPH [6] According to Izikson et al, "When evaluating patients with rosacea, it is important to exclude the diagnoses of polycythemia vera, photosensitive eruption, lupus erythematosus, mixed connective tissue disease, carcinoid syndrome, systemic mastocytosis, or side effects from long-term facial application of topical steroids." Blushing Propensity and Psychological Distress in People with Rosacea. Su D, Drummond PD. Clin Psychol Psychother. 2011 Jun 23. doi: 10.1002/cpp.763. [7] "Discoid lupus erythematosus (DLE) represents a common form of cutaneous lupus erythematosus (CLE) that often prompts dermatologic consultation....In turn, lymphohistiocytic infiltrates in CLE have rarely been reported in the literature, and when arising on the H-zone of the face, this represents a recognizable guise that could be misconstrued as acne/rosacea." Cureus. 2018 Sep; 10(9): e3310. Histiocyte-rich Discoid Lupus Erythematosus: A Peculiar Perifollicular Distribution Histologically Mimicking an Acneiform Disorder Monitoring Editor: Alexander Muacevic and John R Adler Ryan M McKee, Amanda F Marsch, and Brian R Hinds Discoid lupus erythematosus (DLE) and and rosacea share common features in etiopathogenesis and clinical presentation. These two diseases can be seen concomitant, mimic each other clinically and share common possible etiologic factors. Dermatol Ther. 2020 Apr 10;:e13394 Demodex positive discoid lupus erythematosus: Is it a separate entity or an overlap syndrome? Dursun R, Durmaz K, Oltulu P, Ataseven A [8] "In case of multiple recurrent chalazia in a child, ametropia and ocular rosacea should be ruled out." Rev Prat. 2019 Oct;69(8):881-883 Recurrent chalazions in children Doan S [9] JAAD Case Rep. 2020 Apr; 6(4): 266–272. Published online 2020 Mar 24. doi: 10.1016/j.jdcr.2020.01.014. PMCID: PMC7109359 Demodex-induced follicular mucinosis of the head and neck mimicking folliculotropic mycosis fungoides Megan H. Trager, BA, Dawn Queen, BA, Diane Chen, MD, Emmilia Hodak, MD, Larisa J. Geskin, MD [10] "Clinical manifestations, which range from milder erythematous to urticarial reactions to severe lethal anaphylaxis, may be indistinguishable from immune system-mediated hypersensitivity reactions." Clinical and Basic Immunodermatology. 2017 Apr 25 : 439–467. Published online 2017 Apr 25. doi: 10.1007/978-3-319-29785-9_25. PMCID: PMC7123512 Adverse Medication Reactions Anthony A. Gaspari, Stephen K. Tyring, Daniel H. Kaplan [11] Int J Clin Exp Pathol. 2020;13(3):556-558 Granulomatous rosacea-like skin rash: extranodal Rosai-Dorfman disease. Shen HP, Lu ZF, Zhu JW [12] Indian Dermatol Online J. 2013 Apr-Jun; 4(2): 133–142. Paradoxes in dermatology Keshavmurthy A. Adya, Arun C. Inamadar, and Aparna Palit [13] J Am Acad Dermatol. 2010 Jun;62(6):1050-2. doi: 10.1016/j.jaad.2009.01.029. Rosaceiform dermatitis associated with topical tacrolimus treatment. Fujiwara S, Okubo Y, Irisawa R, Tsuboi R. [14] Folliculitis - Another Rosacea Mimic Aust Prescr 2018;41:20-4, 1 February 2018, DOI: 10.18773/austprescr.2018.004 An update on the treatment of rosacea Alexis Lara Rivero, Margot Whitfeld DermNet NZ lists rosacea as an acne like variant in a differential diagnosis of folliculitis [15] "A red, flat rash which usually starts on the face and then spreads to the rest of the body typically begins three to five days after the start of symptoms." Measles, Wikipedia [16] "At his most recent follow-up after almost 3 years of treatment with secukinumab, he had complete clearance of his facial erythema and only 1 mild flare of the polycyclic plaques on his trunk and extremities several months before." JAAD Case Rep. 2020 Jun; 6(6): 577–578. Successful use of secukinumab in Netherton syndrome Sarah K. Blanchard, MD and Neil S. Prose, MD [17] Cutis. 2014 July;94(1):39-45 The Great Mimickers of Rosacea Jeannette Olazagasti, BS; Peter Lynch, MD; Nasim Fazel, MD, DDS Case Rep Dermatol. 2021 May-Aug; 13(2): 321–329. Lupus Miliaris Disseminatus Faciei versus Granulomatous Rosacea: A Case Report Ji-In Seo and Min Kyung Shin [18] "Post-Inflammatory Erythema (PIE) and Hyperpigmentation (PIH) are not exactly the same thing. Post-inflammatory Hyperpigmentation (PIH) is brown or black marks caused by an inflammatory reaction producing an overproduction of melanin. Causes include getting a pimple, aging, pregnancy (melasma), hormones, and sun exposure. Post Inflammatory Erythema (PIE) refers to the red or purplish marks left behind from acne. The redness is from damage or dilation done to capillaries near the surface of the skin resulting in small flat red marks. Patients can have a combination of both PIE and PIH." ACNE SCARRING TREATMENT OPTIONS, PENNSYLVANIA CENTRE FOR DERMATOLOGY J Clin Aesthet Dermatol. 2013 Sep; 6(9): 46–47. Easy as PIE (Postinflammatory Erythema) Yoon-Soo Cindy Bae-Harboe, MD, Emmy M. Graber, MD J Clin Aesthet Dermatol. 2010 Jul; 3(7): 20–31. Postinflammatory Hyperpigmentation A Review of the Epidemiology, Clinical Features, and Treatment Options in Skin of Color Erica C. Davis, MD, Valerie D. Callender, MD [19] Aust J Gen Pract. 2020 Jan-Feb;49(1-2):36-37 A new facial rash. Sun C, Muir J [20] Poikiloderma is "most frequently seen on the chest or the neck, characterized by red colored pigment on the skin that is commonly associated with sun damage." Wikipedia It was reported by Tont at RF that someone said it was either Poikiloderma or Rosacea. [22] An Bras Dermatol. 2020 Nov-Dec; 95(6): 754–756. Case for diagnosis. Eyelid edema and erythematous papules disseminated on the face⋆⋆⋆ Ana Cristina M. Garcia, Ângela Marques Barbosa, Marilda Aparecida Milanez Morgado de Abreu, and Carlos Zelandi Filhoc [23] is (Bern 1994). 2004 Oct 13;93(42):1727-32. [The red face] Ch Schuster, G Burg [24] Clin Dermatol. Jan-Feb 2014;32(1):153-8. doi: 10.1016/j.clindermatol.2013.05.037. The red face revisited: connective tissue disorders Jana Kazandjieva, Nikolai Tsankov, Kyrill Pramatarov [25] Int J Womens Dermatol. 2020 Dec; 6(5): 458–459. Recalcitrant facial rash: Cutaneous coccidioidomycosis Shanice A. McKenzie, BS,a Amy R. Vandiver, MD, PhD,b Natalie M. Villa, MD,b Chandra N. Smart, MD,c Vivian Y. Shi, MD,d and Jennifer L. Hsiao, MD [26] Viewpoints in Dermatology The red face—an overview and delineation of the MARSH syndrome W. A. D Griffiths St John’s Institute of Dermatology, London, UK piquero1.pdf [27] Indian Dermatol Online J. 2021 Mar-Apr; 12(2): 312–315. The Puzzle of Papules Over Face and Extrafacial Areas: A Rare Case of Disseminated Idiopathic T-Cell Pseudolymphoma Sumit A. Hajare, Vaishali H. Wankhade, Gitesh U. Sawatkar, and Rajesh Pratap Singh [28] Am J Case Rep. 2021; 22: e932320-1–e932320-4. Extensive Facial Trichoblastoma – A Rare and Disfiguring Condition Siti Nur Hidayah Abd Rahim, Nur Ashikin Ahmad, and Mohamed-Syarif Mohamed-Yassin [29] "Some new clinical presentations that may be imitated by MF are also presented in Table 1, including keratosis punctata palmaris, seborrheic dermatitis, angular cheilitis, psoriasis inversa, rosacea, varicous eczema. Furthermore, some particular localizations of MF lesions and a series of dermatoses developing in preexisting MF lesions are presented." Dermatol Ther (Heidelb). 2021 Dec; 11(6): 1931–1951. A Comprehensive Update of the Atypical, Rare and Mimicking Presentations of Mycosis Fungoides Eve Lebas, Patrick Collins, Joan Somja, and Arjen F. Nikkels

There are a number of prescription drugs you could ask your physician about that have been reported to help reduce flushing. There are also over the counter drugs [OTC] non prescription treatments used to reduce or avoid flushing as well. This post is dedicated to those of you searching for methods to control or reduce flushing. Post your own method in this thread, please. "Flushing can be treated with medications that have provided some success in other studies, including beta-blockers, clonidine (Catapres, Boehringer Ingelheim), naloxone (Narcan, Endo), ondansetron (Zofran, GlaxoSmithKline), and selective serotonin reuptake inhibitors (SSRIs). However, evidence supporting many of these therapies is limited." [1] The prescription drugs in the list below came from anecdotal reports posted in various online support groups for rosacea that reported that their physician prescribed the drug to reduce flushing or an anecdotal report mentioning the drug. The same is true for the sources listed for the non prescription treatments or over the counter [OTC] which all these sources are listed in the end notes or as links. Lastly, there is a subheading if you scroll below of 'Other Treatments' for flushing avoidance, and find the end notes. Prescription Drugs Amlodipine (very low dose) [28] Amitriptyline (Elavil) [37] Antihistimines (also available OTC) [9] Atenolol [6] Benadryl Botulinum Toxin [30] Brimonidine Carvedilol [7] Citalopram (brand names: Celexa, Cipramil and others) Clonidine [1] Cymbalta [2] Diclofenac [16] Duloxetine [2] Effexor [2] Epinephrine Famotidine [24] Gabapentin (Neurontin) Hormone Replacement Therapy Hydroxychloroquine (Plaquenil) [4] Isotretinoin (2.5 mg generic low dose) Ketamine 0.5% and Amitriptyline 1% Lanreotide Loratadine (Claratin) [5] Low Dose Isotretinoin Lyrica [2] Maxalt [2] Megestrol acetate Mepacrine (INN), also called quinacrine (USAN) or by the trade name Atabrine Metoprolol Metformin [35] Mirtazapine (Remeron) [12] Monoxidine Montelukast (Singulair) [5] MSM [33] Nadadol Naloxone [1] Naltrexone (low dose) [32] Ondansetron [1] Pavinetant [25] Paxil [26} Propranolol (Inderal) [8] Pseudoephedrine [3] Ranitidine (Zantac) [5] Roxicodone [2] Sandostatin LAR Serotonin Reuptake Inhibitors (SSRIs) [1] Sumatriptan Treximet [2] Triptran ( Imitrex or Sumatriptan) [19] Venlafaxine [17] Veralipride [18] Over the Counter (OTC) NON PRESCRIPTION (or other treatments) [9] Air Purifier [38] Antihistimines (OTC) [9] Aspirin Before Elixir [13] Benadryl Breathing Exercises [29] Bromelain [10] [23] Chili (capsaicin) [36] codeRed [14] Diamine oxidase (DAO) [34] Full Face Gel Mask Gaviscon [21] Ibuprofen [27] MSM [22] Quercetin Bromelain [10] [23] Red clover Sepia [15] Topical ibuprofen [20] Vitamin C [10] [23] Other Treatments Tixel followed by topical application of 100 U of abobotulinumtoxin [31] Reply to this Topic There is a reply to this topic button somewhere on the device you are reading this post. End Notes [1] Rosacea: A Review Brittney Culp, BA and Noah Scheinfeld, MD P T. 2009 January; 34(1): 38–45. realwork says, "SSRI's work the best for me. Luckily I didn't suffer many side effects." post no. 2 Nat007 writes about "Medication that has proved to be helpful for facial flushing, redness and burning" American Family Physician. 66 (3): 435–441. PMID 12182520. "Rosacea: A Common, Yet Commonly Overlooked, Condition". Blount, BW; Pelletier, AL (2002). "Clonidine is an oral alpha2 agonist that has been used for flushing." Australian Subscriber An update on the treatment of rosacea Alexis Lara Rivero, M Whitfeld [2] Cymbalta [Duloxetine] Anecdotal report from Meg post #3 on 6/14/11 Momof reports [in post no 11], "I have been taking 60mg Duloxetine in the morning for the past few days ( instead of amitriptyline) and it is proved a magic bullet." [3] valby - Post #8 6/16/11 at 3:04AM [4] Post #14 by shantelle 6/20/11 at 04:51 AM antwantsclear recommends hydroxychloroquine [see post no 4] [5] Brook - Post #11 6/25/11 [6] Read Judworth's post 28th November 2011 02:13 PM Post #2 [7] Pronounced facial flushing and persistent erythema of rosacea effectively treated by carvedilol, a nonselective b-adrenergic blocker J AM ACAD DERMATOL VOLUME 67, NUMBER 3, Letters, page 491 jlb2010 Post #1 "Carvedilol, 6.25 mg twice a day, was prescribed for the first week, followed by 3 times a day thereafter. She monitored her blood pressure and pulse rate regularly at home, and no hypotension or bradycardia was noted. A dramatic improvement in the erythema and telangiectasia was noted in 2 weeks." Carvedilol for the Treatment of Refractory Facial Flushing and Persistent Erythema of Rosacea Chia-Chi Hsu, MD; J. Yu-Yun Lee, MD; Department of Dermatology, National Cheng Kung University Medical College and Hospital, Tainan, Taiwan Download pdf carveArchives_of_Dermatology_2011_147.pdf J Am Acad Dermatol. 2012 Sep;67(3):491-3. Pronounced facial flushing and persistent erythema of rosacea effectively treated by carvedilol, a nonselective β-adrenergic blocker. Hsu CC, Lee JY. "These findings demonstrate facial flushing and persistent erythema can be effectively treated by carvedilol long-term with a fast onset of improvement in a dose well tolerated." J Dermatolog Treat. 2017 Jul 27;:1-16 Long term management of distinct facial flushing and persistent erythema of rosacea by treatment with carvedilol. Pietschke K, Schaller M Dermatol Ther. 2020 Nov 11;:e14520 Facial Flushing and Erythema of Rosacea Improved by Carvedilol. Seo BH, Kim DH, Suh HS, Choi YS [8] Symptomatic treatment of idiopathic and rosacea-associated cutaneous flushing with propranolol. Craige H, Cohen JB. J Am Acad Dermatol. 2005 Nov;53(5):881-4. [9] Over The Counter (non prescription) [10] DianaLynn's anecdotal report [12] J Support Oncol. 2004 Jan-Feb;2(1):50-6. Pilot evaluation of mirtazapine for the treatment of hot flashes. Perez DG, Loprinzi CL, Barton DL, Pockaj BA, Sloan J, Novotny PJ, Christensen BJ. The Effect of Mirtazapine for Treatment of Hot Flashes in Depressed Woman with Breast Cancer Receiving Tamoxifen: A Case Report Lee SH; Ko YH; Joe SH. Korean Journal of Psychopharmacology; 17(1): 101-104, 2006. Obstet Gynecol. 1990 Oct;76(4):573-8. Alpha 2-adrenergic mechanism in menopausal hot flushes. Freedman RR1, Woodward S, Sabharwal SC. pleasehelp123 reports taking Mirtazapine nat007 and BlueDog report taking Mirtazapine Chai reports taking Mirtazapine with a severe rebound of rosacea when withdrawing from it [13] Before Elixir (no longer available) PREVENTS ALCOHOL FLUSH: Reduces flushing of face and symptoms of Alcohol Flush According to Asian Flush Cure Before Elixir is no longer available and has been replaced by three other treatments, Lighten Up, Nightcap, and Morning After. [14] codeRed No longer available at Amazon (Google it) . [15] 'There's also anecdotal evidence that sepia tablets - a homeopathic remedy - can help flushes. I have had many patients who found that it helped.' Why your 'flushing' could be a red alert to see your doctor By Caroline Bellamy, Daily Mail [16] Diclofenac Violetsareblue post #13 [17] Venlafaxine realwork, post #5 DunkWheezy post no 35 says, "Ever since I started taking a 37.5mg Venlafaxine pill daily I haven't had a problem with flushing. Ask your doctor about trying it, it majorly helped me and I'm sure it could help you. I take a super low dose and experience no side effects." Prim Care Companion J Clin Psychiatry. 2007; 9(1): 70–71. PMCID: PMC1894834 Alleviation of Hot Flashes With Increase in Venlafaxine Dose Prasad R. Padala, M.D., Srinivas B. Rapuri, M.D., and Kalpana P. Padala, M.D. [18] Climacteric. 2010 Apr;13(2):141-6. doi: 10.3109/13697130903219208. Reduction of serum serotonin precursors after veralipride treatment for postmenopausal hot flushes. Carretti N, Florio P, Reis FM, Comai S, Bertazzo A, Petraglia F. [19] Topical Ibuprofen laser_cat [20] Eur Neuropsychopharmacol. 2013 Dec;23(12):1747-53. doi: 10.1016/j.euroneuro.2013.07.013. Epub 2013 Aug 6. Topical ibuprofen inhibits blushing during embarrassment and facial flushing during aerobic exercise in people with a fear of blushing. Drummond PD, Minosora K, Little G, Keay W. [21] Giviscon Boris reports, "taking a slug of giviscon liquid before i head out to the pub stops me from flushing completely." [22] antwantsclear post no 7 writes, "Helpful supplements for me include Solgar MSM 1000mg (you can take up to six per day but start with one initially). Higher Nutrition for Healthy Veins. Symprove probiotic (this is very helpful). Zinc 15mg twice per day. Vaxa Buffer pH." [23] WazzyG started a thread on Quercetin Bromalein at post no 1 while BVokey post no 12 says, "Vitamin C, msm, riboflavin (by itself, not in a b-complex vitamin)" [24] realwork at RF says, "Famotidine massively reduces the alcohol flush. Always consult your doctor first before taking any medication." [25] Pavinetant (INN, USAN; developmental code names MLE-4901, AZD-4901, AZ-12472520, AZD-2624) "In November 2017, development of the medication for hot flashes and PCOS was also terminated after its developer assessed the clinical risks and benefits." Wikipedia"In 28 healthy women aged 40–62 years, oral administration of a 40 mg dose twice per day for 4 weeks reduced the number of hot flushes during week 4 by 45 percentage points (95% CI 22–67) compared with placebo (intention-to-treat adjusted means: placebo 49·01 [95% CI 40·81–58·56] vs MLE4901 19·35 [15·99–23·42]; adjusted estimate of difference 29·66 [17·39–42·87]; p<0·0001). This finding was also supported by an objective assessment of flushes, using the Bahr sternal skin conductance monitor. Reductions in the number of flushes might be less important to women than measures of quality of life, thus it is of interest that the authors found hot flush severity, bother, and interference to be significantly reduced during treatment with MLE4901."The Lancet Volume 389, No. 10081, p1775–1777, 6 May 2017New pathways in the treatment for menopausal hot flushesJenifer Sassarini, Jenifer Sassarini, Richard A Anderson [26] antrax1 (Post no 1}says, "My wonder: 5 MG paxil a day. Works GREAT for itching, flushing and blushing. I barely blush and flush now (was VERY severe, even considered ETS surgery)." [27] Violetsareblue [post no 6] says, "Taking a 200 or 400 mg ibuprofen every now and then (twice per week max) if I know I will be triggered. This has helped me a lot to feel that I can have control over the condition. Its not good to do it on daily basis, but for me it is a great help just mentally knowing that I have some sort of control. [28] laser_cat at RF post no 12 writes, "The amlodipine is helpful for both pain + flushing, I think by evening out blood flow / oxygen tension in my face." [29] Flugs reports, "If I close my eyes, exhale deeply, and relax for about 10 seconds, then open my eyes again and look in the mirror, my face is completely pale. The effect only lasts a few seconds before the usual pinkness in my cheeks returns… but, sometimes, if I’m heading towards a light flush, I can actually head it off at the pass by doing this." [30] "Intradermal botulinum toxin injection may be an effective treatment for refractory erythema and rosacea flushing that deserves further study in a larger patient population." Dermatology Botulinum Toxin for the Treatment of Refractory Erythema and Flushing of Rosacea Park K.Y., Hyun M.Y., Jeong S.Y., Kim B.J., Kim M.N., Hong C.K. [31] Lasers Surg Med. 2018 Oct 12. doi: 10.1002/lsm.23023. [Full text with images] The toxic edge-A novel treatment for refractory erythema and flushing of rosacea. Friedman O, Koren A, Niv R, Mehrabi JN, Artzi O [32] Flugs reports "I need more time to know if it has - or will - help reduce flushing. Perhaps if the face pain / sensitivity goes the tendency to flush may reduce through time. I also think that I will need to continue to zap the caps and redness a bit more, in order to get rid of the excess infrastructure that makes flushing so easy." (There are others in Flug's thread that are trying Naltrexone like Judworth post no 567, "my flushing has been knocked out by about 99%") [33] "I've been taking 4000mg a day for 3 days and I've flushed maybe 5 times since I started. I was flushing 10-20 times a day. It's really life changing!" RickSaw12, Reddit [34] Diamine oxidase (DAO), also known as histaminase, is an enzyme (EC 1.4.3.22) involved in the metabolism, oxidation, and inactivation of histamine and other polyamines such as putrescine or spermidine in animals." Wikipedia mac5400 posts at Reddit, "I now take an OTC supplement called UmbrelluxDAO before i eat or drink. It contain the enzymes responsible for metabolizing histamine. And I barely flush anymore. The chronic rosiness on my cheeks has significantly reduced; more than any cream I've ever tried. In combination with a low histamine diet, i think i finally found the "cure" to my "rosacea." It's such a breakthrough for me. This supplement is life-changing." [35] Metformin Brands: Glucophage, Riomet, Fortamet, Glumetza, and Glucophage XR Markhill8 at RF states, "Four weeks ago I started taking 500mg Metformin once a day (right before my evening meal). By the third day my flushing had decreased and after around 10 days had reduced drastically. Now I do not flush at all to food and interestingly the other triggers like heat and laying down to sleep (always use to flush with head getting warm on the pillow) no longer make me flush. My nose seems to be decreasing in volume also (edema slowly going) because I no longer flush. If I do something that use to bring on a flush like taking a really warm shower, now I just get a slight tingling feeling that used to herald a massive flush but now only lasts for around 1-2 minutes with no redness or swelling. I don't have diabetes and have type 1 Rosacea with flushing/ nose swelling. For the last week I have reduced the dose to 500mg every other day and it is still working. I hope to reduce it to 500mg every 3 days after another two weeks and see if it still works. Food it seems is a massive delayed trigger for me that is driving my Rosacea." [36] sepi, Rosacea Forum Capsaicin is the active ingredient in chili peppers that makes them hot. Capsaicin is used in medicated creams and lotions to relieve muscle or joint pain. Rugby Capsaicin 0.025% Cream CAPZASIN-HP CREME Zostrix Maximum Strength Natural Pain Relief Cream, Capsaicin Pain Reliever: [37] Momof, reports, "...25mgx2 daily ( 50mg) of Amitriptyline has definitely helped the crazy nerves in my face..." [38] Rtstar [post #9] "Update: about 4 days ago i started flushing at night again. Last night I used an air purifier in my room and i have been leaving it on all night and day. My skin hasn't looked this good in awhile. I have noticed that because I haven't been flushing as much as before my baseline redness is a little better as well. Obviously the redness gets better without flushing but I didn't realize that staying away from a flushing episode helps baseline redness overall. i haven't added any skincare to my routine either. This is simply just from avoiding heat and my indoor allergies."

Natural Treatments for Rosacea Aloe Apple Cider Vinegar Argan Oil Aspirin Azelaic Acid Baking soda & hydrogen peroxide Betaine Hydrochoride Black Cohosh Bromelain Burdock B Vitamins Calendula Celazome Serum Vitae Chamomile Chrysanthellum Indicum Cream ClearSkin-A Coconut Oil Colloidal oatmeal Coptis chinensis Franch CoQ10 Enzyme Cucumber Cucurcim Digestive Enzymes Decleor EGF Emu Oil EmerginC Fenugreek Feverfew Flaxseed Oil Gamma-linolenic acid (GLA) Grapeseed Extract Green Tea Cream Herpanicine Honey (Raw) Mask Jojoba Oil Juice Beauty Kerstin Florian Hyaluronic Serum Licorice Melatonin Milk of Magnesia (Epsom Salt) Niacinamide Ole Henriksen Oil of Oregano Olive Leaf Ocean Essence Omega-3 fatty acids Ovanté Pine Tar Soap Probiotics Red Clover Rose Hip Sea Buckthorn Selenium Serrazyme Skinactives Rosacea Control Serum with EGF Soy Isoflavones Topical facial cream that contains alpha lipoic acid (ALA) and vitamin C prepared by a compounding pharmacist Tumeric Vitamin B Vitamin C Vitamin D Vitamin K Woebyzyme Zinc Interesting Post J Drugs Dermatol. 2010 Jun;9(6 Suppl):S72-81; quiz s82-3. Innovations in natural ingredients and their use in skin care. Fowler JF Jr, Woolery-Lloyd H, Waldorf H, Saini R. Rosacea Method Dr. Tara O'Desky's Rosacea Method is a natural, holistic treatment course for rosacea. Dr. O'Desky volunteers on the RRDi MAC and you can learn more from her. Reply to this TopicThere is a reply to this topic button somewhere on the device you are reading this post.

Photo Dynamic Therapy [PDT] are all light devices used for rosacea treatment, sometimes called Broad Band Light. Some light devices are available in the RRDi affiliate store. Laser has been around the longest and the newest lasers are quite effective for rosacea. Intensity Pulsed Light (IPL) Therapy is a newer (than laser) treatment for rosaceans. Reports have indicated successful cosmetic improvement for rosacea. However the side effects include skin peeling, potential loss of facial hair and pain. Many have reported having to return after some time (months or years) for more treatment. The newest treatment for rosacea are LED lamps with various brand name which are are too numerous to mention here, but blue and red light emitting diode based therapy are the two more popular ones. Many rosaceans report buying home LED devices or making a LED device themselves for their rosacea. If any other light devices become available they will be posted in this section. RRDi Affiliate Store Broad Band Light Devices Our affiliate store has a number of broad band light devices available for you to browse.

ETS is a major surgery that involves surgical removal or clamping of sympathetic nerves that supply the hands, neck and face. This surgery may decrease facial blushing and flushing. A similar surgery is endoscopic upper thoracic sympathectomy (EUTS). You might want to read this article about Micro ETS at R2 by David H. Nielson, MD. Please read this article about Corposcindosis before you rush off to get ETS. You should clearly understand not only the benefits of using ETS but also the risks and side effects. One of the posssible risks and side effects is anhidrosis. ETS may stop the blushing/flushing but also upper body sweating. ETS may create a situation where the top part of the body has lost vascular control and cannot sweat, while the bottom part retains vascular control and sweats more. One report on EUTS said "the sympathetic dysfunction of the heart was limited to the decrement of mean heart rate although EUTS partially destroys sympathetic fibers innervating the heart." [1] ETS patients may report feeling too hot and too cold at the same time. A newspaper article in the UK reported a very postive report using "an ultrasonic dissector which cuts through tissue by vibrating up to 50,000 times a second." However, another report from a newspaper shows what risk may be involved with ETS, death. [2] There used to be a great page on ETS at the rosaceagroup.org but now it is missing. Reports on ETS: # 1 - mmw21 #2 - rosacea_patient #3- Mermaid #4 - fab0149 Question #4 Mermaid again #5 - Mike's Report #6 - Songboy #7 - dogsr124 #8 - peteroche (see post #'s 3 & 5 #9 - "Unfortunately i haven't got all the answers for you, but i can advise you to not even consider ETS. I have had it done and all it does is add more problems to your life, such as overheating and compensatory sweating." burner, post no 4, RF #10 - "I have had ETS surgery for type 1 rosacea flushing and it is the worst decision that i ever made. In my opinion this surgery should be banned, as it has no effect whatsoever on flushing, but instead gives you more complications and problems to deal with such as compensatory sweating and increased core temperature. Please don't even consider it as it is not the answer." burner post 2 at RF #11 - "I wish it was an option. But I had ETS 7 years ago and everything is back and even worse. My body cant regulate heat no more which triggers my rosacea symptoms (I think). I'm looking at getting reversal Do not do ETS" opare post no 3 Anhidrosis and EM Some report having Anhidrosis and Erythromelalgia (EM) which is in a thread at RF. Links on ETS http://www.truthaboutets.com/TruthAboutETS.MainPage.html http://www.ets-sideeffects.netfirms.com/home3.4.html ESFB Channel Forum ETS Reversals Forum Aurelia's comment on ETS End Notes [1] Changes of autonomic functions by endoscopic upper thoracic sympathectomy on idiopathic hyperhidrosis Kondo M, Mezaki T, Higuchi K, Watanabe Y, Kuzuhara S. Rinsho Shinkeigaku. 2000 Nov;40(11):1069-75. [2] €5m payout to family after fatal operation, Ann O’Loughlin, Independent.ie National News, December 01, 2005

According to this initial report, Oracea works for rosacea sufferers: "After 16 weeks' therapy, anti-inflammatory dose doxycycline 40 mg was significantly more effective in improving rosacea than placebo, providing a greater reduction in the total inflammatory lesion count (primary endpoint) than placebo." [1] "In addition, there were significant differences in the distribution of baseline and week 12 IGA scores in the PP group (P = .0012). At week 12, most participants (63.6%) had mild CEA scores; the distribution was significantly different from baseline (P = .0407). Only 7% of participants had treatment-related adverse events (AEs), mostly mild or moderate in severity. Thus the 40-mg formulation of doxycycline proved to be effective and well-tolerated in a real-world setting in participants with rosacea who were receiving topical therapy but still experiencing symptoms." Effectiveness and safety of doxycycline 40 mg (30-mg immediate-release and 10-mg delayed-release beads) once daily as add-on therapy to existing topical regimens for the treatment of papulopustular rosacea: results from a community-based trial. According to one report, " A sub-antimicrobial dose of slow release doxycycline 40 mg daily is an effective long-term therapy for ocular rosacea. It is not associated with the side effects of long-term antibiotic therapy or the risk of resistance.' [2] An article issued in August 2012 reports, "it now seems clear that the role of antibiotics in patients with rosacea depends upon their anti-inflammatory rather than their antimicrobial properties." [1] Thus the emergence of Oracea. [5] There is speculation that generic Oracea may be available according this 2010 report (More info}. However, this has never happened. Cost The price range for Oracea is from $218 to $289 for 30 capsules (40 mg) at the different drug stores in the USA. Click here for the current price. So if you are interested in asking your physician for a prescription you might want to read below about price discounts: There was the Best Face Forward Program to obtain a 30 days supply of Oracea for $25, but now Galderma is offering a savings coupon. Click here to find out more about the CareConnect Savings Card. Exclusive rebates—save on your MetroGel; 1% and/or Oracea; prescriptions or go to bestfaceforward.com for savings cards. One report says 'the company is no longer honoring the $25.00 deal. Another report about this is similar. However, another report says the savings card works as long as you have insurance. If you don't have insurance there is a telephone number to call to ask questions: 1-866-954-5516 The web sites mentioned still show the savings card is available for the discount so the odds are Galderma will honor the savings coupon and if you are willing to jump through some Galderma hoops you may be able to save money. If you were low income you could get Oracea for free back in 2010 by asking your pharmacist questions how to do this. Prescribing Information In Canada, the UK and in Europe Oracea is known as Efracea. MHRA Product Info on Efracea According to Galderma, "Oracea (doxycycline, USP) is the first and only oral therapy approved by the FDA to treat the inflammatory lesions (red bumps, blemishes, and pustules) of rosacea." It may not help the erythma or redness associated with rosacea. Oracea was originally made by Collagenex which was bought up by Galderma for $420 Million in April 2008 has now been promoted by Galderma as a first line of treatment dermatologists should use along with topical Metronidazole (usually Metrogel - also a Galderma product or other Galderma topical forms of metronidazole). Galderma was formed in 1981 as a joint venture between Nestle and L’Oreal. David Pascoe has been following this closely and has more scoops on Oracea than anyone. If you have no idea what Oracea is, it is a special form of tetracycline called doxycycline in an enteric coated capsule which makes it timed released and only in 40 mg. doses which makes it 'submicrobal, anti-inflammatory' and not anti-bacterial. Supposedly Oracea touts the claim that it will not cause antibiotic resistance. Therefore, it is now being promoted as a long term solution for rosacea. Joseph P. Shovlin, O.D., points out that "When Periostat went generic, CollaGenex re-introduced it as a 40mg, once-daily, time-released pill called Oracea, which gained FDA approval for treating rosacea in May 2006. Oracea is the drug of choice for rosacea, says Joseph Bikowski, M.D., assistant professor of dermatology at Ohio State University. However, the cost may be prohibitory. It is about $4 a pill. For that reason, some clinicians prescribe doxycycline off-label." The New York Times reports that sales of Oracea for the first half of 2006 totaled $9.1 million. According to Pascoe he says that if he is reading the graph right, Oracea prescriptions numbered 1.2 million a month in December 2007. Oracea sales was worth approximately $104 million for the twelve-month period ending July 2009. This figure is up almost 200% from the previously reported sales of $52.5 million in 2007. Click here for Source You can imagine how many prescriptions have been handed out now that Galderma is targeting dermatologists all over the world with this prescription drug for rosacea, touted as the 'only FDA approved oral prescription for rosacea.' Business Wire reports that a "double-blind, placebo-controlled trial enrolled a total of 72 rosacea patients at 3 centers....The study successfully met this endpoint and demonstrated a statistically significant, greater reduction in inflammatory lesions at Weeks 12 and 16 in the Oracea + MetroGel group compared to the Placebo + MetroGel group." A conference reports that "A multi-center, randomized double-blind trial compared the efficacy and safety of anti-inflammatory dose doxycycline 40 mg daily (Oracea) versus non enteric-coated doxycycline 100 mg once daily. Patients in both arms of the study were also treated with metronidazole1% (Metrogel 1%) once a day. At the end of 16 week, there was the same onset and extent of therapeutic effect in both groups based primarily on reduction in inflammatory lesions. The major difference in both groups was in the number of subjects who experienced gastrointestinal side effects, such as nausea, vomiting and abdominal pain. The non-enteric-coated doxycycline 100-mg once-a-day group reported significantly more side effects, especially gastrointestinal side effects, with no cases of nausea, vomiting or abdominal pain noted in the group receiving anti-inflammatory-dose doxycycline." [3] Another report Pascoe brings out is that 100 mg doxycycline no better than Oracea. Pascoe also has an interesting article he entitles, "Galderma wants to own the Rosacea Market" which is worth reading. The biggest complaint from rosaceans is the high cost of this prescription. Some have been getting rebates from Galderma but again and again the complaints are how much this prescription costs. Paul says, "...There is no difference between delayed release 40mg Oracea vs. 50 mg doxycycline. The only difference is price..." Scroll down to Comment #82 "Efficacy of ORACEA beyond 16 weeks and safety beyond 9 months have not been established." [4] "Treatment with doxycycline significantly reduced inflammatory lesions and improved investigator global assessment scores compared with placebo. Cathelicidin expression and protein levels decreased over the course of 12 weeks in patients treated with doxycycline. Low levels of protease activity and cathelicidin expression at 12 weeks correlated with treatment success. Low protease activity at baseline was a predictor of clinical response in the doxycycline treatment group." [6] Annual Sales "Oracea® Capsules had annual U.S sales of approximately USD 319 million for the twelve months ending March, 2013 (IMS Health data)." [7] End Notes [1] Doxycycline 40 mg Capsules (30 mg Immediate-Release/10 mg Delayed-Release Beads): Anti-Inflammatory Dose in Rosacea. McKeage K, Deeks ED. Am J Clin Dermatol. 2010;11(3):217-22. [2] Treatment of ocular rosacea with 40 mg doxycycline in a slow release form. Pfeffer I, Borelli C, Zierhut M, Schaller M. J Dtsch Dermatol Ges. 2011 Jun 15. doi: 10.1111/j.1610-0387.2011.07723.x [3] Skin &Aging Supplement to the February 2009 27th Anniversary Fall Clinical Dermatology Conference [4] Product insert for Oracea [5] J Drugs Dermatol. 2012 Jun;11(6):725-30. Diagnosis and treatment of rosacea: state of the art. Baldwin HE. [6] J Am Acad Dermatol. 2016 Jun;74(6):1086-92. doi: 10.1016/j.jaad.2016.01.023. Epub 2016 Mar 5. Improved clinical outcome and biomarkers in adults with papulopustular rosacea treated with doxycycline modified-release capsules in a randomized trial. Di Nardo A, Holmes AD, Muto Y, Huang EY, Preston N, Winkelman WJ, Gallo RL. [7] Lupin Receives Tentative FDA Approvals for Generic Nuvigil® Tablets and Generic Oracea® Capsules Lupin Pharmaceuticals, Inc. Newsroom

Flushing is one of the primary signs of rosacea and has become so important to most rosaceans to the point of confusing flushing with rosacea. However, flushing is one of the signs of rosacea, just as erythma (redness), pustules and pimples are signs of rosacea. To confuse flushing as rosacea is like confusing pustules and pimples as rosacea. While flushing is indeed one of the distinguishing signs differentiating rosacea from acne or other rosacea mimics, not all rosacea sufferers flush or blush any more than the general public or complain of flushing. Another important point to consider is that a rosacea sufferer may experience a flush or blush that subsides and does not result in a rosacea flare up. Many rosacea sufferers do indeed complain of frequent and prolonged flushing which aggravates rosacea. One clinical paper says that "rosacea sufferers thought that that they blushed more intensely and were more embarrassed than controls during most of the tasks." [10] This has led to some theories that rosacea is a vascular disorder which assumes that flushing is at the heart of this disorder. However, this has never been proven. Gerd Plewig, MD, says, "there is no direct evidence that rosacea is primarily a vascular disorder. The response of the facial vessels to adrenaline, histamine and acetylcholine is normal, and the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls. In addition, the distribution of rosacea is not identical with the flush area." [1] The controversy about flushing is best described by a noted authority on rosacea, Albert Kligman who wrote, "I, and others, regard rosacea as fundamentally a vascular disorder which ineluctably begins with episodes of flushing, eventuating in the 'red' face." [2] However, another noted authority on rosacea, Dr. Frank Powell "insists that episodes of flushing are not a prerequisite for making a diagnosis of rosacea, and that some patients can develop the full-blown disease without a prior history of frequent flushing. Rebora too, another investigator, says that flushing is not a necessary stage in the sequence leading up to the full-blown 'red face'." [4] [12] Powell in his book wrote a chapter on Flushing and Blushing and confirms what other clinicians have found that while both are seen 'sufficiently often enough' in rosacea patients and both flushing and/or blushing are the 'first features of rosacea to appear in some patients," nevertheless, "flushing and blushing are not necessarily a component of the clinical picture in all patients with rosacea." [5] Another paper put this controversy into perspective: "Flushing due to rosacea may be mistaken for sensitive skin, which can manifest as abnormal sensations during fairly acute reactions to a variety of triggers, many of which are shared by rosacea and sensitive skin. Nevertheless, the two conditions are clearly different. Rosacea is a vascular disease, worsens gradually over time, manifests as flares triggered chiefly by systemic factors, is largely confined to the facial and/or ocular regions, and responds to specific treatments. Sensitive skin, in contrast, is an epidermal cosmetic problem that runs a variable course, with diffuse skin involvement and flares triggered mainly by contact factors. The flares respond to specific cosmetics and are usually worsened by treatments for rosacea." [8] So with the above paragraph in mind, it is possible you are suffering from flushing and sensitive skin, but the treatment for each of these are quite different and shouldn't be confused with each other. Flushing is totally different from sensitive skin. When rosaceans complain of frequent flushing, especially accompanied by burning, flushing avoidance is one of the chief means of controlling it usually with anti-flushing drugs. Rosacea triggers can be divided into two categories: (1) Anything that produces a rosacea flare up (2) Anything that causes a flush or blush To reiterate, it is important to remember that not every flush produces a rosacea flare up. It is possible to flush and later your skin returns to normal. Another important point is to differentiate between rosacea flushing and other conditions that produces flushing. According to Izikson et al, "When evaluating patients with rosacea, it is important to exclude the diagnoses of polycythemia vera, photosensitive eruption, lupus erythematosus, mixed connective tissue disease, carcinoid syndrome, systemic mastocytosis, or side effects from long-term facial application of topical steroids." [6] You may not be suffering from rosacea, instead, your condition may be something else. However, most rosaceans are more concerned with flushing/blushing and avoiding anything that could cause a flush/blush. Balance is the key and to not become obsessed with flushing avoidance. The following study underscores why a rosacean should be careful not to become overly obsessed with flushing avoidance: "Blushing propensity scores are elevated in people with severe rosacea. Fear of blushing may contribute to social anxiety and avoidance in such cases. Cognitive-behavioural therapy for fear of blushing may help to reduce social anxiety in people with severe rosacea." [7] It is important to differentiate flushing disorders from rosacea. As one report puts it, "The differential diagnosis of cutaneous flushing is extensive and encompasses a variety of benign and malignant entities." [11] "However, trigger causation mechanisms are currently unclear.....These data indicate that rosacea affects SSNA and that hyperresponsiveness to trigger events appears to have a sympathetic component." [13] An excellent article on flushing by Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, is worth the time reading. [14] "Flushing is a phenomenon of transient vasodilatation, which is part of a coordinate physiologic thermoregulatory response to hyperthermia, resulting in increased cutaneous blood flow. Various benign and malignant entities may cause flushing. The most common reasons for flushing are fever, hyperthermia, menopause, emotional blushing, and rosacea. But, the most likely causes of high fever with facial flushing are dengue infection, influenza, and scarlet fever, which usually has a pale area around the mouth called circumoral pallor." [15] Treatment Prescription and Non Prescription Drugs ETS Micro ETS at R2 Stellate Ganglion Nerve Block More Help More info on triggers More info on Flushing More info on Flushing Avoidance Avoid WiFi [16] End Notes [1] Rosacea: classification and treatment. T Jansen and G Plewig J R Soc Med. 1997 March; 90(3): 144–150. [2] A Personal Critique on the State of Knowledge of Rosacea Albert M. Kligman, M.D., Ph.D. The William J. Cunliffe Lectureship 2003 –Manuscript [4] Rebora A: The management of rosacea. Am J Clin Dermatol 2002; 3: 489-496. [5] Rosacea Diagnosis and Management by Frank Powell with a Contribution by Jonathan Wilkin [6] The flushing patient: differential diagnosis, workup, and treatment. Izikson L, English JC 3rd, Zirwas MJ. Department of Dermatology, University of Pittsburgh Medical Center, Pennsylvania, USA. J Am Acad Dermatol. 2006 Aug;55(2):193-208. [7] Blushing Propensity and Psychological Distress in People with Rosacea. Su D, Drummond PD. Clin Psychol Psychother. 2011 Jun 23. doi: 10.1002/cpp.763. [8] Sensitive skin and rosacea: nosologic framework. Misery L. Laboratoire de Neurobiologie cutanée, Université de Brest, France; Service de Dermatologie, CHU de Brest, 29609 Brest, France. Ann Dermatol Venereol. 2011 Nov;138 Suppl 3:S207-10. [10] Blushing in rosacea sufferers. Drummond PD, Su D. J Psychosom Res. 2012 Feb;72(2):153-8. Epub 2011 Oct 1 [11] J AM ACAD DERMATOL, AUGUST 2006, p. 193 - 208 The flushing patient: Differential diagnosis, workup, and treatment Leonid Izikson, MD, Joseph C. English, III, MD, and Matthew J. Zirwas, MD [12] Anecdotal reports of patients who received a diagnosis of rosacea who report no flushing: Rhea, 4th August 2012 01:58 PM [13] J Neurophysiol. 2015 Sep;114(3):1530-7. doi: 10.1152/jn.00458.2015. Epub 2015 Jul 1. Augmented supraorbital skin sympathetic nerve activity responses to symptom trigger events in rosacea patients. Metzler-Wilson K, Toma K, Sammons DL, Mann S, Jurovcik AJ, Demidova, Wilson TE. [14] Flushing, Dr Amanda Oakley, Dermatologist, Hamilton, New Zealand, DermNet NZ [15] Case Rep Infect Dis. 2020; 2020: 8790130. Published online 2020 Feb 13. doi: 10.1155/2020/8790130 PMCID: PMC7040398 Invisible Facial Flushing in Two Cases of Dengue Infection and Influenza Detected by PC Program and Smartphone App: Decorrelation Stretching and K-Means Clustering Manote Arpornsuwancorresponding author 1 and Matinun Arpornsuwan [16] antwantsclear (post no 4) says, "My flushing is very sensitive to wi-fi so if I was coding without the computer being on the ethernet I would certainly flush - similarly if I was reading on a wireless device. I do have an air conditioner which is very helpful but the activities you suggest don't necessarily provoke my flushing when reading old fashioned books or using a wired computer - Apple devices are some of the worst for people who are sensitive to EMF fields."

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Periorol Dermatitis is a rosacea mimic and is considered in a differential diagnosis of rosacea. It can co-exist with rosacea and some clinicians consider Periorol Dermatitis as a rosacea variant. The RRDi classifies Rosacea Periorial Dermatitis as a rosacea variant. "Perioral” refers to the area around the mouth, and “dermatitis” indicates a rash or irritation of the skin. Usually Periorol Dermatitis is characterized by tiny red papules (bumps) around the mouth. The areas most affected by perioral dermatitis are the facial lines from the nose to the sides and borders of the lips, and the chin. The areas around the nose, eyes, and cheeks can also be affected. There are small red bumps, mild peeling, mild itching, and sometimes burning associated with perioral dermatitis. When the bumps are the most obvious feature, the disease can look like acne. For more info on Perioral Dermatitis