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"In this case report, we detail the response of a 37-year-old Caucasian man with an overlap of erythematotelangiectatic rosacea and telangiectatic photoaging to brimonidine tartrate gel. With the application of brimonidine only on half of his face, skin analysis images, clinician's and patient's assessment showed that there was significant improvement in the erythema. This case has lent insight into how brimonidine can be used to assess the extent of photoaging by eliminating the erythema of rosacea to some degree. We propose that it can be used as a non-invasive test to differentiate between the two conditions, sparing patients from skin biopsies and molecular analysis." Australas J Dermatol. 2017 Feb;58(1):63-64. doi: 10.1111/ajd.12430. Epub 2016 Jan 13. Rosacea or photodamaged skin? Use of brimonidine gel in differentiating erythema in the two conditions. Oon HH, Lim ZV.

Telangiectatic Photoaging "Telangiectatic photoaging is characterized by less transient and nontransient erythema, a more lateral distribution of erythema and telangiectasia, less neurogenic mast cell activation, and less MMP-mediated matrix remodeling than ETR. These data demonstrate that TP is a distinct clinical entity from ETR that can be distinguished on the basis of clinical, histologic, and gene expression findings." JAMA Dermatol. 2015;151(8):825-836. doi:10.1001/jamadermatol.2014.4728 Clinical, Histologic, and Molecular Analysis of Differences Between Erythematotelangiectatic Rosacea and Telangiectatic Photoaging Yolanda R. Helfrich, MD; Lisa E. Maier, MD; Yilei Cui, PhD; et al JAMA Dermatol. 2015 Aug;151(8):825-36. doi: 10.1001/jamadermatol.2014.4728. Clinical, Histologic, and Molecular Analysis of Differences Between Erythematotelangiectatic Rosacea and Telangiectatic Photoaging. Helfrich YR, Maier LE, Cui Y, Fisher GJ, Chubb H, Fligiel S, Sachs D, Varani J, Voorhees J. JK Wilkin has a comment on the above article published in JAMA and another in the NEJM.

Staphylococcus epidermidis image courtesy of Wikimedia Commons Bacteria has been implicated and investigated as the leading microbe associated with rosacea for over sixty years. Antibiotics have been prescribed for rosacea, particularly tetracycline and more recently with doxycycline, along with many other antibiotics, which leads to the bacteria theory on the cause of rosacea. There has been a bias in most, if not all, the clinical papers investigating the skin microbiome in rosacea patients ignoring other microbes, i.e., virus, archea, fungus, protozoa. Demodex mites have been the other most investigated microbe of the skin microbiome with a vast number of clinical papers. A typical paper indicating this bias towards chiefly investigating bacteria and demodex is the following conclusion on this subject: "Although we were not able to pinpoint a causative microbiota, our study provides a glimpse into the skin microbiota in rosacea and its modulation by systemic antibiotics.' J Clin Med. 2020 Jan; 9(1): 185. Published online 2020 Jan 9. doi: 10.3390/jcm9010185 PMCID: PMC7019287 PMID: 31936625 Characterization and Analysis of the Skin Microbiota in Rosacea: Impact of Systemic Antibiotics Yu Ri Woo, Se Hoon Lee, Sang Hyun Cho, Jeong Deuk Lee, and Hei Sung Kim The above paper only investigated bacteria and mentions demodex and ignores all other microbes of the skin microbiota. Bacteria and Rosacea Theory Microorganisms of the Human Microbiome

image courtesy of Pinterest Odd that a rosacea plant would have natural antibacterial properties. The photo above is one of Pyrus glabra while the one below is Pyrus syriaca: image courtesy of Wikimedia commons

Topical ivermectin has been found effective in the treatment of T‐cell‐mediated skin inflammatory diseases. For more information.

"Altogether, our results show that IVM is endowed with topical anti‐inflammatory properties that could have important applications for the treatment of T‐cell‐mediated skin inflammatory diseases." Topical ivermectin improves allergic skin inflammation E. Ventre A. Rozières V. Lenief F. Albert P. Rossio L. Laoubi D. Dombrowicz B. Staels L. Ulmann V. Julia E. Vial A. Jomard F. Hacini‐Rachinel J.‐F. Nicolas M. Vocanson More on Ivermectin Reply to this TopicThere 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.

Fictional parasitism: oil painting Parasites by Katrin Alvarez, 2011 image courtesy of Wikimedia Commons For a long time microorganisms of the skin microbiome have been suggested as a cause of rosacea. The list includes, bacteria, virus, and demodex mites. Further, there are some papers that suggest that the gut microbiome may be involved in rosacea. [Microorganisms of the Human Microbiome] "Antiparasitics are a class of medications which are indicated for the treatment of parasitic diseases, such as those caused by helminths, amoeba, ectoparasites, parasitic fungi, and protozoa, among others." Wikipedia "Broad-Spectrum antiparasitics, analogous to broad-spectrum antibiotics for bacteria, are antiparasitic drugs with efficacy in treating a wide range of parasitic infections caused by parasites from different classes." Wikipedia Bacterial, Viral, and Fungal Cutaneous Infections are classified as part of the Skin and soft tissue infections (SSTIs)." Bacterial skin and soft tissue infections (SSTIs) constitute approximately 20% of outpatient dermatology visits and are among the most common types of bacterial infection." [1] Other prescription anti-parasitic drug therapies are Anticestodes, Antitrematodes, Antiamoebics, AntiFungals, and new drug therapies such as "triazolopyrimidines and their metal complexes have been looked at as an alternative drug to the existing commercial antimonials.' Wikipedia Anti-Parasitic Treatments for Rosacea Prescription Antinematodes include ivermectin. Prescription Antiprotozoals include metronidazole (also used for its antibiotic and anti-inflammatory effects), artemisinin, artesunate, chloroquine, hydroxychloroquine, and mepacrine. These treatments have not yet been mentioned to treat rosacea: ornidazole, secnidazole, and tinidazole. Anticestodes for Rosacea Anticestodes treatments used to treat rosacea include Benzyl benzoate, Crotamiton, Permethrin, and Praziquantel. Antiviral Treatments for Rosacea Acylovir has been reported to be effective in the treatment of Pityriasis rosea, a type of skin rash and at least one anecdotal report improves rosacea. Coronavirus and Rosacea There are anti-parasitic agents used in the treatment for rosacea that are also being investigated in treating coronavirus, i.e., chloroquine, hydroxychloroquine, ivermectin, and metronidazole which we are adding TO THIS POST. AntiFungal Treatments (antimycotic medication) are listed under the same subheading on this post. 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] "Over the past decade, there has been an increase in the incidence of SSTIs presumably due to the aging population, increase in number of immunocompromised people, and the emergence of multi-resistant pathogens. Data from 2012 showed that the total cost of SSTIs in the USA alone was $13.8 billion, mostly due to hospitalizations. Clearly, cutaneous infections and their management are a significant health and financial burden and providers should be educated on the most recent developments in order to provide effective, evidence-based care for their patients." Curr Dermatol Rep. 2020; 9(2): 152–165. New Developments in Bacterial, Viral, and Fungal Cutaneous Infections Samuel Yeroushalmi, Joshua Yoseph Shirazi, Adam Friedman

Thanks BlackMamba24 for the update and so happy for you!

image courtesy of the CDC Sugar is just as much a valid rosacea trigger as any of the other proposed rosacea triggers since Sugar = Rosacea Fire. You will not learn that sugar is a rosacea trigger from any other rosacea non profit organization because the RRDi is the only one that lists sugar as a rosacea trigger. This post will help you understand how you can figure out better what added sugar is in the processed food or drink you might consume to see how much sugar you are allowing in your diet. We reported in 2015 how the FDA was considering make a a change on the nutrition facts label about how many grams of added sugar is in a food or drink (the eighth post in this thread dated Posted July 25, 2015). The FDA did change the Nutrition Facts Label to show added sugar with this announcement in October 2018 that allows certain manufacturers until 2021 to comply with the change. While there are six new differences in the label, item number 3 is about added sugar and note what the FDA states about this: "3. Added sugars are now listed to help you know how much you are consuming. The 2015-2020 Dietary Guidelines for Americans recommends you consume less than 10 percent of calories per day from added sugars. That is because it is difficult to get the nutrients you need for good health while staying within calorie limits if you consume more than 10 percent of your total daily calories from added sugar." October 2018 announcement Healthline had this to say about the above label change: "Before this label change, different types of sugars were lumped into a total sugars category on the Nutrition Facts label. For example, many fruit yogurts contain sugars from three sources: lactose from milk, natural sugars from fruit, and added sugars. All of these were tallied as one figure under total sugars. The new labels will distinguish added sugars to help people understand exactly how much they’re eating, which shouldn’t be more than 10 percent of their daily calories, according to the FDA’s dietary guidelines." New Nutrition Labels Reveal How Much Added Sugar You’re Eating, Healthline, November 2, 2018 WebMD had this to say about the label change: "It can be tough to recognize added sugars by looking at the list of ingredients on a label, the U.S. Centers for Disease Control and Prevention says. Brown sugar, corn sweetener, corn syrup, dextrose, fructose, glucose, high-fructose corn syrup, honey, lactose, malt syrup, maltose, molasses, raw sugar and sucrose are just some of the many different ingredients that contribute added sugars to food, the CDC notes. To make things simpler for consumers, the FDA proposed a new line on the Nutrition Facts label that totals up all these sources of added sugar." 'Added Sugars' Label on Foods May Save Many Lives, Dennis Thompson, WebMD Later, the FDA allows manufacturers of certain "single-ingredient sugars and syrups and certain cranberry products' that "allow for the use of a “†” symbol immediately following the percent Daily Value declaration for Added Sugars, which leads consumers to a statement that provides information about the gram amount of Added Sugars, as well as information about how that amount of sugar contributes to the percent Daily Value." Statement on new guidance for the declaration of added sugars on food labels for single-ingredient sugars and syrups and certain cranberry products, Susan T. Mayne Ph.D., Director - Center for Food Safety and Applied Nutrition (CFSAN) The CDC has this to say about the amount of added sugar you should consume each day: "Americans should keep their intake of added sugars to less than 10% of their total daily calories as part of a healthy diet. For example, in a 2,000 daily calorie diet no more than 200 calories should come from added sugars." Know Your Limit for Added Sugars To convert calories to grams you should remember that there are 4 calories in one gram of carbohydrate. So the above recommendation from the CDC which is based upon the new FDA recommendation means that 10% of added sugar amounts to 50 grams of carbohydrate. Sugar is carbohydrate. Further, the added sugar is just what the label is pointing out to you besides the natural sugar or carbohydrate in the food or drink your are consuming. So if you look at the new label at the top of this post the TOTAL carbohydrate (sugar) contained in the item is 37 grams. Of that 37 grams there is included 10 grams of added sugar. In other words, if the product didn't add the 10 grams of sugar the food item still has 27 grams of carbohydrate (sugar). If you want to learn for your self whether reducing sugar (carbohydrate) in your diet improves your rosacea, looking at the Nutrition Facts Label can be an eye opener for many who are not aware how much carbohydrate (sugar) is in the diet. A simple test to discover that sugar (carbohydrate) is a rosacea trigger for you, reduce the amount of sugar (carbohydrate) in your diet to no more than 30 grams a day for 30 days. During this test you should see some improvement in your rosacea within the thirty days. After the thirty days, gorge yourself with all the sugar and carbohydrate you want and see if your rosacea comes back? That is the basic nutshell version of the Rosacea Diet. This post on the new label requirements for added sugar makes it easier for you to spot added sugar. The New York Times had this to say about added sugar: "While you might think you’re not eating much sugar, chances are you’re eating a lot more than you realize. Added sugar lurks in nearly 70 percent of packaged foods and is found in breads, health foods, snacks, yogurts, most breakfast foods and sauces. The average American eats about 17 teaspoons of added sugar a day (not counting the sugars that occur naturally in foods like fruit or dairy products). That’s about double the recommended limit for men (nine teaspoons) and triple the limit for women (six teaspoons). For children, the limit should be about three teaspoons of added sugar and no more than six, depending on age and caloric needs." Make 2020 the Year of Less Sugar, Tara Parker-Pope, The New York Times, December 31, 2019 The above article also included a seven day challenge. There was a follow up article on the above article which added: "As an example, take a look at the label on whole milk, which shows 11 grams of sugar in a one-cup serving. That sounds like a lot, but the new label will make it clear that all that sugar occurs naturally as lactose and that the same cup of milk has zero grams of added sugar. A chocolate milk label will show 26 grams of total sugar, which includes 11 grams of lactose, and the extra information that a serving has 15 grams of added sugar." Dried Fruit, Oats and Coffee: Answers to Your Sugar Questions Our 7-Day Sugar Challenge prompted a number of questions about cutting added sugar from our daily diet. Tara Parker-Pope, The New York Times, Jan. 8, 2020

While the above study admitted the limit of a small sample size, as well as, 'The lack of an objective scoring system in the diagnosis of Demodex infestation is another limitation,' it doesn't mention that Light Microscopy Skin Scraping is Not as Reliable as 'Confocal laser scanning in vivo microscopy' which is more reliable. See item one in this post. What it does conclude is demodex mites are indeed in higher density in rosacea patients over the control group. Demodex Density Count - What are the Numbers?

"Oral ivermectin (200 micrograms/kg/day) is also a treatment alternative for PPR although it is supported with level D evidence. In patients with treatment resistant rosacea, combination of oral ivermectin and permethrin 5% cream can be considered since this combination was found to be effective in decreasing demodex density in immunocompromised patients as well." Clin Cosmet Investig Dermatol. 2020; 13: 179–186. Published online 2020 Feb 20. doi: 10.2147/CCID.S194074 PMCID: PMC7039055 PMID: 32110082 Conventional and Novel Treatment Modalities in Rosacea Burhan Engin, Defne Özkoca, Zekayi Kutlubay, and Server Serdaroğlu

The February 2020 issue of the Clinical, Cosmetic and Investigational Dermatology reports, "Therefore, in 2017, there was a shift from subtypes to phenotypes in the diagnosis of rosacea and at least one diagnostic or two major phenotypes are required in order to diagnose a patient with rosacea."

Rosacea image Courtesy of Wikimedia Commons Phenotype 4 used to be classified as Subtype 2 (Papules & Pustules), which looks similar to acne vulgaris with the exception that blackheads are not indicated in rosacea. Papule, Pustule, Pimple, Comedo, Lesion, Cyst & Abscess Explained Treatment for Phenotype 4

"In this longitudinal cohort study of more than 82 000 participants with more than 1.1 million person-years of follow up, higher caffeine intake was associated with lower rosacea risk after adjustment for several confounders. Overall, participants who drank 4 cups of coffee per day were less likely to develop rosacea compared with participants who did not drink coffee. A dose-response association was found for both increasing caffeine and coffee intake. The authors hypothesized that caffeine’s vaso-constrictive and immune suppressive effects might decrease the risk of rosacea." Source JAMA Dermatol. 2018 Dec 1; 154(12): 1385–1386. doi: 10.1001/jamadermatol.2018.3300 PMCID: PMC6510488 NIHMSID: NIHMS1020506 PMID: 30347020 One More Reason to Continue Drinking Coffee–It May Be Good for Your Skin Mackenzie R. Wehner, MD, MPhil and Eleni Linos, MD, MPH, DrPH,

Here is a link to the entire article

image courtesy of Wikimedia Commons There is a hypothesis that the 'cross reaction between the GroEl chaperonin antibodies against the B.oleronius and human GroEl chaperonin' 'will not fold normally the ALDH2, and then the enzyme will not metabolize the acetaldehyde' and therefore, 'As a result, high amounts of acetaldehyde will circulate for longer time in the blood, until the liver CYP2E1(p450) enzyme system finally metabilizes the acetaldehyde, during that period of time the patients will experience a flushing as well as the people with the "Asian flushing syndrome" suffer when they drink ethanol.' Med Hypotheses, 84 (4), 408-12 Apr 2015 Hypothesis of Demodicidosis Rosacea Flushing Etiopathogenesis Mary Ann Robledo, Mariana Orduz

Flushing avoidance is one of the chief concerns of Phenotype 1 rosaceans. For more information.

Ball-and-stick model of cromolyn molecule gif image courtesy of Wikimedia Commons "Cromolyn sodium or other MC stabilizers affect the release of histamine and other inflammatory mediators from MCs to ameliorate erythema in ETR. Drugs including brimonidine and BoNT can also reduce the recruitment of MCs and inhibit MC degranulation to improve inflammation associated with rosacea." Front Med (Lausanne). 2019; 6: 324. Published online 2020 Jan 28. doi: 10.3389/fmed.2019.00324 PMCID: PMC6997331 PMID: 32047752 The Theranostics Role of Mast Cells in the Pathophysiology of Rosacea Lian Wang, Yu-Jia Wang, Dan Hao, Xiang Wen, Dan Du, Gu He, and Xian Jiang

Acuri reports using aspirin improves flushing (at RF).

I haven’t figured out how to get the full article. Sometimes in the author information it shows an email address and I ask for the full article and one of authors sometimes sends a copy. If anyone would volunteer to figure out how to get copies of articles like this (without paying for it!) that would be most helpful. We are searching for volunteers!

The RRDi financial report shows clearly how we are spending member donations. If the over 1300 members would each donate ONE DOLLAR that would keep us going for another year. If you appreciate the amount of rosacea data preserved on our website and forum would you consider donating one dollar so we can keep this non profit organization for rosacea patient advocacy going? If you have the volunteer spirit you could read our current financial situation and with some math figure out how long our current spending will last. As you can see our funds our meager compared to the other non profit organizations for rosacea which will be the only ones left if the RRDi doesn't receive donations to continue its operation.

A new paper states the following, 'A Western diet rich in fat and sugar may lead to inflammatory skin diseases such as psoriasis, a study by UC Davis Health researchers has found." The article mentions that "cholestyramine, a drug used to lower cholesterol levels by binding to bile acids in the intestine, helped reduce the risk of skin inflammation.' Western diet rich in fat and sugar linked to skin inflammation, Science Daily, February 18, 2020

Trevi has a post that he says just using warm to hot water for three months and he has clearance. He does mention in the initial post he has been using some boric acid as well. We will follow up and see if anyone else confirms that this helps improve SD/Rosacea or not. Using just warm water to hot water is about as natural as it gets. You be judge whether boric acid is natural or not.

Welcome Steven Zeigler to the RRDi. As Apurva points out you are correct in your research. You can take time in this forum category you posted in, PSYCHOLOGY AND ROSACEA, to continue your research by reading all the posts. One of the many theories on rosacea is the Nervous System Theory which is worth some of your time to investigate since it is related somewhat. However, your doctor isn't acquainted with the Gold Standard of treatment for rosacea and is old school prescribing [probably] topical metronidazole and doxycycline. What exactly did your doctor prescribe? There are a number of rosacea theories on the cause of rosacea, but this post is worth considering. If you want a free copy of Rosacea 101 which includes the Rosacea Diet, just use the contact form [request a copy]. Avoiding sugar and carbohydrate may improve your skin. You may want to read this post about alcohol and rosacea. The RRDi official trigger factor list has a number of environmental triggers. As for everyone being different with regard to rosacea, we have dubbed this the X-Factor in Rosacea.

Thanks Ruby, keep us posted.