Guide

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. 

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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

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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

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]

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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

[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 2017
New pathways in the treatment for menopausal hot flushes
Jenifer 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. 

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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."

This post has been promoted to an article

The RRDi has collected a number of cosmetics to consider in your search by using our affiliate store. 

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 

This Post Has Been Promoted as an Article

Glandular Rosacea is recognized as a rosacea variant. 

"In 2004 in an article appearing in the Journal of the American Academy of Dermatology, Crawford et al. proposed the concept of glandular rosacea to describe another phenotype distinct from the four subtypes introduced by the expert committee. Glandular rosacea occurs predominantly in males who characteristically have oily skin, large pores, a tendency to rhinophyma, and inflammatory lesions, including papules, pustules and nodulocystic lesions, that extend onto the lateral cheeks and neck." [1]

Whether Glandular Rosacea should be classified as a phenotype, subtype or variant remains to be seen, but for now it is listed with the variants of rosacea to end the confusion (we also listed it previously as a proposed subtype). 

End Notes

[1] Literature review highlights renewed interest in rosacea research
Dermatology Times, Modern Medicine, Nov 1, 2006, Cheryl Guttman, page 2

Rosacea Variant:
Granulomatous Rosacea [also known as Lupoid rosacea]

This is the only variant as of this date recognized by the NRS 'expert committee' who first classified rosacea into subtypes and variants. This variant of rosacea is characterized by firm, yellow, brownish or redish, cutaneous papules or nodules. These lesions are less inflammatory and frequently sit upon relatively normal-appearing skin but sometimes it is diffusely red and thickened. Typically, they are monomorphic in each individual patient affecting the cheeks and the periorifical areas. For diagnosing this form of rosacea, other signs and symptoms of rosacea are not necessary. Diascopy with a glass spatula reveals the lupoid character of the infiltrations. Lupoid or granulomatous rosacea may lead to scarring of the skin. [1]

"Granulomatous rosacea is a rare chronic inflammatory skin disease with an unknown origin. The role of Demodex follicularum in its pathogenesis is currently proved." [9]

Granulomatous rosacea Image Dermatology Online Journal

One source describes granulomatous rosacea:

"A rare caseating granulomatous variant of rosacea (acne agminata/lupus miliaris disseminatus faciei) can manifest with inflammatory erythematous or flesh-colored papules distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. The lesions tend to be discrete, and surrounding erythema is not a marked feature but may be present. This pattern of rosacea is sometimes associated with scarring and may be resistant to conventional treatment." [1]

"...Although usually considered a non-pathogenic parasite in parasitological textbooks, Demodex folliculorum has been implicated as a causative agent for some dermatological conditions, such as rosacea-like eruptions and some types of blepharitis. Several anecdotal reports have demonstrated unequivocal tissue damage directly related to the presence of the parasite. However, this seems to be exceedingly rare, in contrast with the marked prevalence of this infestation. We have had the opportunity to observe one of such cases. A 38-year-old woman presented with rosacea-like papular lesions in her right cheek. Histopathological examination revealed granulomatous dermal inflammation with a well-preserved mite phagocytized by a multinucleated giant cell. This finding may be taken as an evidence for the pathogenicity of the parasite, inasmuch as it does not explain how such a common parasite is able to produce such a rare disease." It is associated with demodex. [2]

"Histological investigation revealed follicular cysts and a chronic granulomatous perifolliculitis with many of Demodex folliculorum." [3] Another report had a similar finding. [4]

A report by Neri, et. al., suggested that Idiopathic Facial Aseptic Granuloma (IFAG), or pyodermite froide du visage be "considered the possibility that IFAG might be included in the spectrum of granulomatous rosacea (GR)." [5]

Other names considered are "Micropapular tuberculid", or "Rosacea-like tuberculid of Lewandowsky") [12]

Treatment

Dapsone [6]

Isotretinoin (10-20 mg daily) [7]

"The aetiopathogenetic role of Helicobacter pylori in rosacea remains controversial. We report a 27-year-old man with a 4-year history of intractable rosacea. Histopathology showed epithelioid granulomas. H. pylori infection was proven directly on gastroscopy and by serological testing. Treatment with clarithromycin, metronidazole and pantoprazole eradicated H. pylori. Skin changes were markedly improved by the end of this therapy and had resolved completely 2 months later. The patient has been followed up, and has remained free of symptoms for 3 years. We suggest that H. pylori may be involved in the aetiopathogenesis of granulomatous rosacea." [8]

elmonxito says he is convinced that removing some of his infected teeth improved his granulomatous rosacea. [10]

"a 66-year-old lung transplant recipient, who was successfully treated with oral metronidazole and ivermectin cream." [11]

Reply to this Topic

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End Notes

[1] rosacea.dermis.net

[2] Granulomatous rosacea associated with Demodex folliculorum.
Amichai B, Grunwald MH, Avinoach I, Halevy S.
Int J Dermatol. 1992 Oct;31(10):718-9.

[3] Tubero-pustular demodicosis
Grossmann B, Jung K, Linse R.
Hautarzt. 1999 Jul;50(7):491-4.

[4] Demodex folliculorum and the histogenesis of granulomatous rosacea
Grosshans EM, Kremer M, Maleville J.
Hautarzt. 1974 Apr;25(4):166-77.

[5] Should Idiopathic Facial Aseptic Granuloma Be Considered Granulomatous Rosacea? Report of Three Pediatric Cases.
Neri I, Raone B, Dondi A, Misciali C, Patrizi A.
Pediatr Dermatol. 2012 Feb 16. doi: 10.1111/j.1525-1470.2011.01689.x.

[6] Hautarzt. 2013 Apr;64(4):226-8. doi: 10.1007/s00105-013-2556-7.
Successful treatment of granulomatous rosacea with dapsone.
Ehmann LM, Meller S, Homey B.
Hautklinik des Universitätsklinikums Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.

Other Sources

A case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affect the face.
Omar Khokhar MD, and Amor Khachemoune MD CWS
Dermatology Online Journal 10 (1): 6

Granulomatous rosacea.
Sánchez JL, Berlingeri-Ramos AC, Dueño DV.
Am J Dermatopathol. 2008 Feb;30(1):6-9.

J Cutan Med Surg. 2012 Dec 1;16(6):438-441.
Isotretinoin for the Treatment of Granulomatous Rosacea: Case Report and Review of the Literature.
Rallis E, Korfitis C.

Please read this notice about Subtypes

Subtype 4:
Ocular

Ocular rosacea is common but often not recognized by the clinician.[1] It may precede, follow, or occur simultaneously with the skin changes typical of rosacea. In the absence of accompanying skin changes, ocular rosacea can be difficult to diagnose, and there is no test that will confirm the diagnosis. Patients usually have mild, nonspecific symptoms, such as burning or stinging of the eyes. A sensation of dryness is common, and tear secretion is frequently decreased. [2] Mild-to-moderate ocular rosacea (including blepharoconjunctivitis, chalazia, and hordeola) occurs frequently, whereas serious disease with the potential for visual loss, such as that which results from keratitis, occurs rarely. 

"Probably the first description of ocular rosacea was by the famous English dermatologist Willan in the earl 1800’s whose handwritten note on an illustration fo a patient with PPR documented the presence of ocular inflammation." [16] 

Ocular problems occur in at least 50 percent of patients with rosacea. [3]

"Although considered a skin disease, rosacea may evolve the eyes in 58-72% of the patients, causing eyelid and ocular surface inflammation. About one third of the patients develop potentially sight-threatening corneal involvement. Untreated rosacea may cause varying degrees of ocular morbidity." [14]

There may be a clinical diagnositic test now available for ocular rosacea. [4]

One report said, "Patients with rosacea have thinner corneas, which could be attributed to the observed deteriorated tear function parameters." [12]

For images of Ocular Rosacea click here:

http://goo.gl/ESG4n

Treatment

Treating ocular rosacea (from the AAO)

Topical Cyclosporine Proves Beneficial For Ocular Rosacea [6]

Avermectin Milbemycin Eyewash for Ocular Rosacea [7]

Might consider demodex mite treatment. [8]

Terpinen-4-ol (T4O) Pass [11]

One report states, "We suggest that a clinically acceptable dosage of PRP provides the ocular surface with the components necessary to restore normal cellular tensegrity and provides a foundation to eliminate the recurrence of the inflammation associated with DES [Dry eye syndrome]." [13]

Cliradex [15]

Diagnostic Test

While there is no diagnostic test for Ocular Rosacea there may be indicators coming down the pipeline for such a test. One paper suggests, "The abundance of highly fucosylated N-glycans in the control samples and sulfated O-glycans in ocular rosacea patient samples may lead to the discovery of an objective diagnostic marker for the disease." [9] Another paper suggests, "The high abundance of oligosaccharides in the tear fluid of patients with rosacea may lead to an objective diagnostic marker for the disease." [10]

"There is not yet a diagnostic test for rosacea. The diagnosis of ocular rosacea relies on observation of clinical features, which can be challenging in up to 90% of patients in whom accompanying roseatic skin changes may be subtle or inexistent." [14]

Links [5]

Dry Eye: Awareness, Diagnosis, and Management

All of the ocular rosacea articles at rosacea news

Ocular Rosacea: Dr. Eric Jones, MD

Ocular Rosacea: Dr. Mark J. Mannis, MD

Ocular Rosacea: Curse of the Celts and Celebs, Heather Potter, MD, University of Wisconsin, School of Medicine and Public Health

End notes

[1] Kligman AM. Ocular rosacea: current concepts and therapy. Arch Dermatol 1997;133:89-90.[CrossRef][iSI] [Medline]

[2] Gudmundsen KJ, O'Donnell BF, Powell FC. Schirmer testing for dry eyes in patients with rosacea. J Am Acad Dermatol 1992;26:211-214.[iSI] [Medline]

[3] Rosacea: A Common, Yet Commonly Overlooked, Condition
B. WAYNE BLOUNT, M.D., M.P.H. and ALLEN L. PELLETIER, M.D.
Am Fam Physician. 2002 Aug 1;66(3):435-441.

[4] Glycomics Analyses of Tear Fluid for the Diagnostic Detection of Ocular Rosacea
Hyun Joo An, Milady Ninonuevo, Jennifer Aguilan, Hao Liu,‡ Carlito B. Lebrilla, Lenio S. Alvarenga, and Mark J. Mannis
J. Proteome Res., 2005, 4 (6), pp 1981–1987, October 6, 2005, American Chemical Society

Trail of Tears May Lead to the First Diagnostic Test for Ocular Rosacea
Ocular Rosacea Test
Updated: 6/21/2006 9:16:46 AM Dental Care & Health Care Articles

[5] Link list courtesy of David Pascoe

[6] Topical Cyclosporine Proves Beneficial For Ocular Rosacea
Skin and Allergy News, Medical Dermatology
BRUCE JANCIN, Skin & Allergy News Digital Network

[7] Patent applied for by Galderma
David Pascoe's comment on the above patent

[8] In vitro and in vivo killing of ocular Demodex by tea tree oil.
Gao YY, Di Pascuale MA, Li W, Baradaran-Rafii A, Elizondo A, Kuo CL, Raju VK, Tseng SC.
Ocular Surface Center, 7000 SW 97 Avenue, Suite 213, Miami, FL 33173, USA.
Br J Ophthalmol. 2005 Nov;89(11):1468-73.

[9] Glycomic analysis of tear and saliva in ocular rosacea patients: the search for a biomarker.
Vieira AC, An HJ, Ozcan S, Kim JH, Lebrilla CB, Mannis MJ.
Ocul Surf. 2012 Jul;10(3):184-92. Epub 2012 May 3.

[10] Glycomics Analyses of Tear Fluid for the Diagnostic Detection of Ocular Rosacea
Hyun Joo An, Milady Ninonuevo, Jennifer Aguilan,Hao Liu, Carlito B. Lebrilla, Lenio S. Alvarenga,and Mark J. Mannis
J. Proteome Res., 2005, 4 (6), pp 1981–1987, DOI: 10.1021/pr0501620, Publication Date (Web): October 6, 2005

[11] In clinical trials as of August 2012:
Demodex Blepharitis Treatment Study (DBTS)

[12] Can J Ophthalmol. 2012 Dec;47(6):504-8. doi: 10.1016/j.jcjo.2012.07.009.
Central corneal thickness in patients with mild to moderate rosacea.
Onaran Z, Karabulut AA, Usta G, Ornek K.

[13] Optometry. 2012 Mar 30;83(3):111-3.
Dry-eye--is inflammation just the tip of the iceberg?
Jarka ES, Kahrhoff M, Crane JB.

[14] Arq Bras Oftalmol. 2012 Oct;75(5):363-9.

Ocular rosacea: a review.

Please read this notice about Subtypes

Subtype 3 is now known as Phenotype Phymatous (Rhinophyma)

Please read this notice about Subtypes

Subtype 2:

Papulopustular (PPR)

(characterized by persistent redness with bumps [papules] and pimples [pustules])

Usually the most responsive to treatment subtype. Usually, small, dome-shaped erythematous papules, some of which have tiny surmounting pustules, on the convexities of the central portion of the face, with background erythema typify papulopustular rosacea.

for images of PPR click below:

http://goo.gl/aNoPX

Please read this notice about Subtypes

Subtype 1:

Erythematotelangiectatic (ETR)

(characterized by persistent redness, usually with the Butterfly or T -Zone)

This is usually the most difficult to treat.

Flushing, with persistent central facial erythema (erythematotelangiectatic rosacea), is probably the most common presentation of rosacea.

Click below for images:

http://goo.gl/68HpW

image courtesy of the University College Dublin

Please read this notice about Subtypes

Neurogenic Rosacea recognized by the RRDi as a Subtype of Rosacea since 2011, now recognizes Neurogenic Rosacea as a variant of rosacea. 

This post has been promoted to an article

Human steroidogenesis*

Steroid Rosacea is recognized as a Rosacea Variant

Steroids are sometimes used for rosacea and other skin conditions for treatment, usually in severe cases, for a limited time or short term therapy (scroll down to the subheading SHORT TERM STEROID TREATMENT). Steroids are not recommended for long term treatment of rosacea. If your doctor recommends a steroid treatment for your skin problem it should be explained to you what the benefits and risks or side effects associated with this treatment are. Usually the insert that comes from the product explains what these risks and side effects might be. Obviously, sometimes short term steroid treatment has been helpful to some who have had rosacea or other skin condition, or we wouldn't even hear of anyone being prescribed steroids.

Topical Steroid Rosacea - image courtesy of Wikimedia Commons

Steroid rosacea photos by DermNet NZ • Google images of Steroid Rosacea

While some rosaceans have mixed the two, steroids and rosacea, it is not a good idea. And if you want some good advice, never mix the two. Do not use topical steroids on rosacea, period! Why is this such a problem that it is listed as a variant? Because rosaceans continue to use steroids or allow their physicians to treat them with steroids. An informed rosacean can decide whether the benefit of using steroids for rosacea is worth the risk, and your physician should explain the benefit/risk ratio to you. You have the choice to either accept the treatment or decline it.

Dermatologists have been using topical corticosteroids since the 1950s treating intractable dermatoses. However, a report in 1988 says, "Disadvantages of corticosteroid activity include the possibility of adrenal suppression, epidermal and dermal thinning, and local effects such as purpura, striae, and steroid-induced rosacea and perioral dermatitis." [1]

Various Names for Steroid Rosacea

One paper calls it Facial corticosteroid addictive dermatitis (FCAD). [2] Another paper calls it Topical Steroid-Induced Facial Dermatosis [3] One paper designates this as Topical steroid dependent/damaged face (TSDF). [31] The names are a growing list. 

Another report called it "steroid dermatitis." [25]

One paper calls it "Topical corticosteroid withdrawal ("steroid addiction")." [34]

"Based on the patient’s history of the long-term topical corticosteroids and physical examination, we finally diagnosed this case as unilateral steroid-induced rosacea-like dermatitis (SIRD)." [36]

"Topical steroid damaged face (TSDF) was a newly described phenomenon in 2008, which is characterized by a group of symptoms induced by the prolonged, unsupervised usage of TCs on the face, regardless of the potency." [37]

History of Treating Skin Conditions with Steroids

"...Corticosteroids were first introduced for topical use in dermatology in 1951. Since then uncontrolled use (abuse) has caused many different reactions, often with manifestations resembling those of rosacea..." [3]

"...Dermocorticosteroids can be indicated in numerous inflammatory skin diseases (psoriasis, eczema ...). They are formally contraindicated in case of skin infections, diaper rash, acne and rosacea..." [4]

"Never, never, never, ever prescribe steroids for rosacea." [5]

Ironically, uninformed physicians sometimes prescribe steroids for rosacea or rosaceans may use over the counter non-prescription steroid topicals for rosacea and initially the rosacea may improve but after continuous use the rosacea gets worse. Hence the term, steroid-induced rosacea has developed due to uninformed rosaceans using long term topical steroids to treat rosacea or other skin conditions. This indicates that it is up to rosaceans to be informed and ask their physicians if they are keeping up with current treatment for rosacea. Reports still show that physicians prescribe steroids for acne rosacea, for example:

"The first patient was treated with oral steroids, as well as doxycycline, to control his acne rosacea." (1998) [6]

Here is a classic example of physicians treating rosacea with prednisolone, a steroid, in 1990:

"Metronidazole was investigated in the basic dermatologic agent Elacutan W to improve the topical therapy of rosacea. The suitability of that basic dermatologic agent was verified for metronidazole, prednisolone and dexamethasone by stability tests (UV-spectroscopy, pH) and by in-vitro-liberation-measurements (membrane method). The drugs are stable for a period of 100 days." [7]

And here is what these physicians should have read about prednisone in 1989:

"A patient with malignant lymphoma repeatedly developed transient rosacea-like dermatitis several days after each interruption of continuous oral prednisone intake. We thought that the eruption was provoked by withdrawal of orally administered steroid, and thus we diagnosed the patient as having steroid-withdrawal rosacea-like dermatitis, one manifestation of steroid-withdrawal syndrome." [8]

What is difficult to understand is that two variants of rosacea, Rosacea Fulminans, and Perioral Dermatitits are treated with Accutane and steroids. One report says that Corticosteroids and isotretinoin are regarded as the two main therapeutic agents for treating RF. [9]

Periorol Dermatitis, a variant of rosacea, is sometimes the result of steroid use so rosaceans wonder what should they do if the physician prescribes steroids with all this conflicting data?

Demodicosis may develop after the use of steroids according to the following two reports:

"...the highest density of mites was found on the cheeks. A statistically significant increase in mites was found in all subgroups of rosacea, being most marked in those with steroid-induced rosacea...CONCLUSION: Increased mites may play a part in the pathogenesis of rosacea by provoking inflammatory or allergic reactions, by mechanical blockage of follicles, or by acting as vectors for microorganisms." [10]

"...Demodex folliculorum were also more frequently detected in patients who had previously been treated with topical corticosteroids (even in 91.9%), what was often followed by epitheloid granulomas..." [11]

However, one report in 2002 says the following:

"...Recently, steroid components have been synthesized that aim to have adequate anti-inflammatory effects and minimal adverse effects. The newest topical corticosteroids used for the treatment of different dermatoses and allergic reactions of the respiratory tract (in particular asthma) are budesonide, mometasone furoate, prednicarbate, the di-esters 17,21-hydrocortisone aceponate and hydrocortisone-17-butyrate-21-propionate, methylprednisolone aceponate, alclometasone dipropionate, and carbothioates such as fluticasone propionate..." [12]

As these new synthesized steroids are used, no doubt we will hear reports later of the long term effects for treating rosacea with these drugs. You as a rosacean have the right to ask questions about what treatment your doctor recommends.

"...54% developed the steroid rosacea while being treated with the lowest-strength (class 7) topical corticosteroids. Even over-the-counter hydrocortisone preparations induced steroid rosacea in susceptible children. Susceptibility may be genetic as 20% of children had a first-degree relative with rosacea." [13]

"...Initially, the mass was thought to be rhinophyma, but biopsy of the mass revealed noncaseating granulomata consistent with sarcoidosis. The mass resolved following several steroid injections..." [14]

Apparently topical fluorinated steroid therapy resulted in an onset of smooth, shiny, erythematous papules on the face according to one report. [15]

1% hydrocortisone was applied to six patients. Three developed a rosacea-like eruption for the first time and one also had perioral dermatitis. [16]

With Primary care physicians (PCPs), "When asked to rank the potency of 4 surveyed TCs [Topical Corticosteroids], 51.2% respondents were able to identify hydrocortisone acetate 1% cream as a low potent topical steroid." And with PCPs, "33.9% incorrectly responded that TCs can be used in all skin rashes, and 37.8% in acne vulgaris." [27]

Tthe University of Bristol has found evidence that prolonged treatment of synthetic corticosteroid drugs increases adrenal gland inflammation in response to bacterial infection, an effect that in the long-term can damage adrenal function. [28]

One report discusses the "Implications of Borderline Personality Disorder [with] Topical Steroid Dependence." [32]

"Exposure to potent topical corticosteroids is associated with increased risk for osteoporosis and major fracture, according to an observational study in JAMA Dermatology." [33]

"The long-term use of topical corticosteroids can result in rosacea-like dermatitis or facial perioral dermatitis." [35]

Short Term Steroid Treatment for Rosacea
Sometimes if your rosacea is severe your physician may prescribe short term steroid treatment, usually oral systemic steroid like Prednisone or in some cases a topical prescription steroid. Short term steroids are incredible to attenuate rosacea. [29]

Treatment for Steroid Rosacea 

0.03% tacrolimus and 595-nm pulsed dye laser [17]

1% pimecrolimus cream [18]

FK506 (tacrolimus) may control the increase in IL-1alpha with glucocorticoid in KCs, suggesting FK506 to suppress harmful effects of glucocorticoids such as steroid rosacea. [19]

Combination therapy of tetracyline and tacrolimus [20]

However, one report of using Tacrolimus resulted in a "proliferation of Demodex due to local immunosuppression." [21] Caveat emptor! Another report concluded "Topical tacrolimus is becoming an important cause of RD [rosacea-like dermatitis] along with topical steroids." [24]

A combination of oral antibiotics and topical tacrolimus is the treatment of choice for steroid-induced rosacea. [22]

Treating Steroid Induced Rosacea, Linda Sy, MD [23]

Calendula cream for steroid induced rosacea by May2012

Episofit A [26]

Probiotics

Topical 10% Tranexamic acid [31]

Anecdotal Reports

Henry

Two Reports in one.

M's report of what to do for steroid rosacea

TrixP was diagnosed with dermatitis and treated with a steroid and developed steroid induced rosacea.

reddy says, "My doctor gave me Daktakort cream which I have been using for the past 3 years but she told me if I kept using the cream it would make my skin very thin, only recently the cream has stopped working and when I use it now it makes my face even worse."

Fallout2077 writes, "...however I stupidly continued to use this same steroid cream on and off for 3 years and then every single day for the next year. Whilst it did suppress the flakes and dryness, it made my face gradually become very sensitive, red and spotty and so i thought i had developed rosacea...."

frank88 reports, "...I decided to cease the 1% cream on the 27th April about 20 days ago and my entire face has become very red, blotchy and inflammed with little pimples, all moreso in both the applications sites where I lightly applied the cream...."

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End Notes

*Image courtesy of Wikimedia Commons

[1] Clinical pharmacology and pharmacokinetic properties of topically applied corticosteroids. A review.
Goa KL., Drugs. 1988;36 Suppl 5:51-61.

[2] Facial corticosteroid addictive dermatitis in Guiyang City, China.
Lu H, Xiao T, Lu B, Dong D, Yu D, Wei H, Chen HD.
Clin Exp Dermatol. 2010 Aug;35(6):618-21. Epub 2009 Dec 8.

[3] Steroid dermatitis resembling rosacea: aetiopathogenesis and treatment.
Ljubojeviae S, Basta-Juzbasiae A, Lipozenèiae J.
J Eur Acad Dermatol Venereol. 2002 Mar;16(2):121-6.

[4] Local corticosteroid therapy in dermatology
Chosidow O, Lebrun-Vignes B, Bourgault-Villada I.
Presse Med. 1999 Nov 27;28(37):2050-6.

[5] "Dr.Kligman (Dermatology-University of Philadelphia) & Dr. Plewig (Dermatologische Klinik Und Poliklinik der Universitat Munchen, Germany) state in their 1973 book, entitled Acne & Rosacea, First edition. Likewise, their second edition in 1993 harshly criticizes dermatologists that prescribe steroids for rosacea."

Topical Steroids International Rosacea Foundation

[6] Mooren's ulcer.
Seino JY, Anderson SF.
Optom Vis Sci. 1998 Nov;75(11):783-90.

[7] Stability of metronidazole, prednisolone and dexamethasone in urea-containing Elacutan W dermatologic agent
Heyde R, Dorsch S, Heidenreich S, Illig G.
Dermatol Monatsschr. 1990;176(7):407-15.

[8] Steroid-withdrawal rosacea-like dermatitis.
Tomita Y, Tagami H.
J Dermatol. 1989 Aug;16(4):335-7.

[9] Rosacea fulminans in pregnancy.
Lewis VJ, Holme SA, Wright A, Anstey AV.
Br J Dermatol. 2004 Oct;151(4):917-9.

[10] The Demodex mite population in rosacea.
Bonnar E, Eustace P, Powell FC.
J Am Acad Dermatol. 1993 Mar;28(3):443-8.

[11] The possible role of skin surface lipid in rosacea with epitheloid granulomas.
Basta-Juzbasi&#263; A, Marinovi&#263; T, Dobri&#263; I, Bolanca-Bumber S, Sencar J.
Acta Med Croatica. 1992;46(2):119-23.

[12] New and established topical corticosteroids in dermatology: clinical pharmacology and therapeutic use.
Brazzini B, Pimpinelli N.
Am J Clin Dermatol. 2002;3(1):47-58.

[13] Steroid rosacea in prepubertal children.
Weston WL, Morelli JG.
Arch Pediatr Adolesc Med. 2000 Jan;154(1):62-4.

[14] Sarcoidosis of the external nose mimicking rhinophyma. Case report and review of the literature.
Goldenberg JD, Kotler HS, Shamsai R, Gruber B.
Ann Otol Rhinol Laryngol. 1998 Jun;107(6):514-8.

[15] Recent onset of smooth, shiny, erythematous papules on the face. Steroid rosacea secondary to topical fluorinated steroid therapy.
Martin DL, Turner ML, Williams CM.
Arch Dermatol. 1989 Jun;125(6):828, 831.

[16] Complications of topical hydrocortisone.
Guin JD., J Am Acad Dermatol. 1981 Apr;4(4):417-22.

[17] Eur J Dermatol. 2016 Jun 1;26(3):312-4. doi: 10.1684/ejd.2016.2757.
Recalcitrant steroid-induced rosacea successfully treated with 0.03% tacrolimus and 595-nm pulsed dye laser.
Seok J, Choi SY, Li K, Kim BJ, Kim MN, Hong CK.

[18] The use of 1% pimecrolimus cream for the treatment of steroid-induced rosacea.
Chu CY., Br J Dermatol. 2005 Feb;152(2):396-9.

[19] FK506 (tacrolimus) inhibition of intracellular production and enhancement of interleukin 1alpha through glucocorticoid application to chemically treated human keratinocytes.
Horiuchi Y, Bae SJ, Katayama I., Skin Pharmacol Physiol. 2005 Sep-Oct;18(5):241-6.

Rosacea: where are we now?
Bikowski JB, Goldman MP.
J Drugs Dermatol. 2004 May-Jun;3(3):251-61.

[20] Combination therapy of tetracycline and tacrolimus resulting in rapid resolution of steroid-induced periocular rosacea.
Pabby A, An KP, Laws RA., Cutis. 2003 Aug;72(2):141-2.

[21] Induction of rosaceiform dermatitis during treatment of facial inflammatory dermatoses with tacrolimus ointment.
Antille C, Saurat JH, L&uuml;bbe J.
Arch Dermatol. 2004 Apr;140(4):457-60.

[22] Steroid-induced rosacea: a clinical study of 200 patients.
Bhat YJ, Manzoor S, Qayoom S.
Indian J Dermatol. 2011 Jan;56(1):30-2.

[23] Rosacea Support
Treating Steroid Induced Rosacea
December 4th, 2007, by David Pascoe

[24] Tacrolimus-Induced Rosacea-Like Dermatitis: A Clinical Analysis of 16 Cases Associated with Tacrolimus Ointment Application.
Teraki Y, Hitomi K, Sato Y, Izaki S.
Dermatology. 2012 May 22.

[25] ISRN Dermatol. 2013 Apr 21;2013:491376. doi: 10.1155/2013/491376. Print 2013.
Steroid dermatitis resembling rosacea: a clinical evaluation of 75 patients.
Hameed AF.

Et Cetera

Steroid-induced rosacea.
Litt JZ.
Case Western Reserve University School of Medicine, Cleveland, Ohio.

Topical tacrolimus Protopic.
Lazarous MC, Kerdel FA.
Department of Dermatology and Cutaneous Medicine, University of Miami School of Medicine, Miami, FL 33136, USA.

Potential future dermatological indications for tacrolimus ointment.
Ruzicka T, Assmann T, Lebwohl M.
Department of Dermatology, University of Dusseldorf, Moorenstr 5, 40225 Dusseldorf, Germsny

Tacrolimus clinical studies for atopic dermatitis and other conditions.
Bergman J, Rico MJ.
Division of Pediatric and Adolescent Dermatology, Children's Hospital, San Diego, CA, USA. - 2001

Tacrolimus ointment for the treatment of steroid-induced rosacea: a preliminary report.
Goldman D. - 2001

Rosacea in association with the progesterone-releasing intrauterine contraceptive device.
Choudry K, Humphreys F, Menage J.

Rosacea induced by beclomethasone dipropionate nasal spray.
Egan CA, Rallis TM, Meadows KP, Krueger GG.
Department of Dermatology, University of Utah School of Medicine, Salt Lake City 84132, USA.

Practical aspects of local steroid treatment
Gehring W, Gloor M. - 1989

Possible side effects of topical steroids.
Morman MR. - 1981

Steroid rosacea in children.
Franco HL, Weston WL. - 1979

Differential diagnosis of facial skin swellings (author's transl)
Hornstein OP. - 1979

Perioral dermatitis (rosacea-like dermatitis)--adverse effects of externally applied steroid preparations
Urabe H. - 1978

The treatment of steroid-induced rosacea and perioral dermatitis.
Sneddon IB. - 1976

Perioral dermatitis and rosacea-like dermatitis: clinical features and treatment.
Urabe H, Koda H. 1976

Steroid rosacea.
Leyden JJ, Thew M, Kligman AM.

Rosacea with steroid atrophy.
Abell E, Borrie PF - 1969

Demodectic rosacea is as valid a variant as any other proposed variant for rosacea.

Demodectic Rosacea (Variant)

For more info click here.

One rosacea trigger that is always on every rosacea trigger list is stress. We all have noticed that when we are under stress our rosacea breaks out big time. Many anecdotal reports confirm this finding. It may be one rosacea trigger that everyone could agree with, but there is little research being done on this. You might find some useful information by reading this post on Psychology and Rosacea.

One report suggests, "For example, inflammatory skin disorders; such as psoriasis, atopic dermatitis, rosacea and acne; are widely believed to be exacerbated by stress." [1]

"Muller et al. reported that mental stress leads to an increase in skin sympathetic nerve activity (SSNA). SSNA is involved in vasodilatory activities and has been shown to elucidate intermittent vasodilatation on the skin [81]. SSNA hyperresponsiveness after mental stress was observed in the supraorbital skin of patients with rosacea. Such exaggerated sympathetic responses might trigger the symptoms of rosacea and also cause local inflammation and neurovascular dysregulation in these patients." [2]

End Notes

[1] Brain Behav Immun. 2013 Mar 18. pii: S0889-1591(13)00135-9. doi: 10.1016/j.bbi.2013.03.006. [Epub ahead of print]
Nerve-derived Transmitters Including Peptides Influence Cutaneous Immunology.
Madva EN, Granstein RD.

[2] Int J Mol Sci. 2016 Sep; 17(9): 1562.
Published online 2016 Sep 15. doi:  10.3390/ijms17091562, PMCID: PMC5037831
Rosacea: Molecular Mechanisms and Management of a Chronic Cutaneous Inflammatory Condition
Yu Ri Woo, Ji Hong Lim, Dae Ho Cho, and Hyun Jeong Park, Chris Jackson, Academic Editor

Propionibacterium acnes grown in thioglycollate medium image courtesy of Wikimedia Commons

"Based on the theory that rosacea shares the same inflammatory features of acne, a recent study showed that, just as the combination of benzoyl peroxide 1 percent and clindamycin 5 percent gel is a powerful treatment modality for reducing Propionibacterium acnes levels, it also significantly reduces the papules and pustules of rosacea, according to Debra L. Breneman, M.D. ...."Benzaclin, once daily, was found to be well tolerated and effective in the reduction of papules and pustules in patients with rosacea," said Dr. Breneman. "This lends credence to the theory that P. acnes is a potential aggravating factor in rosacea. This gives dermatologists a very effective treatment for rosacea." [1]

However a recent report states, "Our results suggest that P. acnes does not play a major role in the pathogenesis of rosacea." [2]

End Notes

[1] P. Acnes Possible Factor in Rosacea

BenzaClin a significant Tx in lesion reduction

Apr 1, 2003, By: Beth Kapes, Dermatology Times, Modern Medicine

[2] No link between rosacea and Propionibacterium acnes.

Jahns AC, Lundskog B, Dahlberg I, Tamayo NC, McDowell A, Patrick S, Alexeyev OA.

APMIS. 2012 Nov;120(11):922-5. doi: 10.1111/j.1600-0463.2012.02920.x. Epub 2012 May 18.

See this list.