Guide

"A recent study in the British Journal of Dermatology makes a case for treating and managing rosacea based on the clinical presentation, or phenotype."

Global Consensus on Rosacea Treatments by Phenotype, by Jennifer Newton, Medical News Bulletin

You've probably heard of common skin conditions like psoriasis and eczema, but do you also know about rosacea? If not, you've got to listen up. "Rosacea is abnormal blood vessel growth in all layers of the skin, caused by internal problems and inflammation within the body and skin," says Julia T. Hunter, MD, a dermatologist and founder of Wholistic Dermatology. This abnormal blood vessel growth is the result of low thyroid, fungal overgrowth internally, gut inflammation, and chronic sun overexposure, she says.

10 Things You Need to Know About Rosacea—Whether You Have It or Not, by AUBREY ALMANZA, Reader's Digest

"Topical oxymetazoline applied to the face once daily for 29 days was effective, safe, and well tolerated in the treatment of moderate to severe persistent facial erythema of rosacea."

J Drugs Dermatol. 2018 Mar 1;17(3):290-298.
Pivotal Trial of the Efficacy and Safety of Oxymetazoline Cream 1.0% for the Treatment of Persistent Facial Erythema Associated With Rosacea: Findings from the Second REVEAL Trial.
Baumann L, Goldberg DJ, Stein Gold L, Tanghetti EA, Lain E, Kaufman J, Weng E, Berk DR, Ahluwalia G.

"Oxymetazoline applied to the face once daily for 29 days was effective, safe, and well tolerated in patients with moderate to severe persistent facial erythema of rosacea."

J Drugs Dermatol. 2018 Jan 1;17(1):97-105.
Pivotal Trial of the Efficacy and Safety of Oxymetazoline Cream 1.0% for the Treatment of Persistent Facial Erythema Associated With Rosacea: Findings from the First REVEAL Trial.
Kircik LH, DuBois J, Draelos ZD, Werschler P, Grande K, Cook-Bolden FE, Weng E, Berk DR, Ahluwalia G.

"The topical use of oxymetazoline 0.05% solution in the management of rosacea has been primarily limited to data from case series involving fewer than 10 patients and demonstrating sustained improvements in both erythema and flushing. Alhough oxymetazoline is not recognized in national guidelines, an international consensus statement recognizes the possible therapeutic role of oxymetazoline in the management of rosacea, despite the limited evidence."

Hosp Pharm. 2013 Jul-Aug; 48(7): 558–559.
Published online 2013 Jul 9. doi:  10.1310/hpj4807-558
PMCID: PMC3839519
Oxymetazoline (Topical): Rosacea
Joyce A. Generali, RPh, MS, FASHP, (Editor) and Dennis J. Cada, PharmD, FASHP, FASCP

I haven't used the Soolantra since February 13, 2017 so for more than 72 hours my skin has been healing and I don't have the burning feeling I had, so I thought I would take three more photos to show my skin condition after using Soolantra for 105 days, just three days later. 

20 hours ago, MariaSt said:

It could be the case that your demodex is resistant to ivermectin and after all these years of sulpur usage it's also resistant to sulfur, so I wouldn't expect much of this generic sulfur cream. I know you have the feeling that sulfur controls it, but obviously it's not a cure, otherwise you wouldn't search for other options, Brady. Maybe you could try the permethrin cream. I just read an article about permethrin being effective in ivermectin-resistant cases of scabies infection, the same should apply for demodex.

Maria, 
Actually I am cheap, since it costs me around $40/jar for the ZZ cream which I actually prefer. But since I have insurance in my old age now, I would prefer to pay a nominal fee for a sulphur treatment if it works reasonably well. I was using the sulphur butter due to a post made by Joanne Whitehead, PhD, (Assistant Director of the RRDi) since it was cheap and it works sort of ok, but I don't like the oily part of the formula since my skin is already oily. The ZZ cream is so different and it dries up my skin which is wonderful, and it feels cool when you put it on due to the menthol in it. I just love it and have one jar left as an emergency jar. So if the Americans can make a cheaper sulphur topical I am willing to give it a try and apparently there are a number of them. My insurance wouldn't approve the one my dermatologist prescribed yesterday (not sure of the exact Rx that was denied) and it takes days to do the documents to get it approved and my doctor doesn't like having his staff write up these letters (such are the woes of the American Medical System), so I heard he can write a Rx for a generic sulphur drug that my insurance will accept. Time will tell what Rx I get. 

As to the demodex population, I think I nuked all those little buggers with the ivermectin. My face is healing nicely each day now and I plan on doing nothing but washing with water for the next few days and then I will take photos of my face to show you the difference. I read a post in RF from Toen (post #684) how he only uses Soolantra occasionally which seems like a good idea to me, like if I get a pustule, since I noticed the Soolantra seems to work rather nicely on them and reduces them quickly, within a couple of days. I think I just over did the Soolantra. You would think that someone would mention this, that Soolantra is powerful, that more is not good sometimes. I can still get more tubes of Soolantra if I want. But I think the one I have which is half gone will last me months. 

8 hours ago, MariaSt said:

Brady, what if you have such a heavy infestation with demodex, that it makes it hard for your skin to deal with the die off by itself? I think you should try taking oral antibiotics along with Soolantra and push through this phase for another month. You have put such an effort to this, it would be a pity if you quit earlier.

Maria, 

You are so kind. My face has been burning where I have been applying the Soolantra everynight, even when I wash it off in the am, the burning continues. I explained all this the dermatologist who said to stop using it. I really did give it a go. There must be something in the Soolantra that irritates my skin. It has been over 24 hours since I applied the Soolantra and my face has already started to calm down and cool off. The burning has almost completely gone. I am going to let my skin rest for a few days to recover from this and then apply the sulphur generic prescription my dermatologist prescribed since I have experienced good results from the sublimed sulphur in the ZZ cream. However, the ZZ cream costs more than my generic prescription since I have insurance. I am now convinced that Soolantra just isn't for me. My dermatologist says one out of four of his rosacea patients gets excellent results with Soolantra. I may in the future use a dab of Soolantra on a zit to see what happens, but no more night applications for me. 

Went to the dermatologist today and he advised me to stop Soolantra since I am not a candidate for this treatment. After 105 days, I was hoping Soolantra would work for me, but alas, as you can see below, my rosacea seems to inflamed too much from using Soolantra. My dermatologist prescribed a generic sulphur based cream for me to try since I have responded well in the past to similar treatment using the ZZ cream. I have to pick up the prescription and will start another review later. Here are my photos for today: 

Combined therapy was superior in decreasing the D. folliculorum count in all groups and in reducing the mite count to the normal level in rosacea and in anterior blepharitis. On the other hand, the two regimens were comparable in reducing the mite count to the normal level in acne and peri-oral dermatitis lesions. [1]

"By RCM, a reduction in the density of Demodex mites in facial skin of patients with rosacea under therapy, correlating to clinical improvement, can be quantified and monitored noninvasively." [2]

"Demodex proliferation also appears to be a continuum process in rosacea, and high Demodex density is beginning to be accepted as an important trigger of the inflammatory cascade and as a marker of rosacea: moreover, papulopustules of rosacea can be treated using acaricides...Multiple molecules have been reported to reduce the number or density of Demodex mites and improve or cure symptoms of demodicosis and rosacea in case studies." [3]

In one paper decreasing the demodex count didn't make any difference in the success of the treatment. "This is the first study in the literature investigating the change in demodex density in rosacea patients treated with pro-yellow laser therapy. In this study, it was shown that pro-yellow laser treatment is effective in reducing the density of demodex." This same report states, "There was no significant correlation between the decrease in the density of the demodex mite and the success of the treatment (p = 0.46)." [4]

Et Cetera
Demodex Density Count - What are the Numbers?

Methods for Quantifying Demodex Mites

Increased Blood Glucose Level Shows Increase in Demodex Density Count

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End Notes 

[1] International Journal of Infectious Diseases
Volume 17, Issue 5, May 2013, Pages e343–e347
Evaluation of the efficacy of oral ivermectin in comparison with ivermectin–metronidazole combined therapy in the treatment of ocular and skin lesions of Demodex folliculorum
Doaa Abdel-Badie Salema, Atef El-shazlya, Nairmen Nabiha, Youssef El-Bayoumyb, Sameh Salehc

[2] Br J Dermatol. 2015 Jul;173(1):69-75.  doi: 10.1111/bjd.13783.  Epub 2015 May 29.
Reflectance confocal microscopy for monitoring the density of Demodex mites in patients with rosacea before and after treatment
EC Sattler, VS Hoffmann, T Ruzicka, TV Braunmühl, C Berking 

[3] Dermatology and Therapy volume 10, pages1229–1253(2020)
The Pathogenic Role of Demodex Mites in Rosacea: A Potential Therapeutic Target Already in Erythematotelangiectatic Rosacea?
Fabienne M. N. Forton 

[4] The effect of 577-nm pro-yellow laser on demodex density in patients with rosacea

"There are many effective treatments for rosacea. Some common topical medications include metronidazole, azalaic acid, ivermectin, or sulfur-based products. Oral antibiotics are commonly used, such as doxycycline, especially when papules and pustules are present. Redness and broken blood vessels are much more difficult to treat with medications. A topical medication that was originally designed to treat glaucoma can be used, providing temporary relief by blanching the superficial blood vessels. This medication, called Mirvaso, is very effective for some people but, unfortunately, not all patients are responsive."

Reviewing Rosacea, By Darrel Arthurs, ARNP, DCNP , Dermatology Education & Practice from NADNP, Healthcare POV, Advance Web

There are a number of papers indicating niacinamide (Nicotinamide) improves rosacea. You may want to ask your dermatologist about niacinamide. You can purchase niacinamide over the counter (non prescription).  Wikipedia points out that "nicotinamide has the benefit of not causing skin flushing."

Niacinamide eases rosacea inflammation
June 01, 2010 By Lisa Samalonis, Dermatology Times

Niacinamide-containing facial moisturizer improves skin barrier and benefits subjects with rosacea.
Cutis. 2005 Aug;76(2):135-41
Authors: Draelos ZD, Ertel K, Berge C

A review of nicotinamide: treatment of skin diseases and potential side effects.
J Cosmet Dermatol. 2014 Dec;13(4):324-8
Authors: Rolfe HM

There are papers indicating that Niacinamide improves rosacea. For example, Helen M. Torok, M.D. reports in an article in Dermatology Times, "Niacinamide can be an effective treatment for the inflammation related to rosacea"  Several non prescription topicals containing Niacinamide are Acnessential, InstaNatural Niacinamide Serum, Paula's Choice RESIST 10% Niacinamide Booster, The Posh Company B3 Nicinamide Serum, and Luminositie Niacinamide B3 Cream.

3 hours ago, Rory said:

Brady, from your last 2 posts would I be correct in saying you're not convinced that Soolantra kills demodex? 

 

Ivermectin is supposed to kill mites. I am simply not having the success that many have reported happens to them using Soolantra. I was hoping the fourth month would really be more of an improvement but so far I am not impressed. I am seeing the dermatologist on Feb 15 and get a professional evaluation on my progress. I can tell you that using the ZZ cream works way better for me than Soolantra. I guess I am one of those who responds better to sulphur treatment than Ivermectin. 

Trump’s longtime doctor, Harold N. Bornstein, revealed in a New York Times story Wednesday that Trump takes the antibiotic tetracycline to stave off rosacea, which causes redness and bumps on the skin, and Propecia to keep his hair voluminous. Beauty companies selling non-prescription remedies think the president should reconsider his hair-loss and rosacea solutions.

“We know there’s a better way than pill popping for rosacea,” exclaimed Alexandra Calvo, founder of the rosacea-fighting brand NuRevealOrganics. “Trump needs to watch his diet and cut out rosacea food triggers such as avocados, chocolate, yogurt and cheese. Living a lavish lifestyle also may not be the best for rosacea since spa days in the sweltering sauna, and long days on the beach under intense sun both cause rosacea flare-ups.” Salvo additionally recommended a skin-care regimen that includes NuRevealOrganics’ Bella Rosa Oil Cleanser and Rosehip Healing Night Face Cream.

Beauty Companies Offer Trump Rosacea, Hair-Loss Advice – and Products
The president's personal prescription drug plan includes medications for baldness and redness.
By Rachel Brown, Fashion / Fashion Scoops, WWD

Drug Therapies for Rosacea

Treatment Options for Rosacea, Mel Seabright, PharmD, MBA, Pharmacy Times

They found rosacea patients were 46% more likely than controls to have celiac disease; 45% more likely to have Crohn’s disease; 19% more prone to ulcerative colitis; and had a 34% higher rate of irritable bowel syndrome. The co-occurrence of Helicobacter pylori infection and small intestinal bacterial overgrowth was significantly higher among patients with rosacea at baseline, but the risk of developing incident Helicobacter pylori infection or small intestinal bacterial overgrowth during follow-up was insignificant, the study’s lead author Alexander Egeberg, M.D., Ph.D., department of dermatology and allergy, Herlev and Gentofte Hospital, Hellerup, Denmark, tells Dermatology Times.

Rosacea and gastro disorders possibly related, Large study supports likelihood of yet-to-be-defined link, By Lisette Hilton, Dermatology Times

While there’s no way to cure rosacea, New York City dermatologist Dr. Amy Wechsler knows a few simple ways to help control it in winter. She noted that in addition to seasonal changes, flareups can be triggered by a wide variety of factors like stress, sleep deprivation, spicy food, drinking too much alcohol, travel, trying new products, having a cold or being sick in any way.

“People with rosacea often have sensitive skin, so dry, cold weather can exacerbate this,” she said. In addition to whatever medication or regimen your dermatologist recommends, here are three simple ways to manage your redness in the wintertime, according to Wechsler: 

3 Tips And Tricks For Defeating Rosacea In The Winter, Carly Ledbetter, Lifestyle Editor, The Huffington Post

Sorry if I was off topic. I wish I could be one of those who could eat or drink anything. I read somewhere (can't find it now) that at a recent dermatologists convention a discussion of the mystery of how Soolanta improves Rosacea with no data on demodex density counts (whether the count is lowered). However there is data that it works better than Mirvaso or Metronidazole. 

Note: There is data on this now: Decreasing Demodex Density Count Improves Rosacea

On 2/6/2017 at 3:22 PM, Rory said:

I noticed where some people reported being able to eat anything after treatment with Soolantra. But i can see that you haven't been that lucky. There was no mention of any kind of diet used in the Soolantra studies.But maybe the 30% who failed to see any improvement could have benefited from restricting carbs. From what I understand so far about you, neither ZZ cream nor Soolantra would help if you didn't adhere to a low carb diet. If that's the case then Its somewhat disappointing because it shows that you still haven't got to the route cause of your particular type of Rosacea. 

Rory,

It has never been proven whether killing the mites improves the rosacea or if the density count is different when using Soolantra. Do the numbers actually go down after using Soolantra? We really don't know for sure. There are no studies done on this. 

A paper published by the American Journal of Clinical Dermatology in April 2015 succinctly clarifies the controversy:

 “According to Rothman’s model of causality, Demodex mites are probably a non-necessary and non-sufficient cause of rosacea.”

[Note added 2/23/2021 that one week after this post there is now evidence that reducing the mite count improves rosacea. Read this post, Decreasing Demodex Density Count Improves Rosacea]

What we do know is that Soolantra use with improvement of rosacea implies that treating for demodectic rosacea is warranted. In other words, if it works for some then it is a valid treatment. 

As for sugar/carbohydrate avoidance, you will note that physicians rarely if ever mention this as a rosacea trigger. Only the RRDi recognizes sugar/carbohydrate as a rosacea trigger. There are few, if any, clinical papers on this subject. I do agree with you that if those who use Soolantra also avoided sugar/carbohydrate they would notice better improvement. 

19 hours ago, MariaSt said:

Brady, do you think you have demodex folliculorum or brevis?

Not sure, but most reports say demodex folliculorum is the culprit. Never have tested for demodex. 

7 hours ago, Rory said:

What I find odd are the ups and downs you're experiencing with Soolantra. I have read many stories of people having these ups and downs with ZZ cream which is believed to be a purge or Demodex die-off. But since you were using ZZ for years before starting Soolantra, I would have thought the purge or die-off or whatever the ups and downs really are, were well behind you. Did you suffer flares when you started ZZ cream years ago?

Rory, 

Basically I controlled my rosacea with my Rosacea Diet and the ZZ cream all those years. This didn't cure it, but it works to control it. If I went off my diet I would get a zit or two or even more depending on how far I strayed from my diet. My rosacea really shows up quickly after I eat sugar/carbohydrate whether on the ZZ cream or Soolantra. For the past year I was using the Sulphur Butter to save some money and see if it works, which it does but not as good as the ZZ cream since my skin is oily and I prefer the way the ZZ cream dries up my skin. 

I read all those incredible results of those who say Soolantra works for them and simply wanted to try it. Today Soolantra seems to be improving my skin so I am hoping after four months it works. Most reports from users say they have to keep using it on a maintenance basis dabbing it on a flareup to keep it under control. With my insurance Soolantra is cheaper than the Sulphur Butter. 

My understanding is that if demodex is the culprit, demodex simply keep coming back, hence, the need to keep using Soolantra. 

The only way to know if a rosacea treatment works is to try it. And we know that it takes time, usually months, to know for sure. 

On 2/2/2017 at 11:27 PM, Rory said:

Looks good Brady. I'm curious. How would you compare compare your results so far with Soolantra to years of using ZZ cream? 

I started Soolantra again 2 weeks ago. 

I would say the ZZ cream works better. However, the ZZ cream is more expensive than Soolantra since my insurance pays for it. 

"Almost a decade and a half has elapsed since the initial proposition of criteria for rosacea diagnosis and grouping into common presentations or subtypes. Reappraisal of these items suggests shortcomings in case-finding and diagnostic accuracy that require revision to facilitate rather than undermine future investigation. Subtyping of rosacea, a post-hoc means of grouping more common presentations, can be and has been subverted inappropriately to imply strict categories without adequate consideration of the varying phenotypic presentation of individuals and the potential for temporal variation. Scales for rosacea severity are also confounded by similar multidimensional aspects represented in subtyping. In clinical investigation, this can interfere with study of the course of singular features of rosacea and their measurement."

Br J Dermatol. 2017 Jan;176(1):197-199. doi: 10.1111/bjd.14819.
Shortcomings in rosacea diagnosis and classification.
Tan J, Steinhoff M, Berg M, Del Rosso J, Layton A, Leyden J, Schauber J, Schaller M, Cribier B, Thiboutot D, Webster G; Rosacea International Study Group.

The Phenotype Classification of rosacea is superior to the subtype classification. 

Rosacea is a chronic skin condition whose symptoms are a persistent redness of the skin of the cheeks, nose, chin and forehead, excessive blushing, and small, dilated blood vessels. There can also be swelling and pimple-like bumps on the skin. More extreme cases can involve the eyes and swelling and disfigurement of the nose. It can begin at any age, and seems to have a hereditary component, as fair-skinned people of northwestern European descent are most affected. Women are three times as likely to develop Rosacea, and the incidence increases at menopause. Its cause is unknown.

Rosacea: Diagnosis and treatment, Niagara This Week - St. Catharines, Sponsored Content, In Your Neighbourhood, METROLAND MEDIA GROUP

image courtesy of @talontedlex / Instagram
The brave blogger took to Instagram to share her story of rosacea with a selfie showing half of her face with makeup and half without.

Lex expressed her difficulty in posting the photo - which shows the rosacea on her face - at first: "This photo was hard to take and is even harder to post. Every single time I take a photo of my bare skin I am still shocked, because this is not how I picture myself."

She then goes on to explain how she feels it was important to share the image in order to show how much of a positive impact makeup can have on our confidence and the way we feel about ourselves.

Blogger and rosacea sufferer Lex Gillies shares brave before & after Instagram post, By Rebecca Fearn, Glamour

Lex Gillies, Beauty Blogger, and Rosacea

British Skin Foundation Ambassador 

Twitter (the classic butterfly)

Lucy Abbersteen Interviews Lex Gillies About Rosacea

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The phenotype classification uses signs and symptoms better than the subtype classification and particularly focuses on erythema as a pivotal diagnostic feature. 

Dr. Jerry Tan, ROSCO Panel and NRS Expert Committee

“Practically, in our current phenotypic-led classification, it’s not important to be grouping into subtypes. It’s more important to be categorizing based on patients’ presentation in terms of signs and symptoms,” he says. “So, if they simply presented with centrofacial erythema that would be diagnostic of rosacea, but we wouldn’t go onto subtype. We would just leave them as is, as that predominant phenotype. Then, we would manage them based on that, with various treatment options that are indicated for background centrofacial erythema.”

Dr. Jerry Tan, Updated guidelines for diagnosis, treatment of rosacea
Focus on phenotype-led diagnosis, classification
By Lisette Hilton, Dermatology Times

----------------------------------------------------------

Dr. James Q Del Rosso, AARS Panel and the ROSCO Panel (2019)

Dr. Del Rosso concurs that 'persistent facial erythema' (PFE) "is the pivotal diagnostic feature of cutaneous rosacea, including in both the presence or absence of papulopustular lesions...that dermatologists...Consider the role of PFE in essentially all patients with cutaneous rosacea." 

Journal of drugs in dermatology: JDD
June 2019 | Volume 18 | Issue 6 | Editorials | 503 | Copyright © June 2019
What Is “PFE”? It May Just Be Time You Found Out….
Del Rosso Q. James DO
JDR Dermatology Research/Thomas Dermatology Las Vegas, NV

More Information on Phenotypes