Rosacea is skin condition that affects many
adults. It is characterized by flushing of the skin that looks like blushing, but doesn’t go away. According to the American Academy of Dermatology (AAD), “Rosacea often begins with a tendency to blush or flush more easily than other people. The redness can slowly spread beyond the nose and cheeks to the forehead and chin.” The redness and flushing associated with rosacea can be uncomfortable, both physically and emotionally. Some people with rosacea get red papulas and pimples like eruptions on the face. A recent article called “Unlocking the Mysteries of Rosacea” by Jan Bowers from “Dermatology World” stated that, “According to results of a recent NRS survey of 801 rosacea patients, a strong majority of patients in all subtypes said the disease had inhibited their social lives.” The article went on to add that, “respondents also cited receiving negative comments or stares and cancelling social events because of self-consciousness regarding their appearance.” Clearly, these symptoms are having a negative impact that is seriously affecting the lives of rosacea sufferers.
There are a great variety of triggers that can exacerbate a rosacea type skin, such as extreme weather (both hot and cold), spicy foods, alcohol and stress. The Journal of Dermatology outlined some common rosacea triggers based on a recent study in their article titled, “Standard Management Options for Rosacea, Part 1: Overview and Broad Spectrum of Care”. The triggers are as follows in order of those having most effect to those having least effect: “Sun exposure, emotional stress, hot weather, wind, heavy exercise, alcohol consumption, hot baths, cold weather, spicy foods, humidity, indoor heat, certain skin care products, heated drinks, certain cosmetics, certain fruits, marinated meats, certain vegetables and dairy products.” Avoiding and/or reducing the triggers can aid in the reduction of rosacea symptoms, but the skin will still need the proper homecare. Avoiding triggers can help reduce the irritation. Prescription topical medications can provide a reduction in rosacea symptoms as well, as can laser or IPL.
After a few weeks of some hefty stress, I developed mild eczema on my face that rather annoyed me- I had stopped taking my birth control pills (the eczema made me anxious and I suddenly linked the hormones from birth control pills to the eczema, without any real logic behind it btw, just fretting myself) and had started using a mild hydrocortisone (steroid) cream on a some areas of skin around my mouth and cheeks. My GP also advised me to use some vaseline on my cheeks and when I did this, I remember my face started to flush and burn a couple of days after I started with hydrocortisone cream. I wiped it off soon after, but I was flushed and burning red all night. I assumed that by the next day, things would be normal again but I woke up flushed and burning still. It stayed this way, sometimes I would turn pale again but with the slightest emotion, temperature change, eating hot food, drinking hot beverages and so on, heat and redness shot up to my face again. I was bewildered with it. After a month or so, it dawned on me that this was perhaps not a transient thing. Even college classes became a chore, because I would be on fire by the end of them. I started reading up on it, and suspected an allergy at first. The doctors had no real clue and said I just looked healthy with my rosy cheeks. "Uhm, yeah thanks but it burns badly!" They didn't take it serious and sent me back home. So I read all I could about the symptoms, had my mother involved who helped thinking along and made sure I went back to the doctor to get some health issues eliminated; had many allergy tests, tests for Lupus, SLE, ALS, all coming back negative. No one thought of rosacea.
Still not knowing what was wrong, but uncomfortable with all the limitations I had and the way my flushings seemed to worsen over time, I did found out myself that I reacted to certain foods. They matched the 'high histamine foods' foods which many people with rosacea also avoid, as I now know. This list included for instance red meats, tomatoes, egg plant, spinach, old cheeses but also alcohol, sugars and spices. I had visited homeopaths by then, had acupuncture (both no effect) and I had seen a highly recommended Chinese doctor at the other side of the country. The herbal drinks she gave me made my belly swell up and my face burn, and after months and months and more months of herbal teas and an anti inflammatory diet, I was still as bad, if not worse. I tried to forget about it. And after almost 3 years, still thinking and hoping I had some allergy that would pass, I had one whole year of diminished symptoms, and it felt like sort of a remission period. I had a new relationship, felt better, worried less, and actually ate everything I wanted ("bad" stuff, like garlic, tomatoes, chocolate, lots of cheeses, bread, sugar, ice-cream etc etc.), partied a lot for a year, drank wine. And only some minor flare ups!
But by now I couldn’t even use any skincare anymore, my skin had become too sensitive for anything on it. If I stayed in a cool area, with a fan and little triggers, I seemed to do not too bad, but going out into the sun, into a warm place, to the supermarket, to uni, the pub, all made me flush and burn. People made comments about it, asked me if I had sun burn, why I got so red. I tried to not let it affect my life too much, as my bf asked from me, as he hardly recognized me from the girl he had met some years ago. I felt in pain, ugly, overwhelmed. The relationship stranded after a few strained years, maybe even more for him than for me, during which I finally got diagnosed with rosacea. Knowing this I had some facts to build my knowledge around and I read and read till I knew as much as I could find about it. I saw several dermatologists in the country, who all worked with the dated treatment plan of :
1) metronidazol cream (or rosex cream), which made me more red and made my skin feel like acid was thrown at it.
2) oral antibiotics (tetracyclines), which I had to take for 3 months and that gave me IBS and IBD plus intense flushing, even more than I normally had.
I tried otc antihistamines which did very little. I took moxonidine by now, a blood pressure lowering medication that a certain Dr. N. wrote about in his rosacea book. It seemed to work initially, mainly by making me hypotensive, and therefore also more tired, dizzy and drained. After a few years I felt it made me flush even more and I found out one of the side effects are vasodilatation, widening of the blood vessels. I tried diazepam and anything I read positive reports on and that I could my GP convince of to prescribe me. The only other option left seemed IPL or laser therapy at some point. In my next post you can read what happened when I had an IPL treatment in England.. You can read in much more detail what I tried in the process of finding a treatment, and all the (sometimes lame and desperate) messages I posted on Rosacea Forums here, in this blog post. At the bottom of that post I also summarize everything I tried in the past, from acupuncture to traditional Chinese medicine and healing crystals.
In hindsight, I asked my doctors how all of this could have started. I've been told by my latest doctors that they suspect that I already had the rosacea gene so to speak. Meaning in my case: the tendency to blush and an otherwise very pale skin. He thought that sometimes something has to trigger rosacea to erupt. For one person that can be stress, for another a steroid cream potentially, for another it is hormonal change or something else.
Ephemerality wrote in regarding steroid use in rosacea on January 9, 2017: "Steroid induced rosacea does not requires long term usage of steroid. for some people, even 1 time application can do all the damage. don't believe the standard BS thrown out there by those "medical professionals". everyone's body is different;everyone's blood vessel flexibility/resilience/stability is different. maybe, it is true, for majority people, it takes months of steroid to develop rosacea red face; and there are people who never develop red face no matter how long they keep using steroid. however, for a small number of people, the full steroid damage only requires very short times (days, not even weeks). There is no possibility to persuade those medical professionals to admit/believe the severe danger from steroid. biggest tools (pretty much the only tools) western medecines have are "antibiotic" and "steroid". by playing with those 2 things, pharma comps and docs have been able to make tons of shxt loads of money. especially those dermatologies, without steroid cream, half of them would show up with dumbface and lose job right there, because they really have and know nothing else to offer patients. It is all about money! 1 unlimited supply in the world for derms (and docs and pharma comps) are people. they can keep making money, have their "respectful careers", and pile up assets for their children, as long as general population keep believing their fooling with the notion that "short-term steroid use does not cause problem" and "steroid usage under direction of your doctors is safe".
And ephemerality went on to ask me: "There is not much useful info on internet about treatment/ recovery of steroid induced rosacea. also, it seems like a lot discrepancies regarding whether "steroid induced rosacea" can be cured or not. Some threads here say that it can be gone in 6 months. but, I notice that some people say that they are still suffering from it even after many many years. Did you develop constant background redness (looks like a painted veil --- very diffused) right after hydrocortisone? Did you notice some kind of weird glistening/shine over all area you applied that steroid (but the glistening is not from oiliness on the skin)? What did your derm say about recovery from constant redness caused by steroid?"
It is true; normally a short course of steroid cream use doesn't give people steroid induced rosacea overnight.
It usually takes a prolonged time of steroid cream use before rosacea can appear. However both my dermatologists told of patients who had their rosacea 'triggered' by steroid use (creams or injections) only after short term use. One told me steroids can be a 'switch trigger' for people with lingering rosacea predisposition (paler skin, fair features typically, ability to blush). I don't think in my personal case that it caused me steroid induced rosacea, strictly speaking, conflicting as this might sound. When you google images of 'steroid induced rosacea', it usually shows symptoms that look more like subtype 2, with thickened inflamed and more permanently red skin. You usually get that after prolonged use of steroid cream on the skin. My dermatologists said that in my case, they think the steroid cream somehow triggered my facial flushing and burning; that it triggered some predisposition for rosacea. That I had the (dormant) rosacea gene so to speak, with a tendency to blush (very mild hint of redness after I drank alcohol in my teens), with very pale skin, and that sometimes something has to trigger rosacea to erupt. For one person that can be stress, for another a steroid cream potentially, for another it is hormonal change or something else. Yes at the time my skin seemed to have a shiny veil over it, indeed, and showed redness. I had always had pale skin and never flushed like that, with such heat and redness in my face that it felt like a very bad and painful sunburn. That developed overnight. After that steroid use (and the stress that I had at the time won't have helped either) I suddenly got flushing episodes, where my face would turn red and hot and this wave of heat came over my face, lasting for hours sometimes. But when the flush stopped, initially my skin would look normal again. Now, 18 years later, I have a lot more background redness but I think that is just the natural progression of the rosacea, and all those years of flushing.
For strictly steroid induced rosacea, there seem to be patients who can get their skin back to relative normality after treatment. Antibiotics for instance, certain creams. For subtype 1 and flushing and burning, what I have, this hasn't proved helpful. I can mainly try to keep the flushing and redness at bay with anti flushing medication and trigger avoidance. I only used a hydrocortisone cream for around 3 or 4 days in the area around my mouth and nose, a bit on a cheek, and developed rosacea, flushing, redness and burning seemingly overnight from it. It was ridiculous really. The problem is that for some people on here even, with existing rosacea, short term steroid use doesn't hurt their rosacea. You just don't know beforehand if you'll be fine with it, or if you are one of the unlucky few who have their rosacea worsened or even started by it. But my derm always says to me that he thinks it is Russian roulette if you are a heavy flusher. He warns me against any type of steroid use, including steroid nose spray and eye drops. The worst part is that the steroid use is often not even strictly necessary.. I had some mild eczema and it really didn't require a steroid cream, but I never had skin problems prior and never thought a short period of use could pose such risks. In a way, steroid creams can be used as an easy fix for all sorts of skin conditions, but I feel that doctors, both dermatologists and GP's, need to be aware of the fact that steroids can trigger rosacea in those with a higher risk for it, like a tendency to blush, to sunburn and people with pale skin that easily goes red.
So what worked for me so far?
There is not really a test to confirm rosacea, but doctors can do tests to rule out other flushing conditions... It is hard to treat.. Many say; 'just avoid your triggers'. But that can be tedious and means often avoiding a long list of things, from sun exposure to bright fluorescent lights to warm rooms and so on. Food can be a trigger for too, but this depends very much on each individual person. I can't eat alcohol, spices or very high histamine foods without getting inflamed, red and flushed. So no yogurt and old cheeses or tomatoes for instance. But when the flushing threshold is low, anything from stress to exertion of any kind to any emotion to warm temperatures etc can set the flushing off... Facial flushing and burning can be affecting your every day life and professional life too. It's bad enough that the redness is so visible for others, but the pain and flushed feeling is like a fire that requires a fire hose right away, or that feeling it can give, and you can't when you aren't home and in a controlled area with means to cool your face...
I have been through this for a long time, and still do to a good degree, but there is certain medication that can take the pressure off the blood vessels of the face (and hands and feet), so that they (often) won't dilate as much, won't flush as bad, and get a chance to normalize again. Some meds that can really help and have been scientifically tested for flushing and hot flashes are:
-propranolol (or certain other beta blockers, for instance carvedilol)
-Certain antidepressants (they calm the central nervous system, and some are antihistamines too)
-anti inflammatory medication such as plaquenil or mepacrine
My experience; I have tried pretty much every med and every treatment out there over the years, and I still haven't got things under complete control, I still have to cool my face all the time and deal with flushing and burning and redness. But it has become a lot better, at my worst I flushed literally non stop for a year. It was unbearable. I see a London based professor, Tony Chu, who is really knowledgeable on rosacea and prescribed me a combination of anti flushing meds: clonidine, propranolol and mirtazapine. For mild flushers one or the other alone can work but I was in a constant flushing state so he threw this at me right away to see how I responded to it. It was great, I finally could be pale again, could sleep through the night without waking flushed and in need of cold packs. I still use those meds (since 2006) and still have a much better control over the flushing. I'd say 60% improvement for me I also take a high dose antihistamine (Xyzal) because of mast cell issues (I flush from histamine release, even from someone next to me wearing perfume for instance). You can read more about this medication and the science behind it in this blog post. I keep cool and comfortable these days by using a gentle small ventilator when I work or sleep, which often can be just enough to keep the face flushing in check, without causing a tornado of wind and possible rebound. I have tried mepacrine and plaquenil, which some rosacea patients have very good results with, but I couldn't handle the side effects of plaquenil, nor the dye in mepacrine.. You can read more about these medications for rosacea and my own experience with them in this blog post.
I took doxycycline for 3 months and it made the redness and flushing problem worse.. I tried minocycline, metronidazole and azithromycin, all made my redness and flushing worse while I took them. I've also tried nerve pain medication (Neurontin and Lyrica and amitriptyline) which also all made the flushing worse (but this is not the case for everyone who flushes, there are quite a few good testimonials from flushers+burners out there). So there is where I stand now, I take clonidine (0,1 mg 3 times a day), propranolol (40 mg two to three times a day), low dose mirtazapine (22,5 mg a ay) and Xyzal (10-15 mg a day).
There is also a cream out, Mirvaso, designed to treat the redness and flushing of rosacea subtype 1, but I would personally tread with great care there. Mirvaso often destabilizes the blood vessels more, chemically constricting them terribly and then having rebound where the blood vessels dilate spectacularly. Too risky I think. See for my own trial (and rebound) this blog post. In this blog post, you can read an inventory of hundreds of rosacea reviews of Mirvaso. Soolantra is another new product, a cream that kills demodex mites. I have mostly only read user reviews and success stories from people with subtype 2 rosacea and p&p's. Rarely subtype 1 and very rarely flushing. But it is also an anti-inflammatory cream so it could help a little bit. But I doubt it will stop the flushing problem primarily. I made this blog post about Soolantra and its active ingredient ivermectin. You can read more about the treatment options I have tried over the years if you scroll down in this blog post. You can also read in much more detail what I tried in the process of finding a treatment, and all the (sometimes lame and desperate) messages I posted on Rosacea Forums before and after this dreadful IPL treatment I received in this blog post. At the bottom of that post I also summarize everything I tried in the past, from acupuncture to traditional Chinese medicine and healing crystals.
I wrote in 2006 on The Rosacea Forum about my anti flushing medication:
January 18, 2006
Great meds for persistant flushers
"Hi all, I have posted about this several times already, but do want to emphasize once more how much improvement I see (relatively) after using the following meds for about 2 months: Remeron (mirtazipine, AD), propranolol and moxonidine. I'm 26 years old and have very severe vascular rosacea. In total for 7 years now, but only the last years it has been very bad. Last year I was treated wrongly with the Quantum IPL and after that I didn't stop flushing and burning for almost 9 months!!! Driving me so suicidal in thoughts, that I couldn't pass a building in the street without counting the floors (more then 8 was 'safe', suicidal wise). I was so depressed because I saw so many specialists, took almost all the available medication, but there seemed nothing to stop my neural burning, redness, inflammation and flushing. All the docs told me I was the worst flusher they'd ever seen. Ever. Enough to drive you nuts. And I couldn't physically do anything anymore without cold air, ventilator's, cool packs etc. Just unbelievable. It was total survival; instead of living. Since being on these medication my flushing and redness has decreased. I take an antidepressant called remeron (mirtazipine) for the last 2 months and it has helped IMMENSELY with not only the anxiety and depression, but also the flushing. This drug has antihistamine actions as well, which is helpful for all rosaceans. I didn't want AD medication for a long time, but am so happy I did start this one. I already was on moxonidine (variation of clonidine) and added propranolol, a beta-blocker: they work on different channels: a and b channels, and block adrenaline to a certain degree, for instance. They also keep your blood pressure a bit lower, which helps keeping you less flushed in your face. I still have severe vascular rosacea, for which I now see Dr. Crouch. He has made some test patches, which gave me pale spots en next week we will expand the test patch area. But overall I can sit behind my computer again, do shopping, have sort of a life. I still flush and am red/pink, need to watch what I eat and when, but this has definitely helped me flushing so far.
Best wishes, N."
During a long car drive in the summer, pictures taken with half a days difference, from pale'ish to red..