08 September, 2012

How to treat rosacea redness, flushing and burning with medication - (The science behind my current medication)

Rosacea flushing is easy to recognize, as it gives the cheeks, and sometimes also the chin and the nose and ears, a pink or red look. Flushing often gives you a feeling of warmth in the face, sometimes even of heat. It triggers the nerves in your skin and gives a feeling of skin burn at worst, and of tingling at best. Flushing is often triggered by heat (a warm room for instance), but also by sunlight, stress, crying, alcohol, food triggers and so on. Not everyone with rosacea gets facial flushing.

Facial blushing is an involuntary reddening of the face due to embarrassment, stress or a lot of other triggers 

There are different subtypes and more people with rosacea get skin outbreaks, pimples and papulas and not so much the flushing and deep redness of the skin that comes and goes. Unfortunately, it can be really difficult to treat facial flushing, especially when it is severe. One non-invasive way to reduce flushing, burning and redness of the face, is to take certain anti-flushing medication. I myself have tried virtually everything out there over the past 13+ years and found that the medication clonidine, propranolol, mirtazapine and an antihistamine (Xyzal for me) works best to sort of control the worst of my rosacea. Other treatment options for these rosacea symptoms are IPL and laser treatments, but they are costly and don't always give the desired results. Although they can help tremendously, it takes a good practitioner/doctor, a good machine, the right treatment settings and filters, the right amount of joules for your skin and a bit of luck too. The more reactive and inflamed your skin is, the more difficult it becomes to treat, so nipping things in the bud early on is wise with rosacea flushing.

I wrote a lot more about the phenomonenon of facial flushing and what different conditions can cause it here

Flushing is one of those things you most likely recognize fairly quickly when you have it, but to help describe it, patients have described it as the feeling of having bad sunburn; like the skin on your face is many degrees too hot, glowing, burning, with heat crawling up. Radiating heat. Swelling, stinging. Some people would say that it feels like an iron being pressed to your face, and the heat coming from the inside out. The skin can also feel tingling and itching, or numbing. The skin also tends to become very sensitive, to a point where even touching your face can be uncomfortable. Others feel like they are running a fever and are badly overheating. 
For many people with rosacea, being in the sun can be a trigger and make the redness and potential burning worse. A lot of people also notice that drinking (sufficient) alcohol can make their face more red. Spices and emotional stress can do the same. I think that what makes rosacea typical, is that it can make someones skin go red in a matter of seconds or minutes, when triggered. This mostly goes for subtype 1, and is almost like a heavy blushing attack. But the difference between rosacea and blushing is that over time the 'blush' from rosacea takes quite a long time to subside. And these flushes become more frequent. And with time, many people also find that the redness of the skin starts to hurt, or feel hot. Sometimes the face even becomes a bit puffy. As I said, these are no strict criteria and rules, but maybe they can help you in the right direction. A dermatologist should be able to properly diagnose you ideally, because there are more skin conditions that can look like rosacea, including dermatitis, seborrheic dermatitis, acne or the skin redness might be linked to an allergy, or a systematic illness like lupus even. It's up to a dermatologist to make the right diagnosis. 

Focusing on prescription medication; I wrote before about my failed IPL treatments and how they made matters a lot worse for me unfortunately. So I focused on prescription medication to try and tackle the debilitating flushing, that was at some point pretty much 24/7, despite living and sleeping behind a ventilator. I went to a very good dermatologist in London, Professor Tony Chu, who prescribed me several medications that together should make me less flushed; less intense and less long. These medications are:

*Mirtazapine (Remeron)

Below I will explain a lot more about these meds, and also about other medication that can help rosacea subtype 1.

Facial flushing in general; it is thought that facial blushing is caused by an overactive sympathetic nervous system. This system helps to regulate glands and organs without us making a conscious effort; it automatically controls how much our blood vessels to the face are dilated. In some people, these nerves are unusually sensitive to emotional stress. For a person to flush is to become visibly red in the face and often other areas of the skin, from various physiological conditions. Flushing is different from blushing, because blushing is milder, generally restricted to the face, cheeks or ears, and generally assumed to reflect embarrassment.

Given the right stimulus (such as embarrassment, alcohol, stress etc etc), the nerves signal to the blood vessels to open wide, flooding the skin with blood and causing the characteristic reddening of the face. In some people, the ears, possible neck and chest also blush. As part of the “fight or flight” response when we are exposed to environmental or emotional stimuli, the body responds via the sympathetic nervous system. This causes the widening of small blood vessels (capillaries) just beneath the surface of the skin, hence blushing occurs. Severe facial blushing or flushing is also said to be common in people who have social phobia, an anxiety disorder in which the person experiences extreme and persistent anxiety in social and performance situations, and fears being judged, criticized, ridiculed or humiliated. But also in people with rosacea. Symptoms include

  • Intense blushing, often for no apparent reason
  • Sensation of heat in the face
  • Redness of the skin
  • Sensation of burning in the skin
  • Avoidance of any possible triggers, including meeting new people or talking in front of groups, for fear of going red.

Erythematotelangiectatic rosacea is a subtype of rosacea, characterized by permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning or itching sensations.Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some food and drinks that can trigger flushing, including alcohol, food and beverages containing caffeine (especially, hot tea and coffee), foods high in histamine and spicy food. Foods high in histamine (red wine, aged cheeses, yogurt, beer, cured pork products such as bacon, etc.) can even cause persistent facial flushing in those individuals without rosacea due to a separate condition, histamine intolerance. Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion and chemical peels as well as isotretinoin (roaccutane!), benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. Even a short term use of steroids has been documented to cause rosacea, as happened to me.

In most people, facial blushing takes a minute or two for the blush to disappear. However, flushing is a different beast and can last much longer, and it usually is more severe than blushing too: more redness, deeper blood vessel dilation, hotter flushes and longer lasting. In some people severe and frequent blushing can become a real hindrance and affect both personal and professional life. Although the vascular –flushing- aspect is one of the most difficult aspects of rosacea to treat, there are  several medications  available that have proven to help treat facial flushing for a number of patients.

The medication I mention below has helped with my facial flushing, and there are more patient reviews to be found online and on forums, but they are not designed for rosacea. Since there isn't really that much out there yet to control facial flushing and redness (recently Mirvaso cream was officially put on the market for this, but it has a very bad track record and gives most users a lot of rebound worsening after use, so not a solution whatsoever for most users), some are willing to try other routes. Your doctor can help you determine if you are a candidate for this. I'm mainly sharing what options there are and what has helped me personally.

See your doctor for suitability of medical treatments. Oral and topical antibiotics are sometimes ineffective in the treatment of erythema (skin redness) and flushing, although some can help lower skin- and blood vessel inflammation. For subtype 2, antibiotics are often useful in clearing up the lesions and redness, but for those with subtype 1, antibiotics can have a less successful profile. Nevertheless, it's all trial and error with rosacea and very hard to predict for each and every patient what will help them and what not. Each case can respond to different triggers and treatments. I used doxycycline for 3 months and it unfortunately made my flushing, burning and redness worse, and gave me IBS at the end of the course. Over time I had to take other types of antibiotics after wisdom tooth removal and bladder/lung infections, but none of them improved my skin, whereas most made the redness and flushing worse or gave me urticaria. But there are also subtype 1 patients who do well on a low dose doxicycline drug like Oracea, or macrolide type antibiotics. They are typically troublesome to take very long term though (exception is Oracea) and tend to mess up your bowels and natural bacterial equilibrium.

"The erythematotelangiectatic subtype of rosacea 
is the most difficult to treat. There is little evidence 
that topical or oral antibiotics have any role in the 
treatment of erythema, telangiectasias and flushing-
blushing reactions. Isotretinoin may improve erythema 

resulting from inflammation, but this effect may be 
transient. Drugs that antagonize flushing may be 
helpful in some patients. Vascular laser and light 
therapy is the most effective modality in this subtype." 
"The papulopustular type of rosacea is the easiest subtype 
to treat. Most of these patients respond readily to 
topical medications such as metronidazole, benzoyl 
peroxide, clindamycin, erythromycin, and azelaic acid. 
In several studies, topical medications were shown to 
be equally effective to oral medications although therapy
 may take longer to be effective."

It's harder to treat subtype 1. Some people get it under control with anti flushing medication (I take clonidine, propranolol and mirtazapine for it), others use anti malaria medication to cut down on the flushing and redness, then there is red light therapy that helps some, or laser or IPL that helps others, or botox incidentally. There are natural herbs and supplements that can help some. Diet can play a big role in controlling flares. Antibiotics would work as anti inflammatories but have a better track record for subtype 2. They can still help, but not for everybody with subtype 1 unfortunately. Also all of the other treatment options might, or might not help your particular case. It helps to have a doctor who is willing to go different routes and let you try out what helps your rosacea.

And of course, regular medication can come with side effects, which nobody really wants. I found that most of the side effects of my medication wore off with time, but not all of them. I tried the natural route for a good 6 years first, but in the end it wasn't enough to cut down my severe flushing. (I wrote at the bottom of this post all the stuff I have tried initially, ranging from a homeopath, natural herbs for years, acupuncture, Chinese traditional medicine to red light therapy and diets). Nevertheless, if your symptoms are mild to moderate, you can find a lot of relief from natural anti inflammatory herbs, like boswellia, flax seed oil/fish oil, niacinamide, grape seed extract. Some find vitamin C supplements to be helpful. Or quercetin, oregano oil, curcumin, lysine. Some people find that their skin improves with added vitamine D. Keeping an eye on your dietary triggers can also do wonders. Cutting out some of the sugar you might eat, and processed foods to start with. Some foods are high in histamine, which can be a trigger (old cheeses for instance, tomatoes, bananas, yogurt, nuts). Some people see improvement of their skin by cutting out dairy (replacing it for instance with rice milk, almond milk). Some do better without grains. A lot you can still try, and always drink plenty of water and avoid too much alcohol (which is an inflammatory and will dilate your blood vessels).

The cause of rosacea is mostly unknown still
unless you have a demodex infection perhaps (mostly only subtype 2) or an allergic reaction to something, or if it stems from severe vitamin deficiency perhaps, to name a few actual, pinpointable causes. Claims about 'prescription medication doesn't treat the cause of the problem' are flawed in my opinion, because as for now, nothing treats the root of the problem, given we don't even know yet what that root problem is in most cases (although there are new discoveries done all the time, small steps, identifying specific mechanisms in rosacea patients skin and bodies that contribute to these inflammatory symptoms. Check this blog post of mine about new scientific insights). If you have no straight forward food allergies, then diet doesn't treat the cause of the problem either, it merely cuts down on inflammation in the body if you do it right and are sensitive to food triggers. Natural approaches (herbal supplements, natural rinses or oils/fluids) often do not treat the cause of the problem either, especially given that some cases of rosacea are thought to be auto immune related (and there is no root treatment for them yet). They usually mainly alleviate the symptoms. Common prescription medication can certainly help. It's trial and error, for one rosacea sufferer the natural approach helps but if you tried changing your diet, tried natural supplements, tried different skin care and creams, and still feel it doesn't put a dent in your rosacea redness, flushing and burning (the subtype 1 where I focus on here on this blog), then do not write prescription medication off simply because it's not 'fashionable'  right now, and natural is the norm. I don't agree with the whole 'prescription meds are unnatural' - and therefore inferior or something vibe, although I do believe that you should start treating your rosacea with the least invasive means first (herbal supplements can really help, especially milder cases of rosacea, and come with less side effects generally than prescription medication), before going to the big guns. As such, the biggest guns would be laser and IPL treatments. They can help a lot, but also make matters worse for an unlucky minority. So their possible side effects are even more serious than those of prescription medication, which can truly help to calm the rosacea down and bring it even into remission. 

A majority of rosacea patients saw a worsening of their symptoms from triggers like heat, sunlight, hot showers, stress, exercise, and alcohol consumption. Nearly 50% of these patients also experienced some type of neuropsychiatric condition such as a complex pain syndrome, essential tremor, depression, and obsessive-compulsive disorder. In addition, nearly three-quarters of patients with neurogenic rosacea experienced headaches. This group of patients often have a fairly limited response to traditional treatments for rosacea (topical and oral antibiotics). Some patients responded well to medications that focus on nerve pain, such as gabapentin, pregabalin, tricicyclic antidepressants, and duloxetine. Interestingly, hydroxychloroquine (plaquenil), an antimalarial medication and disease-modifying antirheumatic drug (DMARD), demonstrated effectiveness in treating symptoms in a subgroup of the neurogenic rosacea patients. It is most likely the way the blood vessels are triggered to dilate in rosacea, that causes some level of neuronal injury, causing nerve pain and burning pain. Please scroll (a lot) further down to read more precisely how facial flushing exactly happens, and what nerves are involved. I am continuing here to describe what treatment options there are for facial flushing :)

I think anyone looking for a dermatologist or GP that is willing to let them try anti-flushing medication, increases their chances by bringing along some research papers to convince them. If you scroll down in this post, you will find a list of research papers for each of the medication discussed. Pubmed articles are particularly handy to print out and to show, as medical specialists like to see in black and white that an off-label medication is actually effective for the symptom at hand. They are often worried to go off the beaten paths and away from the textbook treatment protocols. But it is important to explain that up until now, there is no official flushing treatment. Nothing. The only thing specifically designed to control flushing, Mirvaso gel, is a liability of a product that has made many users flush worse or made their rosacea worse even in some cases. Medication in pill form is much less risky and can actually really help controlling flushing. A doctor needs to compare it to hot flushes, but then ongoing ones that are not hormone driven often, but that nevertheless widen the blood vessels of the face regularly. Causing pain, heat and worsening of the dilation of the weakened vascular network in the face. Just like with untreated varicose veins. We need to control the flushing, in order to be able to control rosacea subtype 1 or neurogenic rosacea.
I am always worried about invasive treatments like laser or IPL for our subtype of rosacea, to be honest... If they stir up your rosacea and make it worse (which was the case for me), you are often stuck with the outcome! Whereas with medication, anything but steroids is a temporary thing. You try them and if you feel things are getting worse on them, you stop taking them and no long term harm is done. So it surprises me always that dermatologists are more easily swayed to offer laser or IPL treatments than they want to prescribe prescription medication. After all, flushing is a very difficult symptom to treat and if left untreated, it can worsen rosacea over the years and make the problem harder and harder to tackle.

A general overview of prescription medication that is used for the lessening of facial flushing, redness and burning: 

Clonidine - used to treat uncontrollable facial blushing by changing the body’s response to naturally occurring chemicals, such as noradrenaline, that control the dilation and constriction of blood vessels. Therefore it reduces the widening of blood vessels that results in blushing. A few paragraphs below this one I will explain more about this medication. Please scroll down for a lot more specific information about clonidine as a flushing treatment.

"Clonidine has also been reported to improve flushing and blushing reactions at doses of 0.05mg b.i.d. At this dose there was no reduction in blood pressure, but lower baseline malar temperature may have been reduced by peripheral vasoconstriction. Although some patients do remarkably well on clonidine, responders are not clinically identifiable before treatment. Since control of this feature of rosacea is so difficult, a trial course may be indicated" (Source)

Beta blockers - including propranolol and carvedilol, can manage the symptoms of anxiety such as blushing and heart palpitations. They constrict the small blood vessels in the face and lower adrenaline-related flushing. Propranolol is used most often but sometimes carvedilol or atenolol also helps. They don't all work exactly the same, and some have more side-effects than other types of beta-blockers. A few paragraphs below this one I will explain more about this medication, so please scroll down for a lot more specific information about propranolol and beta blockers as a flushing treatment.

"Craige and Cohen recently revisited the use of propranolol in the control of flushing and blushing. At starting doses of 10mg t.i.d., none of their nine patients improved. Six of nine patients improved when doses were escalated to 20-30 mg t.i.d. At such high doses, three patients withdrew from the study due to side-effects. This study shows that the perceived ineffectiveness of beta blockers may be due to inadequate dosing."  (Source

Antihistamines can help control flushing that is stimulated by (food) allergies, foods that are high in histamine or other histamine producing triggers. Histamine released by the body is a blood vessel dilator. I take 20 mg Xyzal a day. Normal dose is 5 to 10 mg a day. A few paragraphs below this one I will explain more about this medication. Please scroll down for a lot more specific information about antihistamines as a flushing treatment.

Certain antidepressants - I take mirtazapine (Remeron) - but there are more who have a good record for helping with facial flushing, Zoloft, Effexor and Celexa (citalopram) as well for instance. SSRI antidepressants in general can help, probably in a similar way in which they can help to combat menopausal hot flashes, by calming the central nervous system. SSRI and SNRI antidepressants also influence the amount of serotonin and norepinephrine in the brain, which in return regulates the internal thermostat; in other words, they can help cool your body temperature down slightly which can cool down flushing and hot flashes. People with rosacea also mention citalopram to help with facial flushing, redness and burning. Celexa (Citalopram) can help cut down on the facial flushing and also anxiety, which can flare up rosacea in itself. Here is more on citalopram for rosacea. There are also antidepressants that can cut down nerve pain, like amitriptyline. Ultimately, I heard from my derms that mirtazapine is one of the best antidepressants for cutting down facial flushing (as well as anxiety, depression ánd insomnia). However, all antidepressants can come with side effects. Mostly..... weight gain. Yes it sucks. I gained weight on mirtazapine (been taking it since 2006) and I gained it despite not eating more, despite eating less than normal at some point, and despite exercise. As my doctor said about it; "You can't diet against it really". Although the more I exercise (walking an hour or two a day), the less the weight gain, And my dad takes the same med and hasn't gained anything; he does a lot of marathon running however:) So yeh, many antidepressants can be super helpful for a host of symptoms we rosacea flushers often deal with, but the weight gain is the only major drawback for me. Nevertheless I keep using mirtazapine, as I can't function without it, with all the additional flushing and anxiety. But I think it's important to be clear about the weight gain risk of many antidepressants in fact (although some are not linked to such weight gain, Wellbutrin for instance, or Cymbalta, but they tend to not be as effective for flushing and also come with other side-effects). Therefore I'd only take them for rosacea if your quality of life is really affected by flushing and burning and anxiety. A few paragraphs below this one I will explain more about Remeron/Mirtazapine, so please scroll down for a lot more specific information about mirtazapine and other antidepressants as a flushing treatment.

Also for the rosacea related nerve pain: certain antidepressants like Cymbalta (duloxetine) and Paroxetine (10 mg daily) might help
In 2008 Duloxetine became the second drug approved by the FDA to treat fibromyalgia. Used to treat treat depression and generalized anxiety disorder, Duloxetine is also used to treat diabetic neuropathy. Duloxetine is class of medications called selective serotonin and norepinephrine reuptake inhibitors (SNRIs).

Non Steroidal Anti Inflammatory Drugs including ibuprofen and diclofenac can help control inflammation and thereby limit facial redness and flushing. Mainly for rosacea sybtype 1 with flushing and redness of the skin. Mainly for rosacea sybtype 1 with flushing and redness of the skin: plaquenil/mepacrine and NSAID. Read more on them here.
Antimalarials (Plaquenil and mepacrine mostly) can help control inflammation and thereby limit facial redness and flushing. I wrote separate blog entries on them here.
Natural anti inflammatory herbs I wrote separate blog entries on them here.
Laser and IPL - I have bad experiences with both devices, as they made my rosacea worse every time I tried it. Nevertheless these are serious treatment options and help many people with facial redness, flushing and burning. Read more on this here and here.                                         

Very low dose roaccutane. This drug has a higher side effect profile and usually works better for subtype 2, with p&ps. For subtype 1, with facial redness, flushing and burning, it has anecdotal success stories, but it's really trial and error with this one. Even on a dose as low as 2,5 to 5 mg a day or every other day (or even a lower dose; some people take 2,5/5 mg a WEEK and see improvement in their rosacea without the high side effect risk that roaccutane normally has), it can help. At very low dose, accutane can also help with skin redness and even with flushing for some patints. Accutane dries out the skin a bit however and at higher doses has the ability to cause accutane-induced flushing and redness. I'm planning a blog post about accutane for rosacea in the future. My dermatologists advised me against using it for my rosacea.

Diazepam/clonazepam - and similar calming anti anxiety medication has helped people with facial flushing as well. I have used it in the past but diazepam made me so dizzy and tired that it wasn't really for me. A friend of mine takes one tablet before having an alcoholic drink, very occasionally, and it helps blunt the flushing he normally gets from alcohol. Both medications and all 'pams' are typically addictive. Best not to use structurally and long term due to dependency and addictiveness.

HRT - for women with rosacea, who are going through menopause or who have instable hormone issues, using Hormone Replacement Therapy can help as well with facial flushing, redness and burning. You can read much more about this on the Rosacea Forum, for instance here, here and here.

Lyrica / Pregabalin, Neurontin / Gabapentin, Sumatriptan, amitriptyline - for the nerve pain and burning sensations that often come with rosacea, there are specific medications that can dampen it and that form specific neuropathic pain control. Most opioids can help with severe skin burning and pain as well. There are also antidepressants that can cut down nerve pain, especially amitriptyline. Gabapentin is an anti-seizure medication that's moderately effective in reducing hot flashes. Lyrica and neurontin make the nerves that control blood flow to the face less active, making you flush and burn less. The migraine and headache pain killer sumatriptan has also been used with some success (100mg up to 3 times a day). All these medications tend to come with side effects however, so make sure to always have them prescribed and discussed with the doctor.
-I used Neurontin myself for a little while and wrote about it here. You can also read more on Neurontin for rosacea hereherehere and here. Gabapentin is developed to treat nerve related pain. Lyrica (pregabalin) is also used to treat nerve related pain, and is approved for use in diabetic neuropathic pain, and for the use in fibromyalgia. You can also read more on Lyrica for rosacea herehereherehereherehere and here.
INFO about gabapentine and reduction of hot flushes:

-Also anecdotally mentioned to help nerve pain and redness: migraine medication like Maxalt or Treximet. Narcotics like oxicodone and roxicodone have also been mentioned by some rosaceans as effective.

-Also for nerve pain; antiarrhythmics, such as lidocaine and oral mexiletine, Aspirin, pentoxifylline, nifedipine and amlodipine
Mexiletine is a non-selective voltage-gated sodium channel blocker, which belongs to the Class IB anti-arrhythmic group of medicines. It is used to treat arrhythmias within the heart or seriously irregular heartbeats. This is a rarely given off-label treatment. Lidocaine infusions help stabilize pain.
You can read more about the use of lidocaine for rosacea herehere and here
You can read more about mexelitine for rosacea here
This young man has erythromelalgia and had success with lidocaine IV infusions:

Aspirin 0.1, twice a day.
Pentoxifylline dilates blood vessels for better oxygen delivery to the muscles, eases muscle pain.
Nifedipine is a calcium channel blocker (usually contraindicated for rosacea): it works by relaxing the muscles of your heart and blood vessels, dilating them. Used for angina, high blood pressure, Raynaud's phenomenon.
Amlodipine is also a calcium channel blocker. You can read more about aspirin for rosacea herehereherehere and here

-(temporary) Nerve block

Tetracycline antibiotics (both oral or in cream form - metronidazole cream and rosex cream) are usually prescribed to help subtype 2 rosacea, and to combat the red pimples and skin outbreaks that come with subtype 2 rosacea. But for some, meds like doxycycline (or low dose doxy: Oracea) and lymecycline can also lower the skin redness, inflammation and sometimes even facial flushing. This is a first line treatment option, and often the very first things a dermatologist gives to a rosacea patient. Metronidazole cream has the potential to irritate very sensitive rosacea skin, but otherwise can be great at reducing skin outbreaks and pimples, and even background redness of the skin. For skin flushing it has a less good track record, although there have been mentionings of it even helping for that (but rarely so). Antibiotics were once prescribed because doctors thought that rosacea was an infectious disease back in the days. That turned out not the case (as in: it's not an acute bacterial infection), but certain types of antibiotics, especially the tetracyclines, do help by lowering inflammation in the skin. There are also plenty of rosacea patients with subtype 1 flushing and burning who saw no effect from these antibiotics. Trial and error..

Medication to lower histamine or mast cells in the body: can help for those who flush and burn: antihistamines, mastocytosis medication including inorial and zaditine, anti asthma meds including montelukast. I had anti allergy medication prescribed by my dermatologist some years ago, that are given for people with mastocytosis. They did help calm flushing and skin redness down for me. Read more on this here and here.

Topical treatment options:

-Finacea gel/cream: used for rosacea subtype 2, with skin outbreaks and pimples and redness. Read more on Finacea here.
Finacea Ingredients
Each gram of Finacea contains 0.15g (15%) micronized azelaic acid in a gel base. It also contains 0.1% benzoic acidpropylene glycol, polysorbate 80, lecithin, polyacrylic acid, triglycerides (medium chain), sodium hydroxide, disodium edetate and purified water.

The Ordinary  

This cream has 10% azelaic acid, just like the prescription cream Finacea does. Azelaic acid is an anti inflammatory and especially can help skin outbreaks and pimples. If you mainly flush and burn just like me, this cream may be too strong for your skin, but best do a test patch on a spot on your face and be safe rather than sorry.

Aqua (Water), Isodecyl Neopentanoate, Dimethicone, Azelaic Acid, Dimethicone/Bis-Isobutyl PPG-20 Crosspolymer, Dimethyl Isosorbide, Hydroxyethyl Acrylate/Sodium Acryloyldimethyl Taurate Copolymer, Polysilicone-11, Isohexadecane, Tocopherol, Trisodium Ethylenediamine Disuccinate, Isoceteth-20, Polysorbate 60, Triethanolamine, Ethoxydiglycol, Phenoxyethanol, Chlorphenesin.

You can read reviews on this product on makeupalley here.

-Antibiotic creams; metronidazole cream, rosex cream: used for rosacea subtype 2, with skin outbreaks and pimples and redness.
Metrogel Ingredients
METROGEL (metronidazole gel), 1% is an aqueous gel; each gram contains 10 mg of metronidazole in a base of betadex, edetate disodium, hydroxyethyl cellulose, methylparaben, niacinamide, phenoxyethanol, propylene glycolpropylparaben and purified water.

-Soolantra/Ivermectin cream: used for rosacea subtype 2, with skin outbreaks and pimples and redness. Read more about them in this blog post.

-Other creams, like sulphur cream, sulphur soap or ZZ-cream: used for rosacea subtype 2 with skin outbreaks and pimples.

-Mirvaso / Rhofade cream: used for rosacea subtype 1 with flushing, redness and burning of the skin. Both have some bad reviews however and can cause rebound flaring of the skin. They constrict the blood vessels in the face temporary, but after that rebound worsening can happen.

-Corticosteroid creams are not to be used for rosacea! But some dermatologists prescribe them regardless, as they will help initially to make the skin less red and inflamed. However they can permanently worsen your rosacea and will do so temporarily for (almost) sure; a big gamble. Steroids, both topical or in pill form, should never ever be used as a rosacea treatment.

"Never, never, never, ever prescribe steroids for rosacea" Dr.Kligman (Dermatology-University of Philadelphia) & Dr. Pleig (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.

Make sure to check all ingredients, as inactive (filler) ingredients can irritate our skin just as much as any active ingredient a cream might have. In bold I highlight common skin irritants in these creams. Read more about this here. 

-Niacinamide; read more on this here.

-Natural anti inflammatory herbs and spices;  Read more on this here.

-Low level red light therapy

-Potential help can come from immune suppressive medication, But this is very serious medication with worse than average side effect profiles):

-Diet changes; reducing the amount of inflammatory foods you eat (sugars and simple carbohydrates especially), and/or testing if you have food allergies or -sensitivities. Read more on food triggers for rosacea here

A note on using medication in general

 I have read people state that using medication is some sort of weakness. I read for instance in a message I received:

"People are too quick to medicate, It doesn't really tackle the heart of the problem, Medication screws you up even more, People who don't feel like fixing the actual problem turn to medication as an easy fix, You should be able to reset the body and health problems through healthy diet and exercise, Why not do a detox?"

My personal point of view is that there is only so much that natural healers and doctors, diet and vitamin pills can do.. They might work wonderful for many people, but some rosacea cases can be very stubborn to treatment, and progressive in nature. There is no evidence whatsoever that diet or exercise can 'reset' an illness like rosacea, unless the cause of the skin symptoms was related to an actual food allergy or sensitivity and you eliminate that trigger. Which is not the case for the vast majority of patients. Not even fasting can reset chronic illness, despite popular belief on some health sites. So most people try a lot of things, only to come to the realization that rosacea is stubborn, comes and goes, and does not disappear overnight. Eating a balanced diet and cutting out sugars can alleviate rosacea for some people however. Others see results by going gluten and/or dairy free. You can read more about this in this blog post I made. I write this blog mostly for subtype 1 rosacea sufferers, with chronic redness, flushing and burning. It is very rare for these patients to see it all disappear by changing their diet. Subtype 2 with skin outbreaks seems to have a better outlook for improvement through diet. But the flushing and redness is hard to tackle. IPL and laser are a better treatment option for this group, but they come with risks too and are invasive and expensive treatments. Not everyone reacts well to these machines or to the specific practitioners who operate them; there are many variables and I have in the past compared it all to Russian roulette of some sorts.. IPL made me a lot worse unfortunately, although this seems to happen to some others too but not very often.

So, in light of all this, medication might be a way for you to control your symptoms and get better quality of life back. They really are helping me, and I want to share my experience with them here. I visited every natural doctor under the sun before even contemplating medication. Saw a natural doctor for 3 years, who worked with medicinal herbs and acupuncture. He always managed to get rid of my minimal eczema (with viola tricolor and acupuncture) but could do absolutely nothing for my rosacea, despite optimistically trying and reassuring me it would clear up soon. Homeopathy -I saw a reputable doctor for 1,5 years- at times made it worse for me personally, or did nothing. I traveled to one of the best Chinese doctors in Rotterdam and religiously followed programs with juices and herbal teas and acupuncture, until he also stated that I just became worse and worse and had a belly so bloated from the herbal teas that I looked pregnant, which he didn't want to continue with. I went to spiritual healers, followed strict diets for at least 6 years, every supplement and vitamin pill imaginable and in the end, the only thing that made a true and clear difference for me personally was medication. IPL made my flushing and burning much worse unfortunately. I didn't dare to take medication for a long time, fearing it would make matters worse, somehow, and also fearing the side effects. Every medication has a long list of possible side effects. But many people get no side effects, or only the most prevalent ones, and even then, they often disappear after a while when the body gets used to the medication. I haveused the below mentioned medication since 2006 now, and they help me a lot with cutting down on flushing and redness. They may not help everyone, but they seem to help some rosacea flushers and burners.

And not all rosacea cases respond the same way to treatment. It's a lot of trial and error, and being cautious about things that can worsen it, like corticosteroid use (usually). I believe natural medicine can help with many ailments and diseases, and I use(d) anti inflammatory supplements too, natural ones. Probiotics can help many, herbs, diet. But for some cases of rosacea they just won't cut it. So if you are in that same boat, and contemplating medication at some point, maybe this info below helps you. My dermatologist tends to say to severe rosacea flushers, that his aim is to break the flushing cycle. Ongoing flushing, redness and swelling can set you up for a continuous cycle, and increase the problem. Like with varicose veins; the more blood is pressing onto the blood vessel walls, the more likely they will be to loose their normal elastic function and the more at risk you might be for angiogenesis; new blood vessel formation.

However: Please always discuss with your medical specialist what drugs and supplements you take together. The more different meds you take together, the more intricate the ways they can interact with each other, and the more at risk you might* be to overload your system. Just be sensible and discuss it with your doctor. Most doctors seem to forget about intermittent check ups (blood work mostly), but always remind your doctor now and then to check blood levels, liver function etc, especially when you take a bag full of medication at the same time (as many of us unfortunately face daily, especially with other underlying illnesses at play).                                                                             


So, for me, after a year of near constant use of fans, cold packs and red hot flushing, this medication helped me control some of it. I have been taking them since the start of 2006, so over ten years by now. These are the drugs that I take, or have used in the past, and that help me:

1. Clonidine 
2. Propranolol (beta blocker)
3. Mirtazapine (remeron, an antidepressant)
4. Xyzal (Levocetirizine, an antihistamine)
5. Diclofenac (NSAID)
6. Gabapentine 
7, How to get your GP or dermatologist to prescribe you medication for your rosacea?

1. Clonidine (Cetapres / Dixarit)

Clonidine official dosing varies between 0,050 mg twice a day to 0,150 mg 3 times a day (and some people take even more than this when the flushing is severe). I take 0,125 mg three times a day, so every 8 hours. The most important thing to realize about clonidine, is that like no other med, it has to be taken regularly. It is notorious for giving rebound flaring (and rebound high blood pressure) when people skip doses. This might sound scary, but this does not mean you cannot try it and stop with clonidine again whenever you want to; it simply means that if you stop, you need to not stop it overnight, but gradually decrease the dose, gently. It also means that you need to remember when to take your next dose. I plan my dosing always so that I take a dose of clonidine when I go to bed, and then set the alarm to be sure I wake up 8 hours later, to take the next dose.

Clonidine showed to be moderately effective in clinical trials for the treatment of hot flashes and facial flushing. I was prescribed this drug by dermatologist and rosacea expert Professor Dr. Tony Chu from London's Hammersmith Hospital, who I have been seeing as a patient since 2005, and who found it helpful in many of his vascular rosacea patients. It helps with facial flushing in several ways, from what I have understood (although the exact precise way of action might not fully understood yet): it acts as a peripheral vascular stabilizer; it makes sure your blood pressure goes down by stabilizing the big arteries and making sure there is less blood available to flow to the face the hands and the feet - basically to the end stations of the bodies blood vessel commuter system. stabilizes (clonidine stimulates alpha receptors reducing sympathetic tone centrally). As such, clonidine constricts the blood vessels in the extremities of the body, including the face (and hands and feet) a bit; it helps the face become a bit less red therefore and it also reduces flushing for many people, as flushing is partly due to vasomotor (blood vessel) instability and dilation. Being a blood pressure lowering drug, it tends to shut down the smaller blood vessels in the extremities (hands, feet and face) to some degree. It widens the big arteries in the center of your body and around your heart, so that the blood pressure in the rest of the arteries goes down. Therefore more blood is drawn away from the extremities (hands, feet and face) and the face gets less red, flushed and therefore it also often burns less. It gives the facial blood vessels some (well deserved) rest and that seems to turn around the severity of the rosacea for many. It reduces the pressure of blood flow through the arteries. It's calming affect is also used to treat anxiety disorders, hot flashes, flushing and sleeplessness.

Unfortunately, there is to this date not a single systematic (pill) rosacea treatment that is effective and side effect free, and clondine can also give some unwanted hassle. Clonidine can make your mouth dry cause dizziness and tiredness mostly, and they might be more pronounced when you take higher doses of this drug. At higher doses, it can be more effective than at lower doses however, which is something you best discuss with your doctor, or gently experiment yourself within safe ranges of doses for this medication. On a lower dose, side effects tend to wear off once your body adjusts to this medication I found, but this also depends on your blood pressure; if yours becomes very low on this type of medication, that in itself can make you feel more sluggish and light headed and tired. I had normal blood pressure to start with, and noticed a short drop of blood pressure (but within the safe range) for a few months after starting with clonidine. Then my body adjusted it, as Dr Chu had predicted, and I have now a steady blood pressure of 100 over 80. Clonidine is often prescribed as a non-hormonal treatment of hot flashes, especially for women with a history of breast cancer, who can use it without increasing the risk of further cancer cell growth (as in the case of estrogen treatment). Again: This medication shouldn’t be used every now and then, but structurally and daily, for a longer period of time preferably, as the full effects of it tend to accumulate over time and it might give rebound flushing if you stop with it suddenly. Instead of clonidine, you could also try moxonidine, which works more or less the same way. I tried both, moxonidine for a few years first and then I switched to clonidine which for me personally works better. But this can differ per patient and comes down to trial and error

Clonidine has been thoroughly tested for the treatment of hot flashes and flushing:

"In a small randomised prospective double-blind study (n = 29), transdermal 
therapy with clonidine (corresponding to 0.1 mg/d) over 8 weeks significantly 
reduced the number (80%, p < 0.04), severity (73%, p < 0.04) and duration 
(67%, p < 0.03) of hot flashes (HF), compared to 36%, 29% and 21% for 
placebo, respectively (Nagamani et al. 1987). In two larger randomised, double-
blind, placebo-controlled cross-over trials in post-menopausal patients, significant 
improvements in the number, severity and duration of HF were observed: In the 
first study (n = 100), patients received oral clonidine in doses ranging from 0.025 
to 0.075 mg b.i.d. for 4 weeks; effects were then compared to placebo (Clayden et 
al. 1974). In the second study (n = 66), patients received a fixed oral dose of 
0.050 mg clonidine or placebo twice daily for 4 weeks (Edington et al. 1980), here 
however, more adverse events (AEs) were observed in the clonidine vs. placebo
 groups (dry mouth: 11 vs. 4, insomnia: 8 vs. 4). Since the reduction in HF 
frequency was small although statistically significant, the authors concluded 
that clonidine was a medication “that makes flushing more tolerable”. 

In this scientific test, conclusions were: "Flushing in rosacea has been investigated by means of (a) pharmacological inhibition of some possible chemical mediators and (b) titration of bradykinin as a possible effector directly in the blood. Clonidine-inhibited flushing was seen in all patients (mean 45%), other drugs had poorer results." In other words: when rosacea patients had been made to flush on purpose, clonidine was most effective of all the medications tested to control the flushing.

In this article, a man with persistent facial flushing and redness was given clonidine:
"This patient's treatment was continued with oral lymecycline to maintain control of the papular and pustular component of the rosacea. Additional options were considered for both the recent onset flushing and the fixed facial redness. Initial treatment for the flushing was 100 microgram oral clonidine three times per day, rising after three to four days to 200 microgram three times per day. The aim was a maximum 1,200 microgram per day in three divided doses, but the side-effect of a dry mouth prevented him from taking more than 200 microgram three times per day." [..] "Systemic agents acting on the adrenergic system, including non-selective beta-blockers such as propranolol or carvedilol, may have a role in anxiety-related flushing, although they are rarely successful for fixed facial redness. Alpha-adrenergic agonists, such as clonidine or moxonidine, can also help in facial flushing by reducing sympathetic tone centrally, but often have troublesome side-effects, such as drowsiness and fatigue. Clonidine in particular has to be used with care and dose escalation and reduction must be gradual."

The London Dermatologist writes here: How do I stop my face flushing?
"Tablet treatments can be very helpful, most usefully clonidine, a blood pressure medication, taken two or three times a day. This has the fortunate side effect in some people of providing excellent facial blood flow control. The dose can be pushed up quite high under supervision from a dermatologist."

Possible side effects:

Cold hands and feet in the winter; in my experience these symptoms are mild ( I have been diagnosed with Raynaud´s syndrome) and for many they are non existent.

Dizziness and tiredness; this happens mainly in the first weeks/months of using, when the body needs to adjust. In time it usually wears off, so you will need to give it some time in this respect as well.

Dry Mouth tends to wear off as well, but Clonidine can dry out your membranes (dry mouth, dryer eyes), so you should drink plenty when you use it.

Low(er) blood pressure. My experience is that both Clonidine and Propranolol didn’t lower my blood pressure too much. Your body tends to adapt also, I heard from my dermatologist, so you might be ok. For those with existing low blood pressure, these drugs are probably not the right choice, but always consult your doctor about the options and risks. You might want to monitor your blood pressure though during treatment. You can buy a small house device for little money usually.

Rebound flushing when you do not use this drug consistently and on time. Clonidine is NOT a medication that you can take now and again. It has to be taken every day and best divided over 3 intakes, every 8 hours. That way you will almost certainly avoid rebound entirely. Taking it every 12 hours might not be a problem, but for severe flushers it might be. In case you want to stop clonidine, rebound flushing isn't automatically on the cards; the trick is to taper the drug off slowly and take smaller doses every time, until you wean yourself gradually off it.

This drug needs to be prescribed by a physician and your blood pressure needs to be checked occasionally.

User reviews on clondine for facial flushing:

Someone emailed me about my clonidine dose and use. He was also prescribed clonidine and started with 0,075 mg twice a day and was now told to take it 3 times a day instead. He experienced rebound flushing well after 6 hours already and wondered how I dose my meds, also the remeron (he uses that too).

I wrote: "With regards to the clonidine, I agree with Dr Chu. I find the clonidine (I take also 0,075 mg per go) to wear off for me after 8 hours and I get rebound flushing around 8,5 or 9 hours, so I always take my next dose after 8 hours. Twice a day (every 12 hours) would mean way too much in between time for me, but I guess this depends on the severity of your  flushing. The timing can be a real pain, as I find that taking remeron and clonidine together -like at the same time- creates some flushing too.. Perhaps because these drugs are registered as antagonists. As long as I keep some time between intake of these two I have no issues however (and the only interaction they can have is that they lower the antidepressant actions and the blood pressure lowering actions of each other, but even when taken together they will still help lowering the flushing attacks for many of us). So I usually watch a series in bed before I go to sleep and plan my clonidine intake then, at the start, and the remeron at the end of the series, right before sleeping. That way they are far enough apart but I don't have to set the alarm for my next clonidine dose. When I was reallly bad I had to take the clonidine every 6 or 7 hours for some time and I did set the alarm then at night, to not oversleep and wake up totally on fire but nowadays I can get away with a 9 hour time span when I wake up later. For me, it still works fine to take every 8 hours; its effect didn't wear off, so to speak. I do try at times to take it every 6 hours but I get more sluggish, tired and light headed from it and it doesn't make the flushing or redness dramatically better, for me at least. But when I was a lot worse than now, I did help, so that would be trial and error.."

Burner wrote on July 9th 2015: For me clonidine has been really useful. Without it I don't think I could function effectively. From what I have read about mirvaso, the two cannot be compared. Mirvaso to me just sounds brutal when it comes to rebound flushing, whereas clonidine has reduced my flushing by between 40 to 70%. burner."

And Burner wrote on October 18th, 2016: "Hi Fiugs, I am sorry you are suffering with this horrible condition. I have had many IPL treatments myself, and although they do not stop the flushing completely (unfortunately nothing does), i found them to be very beneficial, both in terms of appearance and flushing. Coupled with use of medication, in my case clonidine, i am much better than i was when i first developed the condition. Although i still have really tough days, i dread to think what state i would be in without IPL and clonidine, as i could not function at all. The trouble with dermatologists and GP'S is that they simply do not understand how painful this condition can be. If i was you, I would definitely consider laser treatment, but must stress that is important to find someone that is both professional and reputable. Although there is no solution at the moment for this condition, there are things that can make life a little easier. Unfortunately, as we are all different Fiugs, it is a case of trial and error i am afraid. I hope this info is useful to you, and i hope you find the answers you are looking for. My advice to you, don't give up, and stay as positive as you can. All the best. burner"

Sportsfan81 wrote on july 10th 2015: " [..] I take clonidine daily. [..] clonidine has been great thus far (6 months). I do not have any rebound effect, I take it twice daily. Once in the morning and then mid afternoon."

Emz wrote on August 4th 2015: "Hi John, the clonidine helps significantly with the flushing. When I do flush it is usually not as bad or for as long. I can also sometimes stop a flush if I feel it coming on (e.g. by working out whatever I'm doing that may be contributing to it, such as rushing around at work or stressing!) It helps with the flushing I get after eating which was a real problem for me. I would say it's made a 60% improvement and made my condition much more manageable. I wouldn't be without it! Emz"

Romeomilia wrote on December 7th 2015: "Like you I was on the edge of suicide. At only 43 years old I have lost my career in hospitality finance, my friends, the chance to have a family and to have kids. Owing to rosacea erythematous I lost everything and I am a prisoner in my house. Try to listen to the advice of hg24 and take Clonidine 15mg 1 pill per day. I am the living proof that after 6 months of clonidine my daily flushing and redness that were lasting for hours in my case are now gone. Nothing else in this world could stop my nightmare that was lasting for hours. Try try try. You will be a winner. In my case my face is very sensitive now and does not accept any cream. That is a problem as I still cant stand in the sun, heat and hot water. But at least I don't see my face having the colour of a sour cherry everyday and I don't have bad chemical reactions in the skin of the face. Clonidine was prescribed to me together with Zinckit but Zinc does not make any difference. Try Clonidine. I will keep my fingers crossed for you. Good luck with your marathon plans. As antidepressants I take 60mg of Cymbalta daily. I have tried Zoloft but there is no difference. Kind regards, Romeo"

ZK_78 wrote on May 5th 2017: "I am currently taking 3 x 100 mcg of Clonidine per day (breakfast, lunch and evening meals). I find it effective for the flushing with little in terms of side effects. If I could only address the pain then I would be in a really good position. Regards."

Laser_cat wrote on April 25th 2017: "I definitely took my health, and other things, for granted before my inferno face happened :/ And other people don't understand. My friends / family are very understanding in general, but they often forget that simple things for them may be a huge ordeal for me, due to the burning :/My heart goes out to anyone with this disease! I hope that your derm appt is helpful. If not, don't despair though - I think many derms are just not knowledgable about most of this, and it may take a while to find someone you like. It's sad, *most* of the derms I have seen have recommended mirvaso (why aren't doctors learning that mirvaso is not really for flushing...) This whole thing made me realize you really have to be your own health care advocate. Thank god for this forum and its suggestions like propranolol, clonidine, etc. Even though I have found a derm I like now, I never blindly take his suggestion without googling about it, and always tell him my ideas (really ideas I get from this forum).Anyway, hang in there. I'd really be inclined to think your condition will improve once you try out some anti-flushing medications. One day at a time. Best, Lizzy"

And laser_cat wrote earlier on April 25th 2017: "Glad the drug seems to help with your rapid flushes (hate those so much!!). I take it you didn't have the permanent warmness on the cheeks prior to clonidine? Been on it for 6 months-ish myself for afternoon/night flushing ... it actually makes my nose too cold I think during the day which may set it up for worse flushing at night (not sure) ... but I find it generally helpful for ears/cheeks/neck. For ears/cheeks/neck I find my skin generally cooler on the clonidine than before taking it."

Sportsfan81 wrote on March 15th 2017: "Hey Brady, Thanks for the info have you used clonidine previously and if so how would you compare to carvedilol? My main issue I try to control is flushing and I use clonidine in the morning which helps but I still get random flushing episodes throughout the day and always an episode between 3-5pm."

Countrygirl wrote on february 27th, 2017: "I have been on this drug for two months now, and it really helps slow down the rapid rush flushing, when you whole face fills with blood, gets hot and burns for hours on end etc...but it does make my cheeks permanently warm, they never feel cool to the touch unless I'm outside in the cold. Is this normal or is this permanent warm/heat doing damage?"

Madhatter wrote on August 2nd 2014: "New here - subtype 1 rosacea, trialling Remeron and Clonidine under Dr Chu's care. Hi fellow rosaceans. I have been reading this forum for a few months so I thought I would introduce myself and firstly say thank you for all the invaluable information I have found on this forum. Secondly, I would welcome your views on potential treatment options to pursue. My story; I'm a 30 year old female without a typical atopic profile (very fair, porcelain skin, eczema, allergies, childhood asthma). Shortly after moving to London from Sydney in April this year to start a new job as a lawyer, I began experiencing severe facial burning and flushing. It was so severe that I couldn't sleep at all, and was in intense pain at work - it felt like someone was pouring acid all over my face. The GP I saw initially thought it was allergies/eczema and prescribed me a strong antihistamine together with a steroid cream. The antihistamines didn't really help matters and I was loath to use the steroid on my face as I was aware of the potential side-effects. Also, from the research I had done, my symptoms seemed more like rosacea than eczema. So I got myself an appointment to see Dr Chu in July and, in the meantime, convinced the GP and another dermatologist I saw to put me on Clonidine and Mirtazapine based on the research I had done on the forum and the wonderful Scarlet Reds very helpful blog. I also started being quite careful with my diet (cutting out alcohol and trying to adopt a low carb/low sugar diet) and doing anything I could to minimize allergies (taking the antihistamine, getting dustmite covers, keeping a very clean apartment etc). Oh, and I also stay out of the sun, use mineral makeup with an SPF (Jane Iredale) and use very gentle skincare (wash my face with bottled water and use the Avene Tolerance Extreme line and thermal mist).

I started on the Clonidine (50mcg 3 times a day) and Remeron (15mg taken just before bed) in May. These did seem to help quite a bit, and the Remeron certainly helps me sleep. So far I haven't had any side effects from these meds - I already had low blood pressure but the Clonidine didn't lower it too much more, and I haven't put on any weight from the Remeron thus far. However, just before seeing Dr Chu, in June, I had a very nasty outbreak where my whole face was red, burning and incredibly swollen for around a week (for which time I couldn't go to work). I was virtually unrecognizable. My mum even flew over from Australia to support me as I was very scared, unable to sleep due to the pain and having some dark thoughts. I saw Dr Chu and he diagnosed me with co-existing conditions - severe atopic dermatitis (which had become infected) and rosacea. He prescribed an antibiotic (doxy) and told me I was on the right path with the Clonidine and Remeron for the rosacea. I also went to an allergist/immunologist and been tested for allergies and other conditions such as mastocytosis and lupus. Tests came back negative for mastocytosis and lupus, however my Immunoglobin E levels were extremely high and allergy tests revealed very severe allergies to dustmites and moderate allergies to pollen and cat dander."

Burner replied on August 31st 2014: "Hi Madhatter, I also suffer from subtype 1 and have had to deal with the flushing and horrible burning sensations for over ten years now, so i understand the pain you have been experiencing. In my case, i was put on a low dose of clonidine, 50 mcg per day, by my doctor, to see if it helped with my flushing and burning. Like you, i did experience some improvement, but it was by no means significant enough to improve my life, so i went back to my dermatologist. To cut a long story short, i am now on 150 mcg of clonidine per day, and although it has not stopped my flushing and burning completely, i am much better than i was before using this drug. Dont get me wrong, i still struggle, i still have horrible days, but before taking clonidine, everyday was completely unbearable. My point is, it might be worth discussing a higher dose of clonidine with your dermatologist,(make sure he listens to what you have to say), it might be worth a try. In addition to this, I have also found improvement through ipl treatments, moisturising and sunscreen, but i am fully aware that everyone has different experiences with their symptoms and conditions, so what works for one, might not work for another. I hope this helps a little Madhatter and I hope you have success in improving your condition. burner"

This is an interesting post on The Rosacea Forum, by Laser_cat. She had a bad reaction to clonidine and in fact finds good results with a medication called amlodipine, which is a blood vessel dilator in fact, but at the right lower dose 'stabilizes' her blood vessels. It is called a calcium channel blocker, and all meds falling into that category are marked as potential rosacea worseners (and interesting side note; magnesium is a calcium channel blocker too, explaining why stomach acid pills I sometimes take, containing magnesium, make me so badly flushed!). I can't touch it myself, as my blood vessels become a volcano from any type of blood vessel dilator, but it is a very interesting read. Laser_cat also flushes and deteriorates from cold air and actually gets painful pale-white skin on occasions, which is not the case in my rosacea. Either I have pink or red hot skin, or my skin gets a more normal skin tone. I know about the ghostly white painful skin though, as my hands and fingers get it in winter from Raynaud's Syndrome. It is not a nice feeling and has to do with the blood vessels not constricting and dilating normal, but excessively. For that condition (Raynaud's), blood vessel dilating meds like amlodipine are actually prescribed and effective, which makes me wonder if Laser_cat might perhaps have something comparable in her facial blood vessels. Maybe, or maybe not! But cold air is something that actually makes my rosacea skin normal pale in tone, and cool and less painful, so there might be some different mechanisms at play here. Her blood vessels seem to respond violently to being constricted too much, from what I understand from her. Also important detail; Laser_cat takes a low dose of amlodipine (around 0.6 mg a day), not a normal or high dose. And she also takes other meds to help with flushing and burning; Effexor, mirtazapine, plaquenil, and 3 monthly botox sessions. She also has specific underlying other health conditions, including small fiber neuropathy and possibly (from what I understand) erythromelalgia. In her forum posts, she also details specific treatments she received: lidocaine infusions and nerve blocks. Either way, very good posts by her. When I googled amlodipine, I came across this scientific article, stating:

A 45-year-old woman made an outpatient visit to our hypertension clinic. The woman
was diagnosed with essential hypertension, and she had an average blood pressure of
150/90 mm Hg, a heart rate of 70 bpm and a body mass index of 26 kg m2. The patient
was not receiving any treatment at the time. In her medical history, there was a previous
diagnosis of rosacea, and blushing was observed.  She was prescribed amlodipine (5 mg) and
instructed to check her blood pressure three times a week for the next month. After 2 weeks, the patient returned to the clinic because of worsening skin flushing. The
patient reported neither lifestyle changes nor the use of any other drugs or cosmetics. She
reported that the ‘redness’ on her cheeks worsened after a few days and that, after a
week, she started to notice an increased number of telangiectasias. Treatment with
amlodipine was discontinued, and the patient was prescribed ramipril (5 mg). After 2 additional
weeks, skin flushing was reduced from constant to occasional, and there was a consistent
decrease in the appearance of telangiectasias. This case suggests a possible
association between treatment with calcium channel blockers (CCBs) and the exacerbation
of rosacea.

A 45-year-old woman made an outpatient visit to our hypertension clinic. The woman 
was diagnosed with essential hypertension, and she had an average blood pressure of 
150/90 mm Hg, a heart rate of 70 bpm and a body mass index of 26 kg m2. The patient 
was not receiving any treatment at the time. In her medical history, 
there was a previous diagnosis of rosacea, and blushing was observed. She reported 
irregular menses over the past year, with her last menses B2 months before the visit.
She was prescribed amlodipine (5 mg) and instructed to check her blood pressure three
times a week for the next month. After 2 weeks, the patient returned to the clinic
because of worsening skin flushing. The patient reported neither lifestyle changes 
nor the use of any other drugs or cosmetics. She reported that the ‘redness’ on
 her cheeks worsened after a few days and that, after a week, she started to notice 
an increased number of telangiectasias. Treatment with amlodipine was discontinued, 
and the patient was prescribed ramipril (5 mg). After 2 additional weeks, skin flushing 
was reduced from constant to occasional, and there was a consistent decrease in the 
appearance of telangiectasias. This case suggests a possible association between 
treatment with calcium channel blockers (CCBs) and the exacerbation of rosacea.

Patients who presented with flushing were referred to a dermatologist. Of the 62 patients
who discontinued therapy because of flushing, 34 were diagnosed with rosacea or prerosacea.
Rosacea was diagnosed in 34 patients, 23 women and 13 men, who were between 
43 and 57 years of age. These patients were diagnosed with hypertension within the 
last 3 to 5 years and had not previously taken CCBs. When patients with rosacea 
discontinued the use of CCBs, there was a slow but consistent reduction of symptoms.
In all current clinical guidelines, CCBs belong to the class of recommended firstline
antihypertensive drugs for the treatment of essential hypertension. One of the main
clinical side effects of CCB use is flushing, which is experienced by B5% of patients.
These types of side effects, which are drug and dose-related, have a greater incidence in
women than in men (4.5 versus 1.5%, respectively). Rosacea is not listed as a contraindication in the Summaries of Product Characteristics of common clinically relevant CCBs. 
Physicians should be aware that subclinical rosacea could be the cause of treatment 
discontinuation or of the lack of compliance with antihypertensive therapy.
When possible, it may be useful to choose another first-line antihypertensive drug instead of CCBs.

Adverse side effects that forced the interruption of the treatment with CCBs
Side effects
Flushing 23
Peripheral edema 27
Flushing and edema 39
Tachycardia 11

Francesco Natale, Chiara Cirillo,
Chiara Granato, Claudia Concilio,
Alessandro Siciliano, Maria Credendino,
Luigi Aronne, Paolo Calabro`, Maria
G Russo and Raffaele Calabro

On the other hand, this research mentions that calcium channel blockers can in fact help sometimes with neurogenic rosacea

In this small scale study, 14 patients with rosacea were tested. The majority of them were Caucasian females. They had what is called classic rosacea symptoms (burning and stinging, erythema, flushing, facial edema, telangiectasia, pruritus and papules) as well as neurological symptoms. Researchers called these patients sufferers of a special rosacea subgroup: neurogenic rosacea. They suffer from redness of the skin and facial flushing, and some have visible blood vessels on the skin's surface, and they also suffer from stinging, burning and nerve pain of the skin, often even when their face isn't directly flushed or inflamed. They also have a higher risk of suffering from headaches and depressions, or OCD, tremors or complex regional pain syndrome. They emphasize that this subgroup of rosacea patients often has a hard time finding any treatment that really works. Because traditional rosacea treatments often do not work. Many of these trial patients had already tried more standard rosacea treatment options: topical metronidazole, topical steroids, and oral antibiotics with no or limited success. The researchers found that these patients had in fact more benefit from neurological treatment options, including gabapentin (5 of 11), duloxetine (4 of 6), pregabalin (1 of 4), tricyclic antidepressants (2 of 3) and memantine (2 of 2). Some of these patients also saw improvement from topical neurological treatments: Topically formulated neuroleptic agents including doxepin, glycopyrrolate, amitriptyline, capsaicin and ketamine, were effective in some cases (3 of 7). Hydroxychloroquine (3 of 5) and vasoactive agents including beta-blockers and alpha-1-adrenergic receptors (2 of 5) were also helpful in some patients. Photo below is taken from the research article it has the caption: "Facial erythema is seen in most patients at baseline and uniformly during flares. Inflammatory papules and pustules and rhinophymatous change are unusual in this subset of patients."

On top of that, researchers found that these patients reacted well to medication like beta blockers, but also to a group of drugs which do not constrict the blood vessels but in fact relax them and widen them a bit, called alpha-1-adrenergic blocker and calcium channel blockers. Only when patients have pimples (p&p's) or skin outbreaks, did the researchers advise the use of traditional topical or oral antibiotics. In this medical article, clonidine is also said to have some positive effect on nerve pain.

Another very important warning from these scientists, which I wished I had heard of sooner than now, is that neurogenic rosacea patients have a heightened sensitivity to heat and sunlight, which can make laser- and IPL treatments more problematic; there is a bigger risk for these patients that IPL and laser do not give the desired results or in fact worsen matters, and they advise these patients to be very careful when wanting to use IPL or laser for their rosacea. Buggers, if only I had known this back in 2005 :( IPL made my rosacea so much worse...

2. Propranolol (Inderal)

Propranolol can be taken from 10 mg twice a day, up until 160 mg twice a day for flushing (some take even more). I take 40 mg 3 times a day, so every 8 hours, and it really helps control my flushing. Higher doses will reduce your blood pressure further and potentially improve your flushing and redness symptoms more. At 10 mg propranolol is least likely to do anything for your flushing, keep that in mind. We don't use this med to deal with high blood pressure (most likely neither in your case), but to control flushing and burning of the face, so a higher dose is often giving better results. This medication can be used occasionally, and will not give rebound flaring in the way in which clonidine does. However, if you used it for a longer period of time, you do need to taper it off slowly, and not stop overnight. Long term and more steady use tends to give the best results. Besides propranolol there are also other beta blockers that can help with rosacea flushing and redness, particularly carvedilol and atenolol. They work slightly different from propranolol however.

Prof. Dr. Chu prescribed me this medication together with the Clonidine (and a third med, mirtazapine, see more on this one below), as he finds the combination of the three to be significantly more effective in tackling the flushing and inflammation from rosacea. Flushing of the face is known to be very difficult to treat. It is also possible to take these three medications separately from each other however (but for me they work best together). Propranolol is officially a blood lowering medication as well, also called a beta-blocker. It is a beta-adrenoceptor blocking drug (beta-blocker) which is so-called because it blocks the activity of the nerves which form the sympathetic nervous system. Beta-blockers reduce the amount of blood which the heart pumps out at each stroke. This leads to a fall in blood flow through the body tissues, particularly affecting the skin, the muscles and the extremities (fingers, toes, face). As a result people often complain of feeling listless or tired and experience cold hands and feet, especially for a few weeks after starting treatment. Then things often balance out, side effect wise. This is entirely predictable and to some extent is an indication that your treatment is working. So just as clonidine, a beta blocker like propranolol helps with hypertension, but it works in a different way then Clonidine and seems to tackle a different aspect of facial flushing. Beta-blockers to a degree block the activity of the nerves from the sympathetic nervous system, thereby reducing facial flushing responses and especially those that are connected to adrenaline release. When the brain sends signals to the heart to speed up, beta blockers block the uptake of adrenaline which causes the heart to race and subsequent flushing that occurs on the face and neck. It is effective because it stabilizes vascular expansion. It dampens the symptoms of an overactive sympathetic nervous system, including facial flushing and hot flushes, rapid heart beat and adrenaline rushed effects of stress and anxiety, intolerance to heat and sweating. It seems to help particularly for the “fight and flight” flushes, that you might have for instance when speaking publicly, but also for more day to day flushing triggers.

In this article, dermatologist Dr. Paul Hazen states the following about propranolol:

"You can control the diffuse ruddiness by stabilizing it with beta blockers. Inderal is effective because it stabilizes vascular expansion." With regards to flushers: "They all go with an overcompensation of the vascular response. The blood vessels expand dramatically." "Flushing is a tough problem. We think that the nerves that control the blood vessels become hyperactive, but since we don't have a direct cause, we don't have a direct cure. The hardest part to treat is the vasodilation. So something as simple as a 10 milligram beta blocker, taken daily and costing pennies a dose, can forestall the flushing type of rosacea as well as prevent some migraines."

Difference with other types of beta-blockers;

Propranolol is the fast and short acting one of the beta-blockers (half life of around 4 hours), and acts both on beta 1 (mainly heart) and beta 2 receptors (blood vessels). This way, it helps to make the blood vessels in the face less dilated, taking the pressure off them, and as a result your skin should look less red and it should be harder to get flushed. Propranolol also reduces adrenaline output in the body, and is therefore often prescribed for anxiety, or for stressful events where 'stage fright' plays a role as propranolol will help reduce the adrenaline and everything that comes with it, for instance sweating and a fast beating heart. It will calm you down. Propranolol reaches the brain and can worsen depression in some cases. However, propranolol can be a very effective treatment of ruddiness of the cheeks, of redness and of mild flushing, even at the low dose of 10 mg aday.

Atenolol is a selective beta-blocker and also used to treat rosacea flushing. It works more on the heart. It does not reduce adrenaline output, like propranolol does, but it also has far fewer risks of causing or worsening depression. It also does not affect the lungs. It also works longer than propranolol (it has a half life of 7 hours); one dose a day is sufficient. It is not handy to use this drug occasionally, because unlike propranolol, it can cause rebound high blood pressure when it is suddenly stopped and even can cause severe effects on the heart then. So never stop it out of the blue, if you try this drug. You also shouldn't drink alcohol while taking this drug. At lower doses, propranolol was found to be more effective than atenolol at reducing heart rate and palpitations.

Carvedilol is a non-selective beta blocker, like propranolol. This means it affects both the heart and blood vessels. It blocks the beta receptors on heart muscle and other cells, making them more relaxed and less responsive to stress hormones. Just like propranolol, Carvedilol also blocks alpha receptors, which are found on blood vessels, and relaxes the blood vessels, dilating them, which lowers blood pressure and vascular resistance. In testing, it showed that carvedilol can reduce rosacea flushing: "These findings demonstrate that facial flushing and persistent erythema can be effectively treated by carvedilol long-term with a fast onset of improvement in a dose well tolerated."

Nadolol showed in tests to have no effect on flushing, however it was a small scale study and nadolol has in fact been prescribed for its blood vessel distracting and blood pressure lowering effects.

I tried all of these beta blockers myself and think personally that propranolol or carvedilol are the best. Propranolol is my favourite. These drug need to be prescribed by a physician and your blood pressure needs to be checked occasionally.


Possible side effects:

I had a few weeks of tiredness when starting propranolol, but that wore off for me and I have used it at a low dose since 2006 straight, and am very happy with it. It reduces my flushing episodes and makes it harder for me to flush. I don't feel side-effects from it anymore at this point. Nevertheless, all medication has potential side-effects. Propranolols side effects are mainly the same as with Clonidine (possible cold hands and feet in the winter, initial dizziness and tiredness, dry mouth). When it is taken occasionally, propranolol has almost no side effects. Some people may feel a little light-headed, sleepy, find that it mildly affects their short-term memory or feel more lethargic. Because it lowers your blood pressure, it can also happen that your hands and feet feel more cold, numb and/or tingle. There has also been some proof that beta-blockers can make someone more prone to depression, which might be a concern for many rosaceans, but it doesn’t necessarily have to happen. But, science isn't sold on this claim yet:

"The relationship between propranolol and depression is a subject of controversy. Numerous case reports suggest that propranolol can cause depression, but two small prospective trials have failed to confirm this. The contemporary psychiatric literature is divided as to whether propranolol can cause depression." 

A small but statistic increase of depression risk on beta blockers like propranolol is probably related to a reduction of blood pressure and an increase of tiredness. I also heard from a girl on one of the Rosacea Facebook pages that beta blockers like propranolol lower noradrenaline levels in the brain and that this in itself can make you feel more depressed. I happen to take mirtazapine as well, which blocks certain receptors and increases the levels of noradrenaline, so that med counteracts this beta blocker effect for me. I have been feeling significantly less depressed while taking clondine, propranolol and mirtazapine, than before I started taking them. But when you just take a beta blocker, it might affect your mood. But then again, it might not, it is a possible side effect only. Also, theoretically these medication can cause difficulty in obtaining erections in men, but this might be related to the dose you use and it is only a possible side-effect.

It is also important to note that beta-blockers like propranolol can worsen asthma or other chronic lung diseases. This because they can narrow and constrict the airways in the lungs due to the tightening of surrounding smooth muscle. This is not an issue for people with healthy lungs btw.

Low(er) blood pressure. My experience is that both Clonidine and Propranolol didn’t lower my blood pressure too much. Your body tends to adapt also I heard from my dermatologist, so you might be OK. For those with existing low blood pressure, these drugs are probably not the right choice, but always consult your doctor about the options and risks. You might want to monitor your blood pressure though during treatment. You can buy a small house device for little money usually. 

User reviews on propranolol for facial flushing:

GracieTiger wrote on March 23rd 2009: "Hi guys, i hope everyone is well. I wanted to ask a couple of questions about your experiences with propranolol and its effectiveness. I have been taking propranolol for about three months now, and it has DRAMATICALLY improved my flushing. which is kind of puzzling to me because my greatest flushing trigger was a change in cold (or even just a tad chilly) weather to a warmer climate. again, this didn't require going from the freezing cold to a heated room, but even a change in just comfortable light jacket weather to t-shirt weather would trigger a flush. I also experienced anxiety-flushing, although it was much more transient, more like blushing. the cold weather flushing, however, was the classic ten hour long burning pain flushing. So, when I began propranolol, I assumed only the anxiety flushing would be helped out. much to my surprise, I have not flushed at all since being on the propranolol. i can't say that i haven't turned red or anything, but the bright red, burning flush, the kind that everyone asks me if i'm okay and need to see a doctor, haven't had it at all. it was nothing short of shocking to me. I must add that i have had other mysterious health problems starting at the same time as the flushing began. I was diagnosed with an autonomic nervous system dysfunction, so the inderal also helps the rapid heart rate and arrhythmia i experience.. I have noticed that as soon as the beta blocker wears off, the flushing returns. so it is by no means "better," but masked with medication. My doctors still do not seem to take my flushing seriously. I went to a top-ranked dermatologist in my city, who was also recommended on a rosacea site, and he told me that I absolutely do not have rosacea because i have an autonomic nervous system dysfunction. I also do not have papules or pastules. I wanted to speak with him about possible laser treatment, but he wouldn't have it. all my other doctors, who treat the ANS dysfunction, agree that the flushing seems very much like rosacea. So, I am just wondering if anyone else has found total relief, or near total relief, of their flushing from the use of inderal? would one expect that inderal would treat all kinds of flushing triggers in rosacea, or just the anxiety/adrenaline related ones? is my response to inderal in regards to flushing more in line with an autonomic dysfunction, or is it typical for rosacea? Thanks so much guys."

Melissa W replied on March 23rd 2009: "Hi Gracie, First of all it is great that the Propranolol has helped you so much! I understand your desire to "fix" what the problem is rather than masking it and I think that is a smart way to go. To find a doctor who can treat your ANS dysfunction. [..] Are you on the lowest dose possible that still helps curb your flushing? Honestly, I would love to find a med that would help control my flushing and burning and I would have no problem taking it forever LOL as long as the side effects were tolerable. I would have a problem taking a drug that makes me feel sluggish as I love being active but if it helped stop my flushing I might take it when I was going to a social function etc and not when I was going to be outside biking for example. Sorry I am not any help here [..] but I am confident you are under the care of doctors who are experts in that area and I would look to them for more tolerable long term solutions. Best of luck Gracie and let us know how you are doing. Melissa"

GracieTiger wrote on March 23rd 2009: "Hi, thank you so much melissa, it is great to hear from you. and as always, i appreciate your insight so much. I agree that i am pretty much willing to do anything to stop the flushing, and am so grateful that the inderal has helped me as well as it has. however, when i do say that the inderal causes lethargy and unpleasant side effects, i mean they are wicked side effects!!! i pretty much constantly walk around completely detached from the world. i find myself always just staring off into space, into some kind of la-la land, and i'll have no idea how much time has passed. i know some people take some hard drugs to experience these feelings, but for me, they are not good at all!!! i have also always been very active, and i am a student and work, so spending the day completely checked out of the world is not good. And yes, i am on the LOWEST dose. such a low dose that doctors insist the propranolol possibly can't help me. at first, my docs all told me i'm better and don't need it. so i stopped and sure enough, heart rate sky rocketed, all my symptoms came back, and everyone agreed i definitely need to be on it. i'm just super sensitive to its effects. so in most people, it might cause a little tiredness, but in me, i definitely feel drug-induced. Now, when i have to choose between the symptoms that the inderal takes care of (like the flushing) and the constant detachedness, i choose the detachedness. i just fear the day that the effects "wear off" and i'm left with all the old symptoms. Thank you so much once again."

Phlika29 replied on March 23rd 2009: "I found propanolol to be very helpful. I found that the tiredness went away once my body had got used to it and have been taking it for years with no real problems. I take a time release capsule and so just take one per day. What is the actual dose you are on?"

CharmQuark replied on March 27th 2013: "Thumbs up Propranol for flushing! GracieTiger: When I saw your post I felt compelled to register and comment because I've had so many of the same experiences/results with inderal/propranolol! I realize this comment is years after your post but I hope you'll see it and update us on how you're doing and what's working for you now! I started using propranolol 5 years ago (early 20s) and noticed immediately that it helped not only with my social anxiety but also my rosacea. I had the extreme flushing even as a teenager but like you was also told that it couldn't be rosacea due to my age and no papules. Nevertheless I was prescribed metrogel but it didn't seem to do much. I'm so glad that I stumbled on the inderal because honestly it's been a lifesaver for me, not only for situational anxiety and flushing but for other purposes as well (irritability, hypomania). I have 10 mg tablets but sometimes cut them into 5 mg and only need that much. I used to need a lot more. Some of the negative side effects for me have been: cognitive dulling, like you mentioned (it's such a pain to feel my brain slipping away as it kicks in!), decreased libido, and rarely my BP drops too low even on that low of a dose. Anyways, I'll stop this before it's super long but I hope you're well!"

Jossan replied on March 29th 2013: "I've taken propranolol for two weeks today. It may make me less sensitive to heat and cold, but it's hard to tell as I've avoided it as much as possible. I'm pretty sure it helps against my edema though as I haven't had this little swelling in a long long time! However, it seems like it worsens the ache. Anyone experienced this? Don't know if I should continue taking it or not. Sort of wanna try it for at least another two weeks but scared it's making it worse.

Jossan updated on April 18th 2013: "I've taken propranolol for 4-5 weeks now and I find that it reduces my swelling quite a bit. But I've started to get cold burning (it's not really cold but I don't get hot when it burns) in my cheeks that I didn't use to have (mainly had problems with aching and other types of pain). It also seems to both lessen the redness and increase it. I've been almost white a few days but then other days I've been much redder than before. I even notice a shade of purple which I've never seen before. I'm not too worried about that though as long as it goes back to pink-red again and doesn't cause damage. I really like that I reduces the swelling but not so happy that it seems to be causing burning. Don't know if I should continue or if the burning and increased redness means that my rosacea is getting worse. Any advice? Thank you"

Jrlhamcat2 wrote on May 30th 2013: "I found it reduced flushing from the first dose. If 180 mg/day isn't helping at all, I doubt it's going to help you."

fed_up wrote on May 30th 2013: "I also noticed reduced flushing from my very first dose. I have been taking 40mg a day for just over a week and it is really helping me a lot."

Mtred wrote on August 19th 2010: "To describe in words just how much facial blushing (FB) has altered the course of my life would be very difficult. I have been a prisoner of my own body now for nearly 11 years and everyday is a constant struggle to keep a smile on my face. A battle that i will ultimately never win, but hopefully someday will be able to make peace with. However i recently came close........After trying nearly everything on the market I discovered a class of drugs known as Beta-Blockers. The one in which i was taking was propranolol, 20 to 40mg a day as needed. With some research i found it to be best for FB. Basically without going into to much detail they slow your entire sympathetic nervous system down, and not only slow it down but it somehow keeps it there. I dare you to get embarrassed while taking these its literally impossible. Thirty min after my first dose i wanted to cry. I felt a calmness come over me that ive never felt sober. I was finally free. Not only was i unable to blush but my face (cheeks) were barely red at all since the medication also induces vasoconstriction. Sounds perfect right? well not exactly. The calmness that i referred to earlier only last for about an hour or so but the side effects will stay with you all day. My heart sometimes felt like its was barely beating and your lung capacity is greatly diminished. Almost every time i stood up i felt light headed as if i were about to faint. At night was the worst, pretty much the same effects during the day however now your system is slowing down even more as it naturally does before sleeping. I could not stop myself from having panic attacks due to these side effects. I tried to take them several times over a span of a year praying that something might change, but it never did. I cant say for sure how most react to beta-blockers for FB and anxiety since i havent spoken with anyone else that has taken them. Never the less that was my experience but please feel free to share yours and letme know if you have had any success with any other types of meds. Thanks."

ExFB replied on August 21st 2010: "Dear mtred. I tried beta blockers over the course of probably 10 years. I only ever took them in situations where I needed a crutch, normally presentations at work etc, you know the drill. I agree they can have a calming effect that lasts for maybe 1 or 2 hours and for me they worked, I did not blush during that calming period. So I got the desired effect. The problem for me was also the side effects. Taking high blood pressure medication for someone with normal blood pressure is not a good situation. I felt nauseous for the rest of the day. Which is why I only ever took them for when I really needed them. I never tried anything more exotic than beta blockers. I know there are others who have tried Prozac and the like."

Shellykay replied on August 30th 2010: "Beta blockers are also the most helpful tool I have found in regards to my facial/neck/chest blushing. I only took them in social situations where I knew I would blush and they definitely aided in calming me down and therefor not fearing the blush as much(which is half the battle) but didn't stop the blushing entirely by any means. Never felt too many negative side effects. Just as you said, almost couldn't feel my heart beat at times and got quite sleepy. I could definitely see how they might effect you badly if you took them daily though."

Stuckwithme replied on September 29th 2010: "Inderal (propranolol) has been proven to work for blushing in studies. It's not a miracle cure but it does calm down your sympathetic nervous system and ultimately make you less prone to blushing. BUT, it isn't a cure and I'll bet that while it works for some, for others it don't. Thing is also that in the beginning it might seem like a miracle cure, but then you have a blushing episode and then it doesnt seem to work very well any more. Whether or not you suffer from high blood pressure, it is probably best not to be stuck on Inderal. It has all sorts of side effects that ruins your life, like loss of libido, weight gain and a higher risk of developing diabetes."

Brady Barrows wrote on April 7th 2017: "Dilatrend (carvedilol) is a brand name drug manufactured by Hoffmann-La Roche is prescribed for hypertension and congestive heart failure. Another brand is Coreg, manufactured by Glenmark Generics Ltd. Carvedilol is the generic prescription, which is manufactured by many other pharmaceutical companies. Because rosacea sufferers ask their physicians what can they take to avoid flushing, one of the side effects of carvedilol since is reduces blood pressure is it also reduces flushing. Not that flushing completely goes away, it simply reduces flushing. Flushing is one of the signs/symptoms of rosacea. Contrary to a popular belief, flushing is not rosacea. It is a sign/symptom of rosacea just like redness is a sign. So it may help reduce redness but may not. All you can do is ask if your physician will prescribe it and try. Not all physicians will prescribe carvedilol for rosacea, but some do. Depends on your blood pressure. If you blood pressure is low, your physician may have qualms about prescribing it for rosacea. There are a number of other prescription drugs that have been anecdotally reported in RF to avoid flushing and I have collected a list. Carvedilol is simply one among many. There are also several non prescription oral treatments to avoid flushing such as aspirin and red clover."

Emz wrote on April 19th 2017: "I tapered off propranolol 30mg a day a few months ago. I was taking them for flushing but I have found no increase in flushing at all which was a big surprise. I still use them occasionally (10mg once or twice a week max) and find them far more effective with occasional use (I wonder if my body had just got used to them when taking them daily?). As far as I'm aware it is fine to use occasionally although I would check this with your GP."

Tondar wrote on April 6th 2017: "It didn't take long after starting with propranolol before I started noticing that my hands and feet were freezing (tip of my nose as well). I also started seeing my feet turn very red in the shower. I slowly weened myself off the propranolol and started taking atenolol instead which was better (still happens but not as bad as before). I have started to now ween myself off of atenolol and have a found a new "odd" symptom. My sympathetic nervous system seems VERY sensitive now. At work if I speak up in a meeting or get into a disagreement my whole head starts to burn/flush. Beta-blockers are used to treat social anxiety which I never really felt I had before but now coming off of them I feel I now have this condition. I read a research report suggesting this can happen on withdrawal unfortunately it did not say if it was permanent or not."

More scientific links for the use of propranolol for facial flushing:


Some more information on another type of beta-blocker, carvedilol

"Pronounced facial flushing and persistent erythema of rosacea effectively treated by carvedilol, a nonselective β-adrenergic blocker." (source) See also this recent research and these two older ones: this pubmed article and here.

"Rosacea is a common facial disorder characterized by centrofacial erythema, flushing, telangiectasia, edema, papules, and pustules. Treatment of erythematotelangiectatic rosacea (ETR) with severe facial flushing and persistent erythema remains challenging despite some  successes with β-adrenergic blockers, clonidine (α-adrenergic agonist), naloxone (opiate antagonist), ondansetron (serotonin antagonist), and endoscopic thoracic sympathectomy. Traditional β-blockers nadolol and propranolol (20-40 mg, 2-3 times a day)3 can suppress flushing reactions, but the side effects of hypotension and bradycardia may pose problems because most patients are normotensive. Carvedilol, a nonselective β-adrenergic blocker with α1 blocking activity and potent antioxidant activity, is indicated in treating mild to moderate congestive heart failure. We have recently reported a case of refractory ETR successfully treated with carvedilol. In this report, we present the results of carvedilol therapy in a case series. Altogether there were 11 normotensive patients, 9 female and 2 male, ages 17 to 47 years, mean 34.5 years (clinical summary in Table I). They had been treated unsuccessfully with doxycycline, corticosteroids, propranolol, clonidine, ondansetron, metronidazole, tacrolimus and pimecrolimus, endoscopic thoracic sympathectomy, stellate ganglion block, and pulsed dye laser therapy in various combinations. Patient 6 was the subject of our earlier report.
Table I. Diagnosis, treatment, efficacy, and side effects of 11 patients with erythematotelangiectatic rosacea treated with carvedilol"

During the carvedilol therapy, we monitored the severity of facial erythema (based on clinical photographs), cheek temperature, patient's assessment of the symptom severity using a 10-point visual analog scale (score 0-10), and the side effects. Carvedilol (3.125-6.25 mg, 2-3 times a day) was added to each patient's other current medications and the daily dose was titrated gradually up to 31.25 mg/d (Table I). All patients experienced significant clinical improvement within 3 weeks (range 3-21 days, mean 10.5 days), with a mean reduction of 2.2°C of the cheek temperature and a mean reduction of 6.3 of the visual analog scale score (recorded for 7 patients). Fig 1 illustrates the clinical course of 1 patient (patient 11). Our study demonstrated that low-dose carvedilol was effective in treating ETR (erythematotelangiectatic rosacea) with rapid onset of symptom control. Moreover, it also allowed other concurrent medications to be tapered or stopped. The side effect was minimal; only 1 patient discontinued treatment because of asymptomatic hypotension. These results are encouraging, but further prospective controlled studies of carvedilol therapy for ETR are warranted to determine the optimal dosage, treatment duration, long-term therapeutic effects, and side effects.

3. Mirtazapine (Remeron / Zispin / Avanza)

I love mostly everything about this med; how it reduces the most violent flushing for me, how I sleep like a baby on it with pleasant vivid dreams, how my anxiety is completely gone, how much less depressed I feel ever since starting it in 2006. But there is one down-side; it can cause weight gain. And it did for me too. I went from 50 kg (110 pounds) to 65-70 kg (143-154 pounds). And I hate it. Nevertheless, I can;'t do without it. The times I stopped taking it, the weight dropped off without any effort but I started feeling restless, anxious and mostly flushed again all the time. Doesn't way up against the slimline for me personally, but Iam nearing age 40 now so maybe that plays a role as well; I can't be bothered as much now as when I was in my mid twenties.

SO... Mirtazapine dose for facial flushing should vary between 15 mg and 30 mg a day, taken at night before bed time. From what I have understood from Prof. Chu, mirtazapine has not only potent antihistamine actions, but also seems to act somewhat as an anti-inflammatory and shuts down flushing to a degree. It also blocks 5-HT(2A) which helps combating facial flushing. Blockage of 5-HT2A receptors by mirtazapine, has proven to reduce hot flashes and flushing in post-menopausal women. When you have a flush or a hot flush, the core temperature regulation gets  messed up. Your body no longer can regulate the core body temperature the way it is supposed to do, and as a result, you overheat. For people with rosacea, this results often in more blood flow to the skin (trying to release the heat through the blood), opening up and vasodilatation of the blood vessels near the skin and red flared up faces. It is mirtazapines blocking of 5-HT2A, which plays a key role in the thermo disruption, which helps here to control the flushing. Mirtazapine is a new type of tricyclic antidepressant, and it's also called a NaSSA: noradrenergic and specific serotonergic antidepressant. It isn't an official nerve pain treatment option, but research recently showed that it does reduce pain feelings.
Besides mirtazapine (which can give the particular side effect of increased appetite and weight), there are also other SSRI antidepressants which can help with rosacea redness, flushing and burning. Think of Celexa and Zoloft. I was prescribed mirtazapine 15mg back in 2005 (currently taking 22,5 mg), together with Clonidine and Propranolol, but these medications can also be taken individually. Many will find however that these drugs can be more effective together than separately when it comes to cutting down on your face flushing (despite clonidine and mirtazapine being antagonizing drugs on paper, but this has only a slight influence on their ability to lower blood pressure, NOT on their ability to tackle the facial flushing). Mirtazapine is a relatively new antidepressant, that not only is one of the top effective antidepressants and anti-anxiety drugs, but also has a proven track of lowering the severity and incidence of facial (hot) flushes. I absolutely love this drug; it has made my life a lot better since I started taking it. No more 24/7 painful debilitating face flushing and burning, a near complete lift of the anxiety I used to feel and a significant lift of mood, although I take too low a dose to really notice true antidepressant effects.

So, Mirtazapine is a newer type of antidepressant and works on the same primary receptor (alpha2-adrenergic autoreceptor) as clonidine however paradoxically as an antagonist (the theory is that there is an alpha2 dysregulation not simply an excess or deficiency). It recently has been shown to help hot flushes, just as clonidine. It also increases (or more precise, stops the blocking of) serotonin similar to SSRIs, Prozac, Paxil etc with significantly less risk of sexual dysfunction than those antidepressants. Mirtazapines main side effect is an increase in appetite and slight change of metabolism, promoting weight gain. Most antidepressants do this, but mirtazapine does not have their loss of libido side effect. It causes sedation right after taking, and is also used as a sleep aide, so best take these pills around bedtime. I have been sleeping wonderfully since I started taking mirtazapine at the end of 2005. Solid 9 hours of sleep with vivid but very pleasant dreams.

Mirtazapine works in the brain, where it enhances the effect of naturally occurring chemicals called neurotransmitters. These are chemical compounds that act as chemical messengers between nerve cells. Noradrenaline and serotonin are two such neurotransmitters and have various functions that we know of. When noradrenaline and serotonin are released from nerve cells in the brain they act to lighten mood. When they are bound to nerve cells in the brain, they no longer have an effect on mood. It is thought that when depression occurs, there may be a decreased amount of noradrenaline and serotonin released from nerve cells in the brain. Mirtazapine works by blocking receptors called alpha-2 receptors that are found on nerve cells in the brain. Noradrenaline and serotonin would normally bind to these receptors. By blocking them, mirtazapine prevents noradrenaline and serotonin from becoming bound to the nerve cells. This enhances the mood-lightening effect of free noradrenaline and serotonin that is released from nerve cells, and helps relieve depression (source).

The London Dermatologist writes here: How do I stop my face flushing?

"Other drugs that can sometimes be useful are fluoxetine, carvedilol and mirtazapine. Propranolol, a ‘beta-blocker’, is sometimes used, but it is not especially effective in my experience, although it does help with anxiety. All of these medicines are unlicensed in rosacea (meaning that using them to treat rosacea differs to how they were originally intended to be used)." "Tablet treatments can be very helpful, most usefully clonidine, a blood pressure medication, taken two or three times a day. This has the fortunate side effect in some people of providing excellent facial blood flow control. The dose can be pushed up quite high under supervision from a dermatologist."

About the best mirtazapine dose for rosacea redness and flushing

At 30 mg my mood was better than now at 22,5 mg a day, but the drug no longer was as effective then for face flushing. Reason being that mirtazapine is a strange duck of a med and works twofold: at a low dose, so from 1 mg to about 20 mg a day, it has strong antihistamine effects. This means that at these low doses it gives most antihistamine-related side effects: drowsiness, lethargy, tiredness. But it also means that at this dose it has the highest effect on flushing, as histamine is a potent blood vessel dilator. Mirtazapine does more than just block histamine however. But around the dose of 30 mg a day and upwards, noradrenaline action kicks in and takes over the antihistamine effect. This stronger noradrenaline effect is less interesting from an anti-flushing point of view, although mirtazapine at that higher dose is in fact more effective as an antidepressant. Hence why 15 mg a day is the official start up dose of mirtazapine for depressed patients, and not a stall dose. At this higher dose (30 mg and up), the side effects of mirtazapine also change and people are less drowsy and less tired on a higher dose of mirtazapine than on a lower dose. This, because most of those side-effects are tied to the antihistamine actions; they are the same side effects you get from taking other antihistamine medication, for instance Benadryl, Singulair or Zyrtec. Derms I know prescribe mirtazapine however at 15 mg per day for flushing patients, exactly because at this dose the anti flushing effects are said to be highest.

My experience with mirtazapine was that at 15 mg it worked probably best for my flushing (against them I mean). But at that dose the antidepressant effect wasn't big enough, and the drowsiness related side effects were pretty noticeable. I found my best dose now to be 22,5 mg a day; high enough to not feel completely tired, but low enough to really help curb my flushing.

Mirtazapine can improve (menopausal) hot flashes:
"Treatment of hot flushes with mirtazapine: four case reports. To evaluate the effect of mirtazapine on the severity of hot flushes and bouts of perspiration in women. METHOD: In two women with depression a reduction in hot flushes was noticed by serendipity during treatment with mirtazapine 15-30 mg/daily. On the basis of this observation clinical studies were extended with two non-depressed and non-anxious women with hot flushes. Both subjects were prescribed mirtazapine daily. All subjects reported a practically complete disappearance of hot flushes and associated perspiration, within the first week of treatment. Mirtazapine appears to have a substantial ameliorating effect on hot flushes and perspiration bouts. It is postulated that the 5-HT(2A) blocking properties of mirtazapine is accounted in the symptomatic relief of hot flushes. In addition it is hypothesized that the serotonergic system is crucially involved in the pathogenesis of hot flushes and perspiration bouts. Further evaluation in double-blind placebo-controlled studies is encouraged."

My own experience with mirtazapine was that I went within some weeks of using it from a 24/7 flusher, at my wits ends, to a ‘part-time’ flusher. It seems to heighten the threshold for flushing. I have heard this from several other forum members, including WrinkledClue. From the 3 meds mentioned, Mirtazapine has the best scientific studies backing up it’s positive effect on facial flushing (see the link below). It is mentioned in the link that Clonidine and Mirtazapine shouldn’t be used together, but I have done this for 4,5 years now without problems, as have many others and Dr. Tony Chu has explained to me that there is no problem in this, as long as you use both meds mostly for the flushing. They antagonize each other in the way that Clonidine lowers the antidepressant actions of Mirtazapine, and Mirtazapine lowers the blood pressure lowering actions of Clonidine, but this is only partly. The pharmacists in Holland were positive that there is no proof for this as they are up to date on medication interactions they say, and never officially were informed about this. They prescribe both drugs together still without problems, as do dermatologists. For the flushing actions of both, there is no impediment.  Positive note: even on these low doses Mirtazapine works strongly against anxiety and depression. This can lift your darkest rosacea-induced clouds and the better spirits and reducing of anxiety help combat flushing and inflammation even more. It also helps you sleep long and sound.

Possible side effects:

Dizziness and tiredness If you take this med before bedtime, you won’t have much trouble with it probably. But your body might need some time to adjust to it, so give it some time before evaluating. The anti-depressant actions officially will start to kick-in after 3 weeks of use, but many experienced them sooner, as with the anti-flushing actions.

Cold-turkey effects when you miss a dose or stop taking it without tapering off Mirtazapine can give quite strong cold turkey symptoms, including nausea, dizziness, brain zaps and restlessness, as well as terrible insomnia if you go down on your dose too quickly. You need to be careful to taper the dose down slowly, especially if and when you decide to come off the drug - you can get an expensive liquid form to taper it down very slowly, e.g. 5mg for one week, 4mg the next week etc, as withdrawal effects are quite common when you try to come off it. You can also cut your pills in smaller parts, but be aware that even a few milligrams more or less can already give noticeable side effects.

Weight gain and increased appetite. As mentioned above in this blog post: I gained weight, about 15 kilo's (and a few kilo's more some times), I must say this. But there are others on the forum who were able not to, taking care of a good (though strict) diet. It is said that antidepressant-induced weight gain comes merely from the change in serotonin, which normally regulates your appetite. Taking these types of drugs tend to increase your appetite and make people eat more - hence weight is gained. Mirtazapine is particularly suspect here as it also works as an antihistamine, which also increases appetite and creates also an appetite for carbohydrate and sugar rich foods. Someone on a forum compared this effect to wanting to eat glaced donuts morning, evening and night, or having to withstand the urge to eat sugar straight from the package. But there is another reason why antidepressants have a bad reputation for increasing weight: a change in metabolic markers and a lowered thyroid production, as well as a change in adrenal function, causing higher cortisol levels (which is a stress hormone) and lower adrenal production. This in the end leads to slower metabolism. This is something antidepressant users have complained about on forums for as long as these drugs are on the market, basically. People who made sure not to change their diet, nor the amount they were eating, still gained weight while taking antidepressants. Even people who run marathons and never in their adult life gained weight, who burn a fair amount with their sports activities and kept a very strict control of their calorie intake, till stated on forums that they gained weight on these drugs. That being said, my father uses mirtazapine for years now, at the same dose as me and is a sportsman and he didn't gain a single pound on it. Very unfortunate, as these drugs can help tremendous with the improvement of anxiety and depression, as well as peaceful deep sleep. In fact, I love mirtazapine for everything it does except the weight gain.

With strict diet and exercise I did manage to get some of the initial weight gain off again, but its very hard work and I never got back to my skinny normal figure. I was a bit underweight to start with though and am not overweight now technically either, but it did change my weight and figure, I want to be honest about that. I also feel hungry a lot more than before. Keeping a close eye on my diet, having less than normal calorie intake and exercise is the way to go for me personally.. I remind myself that without mirtazapine, I could not exercise at all! I could not leave the ventilator and cold packs in fact. So it is the better of two evils for me. Here the weight gain associated with remeron is discussed, it's a good read.

Left picture was my normal figure (around 50 kg, always close to being underweight), second me around 63 kg, after taking mirtazapine for 6 years. And by now I actually gained a little bit more weight :O

I understand that people who contemplate taking mirtazapine, might be worried about its weight gain side effect. I have gained weight on it too, to be honest. But there is some science behind why this happens, and with a healthy diet, reducing your calories a bit and mild exercise, I managed to keep the weight gain within (for me) acceptable limits. I also found another blog where someone finally seemed to be able to explain why people using antidepressants, in this case remeron, can gain weight, without changing too much in their habits and diet. Scroll a bit further down for an account of blogster Kate Pendley's experience with mirtazapine and weight gain and how she tackled it.

User reviews on mirtazapine for facial flushing:

WrincledClue gives some good advice on how she tries to limit any weight gain, while using mirtazapine (brand name: Remeron):

`I have the same issues with Remeron. I take 30 mg at night and it's critical to blunt the flushing that previously had decimated my life. I read about it online and learned that it increases glucose uptake to the cells, which leaves you with a lower blood sugar, hence the cravings. For me, it removes the feeling of satiety after a meal, so I'm always wanting more more more. I dealt with this very effectively by going on a very low carb diet. I eat meat, chicken, eggs, fish, teeccino with 2%milk, and tons and tons of veggies. Also butter and olive oil. NO FLOUR AND NO SUGAR AND NO FRUIT. The protein and the fat blunt my appetite and stabilize my blood sugar. No blood sugar swings mean much less cravings. Google Paleo Diet or read Atkins or South Beach diets online, it's the same thing. Nothing that causes big blood sugar spikes and the subsequent big blood sugar drops. Now my eating's back under control and I'm losing the Remeron weight almost effortlessly, which I couldn't do when I was stuffing cookies into my mouth on a daily basis. For me, moderation is difficult. I do much better having certain foods simply not allowed. Then, I don't have to try to eat just a bit; I know I can't have any, so it's not an issue. Good luck to you! It was important to me to solve this, I didn't want to double in weight while I was blunting the flushing. `

MissM wrote on July 13th 2017: "This past year I hit an all time low. Suicidal thoughts were on the forefront of my mind almost all times of the day. Like Nat007 mentioned, medication did help me a bit. I'm on Remeron as well and it has helped greatly with my depression/anxiety (and sleep!!) and decreased my flushing episodes by probably 60-70%. I still get bummed and anxious (I am still trying to accept that this is now my life and that is hard to do) and I still flush, but I am closer to the person I was pre-rosacea diagnosis (most of the time). I think the most challenging thing for me to accept is that my life will never be the same no matter what treatment I pursue (I have subtype 1 mostly). That's a tough pill to swallow, I know...but for me, I'm starting to work on my mindset a little more (now that I am medicated, haha) and realize that though I might not be able to change the disease, I do have control over how I perceive it and how I respond. [..]  My "blushing" went away ~95%...which brought down my overall baseline redness. I still flush though and get blotchy (burning/stinging) when I'm in a hardcore flare. I'm very grateful for the meds. My anxiety is greatly reduced and I can actually enjoy my life a little more now...where before I was constantly in mental anguish and didn't want to do anything but lie in bed with a fan on my face. My whole nervous system was whacked out and I couldn't even sleep. It took about 2 months though for my flushing to improve, so for me, patience was key. Everyone is different...sometimes SSRI's work very quickly to bring down flushing for some people."

Fed_up wrote on June 16th 2015: "I'm on mirtazapine too and it does help. In fact, I basically stopped coming to this forum for quite a few months because my skin was pretty good and rosacea stopped being such a big issue in my life. It has been flaring up again recently though, I think because of stress. Another good thing about mirtazapine - I no longer get those crushing, debilitating lows I used to get with this disease. Partly because my skin is generally flaring less, and also because mirtazapine has made me a more emotionally stable person. I still get mildy pissed off when my skin is playing up, but I'm now much more able to keep things in perspective and adopt a "this too shall pass" mentality. I have been on it for about a year and put on probably 10 pounds, but this is actually a good thing for me, because I was too skinny before."

Richie1 wrote on May 10th 2008: "Hello people, For years I have had chronic facial flushing which has been sore and itchy.I have had 3 ipl treatment which have helped but by no means cured the problem.The doctors I visited were pretty much useless saying its a healthy glow etc! After much trial and error orally and topically I have recently started taking Remeon 15mg a day and this has totally stopped the flushing.I do not flush simple as!I still have a few pink marks on my cheeks from skin damage from prevoius flushing but I would say I am 95% symptom free and no more dark red nose and cheeks!Remeron blocks signals in the brain and is used as an antidepressant,I presume it is blocking the flushing signals from working.It is also used as an antihistamine which is linked to rosacea so I don't know if its killing all of that in my system but to be honest I don't care because its working!! I don't want to get anyone hopes up as different thing work for different people but I can only share the success i have had and if it benefits only one other person it has been worthwhile."

Kiwisamchi wrote about remeron and how it alleviated flushing: "[..] I just started taking mirtazapine (Remeron) which is a NaSSA (noradrenaline specific serotonin antagonist) and it is unique in that due to the receptors that it blocks (H1, 5HT2, 5HT3), it can be useful to treat anxiety, depression and agitation with the relative low risk of causing insomnia (mainly causes drowsiness and sedation) and sexual side effects. However, it has a very high risk of weight gain (quoted at 54% vs. the negligible effect of citalopram on weight gain) which in itself, may be a major deterrant if you already have issues with self-image. I am only on Day 5 of taking this medication and I already feel that my body's metabolism has slowed to a crawl. It is giving me the biggest sugar/carb cravings too so that hasn't helped with my attempts to control my appetite. I also have noticed it hasn't helped my insomnia (hey, there's the "no guarantee" clause). But the most important thing that I have noticed is that my daily cyclical flushings (3am and 3pm) have stopped. It is way too early for me to say for sure if it is due to the mirtazapine so I can keep you posted in case you decide you want to try this med. The daily flushing was becoming intolerable so I decided weight gain was the lesser of the two evils. If you decide to come off the citalopram due to aggravation of your Rosacea symptoms, you may want to consider venlafaxine. It is classed as SNRI (serotonin and norepinephrine reuptake inhibitor) and have been used to help with "hot flushes" in menopausal women. It has similar sexual dysfunction side effects to the SSRIs but has the tendency to cause more weight loss than gain. Just keep in mind that it has varying effects depending on the dosage (which of the receptors blocked are dose dependent). Your doctor can further discuss this with you at the time."

And she updated: "I've been taking mirtazapine for 2&1/2 weeks now and have DEFINITELY noticed major improvements. My skin is not sensitive to touch anymore (used to flush all night from my skin rubbing on my pillows... can sleep on my side again) and I have stopped using the metronidazole cream and sea buckthorn oil serum (both seemed to dry my skin even more and caused very large pores). So I suppose that the general idea is.... in terms of helping with Rosacea: which specific agent used may not matter so much as long as it is helping the person feel better, get more sleep and feel less anxious.  I am convinced that my flushing and P&P's were related to my high level of anxiety before I started taking the antidepressants. I have also been tracking my menstrual cycle to see if my flushing is related to my level of hormones and I am currently mid-cycle (when all hormone levels are highest) and still... so far so good since I've been on the antidepressants. Hope this thread helps more people make a more informed decision about whether or not to start "mood-enhancing" pills or antidepressants."

Bluedog wrote on February 6th 2017: "Reducing Mirtazapine - burning face. Been on 15 Mgs of Mirtazapine for about a week for flushing. Slowly worked up from 1/4 tab( 3.75). Not that effective for me and I could not stand the side effects, total fatigue, no motivation and increasing anxiety. Felt actually better at 7.5 Mgs. At any rate, decided to taper to 11.5 Mgs over the past 3 nights and slept better and felt more like my old self. Woke up this morning with increased redness and facial burning, which had been better last week. Was making the bed this am and found 7.5 Mgs of the pill on my duvet! So, I only actually took 3. 75 Mgs last night.
What should I do from here? I really can't stand the facial burning and my face feels warm again to the touch. Should I add an ant-histamine today? What dose should I take tonight? Obviously, I am going to have to taper this drug, but not sure where to start. Any suggestions would be appreciated."

I replied on March 2nd 2017: "Hi. I didn't understand entirely from your post if you had less facial burning and redness on 15 mg of mirtazapine, or more? Maybe it is good to know, that antidepressants typically take FIVE WEEKS of use, before they start working on anxiety and depression. Mirtazapine works statistically a bit quicker, more around the three week line, but one week is statistically too short to see any effect, other than side effects. Side effects happen right away, and tend to decrease and ease up over time, but the benefits of antidepressants take a ridiculously long time to kick in. This is something everyone is warned for btw, both in the med leaflet and usually by your doctor. Because that 5 week time window is dangerous for severe depressed people. The increase of anxiety and depression is temporary, but might tip some people over the edge. In your case, mirtazapine is actually one of the strongest antidepressants that work both on anxiety and depression. But... you need to give it time. It won't work for everyone, but it certainly needs more than one week for most people to start working. The right dose needs to be built up first. For flushing and burning, 15 mg is a good dose. 7,5 mg will mainly work as a sleeping pill. The lower the dose of mirtazapine, the stronger the anthistamine actions, and the more tired and slugged you will feel most likely. This is because only at higher dosis, the noradrenaline effect kicks in (above 30 mg). Because of this, 7,5 mg is only used as a sleeping aid, and the start up dose for depression is 15 mg. Then needs to be upped to 30 mg. For depression doctors can go as high as 45 mg or 60 mg, but for rosacea, 15 to 30 mg is best usually. If you struggle with tiredness and lethargy, then those are typical side effects of the lower dose of mirtazapine, and side effects that might get better over time, as your body adjusts to the drug. Below 15 mg you won't get the right effect on your rosacea and only get more tired. At 7,5 or even 3,5 mg you might as well see it as a very dopey making anti insomnia pill.  I'm not saying this would be a good med for you, but one week is not really a good time window to come to any conclusion, given the side effects you mention.... best wishes"

Bluedog replied on March 2nd 2017: "Thx for your reply, Nat. My face felt calmer on the 15 mgs, but it was too debilitating for me and was giving me very bad insomnia and anxiety at night. I felt very weak while exercising which I did not like. I am not sure how the Mirtz helps the flushing response as a stand alone med? I was unable to tolerate clonidine as it made my heart race and turned my body into a firey inferno at 1/4 dose. That was a huge disappointment as I felt that might be my flush-saver! I am very slight and also very drug sensitive. I saw my GP yesterday and he gave me 10 mgs of propanderol to start and then titrate upwards. I am not sure if this will help on its own. I have reduced my triggers immensely and also on a low histamine diet as I was reacting to anything and everything I ate. The diet is only working after I did a cleanse for 3 days and totally reduced my histamine levels. I am eating 3 or 4 low histamine foods without anti-histamines and without reacting. Baby steps! Do you think propanderol on its own will help the flushing now mainly with stress, temps and exercise? Many thx!"

replied on March 2nd 2017: "That is such a shame that you are so sensitive to medication and their side effects.. I still think that you might have far less side effects from mirtazapine when you are 4 weeks down the line, but that is really your call. Insomnia is the opposite of what mirtazapine usually causes; it's a known sleeping aid normally. The anxiety should also be reduced if the drug is given some time to start working properly. But only you will know what is best here, if you feel this drug is intolerable within one week then you should absolutely discuss this with your doctor, as you did. Mirtazapine helps with the flushing, in a similar way to which it helps to combat menopausal hot flushes, which are a little bit related in mechanism to our type of facial flushing. Literature says about it: "Mirtazapine possesses potent inhibitory effects on serotonin, histamine, and alpha2-receptors, and is believed to be beneficial in the relief of hot flashes due to its inhibitory effects on serotonin and alpha2-receptors." I am not 100% sure how mirtazapine helps completely, but my derm has a lot of rosacea patients and sees mirtazapine being effective for the severe flushers. I think he said it somehow lowers the central nervous stimuli to flush, and also lowers histamine. Mirtazapine reduces alpha2-receptors, and they are directly involved in flushing:
Propranolol helps some people too with flushing. There is a lot to be found online about this and also on this forum. But propranolol has side effects too.. Incl tiredness initially and some people also feel more anxious on it.. Here are some more studies that found mirtazapine effective for hot flushes:

Bluedog replied on March 3rd 2017: "Many thanks for all that information, Nat. It is really appreciated esp with all the research studies. Perhaps I gave up too soon, I found all I wanted to do was to sleep all day and would be up all night. It was really crazy. Maybe now that I am getting a semblance of control on the food front, I should give it a try again. It is so hard to figure out what to do when one has an over reactive system. You get really gun shy and figure "less is more". Do you think the Mirtz would help with the exercise flushes? Thx again."

Bluedog wrote on May 18th 2017: "I have tried hundreds of supplements, nothing had any effect whatsoever. SSRI's allow me to completely control the flushing. Famotidine stops the alcohol flush.
Always consult a doctor before taking medication."

Blue Note wrote on October 18th, 2005: "I posted about Mirtazapine a few times on the old forum and thought I'd pass the info along again. I've been using it for over a year with great success. It's an antidepressant that's also a strong antihistamine. It helps me sleep at night, which used to be a big problem. But most importantly, it significantly cuts down on my flushing. I'd say about 60-70 percent. Granted, I can still flush as bad as ever, but it's not as common (used to be every day) and it doesn't last as long as it used to. Also, since it helps me sleep, I'm less stressed and therefore less prone to flush. Any flushers out there should definitely look into this med. Hope this helps someone! Oh yeah, I take 7.5 mg in the morning and late afternoon, and 30 mg before I sleep. Usually knocks me out within an hour. The first few days I felt really sluggish, but adjusted rather quickly. I did get a serious appetite for the first few months, and really had to consciously control it. I put on a few pounds (went from 165 to 180) but then made an effort to not eat so much. Now it's not a problem. I've tried a other antihistamines (in large doses) and they didn't work nearly as well as Remeron. Perhaps the antidepressant in conjuction with the antihistamine is the key."

HalfLife replied on October 27th 2005: "Yeah I'm taking it and its helping alot I think. Definitely has reduced the permanent redness I always had. I'm so glad it wasn't permanent and was actually just flushing/blushing that was all day."

GBforest replied on December 16th, 2005: "Thanks for the update Blue Note. Remeron has several interesting pharmacological properties for an antidepressant. Its good to hear a few success stories.
Generally, the strong antihistamine action goes hand-in-hand with increased appetite, but with time, a person's appetite should re-establish itself. The sedation should also become more tolerable with time, as well. ....but I'm just restating what was already said. Again, thanks for the update."

jlb2010 wrote on November 25th 2010: "I just started Remeron about 1 week ago. I started out using the 30 mg. Seriously, I am self-prescribing because both my derm and primary doctor had no clue about this drug. Within 2 days my flushing has returned to a normal response!!! I can actually make it through the night w/o flushing. It's amazing. However, I am struggling with the sleep thing. It seriously knocks me out and I feel I woudl sleep through anything! I am hoping this will wear off. I also noticed a slight increase in papules. They are very small/fine but I had none of them before taking this drug. I am considering dropping to 15 mg...but I finally have relief from the flushing, so I am scared to change it. Maybe a few more weeks and the bumps will settle down. For anyone out there debating on this drug....it has made such a difference in my flushing, I seriously can't believe it. I feel like I have my life back - I can go into warm rooms, I can sleep, I can work on the computer, etc. Just have to figure out the increase in papules!"

Thelondondermatologist wrote on his website: "Tablet treatments can be very helpful for facial flushing, most usefully clonidine, a blood pressure medication, taken two or three times a day. This has the fortunate side effect in some people of providing excellent facial blood flow control. The dose can be pushed up quite high under supervision from a dermatologist. Other drugs that can sometimes be useful are fluoxetine, carvedilol and mirtazapine. Propranolol, a ‘beta-blocker’, is sometimes used, but it is not especially effective in my experience, although it does help with anxiety. All of these medicines are unlicensed in rosacea (meaning that using them to treat rosacea differs to how they were originally intended to be used). For some people though, flushes can become a major problem which seriously affects their lives. For these people, who have a common skin condition called rosacea, flushes come on very easily, perhaps after a cup of tea or under a little emotional pressure for example at a work meeting. The flushes last much longer, perhaps a couple of hours and can be unsightly, uncomfortable and significantly affect confidence. Antibiotics, either topical (a cream or ointment) or by mouth are also probably almost useless for people with pure flushing rosacea, although they are a great treatment for rosacea with spots or any inflammation. I find other doctors have (understandably) often put patients with pure flushing rosacea on antibiotics. I usually discontinue them however."

Other antidepressants that people with rosacea wrote reviews about

Celexa (citalopram)

Oil king wrote: "Hey everyone, About a year and a half ago I finished a 6 month course of low dose accutane (10mg/day at first, 20mg/day later on) which left me with severe, debilitating flushing. I had cyclic flushing which would occur every single night from around 7 pm to 12 am for around a year post accutane. It would also occur out of this time period if evoked (warm rooms, anxiety, etc.). It was extremely debilitating and affected every waking moment of my life during that year. Luckily I study biomedical sciences at a Canadian university and had some knowledge about rosacea, and could recognize it pretty early on (got diagnosed 4 months post accutane). I knew I needed to do something drastic as I could already see damage occurring at the 4 month mark from repetitive flushing (broken caps, swelling, permanent redness forming) and I formed a 1 year game plan for ending the flushing and rosacea. First, I waited 2 more months until the 6 month post accutane mark to begin V beam treatments with the AMAZING Betty Chan at the Baywood Clinic in Toronto. This is the only human being on the planet I would trust putting a laser to my face. I received 5 treatments over the following year, 3 non-pupuric and 2 that were purpuric in the areas Dr. Chan deemed appropriate (bridge of nose, right cheek). The last 2 pupuric completely eliminated all visible vascular damage on my face, and even improved skin texture and pore size by 50% or more. I knew I needed to do something internally to stop the flushing from occurring, so the V beam could repair the damage without being aggravated by repeated flushing. I went through various medications over the following months (remeron, paxil, propranolol etc.) until I found a combo that stopped the flushing from occurring nightly and during the day. Clonidine (.025 X 3 per day) and celexa (20mg). The clonidine never did anything drastic but definitively took the edge off. Celexa at 20mg was the jackpot and helped eliminate any anxiety, warm room and nightly flushing from occuring, but only after taking it for 8 weeks (didn't do very much until the 8 week mark).
About 6 months ago I began trying topical treatments as an added boost. With a few that didn't work, I began Finacea. At first, finacea made the flushing, veins, and redness must worst. It almost looked like a rash on my face for the first month or so of use. I pushed through it because I had nothing to lose and after the 1 month mark my face became DRAMATICALLY better. Flushing was much better, redness was all but gone. If your going to try finacea please push through the first month to see if it's for you because it made me much worst as first. Today I no longer flush. I no longer have broken capillaries. I no longer have redness. I can drink any amount of alcohol I want or run a marathon and look paler than others around me. I am finally happy."

NotPissedJustFlushed wrote about celexa: "Taken it, at 40mg's for a while. It did not affect my flush at all, in fact it made it better because I didnt care about my flush as much (its semi anxiolytic). The sleeping issues go away for the most part within a week, the sexual side effects do as well but you'll be over both entirely by about a month in.
Good stuff."

RatherBeSkating replied: "I was actually put on citalopram BECAUSE of rosacea - I only flush when anxious really so my doc tried this - didn't really work, and I ended up coming off them for the exact reasons you listed. Didn't make any difference to my skin whatsoever."

Peter B wrote in response: "I have been on Citalopram for about 18 months. I would say it has got rid of my depression and anxiety.. maybe a small improvement on my rosacea."

KayBee01 wrote however: "I have major depression and must take antidepressants however this has never happened before on any other medication....First I took Lexapro which is very similar to Celexa and that triggered my Rosaca (dermatologist said to stop) so I did stop and Rosacea calmed right down. Then dr. wanted me to try Celexa which was fine for about a month (same as Lexapro) and then the Rosacea flared up.  Its been about 2 months now and the Rosace is bad. Has anyone else had this happen with the Celexa???"

RedFace replied: "Some antidepressants and more specifically, Paxil and Remeron have been documented as medications that reduce or eliminate flushing/hot flashes. Other medications such as Pregablin and Gabapentin have even had successful clinical trials for reducing/eliminating flushing/hotflashes. I believe Pregablin/Lyrica is in Phase III for hot flashes after a very successful Phase II result earlier ths year. There are a few possibilities here, the medication could have been helping with your flushing due to its indirect actions on the CNS or possibly due to its ability to reduce your overall anxiety. You also could be just flaring up due to the anxiety that comes with the withdrawl or stopping of the medication, in which case the flushing would be transient and likely last a few weeks. I would take the advice of others, give it a few weeks and see if things settle down. Hang in there."

Allibear wrote: "I was on Cetalopram 3 days and my skin started to break out with groups of Papules. It turned bright red really on the first dose and started to feel burny and itchy. This continued for the six weeks I stupidly continued to take it and as soon as I stopped it only took a week for it to all calm down again."

Knatsabooh wrote"Celexa - Started that initially for the social anxiety I experienced as a result of rosacea flushing in social environments. Helped as I also worked on cutting my overall flushing down. Have cut it way back and plan on losing it soon as its of no real benefit to me anymore that my flushing is under very good control."

Marvin wrote: "I've been taking 20mg Cipralex for over a year now. It's made alot of difference for me, in a positive way. It has by no mean cured me or anything but I flush less often, my burning sensation has not been as severe and I actually manage to smile now and then. It has given me time to come to terms with my situation and try to spin my life in a more positive way. Now I only hope they find a cure for rosacea and psoriasis and Ill be fine. ;o)"

AUsefulObsession wrote on February 3rd 2015: "I have been using Citalopram (Celexa) 20mg a day for a week, and my flushing has near completely ceased. Interestingly my ability to sweat and thermoregulate seems to be partially restored. I can now sit near heaters without issue and my face is cool to the touch. What has happened? What role might serotonin have in regards thermo-regulation or perhaps more broadly the nervous system?"

Oil King wrote on December 21st 2011: "Hey everyone, About a year and a half ago I finished a 6 month course of low dose accutane (10mg/day at first, 20mg/day later on) which left me with severe, debilitating flushing. I had cyclic flushing which would occur every single night from around 7 pm to 12 am for around a year post accutane. It would also occur out of this time period if evoked (warm rooms, anxiety, etc.). It was extremely debilitating and affected every waking moment of my life during that year. Luckily I study biomedical sciences at a Canadian university and had some knowledge about rosacea, and could recognize it pretty early on (got diagnosed 4 months post accutane). I knew I needed to do something drastic as I could already see damage occurring at the 4 month mark from repetitive flushing (broken caps, swelling, permanent redness forming) and I formed a 1 year game plan for ending the flushing and rosacea.First, I waited 2 more months until the 6 month post accutane mark to begin V beam treatments with the AMAZING Betty Chan at the Baywood Clinic in Toronto. This is the only human being on the planet I would trust putting a laser to my face. I received 5 treatments over the following year, 3 non-pupuric and 2 that were purpuric in the areas Dr. Chan deemed appropriate (bridge of nose, right cheek). The last 2 pupuric completely eliminated all visible vascular damage on my face, and even improved skin texture and pore size by 50% or more. I knew I needed to do something internally to stop the flushing from occurring, so the V beam could repair the damage without being aggravated by repeated flushing. I went through various medications over the following months (remeron, paxil, propranolol etc.) until I found a combo that stopped the flushing from occurring nightly and during the day. Clonidine (.025 X 3 per day) and celexa (20mg). The clonidine never did anything drastic but definitively took the edge off. Celexa at 20mg was the jackpot and helped eliminate any anxiety, warm room and nightly flushing from occurring, but only after taking it for 8 weeks (didn't do very much until the 8 week mark).
About 6 months ago I began trying topical treatments as an added boost. With a few that didn't work, I began Finacea. At first, finacea made the flushing, veins, and redness must worst. It almost looked like a rash on my face for the first month or so of use. I pushed through it because I had nothing to lose and after the 1 month mark my face became DRAMATICALLY better. Flushing was much better, redness was all but gone. If your going to try finacea please push through the first month to see if it's for you because it made me much worst as first. Today I no longer flush. I no longer have broken capillaries. I no longer have redness. I can drink any amount of alcohol I want or run a marathon and look paler than others around me. I am finally happy."

More people on the forums who mentioned other antidepressants to be helpful for their facial flushing and redness, in this case Zoloft and some mention effexor, prozac and paroxetine (Paxil) 

Les wrote on March 6th 2014: "Hi There, I've been battling Rosacea and Depression for a number of years and have tried various medicines for both diseases. I started taking Co-Sertraline aka Zoloft for depression and it actually helped tremendously with my flushing and breakouts. I can actually get hot without flushing too much or instantly feeling itchy. This medication may be something to help others also. I just wanted to come back to this forum after a lengthy absence so that I could give back and hopefully help someone like myself who had almost given up. One last thing, I haven't had any side effects with Zoloft either. Good Luck Everyone and Take Care, Les"

Hg24 wrote on March 1st 2015: "Last Sept/Oct I started on Zoloft (sertraline). Very low dose of 25 mg once a day. Then four weeks later, moved to 50 mg a day. I wanted Celexa but dr preferred Zoloft. I was experiencing bad anxiety, so I took it. It helped my anxiety greatly. But once it got well into my system, around November, my skin burning/stinging/inflamed sensations subsided. I was getting IPLS, too, but I believe it was the Zoloft - because I had received IPLs and VBeams with no change before. I think it was due to the fact that the. AD helped quiet the nerves in my face. Before then, I struggled to have anything on my face - lotion, moisturizer, any topical felt like saran wrap (cling film) suffocating my skin and causing it to burn. Suddenly, my skin could tolerate moisturizers, etc.  I have Type 1 rosacea with lots of flushing. I'd say I've moved from severe to moderate now in rosacea stages. I still have huge challenges - can't use computer because it burns and turns my face red badly and lights are mean. But I'm much better with the addition of the AD in my toolkit. Hope that helps!"

Hg24 wrote again on June 15th 2015: "Hi, I take Zoloft. It has helped with burning and stinging and helps my face feel a bit calmer. My flushing is triggered mostly by artificial lights/computer/cell phone screens and heat. I think it's helping a little of my night time flushing/flushing upon wakening. A little bit. It has helped my anxiety a lot. My rosacea is always more uncomfortable when my anxiety is raging. But when my rosacea is raging, my anxiety gets worse."

Dg0980 wrote on June 19th 2015:  "I suffered unbelievable lows when my skin was bad. After many years of this my doc gave me fluoxetine which is Prozac in USA. This really turned my life around, before taking it I couldn't look people in the eye, talk to women without blushing horribly, go out with my friends or family, basically I was a recluse. Now I do all those things, yes I still have flare ups but I don't let it crush me and this slightly more carefree attitude helps reduce the anxiety flaring. I've not experienced any weight gain, but I have noticed a difference in my sex life. It's great! I now last way longer than I ever did before, making my partners... Well I won't go into detail but the word amazing has been used quite a bit."

OilKing wrote on March 8th 2015: "The only real difference between celexa and zoloft is celexa has some stronger antihistamine properties...but all SSRI's i've been on (celexa, prozac, zoloft) work the same for flushing though at different doses respectively. The only SSRI I did not find made a difference is lexapro but I believe I never tried a high enough dose to properly compare it to the others."

And: "It's really trial and error but personally I didn't get much flushing benefit from Zoloft until around 100mg and 8 weeks of use at that dose. All SSRI's I've used have helped me similarly though - but they all took around 8 weeks at one dose for flushing to reduce significantly. When I increase doses, the flushing gets worse again for around 3-4 weeks. Celexa may be more helpful for you but I would try a waiting a full 8 weeks and perhaps a higher dose depending on your weight and gender. Some theorize that SSRI's change the neural pathways of the brain. I've always felt that SSRI's restructure the ease in which the flushing response occurs but this is why it takes a while for them to work. When you are constantly blushing or flushing, you sort of "train" your brains neurons through practice to respond in that way. This is why I think it gets worse over time, of course not taking into account the increased vascularity flushing causes. All hypothetical of course!"

Birdie wrote on February 3rd 2015:  "Effexor 37.5 mg in morning and night, which is lowest dose, helps keep my flushing down. Many meds are used for off label use and anti anxiety meds/ depression are prescribed for pain related illness. Because they work! I was told that Effexor is a good " relaxer" of smooth muscle groups, hence nerve bundles ( I think) I can not tolerate narcotics (had several spine surgeries) so for me, the off label use of antidepressant is wonderful. I am considering weening off of it to replace it with a newer and more modern one that may have even better results. I have posted in the past that in the evening, without this med for me, flushes would be very bad. I'm not advocating this method of treatment I'm simply saying it works for me right now and hope it continues to work in future. Birdie"

ShaunD wrote on July 14th 2017: "Paroxetine helped my flushing in a big way as did zopax (xanax). Unfortunately I abused the medication which caused other problems but if you can control it and use as prescribed then these types of treatments can be a very useful tool against unbearable flushing."

More on other antidepressants to be helpful for their facial flushing and redness

Moclobemide also proved effective at flushing control:

"Two different doses of moclobemide, 150 mg or 300 mg/d, were tested against placebo for 5 weeks in 30 post-menopausal women. The lower dose of this reversible, selective inhibitor of monoamine oxidase-A reduced the HF severity score by 69.8%, compared to 35.0% in the higher dose and 24.4% with placebo (Tarim et al. 2002)."

The same goes for paroxetine and sertraline

Amitriptyline is an antidepressant that is also used for nerve pain. It's a tricyclic type of antidepressants and others in that group (imipramine, clomipramine, desipramine, and nortriptyline) can help with nerve pain as well, but amitriptyline is the best known one. It can reduce neuropathic pain by reducing the nerve cell’s ability to re-absorb chemicals such as serotonin and noradrenaline (neural transmitters). This means that there are less pain messages in the spinal cord reaching the brain, and less sensations of pain. Unfortunately it doesn't work for everyone though.
There is limited evidence that newer antidepressants, called selective serotonin reuptake inhibitors (SSRIs), may also give neuropathic pain relief. Researchers say more studies are needed before they can be recommended for this use. SSRIs include Prozac, Celexa, Luvox, Zoloft, and Paxil. Mirtazapine is a new type of tricyclic antidepressant, and it's also called a NaSSA: noradrenergic and specific serotonergic antidepressant. It isn't an official nerve pain treatment option, but research recently showed that it does reduce pain feelings. I tried amitriptyline myself for a short time and it made me more flushed.

Other antidepressants that have been mentioned to relieve with hot flashes are
sertraline and Celexa and Efexor

Efexor (venlafaxine) for hot flashes:
"In the present case, we observed reappearance of hot flashes in a postmenopausal woman who was being treated with venlafaxine 75 mg daily for a year for depression. Interestingly, increasing the dose of venlafaxine to 150 mg daily alleviated her hot flashes. The exact mechanism of venlafaxine to alleviate hot flashes remains unknown. Venlafaxine is known to affect both serotonin as well as norepinephrine reuptake. Effects of venlafaxine at lower doses are thought to be related to the serotonin reuptake inhibition, and at higher doses its effects are attributed to a combination of both serotonergic and noradrenergic effects. [..] In the present case, the new onset of hot flashes while being treated with a lower dose of venlafaxine is probably related to its effect on serotonin reuptake inhibition. The alleviation of hot flashes at a higher dose may involve its action on both serotonergic and noradrenergic pathways or on a predominantly adrenergic pathway." (source)

More scientific links for the use of mirtazapine for facial flushing:

*Pilot evaluation of mirtazapine for the treatment of hot flashes  (Link)
*Mirtazapine is named here as a rosacea treatment (Link)
"Treatment for flushing and erythema may involve oral drugs with vasoconstriction 
properties including adrenergic antagonists including mirtazapine (alpha blocker), 
propranolol (beta blocker) or carvedilol (both alpha and beta blocker)."

*The London Dermatologist writes here: How do I stop my face flushing?
"Other drugs that can sometimes be useful are fluoxetine, carvedilol and mirtazapine. 
Propranolol, a ‘beta-blocker’, is sometimes used, but it is not especially effective in 
my experience, although it does help with anxiety. All of these medicines are unlicensed 
in rosacea (meaning that using them to treat rosacea differs to how they were originally 
intended to be used). Tablet treatments can be very helpful, most usefully clonidine, 
a blood pressure medication, taken two or three times a day. This has the fortunate side 
effect in some people of providing excellent facial blood flow control. The dose can be 
pushed up quite high under supervision from a dermatologist."

*Forum posts, In Praise of Clonidine and Remeron and Clonidine-Remeron Combo.

*Scientific research that mirtazapine can help alleviate hot flashes and flushes (Link).

Blogster Kate Pendley uses remeron for severe insomnia and finds is very effective: 

"But, I (like many others) made a big mistake when I first started taking Remeron.....I ate. The doctor's will warn you that there is a risk of weight gain (mine said about 6-7 lbs), but what they should tell people is that the risk is actually reality and that most people end up putting on large amounts of weight. I personally gained about 16 lbs, which, given my frame, is a pretty large weight gain. And, like many others, despite how much I exercised the weight kept piling on. For weeks and weeks I was tormented by the weight gain, as I exercised more and more. I tried to change my eating habits by not eating out, watching calories and being more aware of what I was putting in my mouth. But, the fact was that I wasn't a person who ate poorly, but was now a person who could not lose weight. So, I started taking a hard, scientific look at Remeron and why it causes so many people to gain weight. I read up on the methods of action, the studies that link Remeron to a reduction in stress hormones (specifically cortisol) and how all of that could be connected to what was happening to people's bodies.

Here's what I noticed: I couldn't seem to build and maintain muscle mass. If I took a single day off of exercise, the fat would pile back on. After months of exercise, I had barely made a dent. But, then I also noticed that certain exercises seemed to create a bigger effect than others (more on that later) and that some days I could barely walk down the street because I felt so heavy and others I seemed to move faster and easier. Not surprisingly, the research on Remeron talks a lot about the weight gain, but, specifically, about the change in body composition. On Remeron, people tend to gain this layer of fat, or that's how I describe it. I call it the immovable layer of lard. It comes out of nowhere and is very stubborn about leaving. Walk all you want, hit that eliptical all you want....it won't move. It makes you want to give up on the drug. To hate it. To return to insomnia, if that's what will make the weight go away. But then I happened upon some like that lead me another link. And, that's when I put together the cortisol + insulin connection. This is how it goes: Remeron suppresses the stress hormone cortisol. This is one of the reasons it helps people sleep. It basically 'powers down' your brain and slows your metabolism a bit. But, more interestingly is the relationship between cortisol and insulin. Apparently, cortisol counteracts insulin. Insulin basically grabs sugar from your bloodstream and stores it as fat. Your body needs cortisol to counteract and balance this effect of insulin, in addition to helping processing lipids (fats) and proteins.

So, as Remeron is suppressing your cortisol it is also contributing to some of the effects of high insulin, specifically hypoglycemia or low blood sugar. When people say that can't stop eating carbs on Remercon, this may be why. Unabated, the insulin is grabbing sugar out of your blood, which leads you to think that you are carb depleted. So, you eat more carbs. That's problem number one. Problem number two comes from simply suppressing cortisol. Because optimal levels of cortisol are necessary for processing all macronutrients, having too little of it a night could drastically effect your body's conversion of these nutrients into energy. This could cause weight gain and would explain why people gain weight on Remeron so quickly. That's problem number two. So, when I rethought all of this, I actually decided to try a little experiment: To eat a 'Zone' diet that focuses on balancing fats, proteins and carbs, to increase my B-Complex vitamins, add Omegas and incorporate more muscle building activities, such as weight training. The diet gets rid of the carbs that the Remeron are making your body store as fat. The B vitamins help metabolize macronutrients and convert them to energy, omegas can help balance fat levels and muscle building exercise burns glucose and taps your fat reserves. Three days and I lost 4 lbs. So, there is hope. I am going to try and keep this up over the next week and see what happens. But, so far there has been a significant difference. And, given that losing ANY weight on Remeron is almost impossible, I am hoping that this actually works."

Another one on this matter: Mirtazapine is making me fat! Forum post.

In this good research paper, scientists summarized the treatment options for neurogenic rosacea; rosacea subtype 1 with skin redness (erythema), skin burning and flushing. It states that this rosacea subtype requires a unique approach of management. In the paper, typical symptoms and triggers are mentioned for people with this type of rosacea.

4. Antihistamines (Xyzal for instance)

Normal dose for allergies is 5 mg of Xyzal a day. However for rosacea flushing, I have always been prescribed 10 mg a day, which I found a lot more effective than 5 mg. And currently I am taking 20 mg a day, on advise of my doctor as I have a histamine problem diagnosed, which partly explains why I flush so badly from so many foods and triggers, including the smell of perfumes. Normally, 5 - 10 mg a day should work just fine for everyone who does not have allergy related symptoms. Many antihistamines are available over the counter, for instance ceterizine and zyrtec, but they are not as powerful as Xyzal, which is a new antihistamine with less side effects than older antihistamines. In fact, I have no side effects from Xyzal. Antihistamines block histamine release in the body, which can be a major trigger for facial flushing. Histamine is involved in the widening of the blood vessels. So by blocking histamine, you might be able to eat more foods that are normally high in histamine or histamine releasers, be better protected against allergens from for instance hay fever or animal allergies. They help me a lot, but this is different for everyone.

Update, I took 2 different antihistamine medications on top for a month: Inorial and zaditine. They initially really helped me quite a lot to cut down further on the facial redness. But after a month or so, I felt I became more red and more easily flushed, possibly because they made my skin more dry? Not sure. I stopped, things normalized, and then I reintroduced both meds again, only for the same thing to happen. Since stopping them and instead doubling my Xyzal dose, I am at a good stage now. I therefore no longer use Inorial and zaditine (but still use Xyzal daily), only when I can't get out of some dinner party invite and know I will have to eat foods high in histamine. For occasional use I get relief from them therefore. However, for those who have mastocytosis; see for more info this blog post about it: 

Clarityn Allergy Tablets
Zirtek Allergy Relief 7 Tablets
Hayfever Tablets (Cetirizine) 2 x 14 (GSL)
Benadryl One A Day Allergy Relief Tablets Pack of 14


5. NSAID's like diclofenac or ibuprofen

Several times I re-started with an old medication, that I used to take for years, between 2007-2010; diclofenac. It's a non steroidal anti inflammatory (NSAID), and I felt at times that it dims the redness a bit. It's not helping me with flushing, but I feel that while taking it, the background redness is not as deep. I have been taking 100 mg a day. (See added pictures, while taking diclofenac). I stopped taking it structurally because it gave me heart pains when out exercising. Another downside of this medication is that you need to be really careful with your stomach. It's quite harsh on the stomach lining. I used to take my dose with a proper main meal, never on an empty stomach, or it feels like it burns an ulcer right away. It won't right away of course, the pills have a protective coating, but they are linked to ulcers after long(er) term use, so you need to be careful with this one.

I started taking diclofenac after an IPL treatment, that gave me post treatment inflammation and bad facial redness. My dermatologist wanted to avoid steroids to calming matters down, as I developed rosacea after using hydrocortisone cream. Some can handle steroids, but doc wants to avoid them in my case. Aspirin can help for rosacea and flushing, but it has higher levels of salicylates, which can also make people more flushed, if they are very sensitive to salicylates (it makes me more flushed). His best bet was therefore diclofenac; a non steroid anti inflammatory drug, that doesn't have the
Still really swollen cheeks after IPL nr 2, in 2006. Skin cant handle it
 salicylates, like aspirin or ibuprofen have. So I took the diclofenac for a period of 2 weeks at the time, 150 mg a day divided in 3 doses. It calmed the inflammation of the IPL treatment down and I felt a bit less flushy on them. Looking back at pictures from that time, I am not convinced they made me less red, but I felt a bit less flushed and burned up at least. I was only supposed to take it for 2 weeks, but asked my derm if I could continue using it on a lower dose; 50 to 100 mg at night. He was a little bit worried about stomach ulcers initially, but gave me the green light anyway. I have to emphasize another time here that the drug is heavy on the stomach, it thins the stomach lining and makes you more prone to acid pains there or bleedings, but I have always taken the pills straight after a proper big meal in the evening and somehow was ok this way. I used it a few years but when we started to try to conceive I stopped.

NSAID's are typically a lot more safe to try for your rosacea than resorting to steroids, either topical (absolutely not wise to use any steroid cream when you have rosacea, or a tendency to blush and flare, it can really make things a lot worse), or systematic; even taking prednisone orally is a risk when you have rosacea, and it can trigger rosacea too, in those with a predisposition for rosacea. But not necessarily. Some people with rosacea take steroids short term and it doesn't affect their rosacea. And in general, many people take steroids for all sorts of health problems and never develop skin problems from it. But people with pale skin, a tendency to sunburn and blush, do have a higher risk to develop a flushing or rosacea skin problem, after using corticosteroids. This risk is unfortunately not something that dermatologists and GP's are always aware of.

ephemerality wrote about this on The Rosacea Forum:
"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". What consequence is there to them when they ruin our faces!!! they will just get new patients and keep doing the same thing, and anyway, some people will be fine, and some will be ruined!"

I agree with this post-writer. In 1999 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 with rosacea, doctors do prescribe short term use of steroids (either something like prednisone, or a cortisone cream even, in an attempt to bring inflammation down) and some do fine on it, and it doesn't hurt their rosacea. But for some others, it does make things much worse. 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 by it. My dermatologist always says; it's Russian roulette to use any steroid, if you are a heavy flusher. I'd not take the risk. 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 at the time, 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. I didn't even know of the risk. 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. It sometimes really is thrown at patients as an easy fix for all. It also rarely cures you from anything, as steroids merely suppress symptoms, and topical steroids not only thin the skin in the long run, but they also make the skin addicted to some degree to this cream (weaning off gives often rebound symptoms). So just be careful with steroids, if you have rosacea.

6. Gabaptentin/pregabalin

Lyrica and neurontin make the nerves that control blood flow to the face less active, making you flush and burn less. I used gabapentin for a month or so when I had neuropathic pain, after falling asleep on a frozen gel pack with one cheek. It helped with nerve pain, and helped me get more pale for a little while as well. Gabapentin/pregabalin has a proven track record for alleviating hot flashes during menopause. It also has potential in reducing facial flushing. This effect has been replicated in many scientific researches.

On PubMed:
"In a randomised, double-blind, placebo-controlled trial in 59 post-menopausal women with seven or more HF per day, the effects of 900 mg oral gabapentin on hot flashes (HF) frequency were assessed after 12 weeks of treatment. Gabapentin evoked a 45% reduction in HF frequency and a 54% reduction in the HF composite score compared to the placebo response (29% (p = 0.02) and 31% (p = 0.01), respectively). In an extension phase, patients were studied in an open-label trial where the dose of gabapentin could be increased up to 2700 mg/day, as needed. Treatment with the higher dose showed a further reduction of 54% and 67%, respectively. Common AEs in the gabapentin group were somnolence (n = 6), dizziness (n = 4) and rash with and without peripheral oedema (n = 2), which were not observed in the placebo group.


How to get your GP or dermatologist to prescribe you these medications?

Start by reading this blog post I wrote about the entire matter :) I took a recommendation letter from prof. Chu to my GP and discussed with her if I could try the meds for a month and then evaluate with her. I went from 24/7 flushing and cold packs dragging with me wherever I went, to about 60% improvement within that month and when she saw me back it was immediately clear to her that I had to continue with these medications. I have had tests to control liver function and some other things after 4 years and they were all in excellent shape, so she felt fine with continuing to prescribe it to me (almost 7 years by now). My rosacea is doing fairly good now, although summer is always a lot milder for my skin than winter, I am looking still red and ruddy and burn all up in winters. But there has been massive improvement. I would print out some of the medical links I posted here, or try to find some betters perhaps even yourself. I would bring the testimonials from people on The Rosacea Forum, show my website if needed (you can always use my personal contact data and I will be very happy to help out with a testimonial, written or by phone, or sending pictures). Negotiating about a trial period helped for me as well, GP’s are careful not to put their patients at risk, so you will give them some sense of control then. They might say that these are serious drugs. But they are common drugs as well, that have been on the market for a long time, that are widely used and documented and the effect of ongoing inflammation and flushing on the body is very destructive. Stress that as well. This is a progressive disease that has to be stopped in it’s track. Even when you might not look that red to others, the burning and pain is often not immediately visible. Flushing has a snowball effect and the only road to recovery, is to stop it in it’s tracks. Good luck!

(Update)a girl on the forum wrote that despite going to her gp with the information about clonidine and propranolol for flushing, her GP refused. Here is her post and my (not as subtle) response. Note, I never had to rely on such measurements as described about my friend, I was red enough as it was to make them realize the problem, at that stage. And I unfortunately can't send meds to other people either. But perhaps others reading this have the same issue.

Original post: "So I have posted a few times on the forum, so a little recap of my condition: The rosacea started up fairly recently, a few months ago at most. I suffer mostly from flushing. I have always flushed/blushed easily but usually just my cheeks and would go away, no permanent redness. The flushing has been getting progressively worse, spreading to other areas of my face (chin, nose, a bit of my forehead). I saw a derm who prescribed fiancea and noritate - I don't get many P&Ps, my problem is really just the FLUSHING. I printed out a page from this forum , "Medication that has proved to be helpful for facial flushing, redness and burning" by Nat007, and have taken it with me from doctor to doctor practically begging for a prescription(s). I have dropped out of school, stopped seeing friends, I used to love jogging but have stopped that too. Anything and everything causes a flush, worse in the mornings and evenings. It's more than just a cosmetic concern, it burns, it's all I can think about, can't concentrate or focus because my face feels like it's on fire. It's one thing to have had to give up going out, drinking with friends, (sex... ) but at this point I'm literally homebound 24/7 doing anything I can to avoid flushing, but even then my face constantly burns (even when not flushing!) I have become so anxiety-ridden because of the condition, having frequent panic attacks, and overall am just really depressed. I miss my life. Went for dinner with my boyfriend, started feeling warm, had to take our food to go. Went to the movies, started getting too warm and left half way through the movie. These are just a few instances of how drastically it is affecting my life. Problem is, no doctor is willing to prescribe me ANY of the meds. They barely glance at the papers I bring, simply state the side effects and tell me to avoid triggers. Went to another doctor today, my skin was fairly calm, I explained everything to him and guess what he says - "I'm not even convinced you have rosacea, I think it's psychological - these are not serious drugs, they are prescribed for menopausal women experiencing hot flashes, but I don't think you have a flushing problem". I responded "Do you think I would go from doctor to doctor if I didn't honestly think i had a problem?"...."Well, next time it happens, take a picture. Prove it to me". I kid you not, that is what he said. Every day that goes by it gets worse, causing permanent damage (which i told him, and he said that it wasn't true...). I'm at my wits end, constantly in pain, given up everything, and these doctors just keep dismissing me. I need advice. My face burns as I write this and every time is stays red longer, and eventually stays that way. I want to stop this disease from progressing but I don't know what else to do. I'm even considering buying the meds online, which is risky but I'm desperate.  Sorry for the long rant but i just can't take it anymore. Any advice? I even tried emailing Dr. Chu.... I live in Canada... I just don't know what else to do."

Suggestion: "God that's awful!! But no surprise, unfortunately. I dragged myself to 4 big hospitals all through the country and got the same rubbish; you are too young for rosacea, there is nothing else we can do, here have some more antibiotics etc etc. Had to go to Dr. Chu finally to get some proper help (and was really at my wits end by then from 6 years of severe flushing and my rosacea going from mild to severe by then, also thanks to an IPL treatment). He prescribed all these meds I posted about and well, I just went to my GP and said; I'm dying from the pain, this is a professor and a specialist, this is the prescription, if you don't give me monthly prescriptions of this I make it into a court case. She agreed with me trying them for a month and then coming back, showing her the results and I was lucky enough to be bright red when I sat there discussing it with her and less red the next month.
A friend of mine had to be retested for her welfare allowance and she has very severe rosacea, but some good days, usually when there is something important she has to be red for. So she had this appointment and we thought out all ways for her to look as red as possible; pizza, hot coffee, hair dryer on her face before leaving, she even put some extra blusher on. No joke, its extreme but such a flare will calm down again in days time, but when you rely on a red face to get your medication or welfare, it might also be an option for you? Its a disgrace that you need to rely on such measurements, but also bear in mind that rosacea is not well known, and that GP's especially are very  careful with prescribing anything they might get in trouble for. Young girls, they don't like to prescribe them meds for menopausal women or for heart problems, especially when they don't see you flushed enough. I remember sitting crying in my gp's office -again- and telling her that's its burning me up, that I couldn't go to uni anymore, couldn't do anything from the flushing and the pain and needed her help and all she said was 'well you look healthy to me, nothing wrong with apple cheeks, I think you just work yourself up too much". It's horrendous to have such a person sitting self righteous in front of you like that. "Thank you. Next!"

If you can't get these meds, I can send you some clonidine and propranolol, I have monthly supplies and will just order an extra one and say I lost my bag on my way home from the pharmacy. Just for you to try out if you can't find any other way ok? Don't order it online, you might get dangerous versions with something else in it as the real medication. You don't want to risk that, not even in this bad situation I think. Then you can make before and after pictures (I know it sounds like the last thing you want to do, but just flush yourself with a hair dryer and hot coffee before making the pictures), make plenty of them, in different lights so the doctor has no leg to stand on and no reason to dismiss them, then tell him perhaps that if he wont give you the trial of these meds, that you'll get them elsewhere and that you just want one month of trial and will discuss it with him afterwards. Like you said, who in their right mind, hypochondriac or not, would use such medications if there was not a real problem? They will make you drowsy and tired in the first weeks. And the remeron might work well at 15 mg but it takes some weeks to start working. The clonidine and propranolol work instantly, if they fit your specific flushing.
Hope this helps a bit :/

And advice for those who have a hard time finding a cooperative GP or doctor, who wants to help you control the rosacea and flushing with medication

Username wrote: "I'm going in to talk to my doctor soon regarding an anti flushing med. She likely won't really understand the situation like a lot of doctors don't but I was thinking I ask her if I can start on clonidine? Is that a good option?

Me: "Yeah as a starting med I would go for clonidine. Maybe ask for 0,075 mg (equals usually half a pill), 3 times a day. You can up it to 0,150 mg 3 times a day. It can cause some rebound flushing for some when you wait longer than 8 hours with the next dose, so I find taking it every 8 hours keeps the clonidine level pretty steady in my body. Another med that might help is a beta blocker, like propranol. Some mention atenolol or other 'lols. I take 40 mg propranolol 1 to 3 times a day. If you have serious flushing issues and find these 2 meds aren't helping enough, consider remeron (Mirtazapine). It's an antidepressant with anti flushing actions. It has more side effects however (like most antidepressants, initial drowsiness and increased appetite, which you can counteract by not overeating). Antihistamines help as well. I take Xyzal. There are people who have good succes with antimalarials like plaquenil or mepacrine. They lower inflammation. They work slowly however and need to build up for a month. They don't work for everyone. Good luck!"

Carpsy wrote: "Not sure if this is against the rules or not but does anyone know if it's possible to get plaquenil online? Was hoping to get it from my gp but the one i normally see is on holiday at the moment so i had to see a different ignorant prick who when i asked for plaquenil looked at me like i'm a complete fucking lunatic and started spewing all the 'it's used for arthritis not flushing so he can't prescribe me it'. I told him everything i knew about it, about tony chu, about everyone's success with it. He was so patronizing as well he kept saying this isn't a mickey mouse drug like paracetomol i can't just hand it out like that. Yes i know that you asshole. You'd think he'd be more understanding seeing as i was only there a few weeks ago cos i wanted to end this nightmare of a life. This is why i always ask to see this certain woman doctor as she's always so understanding. I said it's my last hope having tried everything else and he just said sorry you'll have to see a derm as i'm not licensed to give you it. He said i can refer you to a derm to get his opinion and i just walked out. I'm a 25 year old man who just wanted to burst into tears. I've never felt so deflated after having such high hopes for something. The worst thing was i was sat in the waiting room for an hour absolutely beat red, cheeks pulsating but i didn't care cos i thought i'd come out with a potential cure. I know i don't have rosacea it's just something in my system has been fucked up by taking accutane. I've tried like 5 different lots of anti depressants aswell as counselling but nothing will ever help me. I have a 2 year old son at the end of all this which absolutely kills me as i can't even take him out of the house because i'm such a mess. He's the only thing keeping me going. I am exhausted i've been tired for 7 years now since taking accutane, back ache, flushing, severe sweating, mouth ulcers. They all think i'm crazy. I seriously just want to die right now it's almost like what i'd imagine cancer to be. It's killing me and i can't fight it so i may as well give up."

I replied: "Yes, its frustrating to the point of tears. But this is how most GP's handle, it is the system they are trained in. Plaquenil and mepacrine are more serious drugs than lets say clonidine. Most people here seem to get away with clonidine or even propranolol with their GP's, but mine flat out refuses me anything else at this point (well and remeron). And even those meds were only prescribed with a letter to her from Prof Chu. GP's are no specialists and they generally don't want to be held reliable for prescribing such specialized meds, for specialized conditions. It's frustrating, I have been there, crying, begging my GP for the meds. But you need to go through the system. Just as every new  derm wanted me to go through the same stupid steps of tetracycline antibiotics in the beginning, regardless of past experience with it with a different derm. I now have 3 different derms (it's pathetic and not too clever perhaps): GP for the 3 standard meds, one derm for antihistamine meds, my other derm for plaquenil and more serious drugs alike. And they reside in different countries, so nothing gets mingled up. Anyway, your best bet is probably to find out if there is a derm in your are that has a real understanding and experience with treating rosacea. If you are at your wits end and desperate for relief, I would make a thorough case of this, looking for all derms in a wide area, calling them all and asking specifically if they have experience and are willing to treat hard to treat, antibiotic resistant, facial flushing burning and redness. Its a waste of time and money otherwise. You might want to consider flying to Dr Chu otherwise, or any other derm that is known to be progressive in rosacea treatment known here on the board perhaps? First step to improvement was for me to find a good derm that fitted my health problem. Its depressing, tiring, awful, that you suffer like this and get such a cold treatment, but perhaps doctors these days are more afraid for court cases when things go wrong, and don't want to risk their work/ethics/whatever for a trial with plaquenil for you?  :/ Hope you can sort this out. I looked for online plaquenil, but you risk getting a totally different drug, you don't know which supplier is reliable and which one isn't and most reliable online pharmacies want a referral letter from a doctor for plaquenil. Unlike victim roac's posts, it is also NOT otc available in France, and in no other country that I know of. Sorry..."

Carpsy wrote: 
"was a silly question really asking whether or not a medication was available online.
decided to search deeper than just the first page of google and have come across tons of different pharmacies which seem to sell it. some of them have lots of decent reviews on pharmacyreviewer.com as well. will probably take a few weeks to receive it but it's worth a shot. i just want my life back. it kills me inside when i think back to when i was 17 years old and although i had bad acne, i didn't flush at all. i can't imagine life without flushing these days it's just part of my every day routine. sorry for the ramblings to myself i just needed to vent. this is just for plaquenil btw, can't find mepacrine anywhere online."

I wrote:  "Hmm, you don't know what they put in those pills carpsy.. You risk spending a lot of money and ending up with a half decent or dangerous drug. It's not checked by a licensed pharmacy this way. Have you tried anti flushing meds like propranolol and clonidine already by the way? And remeron? They all are pretty strong anti flushing meds. I have a stack of propranolol here, if you want to try some safely and see if it works for you? I think I can spare a few weeks worth of all three of those medws actually, then at least you know you have safe meds, the real deal, and you can know what to aim for afterwards with your hopefully future derm. Plaquenil takes up to 5 weeks to even start working. To build up in your system. To start having anti inflammatory actions. It is a very long time, especially as you will not know all those weeks if you have been sold a scam version or not. On tops, if you notice no improvement, you don't even know if you were taking calcium pills or plaquenil all that time (or god forbid something worse). :/"

Fed up wrote: "I agree. It's extremely upsetting when you're at your wit's end with this condition, to go in and spill your heart out to a GP, only to be point-blank refused treatment. It happened to me when I asked for remeron - the doctor had just never heard of it being used for facial flushing before and said that from an ethical standpoint she wouldn't be able to prescribe it. I was so disappointed and cried on the way home but looking back she was just covering herself. From a legal and ethical point of view, she couldn't risk prescribing something armed with so little knowledge about how it worked for this particular condition. Carpsy, I'm so sorry you're having such a hard time. I'm a post-accutane flusher too and know how horrible it is to deal with. I would echo Nat and ask if you have tried beta blockers like propranolol and clonidine? I take 40mg of propranolol a day and it does help take the edge off my flushing somewhat. I would also advise extreme caution when ordering drugs online - you just have no way of knowing for sure what's in those pills."

Carpsy replied: "yeah i don't normally like swearing on forums but i am so angry i was fighting back the tears. you are probably right about the doctors wanting to cover themselves, it's a shame really because it's almost like you are talking to a robot. this guy just didn't give a shit quite clearly, not just because he didn't prescribe me it but you should have seen the look he gave me when i suggested it, it was like i was a piece of shit on his shoe. i explained i've done alot of research on it and i defo think it would benefit me as i have accutane induced flushing, not to mention aches, severe fatigue etc. which all seem related. it was like he was talking down to me. acting like i went in there and just plucked a random drug out of midair and suggested it to him. Since i took accutane 7 years ago i have tried most antibiotics for my flushing. i've tried finacea and tons of other topicals, i've tried  literally every moisturizer for sensitive skin yet they all make me bright red so i just gave up on them and i just live with the dry skin which is a nightmare, feels like i have a film over my face almost like i'm trapped inside of another layer (can't really explain it). i've had IPL and yag sessions with dr crouch. was a bit disappointed with him aswell really, he didn't really examine me and he didn't really investigate the real problem which is how my flushing came from accutane (like dr chu seems to do), he just happily took my multiple £300's and zapped my face when i was very vulnerable and seeking an immediate answer. i've tried propranolol which was mainly for my anxiety at the time, didn't really know it was for flushing back then. that never helped. took clonidine for about 5 days back in 2010 and that was godawful. i can't explain the feeling of it but i kinda struggled to breathe and had serious headaches etc. i'm a fighter but that was just too much so i stopped. this is why i'm desperate for plaquenil. since i discovered it a few days ago all i've been doing is googling it and reading forum posts etc about it. must have read every topic on here containing the word plaquenil or mepacrine about 50 times already. it's a shame it's not a more widespread treatment as google doesn't really bring up much. another massive factor in my life is my extreme fatigue. since taking accutane i have been so tired. i've always been so sure there is something wrong with me but all my blood tests always come back clear. the doctors just put it down to depression and throw some tablets at me. it probably is related to my depression but i know my body and i know this isn't normal, like i can't even exercise anymore because i have to stop after 10 seconds, even running up the stairs takes it out of me. i've also been reading a sjogrens forum because i seem to have most of the same symptoms. have had severe dry eyes and mouth since accutane too, so much so that my front two teeth have kinda eroded and are now like jagged, which makes dealing with this so much harder aswell because i'm so paranoid about my appearance. so yeah i'm hoping the plaquenil helps with that aswell because even if it doesn't help my flushing, if it manages to help my eyes, mouth or even put a stop to my fatigue i think i will definitely be able to cope a bit better. life is defo much easier to deal with when you at least have some energy.
About the dodgy medications. yeah i'm not a fan of buying things like this online and it's my first time but i am so desperate right now i probably wouldn't be exaggerating if i said i'd happily become an amputee if it meant being flush free. so it's a risk i'm willing to take. however i did go on pharmacyreviewer.com and said pharmacy has like 5* reviews with around 300 comments praising it, although this is mainly for the more mainstream medications such as tramadol etc. maybe the plaquenil will also be fine. who knows? oh and nat - love your blog btw, great stuff."

wrote: "Yeh I agree and there is actually a member here, who is doing med school and is studying to become a doctor herself, hopefully a dermatologist. And she says the same thing; she is so frustrated with her rosscea and seb derm and the total lack of interest with a lot of dermatologists to dig into the matter or to look for a cure. And the rudeness and psychological harshness of some. I hope that in 6 years time we have our own great dermatologist on the NHS with her :)
Yeh sure, see how you do on the plaquenil once you get your hands on some, and the mirtazapine (=remeron) should have started to make a difference after a week, some notice it sooner. I would keep using it for now if you dont feel it is making you worse, because it is indeed also an antidepressant and has strong antihistamine effects, which are both beneficial for your flushing. I find it most effective at 15 mg, and can up it to 22,5 mg (one and a half tablet) tops, before the anti flushing effect begins to wear off. I swear, I have had endless tests over the years and never something really dramatic or conclusive came up (apart from a mild case of colitis, that doesn't even need treatment according to the doctors) and Raynaud's, which doesn't bother me one bit, and some chronic inflammation of the knee caps (which they don't feel the need to do anything about). All tests for allergies came back negative, tests for infections were negative, etc. But in the end, it were these specialized tests, and the ANA titre test (your dermatologist can perform it, but usually an internist does this) was mild positive. And the blood tests I referred to in my fore last post confirmed that there is some type of systematic inflammation going on and that there is auto immune activity. ANA was fully positive too this last time, so then you have at least some confirmation that you are not crazy and that there is definitely some low grade inflammation issue. But what can you do with that knowledge? I found not much; it's not serious enough to receive treatment for, it is positive but not positive enough to reconsider lupus or other auto immune diseases to be at play. I got the advice to get my vitamin D levels up, to start taking fish oil and omega 3, to take zinc and magnesium and to avoid multivitamins and everything high in vitamin C (as it further strengthens the immune system, and mine turned out to be overly active, attacking the bodies own tissue, causing inflammation). But that's about it. Nevertheless, i got my tests covered by health care so maybe you can as well on the NHS and at least you can eliminate more serious causes for your facial flushing. Good luck either way :)

Tom Busby came with a suggestion:  Hi carpsy, Plaquenil is sold here https://www.inhousepharmacy.biz/p-11...ets-200mg.aspx It's legal to buy these drugs in the US as long as you don't sell them or give them away, and the quantity is only enough for 3 months of personal use. The FDA has a "non-enforcement policy" as of August, 2012, so the US Postal Service and Customs are required to allow drug shipments under these circumstances.   I've never ordered from this company but internet drugs are usually sourced from Thailand or India, where all drugs are incredibly cheap and nearly every drug is OTC, so I'd be surprised if this company was a scam artist. Hi Birdie, I've cut down on my salt intake for general health concerns, and I've found coincidentally that ginger root will increase saliva flow, which thereby mimics the salt of salt. I'm not sure if this will work for you, but ginger root is easy to use -- you can put 6 or 7 thin slices into yogurt overnight in the frig and discard the slices in the morning, or you can shred a little ginger root into food that is cooked. Ginger root has enzymes that make bread rise more in the "final spring," which is why I started using it, but then I found that it mimics salt, and this might help with dry mouth or blocked salivary glands. It's tasty too, so it's worth a try."

Nicofan replied: "i also got my plaquenil from inhousepharmacy. I also ordered propecia, dixarit (clonidine), catapres (clonidine) from them. I always got the medication within about 2-3 weeks. They even replaced a package which didn't arrive.I think they are real because they gave me side effects listed for these medications.I have taken 16 pills of plaquenil so far. not much to say yet."

I replied: "Given all the people here who receive systematic refusals to be prescribed any medication, this online pharmacy would be fantastic. Given that it is safe and reliable of course. You need to be responsible though and read the side effects up yourself and keep a close eye on them, as you are no longer under the guidance of a doctor. For instance, with plaquenil, doctors say that you need baseline eye tests, as plaquenil is toxic to some tissues and can cause eye problems. Some never get them, I get them after a few weeks of use already, so such things might be good to think about yourself now. " I want to stress again that there are always significant risks attached to ordering something online, that isn't provided by a state legislated and reliable pharmacy. But it might be worth the try for those who are entirely stuck with their doctors and suffering badly from their rosacea. Yet, I wouldn't like to use these pharmacies myself unless absolutely no other options are left. You just don't know for sure if you get the right drugs supplied. And there have been horror stories where people died from fake drugs...

Reflection1 replied: "A few years ago I would have found crazy to self-medicate via internet. But when I found this forum and some others with the tons of good testimonials and infos we find in, I told myself "well derms seems to know very little about rosacea, so why not trying to self-medicate". Of course I agree with you, any drugs shouldn't be taken like candies, but sometimes you feel so desperate that you would do it. In the beginning I made the mistake of not choosing a good online pharmacy. I have tried these crappy generic drugs sent from India, but rapidly stopped it. Finally I found this pharmacy and never quit her ! For example, here in France minocycline isn't prescribed for rosacea anymore, but it was the only antibiotic effective for me. So, I was grateful to find an illegal way (to name a spade a spade) to get it. As I am also fighting a rosacea worsened by isotretinoin, I have stocked a few month ago several boxes of Plaquenil but will only use it as a last resort. Don't want to add a problem to my problem, this is not the purpose... I hope for you nat007 that these side efects are past now. Do you found some relief from Plaquenil before developping these bad effects ? Carpsy : I totally validate the caution from nat007. Plaquenil or others very potent drugs shoud be used as last resort. Get an eye ckecking before starting Plaquenil would be a good idea."

I replied: "Yeah best to do an eye test once you start the plaquenil (so I would book one soon in your case) and then later on in treatment, so the eye doc has a point of reference:
http://www.revoptom.com/content/c/27904/ It seems to happen more often that the eyes get affected with doses over 200 mg a day, and after a certain amount of years of use."

Carpsy wrote: "it's quite a scary world we live in isn't it? i'm sorry if i offend anyone on here by saying this but i personally think 99% of derms are absolutely shit. complete waste of time. you wait what, 6 or so weeks to see someone? and then they sit there with their perfect skin and have a look in their god awful doctor bible which is basically google just wrote inside of a paper handbook. every time i go to the doctors and ask them anything they take out their doctors bible and have a look in it. they are all fucking useless. how can you expect to see results in 3 weeks when every one on here and other websites pretty much said 3-6 months? unless it's laser treatment you're after then i'd just ignore all 'professional' advice. i appreciate that i sound a bit of a prick right now but i'm sure most people here will agree with me. i'm 99% certain that derm you seen knows zero about plauenil yet they look in their book and give you a rough estimate. you may see results in 3 weeks yeah and i pray that you do but if i was you i would rather listen to google than that ignorant robot that you spoke to."

I replied: "Lol, yeah I know such derms too :) First they check their hand books, of course the off the beaten tracks flushing medication isn't mentioned in them. If you are lucky they then google it in front of you. I always do my research in advance and print the info out, adding the websites where they can find it (cause they always want to double check), and only if you are very lucky they will take your suggestion. But some find it beneath their level and try to belittle you by telling you you can't just 'pluck info from the net' like that. Even though they have to look stuff about rosacea up themselves too online (shakes head). There are good derms too though, I have 2 excellent ones, both older, both thinking very broadly and constantly coming with suggestions of coexisting possible conditions to check for, or for medication that is used for other diseases, but that might help me in their opinion. They are both types to do a lot of reading and staying up to date despite being in their 50/60's, you need derms who keep eager to learn and to update and with some interest in rosacea, I found at least. Needle in a hay stack perhaps though :( "

Username wrote: "Just had my appointment with my doctor about getting clonidine and she had only barely heard of it. Said she has never prescribed it in 30 years of being a doctor. She said she had to talk to someone else before prescribing it. She said thinks treating the flushing is only a temporarily fix and not treating the root of the problem. I agree with this but the root of the problem is my condition and I've been trying to treat that for 10 years."

I wrote: "That's not fully correct.. I'm sorry your doctor was so negative to the idea.. Part of controlling (vascular, subtype 1) rosacea is to control the flushing. Ongoing flushing will worsen your rosacea and will make you more red and more flushed in the end. Compare it to varicose veins; the pressure of the dilated blood vessels will force the rest of the blood vessels to dilate as well in the end. If you want to stabilize and even improve your vascular rosacea, controlling the flushing is key to most. My rosacea really improved after introducing several anti flushing medications, and I know of many more who experienced this improvement. Maybe you can give your doctor some printed out medical reports on hot flashes and clonidine (hot flashes work in a comparable fashion as facial flushing, partly coming from the central nervous system). On this blog post I gave some links to medical articles, you might perhaps be able to print some out and ask the doctor again?  Facial flushing is very difficult to treat and some very good derms work with clonidine and other anti flushing medications. They do that because it does improve symptoms. It sounds like a rather unconstructive thing to say for your doc that these medications don't fix the root of the problem. Hello?! There is no cause found for it yet, and no cure either. Like for many auto immune diseases in fact. Would that have to mean that such patients are witheld medication that suppress the symptoms and prevent progression of the disease? of course not. I'm sorry you are having such a hard time with your doctor, best wishes"

Username replied: "Thanks for your reply. :) I expressed to her how badly I needed something for the flushing as it really hurts me in social situations. She said she will get back to me. By the root of the problem I think she also meant my anxiety, which is CAUSED by the flushing. My anxiety is fine until I start flushing and that is when I get all nervous and my heart starts beating fast and my skin gets 5x more red than usual. I already have bad baseline redness permanently so it doesn't help to always be flushing. I would say it happens a lot during the day and my face is only calm maybe a few hours out of the 18 I'm awake. I looked into clonidine and I really think it's a good fit, hopefully she understands. :( Thanks for the great link, I learned a lot from that. Maybe I will find a way to forward that to her if she gets back to me and won't prescribe clonidine."

I replied: "yeh sure, maybe it helps to give her the link and scientific data. Also, perhaps tell her that Professor Tony Chu from Hammersmith hospital in London works for decades now with the worst rosacea patients and has prescribed the anti flushing medications clonidine, propranolol and remeron for a very long time, with good results and very little side effects. I feel you might also benefit from propranolol perhaps, together with the clonidine preferably. It is a beta blocker and even taking 40 mg a day (a very low dose), helps many here both with the flushing and with anxiety. It makes your body produce a bit less adrenaline and lowers blood pressure, many people take it now and again for stage fright and stressful things. Remeron also helps many I know here with facial flushing and it is an antidepressant with a very strong anti anxiety element. I take a very low dose, the start up dose of 15 mg, yet it is most effective at this low dose for facial flushing (up till around 25 mg, over 30 mg most feel it is less effective to shunt flushing). Yet, at 15-25 mg a day it still cuts down dramatically on anxiety and it will have a mild antidepressant effect.I hope you can convince your doctor to at least TRY these meds. I made that arrangement with my GP, after dr Chu wrote her his recommendations for me to start using these meds. We agreed I would take it for a month and then see if my flushing and redness would go down or not. It went down dramatically, so there was no discussion about it and I am still taking these meds with her agreement 8 years later now. Despite being on 2 blood pressure lowering meds (clonidine and propranolol), my blood pressure only was lowered initially and soon rebalanced, in a healthy range. My derm had already predicted that, so there is no big risk of becoming severely hypotensive from this medication regime (but make sure to check it regularly in the first months). Good luck"

Username replied: "Thanks so much N. I hope she lets me try them too, I really think they can help me. If she doesn't I may look for a new doctor. I don't want to be rude to her but I've seen too many positive things about it helping severe flushers to not try it. I have a blood pressure machine in my house so that will be beneficial so I don't need to go to all the way to the doctor. I think I'll try clonidine first and see how it goes. If all goes well I may consider adding propranolol in the future. I'm currently taking just an otc anti histamine and I actually think it's a helping a little bit, which was awesome."

I wrote: "I hope she will help you, to at least try clonidine under her guidance. I had to swap GP's a few times too and have a very caring, empathetic but firm if needed female GP, for a good 10 years by now. It helped for me to explain to her that my problems go way further than the esthetic appearance thing; that our flushing and facial redness feels hot and burns and ruins our lives. Clonidine is an old med, widely used and relatively safe. I hope and think that with some extra information and another good talk, your GP might want to help you and let you try it at least. Otherwise you can always try to find a better GP or even order these meds from an online pharmacy (defininately your last option and least preferable one I think). In the end, we are the ones who have to live with this beast and who have the day to day suffering from it, so I would advice you to be your own advocate and to take as much control over rosacea as you can. Good luck!"


Here are some more patient reviews.

Friends who saw improvement on these medication wrote me:

My friend X had horrendous flushing after a recent laser treatment gone wrong. She already had significant vascular rosacea to start with but now was at her wits end, unable to leave the house or go to the store and constantly behind a fan in the cold house, a bit like me half of the year. Here is some communication we had, first about her doing bad after the laser treatment and then about her starting with remeron. Of course sharing with her permission.

Friend wrote: "Hi N., Well I had my 1st full face surgery on Wednesday. It was quite an experience, as the doctor was very verbally abusive to me. She keeps making my appt in the afternoon and then saving me for last because “I’m such a difficult case”. I very kindly told her that if she is purposely saving me for last, to please make my appt the last one of the day, as it’s physically difficult for me to wait (not to mention, it’s not right for her to keep putting patients ahead of me). Anyway, it was the end of the day and she was quite worn out and just let loose on me, telling me that she is bending over backwards for me by doing this and that she stayed late to get me done. She is tired and hasn’t had lunch. I told her that I didn’t appreciate her defensiveness and that I am offended that she would say she is bending over backwards for me, as this is what she does! I was sent there for a 2nd opinion and better technology- she is not doing me any free favors. I am paying $300 for every procedure. It’s not my problem that they squeeze in so many patients, that she missed a meal. Additionally, I stayed late for HER, she did not stay late for ME. My appt was at 3:30 and it was now 6pm.—and I have a 3 hr drive home. Anyway, this is more than you needed to know, but I was quite disheartened and decided that at that moment I had to make a choice between my dignity and my health.. and I chose my health. Once I’m through- then I’ll speak my mind, but I felt totally violated as a human being. These specialists think the waters part when they walk in the room. So that being said, I’ll be seeing her assistant going forward, who will perform the procedures because this dr. doesn’t have time for me. (Apparently her Botox patients are the money makers). They are expecting me to need about 5 more surgeries and this will probably take a year or so, as well as seeing the neurologist to rule out other issues. Additionally, in order to get the strength laser I need, I am going to be experiencing some after effects. I had blisters all under my chin and pain from my teeth down to my ribs for 2-3 days after. This is usually due to the laser hitting nerves in your teeth. I cant give up yet, but this is more than I bargained for . Xo"

Friend: "Soooo much pain today.. How are u feeling?"
Friend: "Well since Ive had the laser- its much more intense! Especially when I wake up or go to a store it feels like hot needles under my skin even if the surface isn't too bad"
Me: "do you also burn when your skin isnt red ?"
Friend:  "Yes. Then sometimes it looks like chemical burns."
Me: "How many hours a day would you say you are flushed ?
Friend:  "It differs. I'm red all day now but flushed maybe 3-4 while I’m awake- mostly when the clonidine wears off. I'm flushed anytime that IM away from a fan for more than 15 mins, I'm burning almost all the time if Im not in front of the fan. It's constant now."
Me: "ok so when you are behind the fan and your skin feels cool to the touch, can you be less red then?"
Friend: "It didn't used to be. Yes and less swollen. I'm having trouble wearing makeup lately and my chin and under my chin burn. Ican only get a break if I have the fan otherwise its constant which is why im working from home now i cant move."
Me: "Because the normal thing is that if your skin would be less red, more calm, cool to the touch, that the burning has to subside to a degree. Do you feel that happens?"
Friend:  "No because i have a pain that is much deeper down- so even if my skin is calm, if Im away from the fan, it starts up- i can feel the burning deep inside my skin and not as much on the surface do you think its leaky blood vessels? sucking on ice or icepops helps alot and my left ear burns like HELL ive never had to have a fan constantly like this before every day.
Me: "i wonder.. I had a cold pack burn, fell asleep on a cold pack, back in 2007. And it caused severe burning senssation deep in my skin. Even when I was not red or cooled, I still had the horrendous burning 24/7. I had medications like gabapentin and Lyrica to cut down on the burning, which was neurological at that point. After 6 months the nerve damage reversed itself, but the neurologist explained me that nerves heal very very slowly." 
Friend: "Just for a few days here and there but its been like 8 months now.
Me: "I just wonder if the laser could have caused you such nerve damage because laser and IPL gave me bright red skin which triggered the burning."
Friend: "that's what I think. The laser made me feel good for about 2 days, then the pain would sta
Me: "and the cold pack burn gave me the burning, regardless of the color of the skin and your situation sounds perhaps more like that?"
Friend: "Yes, that's why im careful to make sure i use ice bags with the ice floating in water so the ice doesn't actually burn my skin its just very cold water and it definitely helps but everything is so temporary. I'm so so depressed N., I cant do anything anymore. My poor husband has to run everywhere"

Me: "your blood vessels and nerves seem very very agitated and triggered right now. I had the most awful years where I flushed and burned 24/7 and thought all was lost, but the skin and vessels and nerves can actually calm down again... it happened a few times with me"
 "I tried to run to the store to get X some pencils yesterday and I thought I was going to collapse from the pain."
Me: "I think you need to get better medication, that cuts down dramatically on the blood pressure and inflammation." 
Friend: "I hope so!!!"
Me:  "You are not yet using remeron, right? an antidepressant
Friend: "the neurologist wasn't keen on giving me the meds you mentioned so I am going to ask my regular dr for them. No I tried, I am taking Lexapro."
Me: "I would go on remeron, 22,5 mg."
Friend: "ok I’ll call my dr today and see what she says"
Me: "Remeron is really the best antidepressant for severe flushing for me, strong antihistamines help as well. Xyzal, 10 mg and on top some extra."
Friend: "Maybe that's why the neurologist called in an anti depressant? The antihistamines work great but they dry me out SO bad, that it ends up worse."Me: "Yeh but make sure they give you remeron, and not amytriptalyne or something, which they prescribe for nerve pain, as it wont help rosacea usually and remeron will, for most."
Friend: "That's what he called in! I didn't pick it up."
Me: "yeh well that one made me worse (but it might work different for everyone)."
k im glad you told me."

Me: "If you google remeron or mirtazapine (non brand name) and hot flashes, you can see it also helps menopausal hot flashes which is the issue we want to tackle, its the same principe as our flushing."
Friend: "I'm calling my dr right now. She's great and willing to help me in any way."
Me: "For my the antihistamines are very important, I just have the air in the house more humid to counteract the dryness. Remeron is fantastic and also helps me to calm down and cuts on anxiety"

Friend: "Dr called in the remeron but a lower dose to start .. She said to take with the lexapro.. Fingers crossed!"
Me: "15 mg is ok as well, but not lower than 15 mg~! Ok fingers are crossed!!!"
Friend: "Shes starting me at 7.5 but said she'll increase it since i also take the lexapro.. Supposedly the two work well together."
Me: "ok, it starts working for rosacea from 15 mg and up but dont go over 30 mg, it works far less on flushing then. I find 15 mg or 22,5 (1,5 tablet) the best personally, I take 22,5 at the moment."
Friend: "Hey Girl- how are you feeling today? I am definitely getting results from the Remeron- TY so much!! I did have pain today because I put makeup on..but I think with time it will get better. I use  all hypoallergenic, oil free, non-comedogenic makeup-...but sometimes I guess the skin can't breathe. I don't wear much at all- just enough to even out my skin tone. Hope you're doing okay!"  
Me: "I'm so so, very glad the remeron is helping you, keep me updated xo" 
Friend: "Im flushed.. Some burning on left side but could be worse... How abt u? Any relief yet? " 
Me: "Ow hmm.. is the flushing at least a tad less severe as before starting remeron?" 
Friend: "No not yet .. Its about the same but i think in abt 30 days ill convince the dr to put me at 30mg. I have been fasting for 2 days due to the overeating ive done sine starting it.. The hunger issues have subsided thank goodness...u in pain today?"
Me:" Yeh well perhaps try to see how you do at 15 mg and then 22,5 (1,5 tablet)? I find remeron most effective at that dose and slightly less again at 30.. very odd."
Friend: "My upper left cheekbone has always been the worst and thats bothering me the most today. Ok on the Remeron.. Ill sneak in another 7.5mg in some days to aee how it goes ... Love ya.. Try to relax xo" 
Me: "Are you seeing some improvement with the remeron? xx"
Friend: "I'm so sorry N! Well I think so- I mean I wake up without any flushing and don't need a fan for a bit. I still flush during the day - but it seems to be less intense. Until a lot of time goes by, it's so hard to tell with this disease since you have goods and bad- you know what I mean? "
Me: "oh i know, thats the remeron kicking in. Dont be fooled you would get such improvement from simple things like diet or bad or good day. Good to hear~!!!"
Friend: "How is your pain? I am definitely getting benefits from remeron and have only you to thank.. Pls tell me how u are xo" 
Me: "Thats very good to hear darling, yes the remeron is a very important med for me too to get some relief. I missed taking it 2 nights ago and was already more flushed the day after. I get crzy dreams from it however and 9 hours solid sleep, how do you do with that? And pls be careful what you eat as this one will make most people gain some weight, even when you dont change your diet at all But I am doing a bit better, still more red and flushed than normal but teeth are healing and bit by bit its getting better, no 24/7 burning and flushing anymore. Yay!" "What dose of remeron are you on now? 15 mg is best, or 22,5 (1 pill and a half). for flushing those are the best doses, 30 mg will make you feel very good, its potent as an antidepressant on that dose, but a bit less for the flushing, another friend of mine noticed the same. I find that even on 15 mg I am less anxious and more 'chill' on the remeron, it shuts down anxiety, do you notice any of that?"
Friend: "I wish I could thank you for telling me about Remeron- I can't tell you how much better I am lately!!"
Me: "glad to read darling. How much flushing is left? Can you do without a fan by now? What dose are you on?" 
Friend: "Im hardly flushing at all and i can go without the fan for a good period of time. Heat still affects me but not nearly as bad. Ty so much!!! Do u think i should still try to go from the 15 to 22mg?" 
Me: "No i would stick to 15mg, thats the dose that dr chu advices, that's very good news. You have part of your life back, yayyyy"

Friend: "Yes!! Now im having back problems from sitting so much for the last 8 or 9 mos in front of the fan. Ive never had back aches in my life til now."

Friend: "It's been about 3 weeks on Remeron and it really seems to be helping! I am not waking up in pain and it's not making me drowsy during the daytime, but the appetite is still increased. I am working hard to keep it under control! If you haven't tried Remeron- ask your doctor for at least 15mg per day for flushing."

How does facial flushing happen exactly? 

When my skin burns and flares and feels on fire, the most natural urge is to open all the windows and let in cold air. Or to put my head in a bucket of cold water. Or to sit right in front of a powerful air conditioning machine. The colder the better! But according to the Warm Room Theory, this is actually not the best thing to do when you have rosacea. Making your rosacea skin very cold, might cause rebound worsening in the long run. It is normal for anyone with rosacea to get a rush of warmth up the cheeks when entering a warm room. Every person that gets too hot, can rely on their body to deal with the overheating, usually by stimulating the body to sweat (a way to release excess heat from the body) but also by widening the blood vessels in the skin. The wider the vessels are, the more warm blood will be closely exposed to the skin and be able to lose some of its heat that way.

When the body signals the blood vessels in our skin that the body is overheating, then the body activates nerves in the skin to dilate the blood vessels in the skin (vasodilation). The way in which the nerves do this, is by releasing certain chemicals, that message to the blood vessels to widen. And to make the effect even stronger; the more blood flows through the blood vessels, the more these blood vessels themselves release chemicals to keep this vasodilation going. This is a normal process; everyone alive experiences this, or else we humans wouldn't be able to regulate our temperature or fight off infections or have proper wound healing, for instance.

The problem occurs when our skin has too many of these flushing events. When it becomes very frequent that the skin flares red and hot. This is the moment that the blood vessels are dilated for a longer period over time, and that the vessels give off a signal that make the body create new (and thus more!) blood vessels in the skin (angiogenesis). The bodies way to create more infrastructure for this extra blood flow. This principle is also normal, but in people with healthy skin it is a limited occurrence. For people with rosacea, it is however the mechanism in which our rosacea progresses, slowly over many years, from mild to moderate, to severe. Because when you have more blood vessels and more nerves in your skin, you will have more dilation of blood vessels and more facial flushing, especially when you are in a warm room and your body goes through its normal steps and paces to cool off the body.


So a person with rosacea will have more blood vessels and nerves in the skin than a person with healthy skin, and they have been made by the body to release heat. They will give a rosacea face often the distinctive red(der) cheeks and sometimes also nose and chin or forehead. The human face and head are special, in that they have more and different blood vessels and nerves than any other area of skin on the body. They have special nerves to dilate blood vessels and special blood vessels to release the heat carried in the blood.

The nerves involved in these areas are sympathetic nerves. They can act to dilate special blood vessels (arteriovenous anastomoses), which open up and shunt blood into the blood vessels of your skin, creating the phenomenon we know as the flush. This also explains why many people have intense flushing confined to certain regions of the face. many people with rosacea flush on their cheeks, some (but far less) also flush in their neck and chest and it is very rare to find rosacea patients who flush on the rest of their body, unless they have other skin conditions that cause skin problems elsewhere. Rosacea, however, is mostly limited to the more densely vascularized face, where our skin is also thinnest, compared to other body parts. Showing the redness in our dilated blood vessels even more!

More on these nerves in the skin that are involved in skin flushing
Another important type of nerve involved in rosacea is the sensory nerve. Unlike sympathetic nerves that are triggered centrally in the brain, sensory nerves are locally handling the blood vessel dilation in the skin. When your face is exposed to sun for instance, or to a skin care product that has irritating ingredients, then it are the sensory nerves that can act immediately and signal to the blood vessels in the skin to dilate and give off a warning signal to us. They play a role in rosacea flushing, as such. When our blood vessels in the skin dilate, after being signaled to do so by the sensory nerves, they not only become wider and let more blood through, but they also create local inflammation, which in turn makes our nerves in the skin give off a burning pain feeling. For most people with rosacea, a deep flush is therefore painful, feeling hot, sore and like a burn almost. Due to rosacea, more nerves are created along with the new blood vessel infrastructure, but the existing nerves can also become hypersensitive. This can explain why early on, with mild rosacea, facial flushing can be fairly painless, but later on the flushing can create moderate to severe pain and hot burning sensations; the nerves in the skin have become super reactive and sensitive from the long history of being triggered by flushing attacks of the skin. As a result, some people with rosacea have such a sensitive and extensive nerve and blood vessel infrastructure, that even a small increase in blood flow will result in significant flushing episodes.

Chemicals involved in facial flushing
There are hundreds of known chemicals involved with nerves and blood vessels. But there are very specific chemicals released by our nerves and blood vessels, when we have rosacea and suffer from facial flushing, such as neurotransmitters, neuropeptides and growth factorsNeurotransmitters are chemicals that transmit a nerve signal to other nerves as well as other tissues, such as blood vessels. Neuropeptides do the same, but are stronger and act longer. Both can signal blood vessels to dilate or constrict, and nerves to feel pain or to go numb again. There is something special going on with these neuropeptides, research showed. More on this soon.
 Growth factors, released by skin cells, help to maintain existing blood vessels and nerve structures, and also make it possible for both to grow. They also play a role in the process of our nerves becoming more sensitive and easily triggered to feel burning and pain. When the nerves in our skin are activated (for instance during a flush), this in turn stimulates more growth factor release, like a waterfall-construction. They are all in place to help the body deal with overheating, but with rosacea patients this system of blood vessels and nerves and chemicals are going in overdrive, causing our increasing facial flushing and red faces.

Peptide LL-37

I was also told about research about a possible link between rosacea inflammation and the peptide LL-37. There is quite a bit of research online available on it, so I will write a bit more about it now. Know and realize here, that the true cause of rosacea has not been discovered yet. Doctors and scientists do not know what causes the different subtypes of rosacea (subtype 1: flushing and redness, Subtype 2: skin outbreaks and inflammation, Subtype 3: rosacea of the nose; rhinophyma, Subtype 4: occular rosacea of the eyes and the recently added Subtype 5: neuropathic rosacea with nerve pain and burning). It is likely that these different subtypes may have some different underlying mechanisms. For instance; subtype 2 is often improving from topical ivermectin or Soolantra applications (see entire blog post about this here). Indicating that demodex mites can play a role in this subtype. However, for subtype 1 with flushing and burning these creams rarely work well. The flushing is also not improving when using textbook rosacea treatments, such as antibiotic pills or creams. In fact, flushing is one of the most difficult to treat symptoms of all, in rosacea patients. Topicals like Mirvaso (brimonidine) and Rhofade (oxymetazoline) have proven mostly disastrous for rosacea flushers. Large groups of people had their rosacea skin burned or deteriorated, had bad rebound flushing episodes that were often called "hellish" and long lasting. They chemically constrict the blood vessels, only for the body to compensate with abnormal blood vessel dilation rebound flushing) afterwards. It destabilizes the blood vessels in the long run and patients have mentioned their rosacea progressing to areas and severity they never had it before. of course another group states to have success with it, but it's a Russian Roulette drug, just like steroids. Better to reduce the flushing in my opinion are anti-flushing medication, or IPL or laser. (Read all about this here and here). And facial flushing goes by different pathways than the spots and outbreaks that subtype 2 patients tend to get. So, one big discovery, of one single cause, might be unlikely. Nevertheless, a (faulty) peptide called LL-37 may play a role in rosacea inflammation according to some research.

In this scientific research, it is stated that:

"Chronic, common inflammatory skin diseases such as atopic dermatitis, psoriasis or rosacea are characterized by dysregulation of cutaneous innate immunity (aka; there is an issue in rosacea skin with the normal functioning of the immune system function). Cathelicidin LL-37 is an important effector molecule of innate immunity in the skin and atopic dermatitis, psoriasis or rosacea show defects in cathelicidin expression, function or processing. 
*In rosacea, cathelicidin processing is disturbed resulting in peptide fragments causing inflammation, erythema [skin redness] and telangiectasias [small dilated blood vessels at the surface of the skin]. 
*In atopic dermatitis, cathelicidin induction might be disturbed resulting in defective antimicrobial barrier function [causing infection]. 
*In contrast, psoriasis is characterized by overexpression of cathelicidin. However to date it is unclear whether pro- or anti-inflammatory functions of cathelicidin predominate in lesional skin in psoriasis. 
In this review, the current evidence on the role of cathelicidin LL-37 in the pathogenesis of inflammatory skin diseases will be outlined. As cathelicidin LL-37 might also serve as a future treatment target potential novel treatment strategies for those diseases will be discussed."

So the research article suggests that the skin of people with rosacea has a disturbed functioning of the LL-37 cathelicidin peptide. Does that mean that there are more of these peptides in rosacea skin? or less than normal? Or that there are normal numbers but that the peptides do not work as they should do in rosacea skin? And what is this LL-37 peptide exactly?

Cathelicidins in the human body play a crucial role in the bodies immune defenses against bacterial infections trying to infect from the outside. Wikipedia states that "Patients with rosacea have elevated levels of cathelicidin." And when wiki states that "Excessive production of LL-37 is suspected to be a contributing cause in all subtypes of Rosacea", it cites this research paper, which is the same as the earlier quoted research. Its authors, M. Reinholz, T. Ruzicka and J. Schauber published in 2012 their research, stating that normal skin has three ways to protect itself from bacteria's from the outside world, trying to get in. First you have the top layer of the skin, which forms a shield (if the skin barrier functions as it should do!). This outer layer of skin has special cells that work as part of the bodies immune system, signalling when substances enter the skin that do not belong to the body itself, for instance a bacteria. They signal to the other cells of the danger once a bacteria does try to invade the skin.  If this happens, the bodies immune system sends specific cells to the surface that are causing inflammation, trying to work out or kill the invading bacteria. One of these specific cells are antimicrobial peptides (AMP's), of which there are to date several hundred different types found. They can kill bacteria by messing with their cell membranes (for instance in case of a skin injury), but also fungi and viruses. So they are part of our skins little army, so to say. Cathelicidins are part of this AMP system. The precise cathelicidin involved in AMP is called Cathelicidin antimicrobial peptide (CAMP). And Cathelicidin LL-37 belongs to the CAMP family. It can break up bacteria, fungi and viruses that land on the skin. But they can also give off an "alarm", which brings the skins army into action, causing inflammation to work out or kill the invading substances. They mainly get active and detectable in the skin once there is a skin injury. When all is normal and the skin functions as normal, they are hardly to be found in the upper skin.

But Cathelicidin LL-37 can also trigger the immune system. Thus, it plays an important, dual, role in the immune function of the skin. And when this LL-37 peptide does not function as it should, it can in fact have the reverse effect on the skin, and cause skin inflammation. And also allow bacteria to infect the skin. The scientists found that in rosacea skin, cathelicidin LL-37 often does not function as it should, and what is worse, they found that rosacea skin has much higher levels of this LL-37:

"Indeed, cathelicidin is strongly increased lesional skin in rosacea compared to the skin of non-affected individuals."

Rosacea skin deals with different symptoms, but mostly from chronic inflammatory and vascular response [blood vessels dilating more than they should]. The "alarm" function of LL-37 is off in rosacea skin, meaning it calls for the help troops to come when there is, in fact, no real threat... No invading bacteria to fight off, no fungi and no viruses. And instead, it stimulates inflammation of the (rosacea) skin and dilation of the blood vessels (thanks to the help of nitric oxide and EDHF):

 "In rosacea increased levels of the vasoactive and inflammatory host-defense peptide LL-37 and its proteolytic peptide fragments are found which can be explained by an abnormal cathelicidin production and pathologic protease activity."

The scientists got confirmation about all this, when they injected these specific cathelicidins in the normal skin of mice. They all developed rosacea-like skin symptoms then. The problem is now, that scientists do not understand yet WHY rosacea skin has these higher numbers of cathelicidins,a lthough they found 3 different 'portals' so to speak, through which the extra peptides were produced. They were retinoid-, vitamin D- and cytokine-activated. The vitamin D-pathway, for instance, could explain why rosacea is only present on the face normally, and not on the rest of the body: the body is usually covered up and it is the face that gets the most sun-exposure and therefore the most vitamin D. And therefore, the more vitamin D is made in the skin, the more Cathelicidin LL-37 (and thus the more disrupting inflammation and vasodilation). But this is only a small part of the puzzle, as many people with rosacea shun the sun and protect their faces from sunlight at all times. Also, many with rosacea have low levels of vitamin D (read more about that in this post). 

But scientists also found that cathelicidins could be triggered by keratinocytes (outer layers of skin cells), which have nothing to do with vitamin D. They found that the outer skin cells themselves can signal the making of more Cathelicidin LL-37 when they are injured, get exposed to UV radiation, or when the outer layer of the skin gets disrupted in any way. Skin Stress, one could call it. Ánd, interestingly: skin stress included heat. "This again could explain why rosacea patients often report on unspecific triggers (e.g. heat) which would mediate their pro-inflammatory activities through ER stress and cathelicidin induction." So when our rosacea skin gets triggered by heat, for instance you enter a very warm room, then this heat touching the skin will cause stress in the outer layer of the skin, sending of "alarm signals", which stimulate the LL-37 and other peptides to come into action and create.... inflammation. Physical stress can trigger the same response by the way, as well as alcohol consumption: Inflammation.. Just like we see happening in our rosacea faces when dealing with triggers like heat. Demodex mite infections can also trigger the skin to make these inflammation alarm reactions, as demodex mites can cause increased protease activity in rosacea skin, which does the alarm bells of  Cathelicidin LL-37 go off again. Which in turn trigger inflammation, redness and blood vessel dilation in the skin. This is probably why oral and topical antibiotics (tetracyclines for instance), azeleic acid and retinoids can work for rosacea: they directly interfere with this pro-inflammatory system and reduce the inflammation or stop it from being formed altogether. So antibiotics can work for rosacea not because of their ability to kill off bacteria, but instead of how they reduce inflammation. And the same goes for anti-demodex treatment. which can take away the prime trigger for LL-37-related skin inflammation IF you have a demodex mite infection. And avoid sunlight on your face. Vitamin D from sun is a direct trigger for LL-37-mediated inflammation and blood vessel dilation of rosacea skin. You can bronze on the rest of your body, just not your face, if you want to calm down rosacea-inflammation. (And now that I am at it, could this perhaps explain why so many people flare up from vitamin D supplements?? I get beyond beet red from them and never understood why. Maybe here we have it, the explanation). Certain supplements and herbs can also act as anti-inflammatories. Check my (still not fully finished, sigh) blog post about them here. Think of supplements like turmeric/curcumin or boswellia for instance.

If you want to know even more detailed, microscopic information about how exactly this mechanism works on cellular level, I advise you to go to this science article and scroll down to the section Rosacea. You can also read more in this scientific article. 

But that is not all, because these LL-37 cathelicidines are not only found in the skin. But also for instance in the bowels. In fact, LL-37 is linking to some other health issues (including many auto-immune diseases) that quite a few people with rosacea mention to suffer from, for instance: gut and bowel infections/inflammation, depression and anxiety and cardio vascular disease. Which could explain why this badly functioning, overabundance of LL-37 has different effects on the body, and perhaps (?) why many of us suffer from bowel issues, depression and anxiety on top of our skin problems. In other words: we REALLY need a treatment ASAP to bring these cathelicidins back under control! It might also be yet another way in which immune suppressing drugs, like the ones I discussed at the top of this blog entry, can work. When you suppress the immune function of the body, you also suppress the formation of LL-37 cathelicidin. And thus of inflammation, blood vessel dilation and redness. Wished those meds came with a better side-effect profile :) 

You can read more about the treatment options I have tried over the years if you scroll down in this blog post

And 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.

Also, I read a really good thorough post on the Rosacea Forum with general advice for rosaceans and I realized I never posted anything like it on my blog. The basic 'rules' so to speak.

hg24 wrote on july 11th2015: "Hi there! Welcome to the forum. Sorry to hear of the distress right now. Yeah, rosacea sucks. But you're just starting out with managing it and learning everything - so there is hope! You'll find what works for you.  First, go kiss your hubby and give him a big hug. It's hard for our loved ones to understand what this disease is like. It's especially hard I think for anyone else to imagine what the physical sensations are behind our red faces. That is, that it's not just redness and/or bumps - but burning/stinging, itchiness, heat, swelling, nerve pain, etc. But many of them try to understand and listen. It gets hard for them, too, to watch us suffer. So I always think they need to know how much we appreciate them. Could you share with us what your dermatologist has prescribed, if anything, for your rosacea? Are you on an antibiotic for the P&P? And/or topical medication?  What do you do for skin care? Are you able to tolerate cleanser? I used to have this problem - sensitive to everything I put on my face. My prob with the creams was my hit, stinging skin couldn't deal with anything on it.

The most important strategy I've found to ease rosacea is to calm inflammation in your body and skin. You want things to quiet your system. You need to address it on many levels - holistically. Everything needs to be made simple, gentle and healthy. 
- Diet: sounds like this is a challenge with your IC. But you need a balanced diet. You want to eat so that wounds can heal, skin can repair, etc. So protein, healthy fats, low sugar, low dairy, gluten free. 
- Nutrient/Vitamin deficiencies/supps: are you vitamin D deficient? Most of us are. Maybe low on omega 3s? Etc. For example, I've recently started supplemnting with Vit D softgels and eating more betacarotene-rich fods (sweet potatoes, etc) and taking a little Vit A supps (NT too much!) and my face bumps have been clearing and face calming a great deal. If you have any nutritional deficiencies per your doctor, see what you can do to get all. Your Vitamins and minerals back up. Consider a multivitamin.
- Underlying conditions: Not sure how your IC might be affecting the rosacea. But if you are on medications for anything or suspect possible other issues, you'll want to see what you can do there. Hormonal times always flare my face - around ovulation and my period. Also, if you have any other inflammatory condition/autoimmune disease, that can also potentially exacerbate rosacea. 
- Stress: This is important. It's amazing how much stress affects rosacea. I've been surprised by it myself. My intolerance to skin care eased once I was able to address the anxiety I developed after developing rosacea. Once I was able to calm my nerves - literally through Zoloft, deep breathing, etc - I could pull out my stash of creams that I couldn't tolerate before and finally use them. I think maybe because I had a lot of stinging/burning - so nerve endings in my face were often inflamed - which riles up the blood vessels. 
- Skin care: this is a tough one, since you're not able to tolerate much right now. But gentle is the way to go. You want to treat rosacea as you would a rash, not acne. You want to soothe the skin and the inflammatory bumps. Nothing harsh. Once your skin calms, you should be able to do fine with makeup. Some people have success with various topical treatments: tea tree oil diluted in essential oil/cream, zinc oxide ointment, prescription topicals, etc. 
- Lifestyle changesYou may find the need to make certain changes, again, so that you can try to keep your system calm. For example: Lukewarm not hot showers, more sleep, avoid sun/wear sunscreen or a hat, careful of warm rooms, make adjustments to exercise (cool water nearby, cool towel around neck, etc). Sleeping with the thermostat turned down a bit helps me. 

Well didn't mean to write such a long post. Hope some of this helps. There is no magic pill or treatment, but there are a number of people who have posted here over the years about what's worked for them. It takes time and research to go through the threads here going back over the years, but trust me, it will educate you and arm you with so much information and new things to try. You'll end up knowing a lot more about rosacea than your doctor.  
So take a look around. I'm sure you'll find some options that will help you feel both empowered and hopeful." 

In response to someone wondering if suggesting the below mentioned prescription medication for rosacea isn't a step too far, here is my motivation to do so: these medications should only be used under the care of a doctor, obviously. The dose at which some specialists, including some dermatologists, prescribe them are lower than for their official use (heart related/high blood pressure related conditions). There is a group of rosacea patients who have severe facial flushing, burning and redness, and for whom diet, anti inflammatory supplements, natural treatment options and laser/IPL have not worked (enough) or made things worse. I agree that caution has to be taken when suggesting medication on a platform like this one. I just come from a different standpoint, as I searched desperately for relief for many years and not one derm could think of anything that could be done about the severe flushing. It is through a friend from one of the forums that I came in contact with my current derm (Professor in dermatology, London Hammersmith Hospital) and that I finally learned about the medication that can be used to stop some of this in it's track. I doubt anybody here are resorting to medication unless they have very serious and life changing (or at least - affecting) symptoms. They are no candies and anybody taking meds is acutely aware of that, if only from the side effects. There are some professors in renowned hospitals who see the worst of the worst rosacea patients; people who might even consider suicide over this, and I personally find it ok and understandable that such doctors discuss with the patients' GP to start up some relatively well known and widely used medications like beta blockers (propranolol mainly) and clonidine. If they help, of course. They are not taken at the same dose as for those with (severe) heart related conditions. I only take 40 mg a day of propranolol for instance. And only the start up dose of 15 mg of remeron. But they take the edge off the flushing. Some people (me incl) went from mild occasional flushing, to almost non stop throbbing flushing in a time span of a decade. Flushing needs to be treated and stopped in its track, or you can end up with uncontrollable rosacea. This can become a serious condition by then as well, slowly ruining the vascularity of your face. And for those who have daily worsening facial flushing and burning, for whom nothing else works anymore, I feel these meds are relatively safe while under the care of a doctor and they can really slow or even stop rosacea in it's tracks. As we know, there have been people who took their life over this, so I don't feel rosacea should ever be looked at simply as 'a benign skin condition'. Although it's not the very worst thing that could happen to someone in life either. A bit of context goes a long way sometimes. There are friends of mine though who are no longer able to leave their houses, for the severe painful flushing, and who spend their lives in cold houses with airco's and fan's, in pain. 

I don't try to advocate to people to start taking medication for the sake of it, but I do like to give the more desperate readers an alternative, because it made mine finally bearable and I searched for ever to find a doctor who said he could actually try to treat the flushing. The other 10+ derms I had seen all said that there was nothing to be done about the flushing. I usually have people in mind when I write here who have the severe vascular subtype, so the devastating ongoing facial flushing redness and burning, and for them I like to be out here that there are medications they can try, under their doctors guidance always.

This is a series of forum posts from 2005, written right before I started taking the medication mentioned below. I was doing very badly, with nearly constant facial flushing and burning back then. It might explain just how desperate I was for some relief, and why I now put up with the side effects of the medication (like remeron induced weight gain), even though I hate this.


April 25th 2014

In this Rosacea Forum post, someone asks how to stop with propranolol in a safe way. Along the way he/she gets tips and some writers warn about the use of beta blockers as a whole for rosacea:

Ants wrote: "Hey guys, I've been taking Propranalol for the past 2 months. First week it really helped with flushing, then it just stopped really working for flushing but really helped for nerves / public speaking. I've decided to come off it as it was giving me a sunburnt burning sensation on my arms. Now here's my question - I came off it cold turkey 5 days ago and since then my flushing has been TERRIBLE. Is this normal? I know you're technically meant to taper off the med. Would massively appreciate a reply please. Thanks, Ants"

"Anyone please? Jeez, these forums are dying = ( "

Fauxmccoy wrote: "i would contact your doctor immediately and ask for advice. the only time i took beta blockers was when i had a hyperactive thyroid and they were prescribed to protect my heart while my body was producing thyroid hormones in dangerous levels. although i see that some people are now taking them for flushing, i can not nor would i. they are serious, systemic meds and stopping cold turkey is dangerous."

Johnabetts wrote: "Beta blockers have a profound effect on the workings of the heart and on blood pressure - these are the real indications for their use, not something non-life threatening like flushing. Suddenly stopping beta blockers can be very dangerous to your health and possibly your life and you are lucky that you are only having minor side effects. Was this medication prescribed or did you just self medicate in the hope it would help you? There are good reasons for beta blockers to be prescription only, which I have partially lighted upon. You should follow the directions given by your health care professional when stopping beta blocker medication, not just stop. I've been on beta blocker drugs (Atenolol 100mg daily) for a long time now for heart disease. I was once requested to attend clinic for a exercise stress test and it was requested that I delay my beta blocker dose until after the test (at 1.00pm). By about 10.00am I became extremely ill, so much so that I called for emergency services who administered loads of things to bring down and stabilise my blood pressure which had gone through the roof merely because I had not taken the beta blocker medication. OK, I was, and am, on a high dose but it does indicate what can happen when the dosage routine is changed. I never did get to do the stress test (and would never volunteer to take one either, after that happened). Regarding the impatience shown in your second post here, it was really only a very short time that you did that follow up and not everyone lives in your time zone. An effect of cold turkeys?

Username wrote: "There can be very serious side effects of stopping beta blockers cold turkey and this is not something to ask a forum. You need to talk to your doctor about it, do not stop them until you have.

Ants wrote: "I have taken this medication for a great many years. It was originally prescribed to combat menstrual migraine and it also masked an essential tremor in my hands. Co-incidentally I saw my G.P. today to discuss taking Propranalol, 10 mg only, on an intermittent basis, not the usual slow release 80 mg pill that I have been taking every day. This was because of my elevated blood glucose in the morning. Apparently Propranolol can cause this reaction during the early hours. I must admit I did choose to go cold turkey and fortunately I have not had any adverse effects apart from regaining my tremor. But I stress I was NOT taking this medication for a heart/blood pressure problem. Regarding higher than normal blood glucose, I will continue to monitor this as I feel a high result might have been exacerbating my skin problems. In other words - high sugar - hungry yeast - yum yum! But only time will tell.

Fauxmccoy wrote: "Sally, the type2 diabetes is sadly, a potential side effect of taking beta blockers. you were taking it for one of its intended uses (migraines, tremors) just as i was for hyperthyroidism. it sounds as if you were in communication with your doc while quitting and elevated blood sugar levels is an indication to stop taking the med. it becomes a question of risks to benefits. you were likely worsening your health if you continued taking it and there are other medications for migraines. i know, i get them too. the problem i see here is that many people are wanting to take this very serious drug for flushing. this drug affects the central nervous system, artificially suppresses heart rate and blood pressure. why would anyone want to touch this for fun and games? (i.e. maybe it will control my flushing -- yeah, but at what cost?) as one who had to take them for life and death reasons, i know exactly how serious these meds are, what they do, how they work and most of all why one does not stop taking them without consulting the prescribing doc. i sure as heck would not be forum gazing while in the midst of what could be a serious medical crisis. quite simply, beta blockers are not an ant-flushing drug. they sure as hell never stopped mine in 18 months of use before my thyroid was removed and i could stop taking them, but then start taking thyroid hormones. beta blockers are here to help (and they do a great job) with life threatening conditions such as elevated heart rate, elevated blood pressure, tremors (all of which i experienced during hyperthyroidism -- to a frightening degree), hyperthyroidism, tremors and occasionally migraines. i would consider any use other than those to be ridiculous when the risk to benefit is properly assessed. just as ridiculous as taking them for the reasons other than indicated would be to stop taking them without medical advice. these are serious meds.

Nicofan wrote: "I don't understand all this scaremongering here about beta blockers (propranolol). If you are not 80 years old, have a heart condition, a heart rate of 50 beats per minute or less and what not, beta blockers won't do much harm to you. Aspirin and Paracetamol have more side effects than Propranolol. I too took beta blockers once a year ago. I started with 3x20 mg per day and my GP switched me to 80mg time released propranolol I (just for rosacea/redness). I took the 80mg for a month or two and decided to throw it away. I called my doc and asked it I have to tamper it off. NO, was his answer. I'm 25 years old, (otherwise) healthy / athletic. Stopped Propranolol suddenly and the side effects I had were increased heart beat (rose from 55 bpm to 80 bpm) and was sweating a bit more. that's it, this was for about 1 or 2 days. But this can be different for everybody. It's up to your overall health. My advice would be to first call your (most likely useless) GP and ask him. If I were you I would just taper it down. Take 3 times 20mg (morning/midday/evening) for 5 days then 3 times 10 mg (per day) for 5 days and maybe another 5 days with 3 times 5 mg. then stop. Your GP won't tell you anything else. Except you have a heart condition or are taking Propranolol for something else I'd taper it as suggested above. cheers"

I wrote in response to the last comment: "I understand your concerns, but what worries me is that there are so many people here who seem to think that severe facial flushing, non stop burning and dilated pulsing dilation of the blood vessels of the face, is NOT something serious. Am I on a rosacea forum or what? I doubt anybody here are resorting to medication unless they have very serious and life changing symptoms. They are no candies and anybody taking meds is acutely aware of that, if only from the side effects. There are some professors in renowned hospitals who see the worst of the worst rosacea patients; people who consider suicide over this, and I personally find it entirely acceptable that such doctors discuss with the patients GP to start up some relatively well known and widely used medications like beta blockers (propranolol mainly) and clonidine. They are not taken at the same dose as for those with heart issues. I only take 40 mg a day of propranolol for instance. But they take the edge off from the flushing. Some people (me incl) went from mild occasional flushing, to almost non stop throbbing flushing in a time span of a decade. Flushing needs to be treated and stopped in its track, or you can end up with uncontrollable rosacea. Most people see medication as a last resort. I went medication free for 6 years, tried every natural/homeopathic/ acupuncture/supplement treatment you can think of, then tried IPL which made it much worse and finally had to start medication. I really don't understand why hyperthyroidism, or high blood pressure, or any other official illness that indicated beta blocker use, is seen by rosacea sufferers here as more serious than debilitating flushing. It is very serious; you slowly ruin the vascularity of your face.
I find your comment: "why would anyone want to touch this for fun and games? (i.e. maybe it will control my flushing -- yeah, but at what cost?) as one who had to take them for life and death reasons, i know exactly how serious these meds are" quite strong, and a little bit offensive to be honest. People have taken their lives over severe rosacea you know? Nobody takes medication out of fun. And good derms and GP"s keep check of their patients blood pressure, liver levels etc while on medication. Some people see it as the lesser of two evils. People should stop talking in a condescending way about others using or chosing medication here, I feel at times. I am sorry that you suffer life threatening thyroid issues but it seems your medication is helping you. Why tell others who have a health condition of which you can't judge from where you are how severe they suffer from it, to no touch medication? What? Because they can't die from rosacea?"

Johnabetts wrote: "Aren't we losing the point here? The title of the thread reveals the problem and myself and others have tried to indicate the folly of stopping beta blocker medication without following a safe procedure to do so."

I wrote: "The discussion was side tracked very early on actually, by others warning for the use of this drug as a whole, altogether. Which isn't a fair message i feel for others reading this thread and perhaps desperately looking for a means to improve their suffering.
It depends at what dose Ants used propranolol. For half a pill or one pill a day for 2 months, as he wrote, you might want to taper the use off. So cutting the dose (in halves, 1/4, 1/6 etc) but taking it at the same times as normal, until you can stop without bad side effects. It is not a problem from what doctors told me, to use propranolol as needed, now and then, for instance for people with stage fright or anxiety. In that case they said it doesn't require any tapering off. It doesn't typically cause the rebound hypertension as a blood pressure lowering med like clonidine does. It's never wise to start any prescription medication without your doctors knowledge and guidance, as others here already pointed out. He/she doesn't mention any heart symptoms, while having stopped the med. Only a return of bad flushing. That seems not per se a side effect of the cold turkey stopping, but more of the normal rosacea returning again.
There is also a lot of info on this problem to be found online, for instance:

Fauxmccoy wrote: "nat, i will apologize if you found my words to be overly harsh. i was speaking to the original poster who stopped taking a very serious medication without medical advice and was now begging for medical advice on a forum of laymen (medically speaking). i do consider that to be fundamentally flawed. yes, this is a forum of rosacea sufferers sharing our own experiences and attempting to help others. i suffer with the condition, else i would not be here. i also come with a vast medical history and more than the average understanding of beta blockers. i would not take them at this point as i no longer need them for a life threatening condition. i am extremely cautious when it comes to taking meds that affect the body systemically, i do not want or need my metabolism, heart rate or blood pressure artificially lowered. i do not want any other medication that affects my central nervous system. i have a number of meds that i must take and would not add to that unless there was a compelling reason to do so. of course, all medication is an evaluation of risks to potential benefit. none of my docs (and it takes a team of specialists to keep me on the planet) have ever suggested beta blockers for rosacea and i would not ask, simply because i understand the medication all too well. that is me. if you are taking them, under the guidance of your doc, with proper testing and presumably not quitting them cold turkey, AND finding some relief, then of course, i wish you well. i understand full well that out of control rosacea makes the condition worse and that it is miserable in its own right. the sense that i got from the original poster was that this was not happening and i spoke my mind. i am disabled and unlike many who post here, if i am having a bad rosacea day, i do not have to face work colleagues, but can remain at home and attend to my flushing as that may be the thing that is adversely affecting me at that moment. it may sound like a luxury, but believe me, i would gladly trade places with those who are not disable and only concerned with flushing. my outlook is different based on a multitude of experiences and although i am never without empathy, i am perhaps somewhat jaded. i realize that as one with numerous medical conditions, that my outlook is perhaps different. i think johnabetts post echoed that. i also sense a bit of something i consider somewhat dangerous in this forum with regards to medication and/or self medication. if one person (say you) report good results with a medication (beta blockers) then a number of people go ask their docs for it and may not bother to become as informed about the risks of the medication. i see this in this forum regarding mirvaso, in spite of all of the negative feedback. also, because i understand the mechanism of how the drug works, there can be nothing but a negative backlash of flushing if it is used. yet, people here are still begging for it. i think the same of every tv commercial hawking meds that we should all 'ask our doctor about". again, this is just me. i am extremely cautious about medication, especially those that involve systemic alteration. i would never want to discourage my fellow rosaceans from using any product that genuinely helped. i only urge caution and education in doing so."

I wrote: "I am truly sorry for your host of medical problems and your disability fauxmccoy. I can relate, even though my other auto immune related illnesses are not as severe probably as yours. I read an older post of you yesterday where you explain about all the surgeries you had and they sounded tremendous, you seem a real trooper. But to have a full body system not working, causing disability, pain, inflammation, need for surgeries etc, does something with you. I don't know about everyone here, but it seems that a lot of patients don't have the rosacea all on their own, but a lot of them also have some underlying digestion problem, and/or Raynaud's, and allergies among others (and some also have ME, MS, fybromyalgia, Sjogrens, Lupus etc). To have so many things in your body not functioning and having the daily burning and pain that a lot of people have here, brings everybody down. I understand that caution that has to be given when suggestion medication on a forum like this one. I just come from a different standpoint, as I searched desperately for relief for many years and not one derm could think of anything that could be done about the severe flushing. I hardly left the house at some point, always attached to a fan or cold packs and always purple red almost. It is through Peter Waters from the forum here that I came in contact with my current derm and that I finally learned about the medication that can be used to stop some of this in it's track. It sadly doesn't help when you suffer badly from something, to try to be happy that at least you don't have a worse/more severe disease. You still have to deal form day to day with this monster and some friends here don't leave the house anymore and are on constant opiads/pain medication to deal with the crimson faces and severe nerve pain that comes with it. So I don't try to advocate to people to start taking medication for the sake of it, but do like to give the more desperate readers here an alternative, because it saved my life to be quite dramatic about it. I agree with nicofan that there is this scaremongering at times here about people taking medication, and this 'pure'vibe that being clean is best. And that resorting to meds is an act of desperation and that just diet or herbs or psychotherapy, or hypnosis will improve everybody's rosacea. I usually have people in mind when I write here who have the severe vascular subtype, so the devastating ongoing facial flushing redness and burning, and for them I like to be out here that there are medications they can try, under their doctors guidance always, although of course some people are suffering so bad and are unwilling to find a cooperative doctor, that they resort to illegal measures. But even then they need advice how to take and stop these meds. Thanks for your clarification and a big hug to you, I hope you find some relief for this soon."

And in response to a question (post) about medication for flushing:

"Is trial and error but there are many patients here who use them and find that it gave them part of their life back. They cut down severely on my flushing. They have side effects yes, but like I wrote earlier in response to Ants, "they are no magic pills and yes they come with some side effects. This disease is not well researched and there is no cause/cure yet, so these are the options we seem to have at this point (plus a host of supplements, dubious in effect at times). It is an awful choice but it might have to come to the point for some here, that they have to trade something. Less rosacea pain, less depression for some weight gain and increased need for excercise for instance. Or any of the other side effects you mentioned. Nothing is free for us sufferers in this world unfortunately."

IPL and laser isn't for everybody unfortunately. Its cruel in a way that it helps some and worsens others or does nothing. So I guess the bottom line is that yes, there are medications out there that can help you with the flushing (hopefully, they don't work for everybody) and yes, they come with some side effects. I don't agree on the remeron-zombie part. That is mainly an issue in the first period of using them, after long term use they give energy and make you sleep well, if anything. But you do need to cut down on your food intake and crank up the calorie burning for sure. Beta blockers can make you a bit tired initially and I am not aware of the sexual side effects, but am no male so not prone to them. Clonidine has similar side effects I guess, for me they all wear off with time. Good luck and I hope you can find something that helps you."

May 25th 2014 
oxycodone for rosacea

A rosacea friend emailed me about her severe rosacea (bad flushing and severe redness in warmer temperatures, she was also in the little video op here) and a new medication that has helped her a bit. 

She wrote: "You asked yesterday how I do, as far as my face… the answer is, not well. So basically we never go anywhere or do anything! It's a boring life but we have nice friends, enough money, a high speed internet connection and a good marriage, so all in all, I'm happy most of the time. My doc put me on Opana ER as Meg suggested, and it's improved me remarkably. I still flush terribly to heat over 22 degrees, but under that, if I follow my diet and don't eat tons of sugar,  I'm fine. That's a big change! Now, with the drug, when I get a flush or a burn, it lasts about 20 minutes instead of 8 hours. It hurts much less and I'm much less anxious about it as well. The drug has two side effects that are wonderful for me, it makes you mildly anorexic and a bit euphoric. Two things I really need! It's a time release opiate called OxyContin (Contin for Continuous). I take it every 8 hours like my clonidine. It's the most improvement to my face that Charlie and I have seen since we started the clonidine/remeron protocol way back in the fall of 2008. I wish you could obtain this drug over there.  But it's even more a controlled substance than the hydrocodone. So if they won't give you hydrocodone, they will never give you oxycodone. Harder to get,  and also more rules concerning it; I have to go back in every three months for a refill instead of every 6 months. But beloved doc sees me at 8 in the morning so the visit is real quick, in and out, so I don't  burn too much in his hot little office. I'll probably be on this drug for the rest of my life,  and I'm fine with that. When I first asked my beloved GP for it a few months ago, I told him I thought it was approaching time for palliative care for me, because I wanted to die from the pain when I couldn't stand the pain any more. He was horrified of course, they're trained to save life not to end it,  so he was delighted to prescribe the pain meds for me. And frankly I never expected they would work this well, that they would have a beneficial effect on my flushing. I thought they would just make the pain easier to manage. What a happy surprise."

I replied: "That is spectacular good news in my book :) I will discuss this med with dr Chu when I see him at the end of the year, he is the only doc I can think of who might be willing to prescribe it. My GP won't for sure, knowing how she responded before to some other questions. So it not only cuts down on your pain and burning but also the flushing? Wow! AND WEIGHT LOSS, I want this stuff too :) I didn't notice too much difference in the flushing on hydrocodone, do you think they are very different, meds or did the hydro do the same thing for your flushing as this new med?"

She replied: "I had no improvement re: flushing with hydrocone and great improvement in flushing with oxycodone." As a little side note, some people using oxycodone did report flushing of the face and neck from it, like with other opiads. However, most medication seems to be able to give this side effect to those sensitive to it. On The Rosacea Forum the drugs is also discussed: 

lakan wrote on November 21st 2008: "Codeine can cause flushing. It releases histamine so flushing, itching and so on are common side effects. Some pain-killers promote angiogenesis too according to studies. As for the histamine release you could of course try to counteract that effect with anti-histamines or maybe switch to some other pain-killer if that's an option, some cause less histamine release than others. As far as i have understood Morphine is known to promote angiogenesis and usually also releases a lot of histamine. Oxycodone for example seems to be a better choice in regards to that. Maybe Tramadol is worth checking out too."

RedFaced wrote on November 22nd 2008: "Hey thanks for the info - I have taken Oxycodone and it did not do good things for my mental state (hositility, agitation etc.). I am interested in this Tramadol though...so you have read or understand that it does not cause the increased flushing that others usually do?"

laka replied: "Yes, Tramadol is a bit different compared to the more traditionally opioids and it shouldn't cause that much histamine release as the others, if any. Also, research about cancer and pain management says that Tramadol is not known to promote angiogenesis at all but i'm not an expert or anything, i've just read a bit about this and tried some opioids myself. Higher doses of Tramadol does make me itchy and flushy but doses under 200mg is not a problem for me. Pretty much the same with Oxycodone, anything under 30mg is fine but if i take more than that i have to take some anti-histamines to not get that flushy and tingling feeling. I can't compare it to Codeine though since i haven't tried it and the reason for not trying out Codeine is just the stuff i've read. Tramadol and Oxycodone seems more rosacea friendly to me."

RedFaced replied: "Great - thanks for the info.The oxycodone made me feel a bit "high" when I took it, but not that I minded that as an alternative to pain. How would you compare the Tramdol to Oxycodone in terms of pain relief and its overall effects?"

lakan replied: "Oxycodone is way more "stronger" and feeling high while on that stuff is very common until you get used to the dose... A lot of people compare it to Heroin actually and i haven't heard anyone claim that Tramadol is anything like Heroin. I feel high when taking Tramadol too but on a different level. More like a general pleasant feeling that doesn't interfere with anything. I only have problems with neropathic pain from rosacea and Lyrica beats both of those meds easily when it comes to that, for me. But then again, that's neuropathic pain and i don't know how those meds work for other types of pain but since Oxycodone is more potent it is probaby more effective but everyone's different and Tramadol might work good for you... I would try it if were you :)"

Redbreanna posted however that she got more flushed from oxycodone, on January 13th 2008: ""I had surgery last Monday, and ever since, my rosacea has been kicked up a notch. Almost constant burning, flushing, redness, and stinging, with very little relief from cold ice packs. I think it might be from the pain meds they gave me, and I was wondering if anyone else had this experience. I was taking percocet, and one of the side effects is flushing. I kept taking it because I needed pain relief, and I had already tried several other drugs with no effect on the pain. But now the percocet isn't working on my pain either (I have a fast/high tolerance to pain meds), so I decided to stop taking it. I haven't had one in about 24 hours, and I'm hoping my face will calm down now. So far it hasn't, but I'm not going to take any more percocet, regardless. Thanks, Breanna"

Artist replied: "Percocet is just a combination of oxycodone and tylenol. Oxycodone is an opioid medication, and opioids really can make you flush. I hate taking them at all because I flush badly with them. There are some good tylenol-type drugs (NSAIDS) you can try. You may want to ask your doctor for some "non-opioid" alternatives. Rest assured, once you stop the opioid, your rosacea will calm down. Cheers! Artist"

Redbreanna replied: "Thanks, Artist. Unfortunately, non-opioids like NSAIDs don't help my pain. I have chronic pain, so I've taken ibuprofen, tylenol, and the like nearly every day for years... because of that, my tolerance is very high, and even when I take high doses it doesn't help. That's why I was happy when my doctor prescribed the percocet for me. It helped for the first few doses, but after that it stopped working. Of course, i kept taking it anyways because I hoped it would still help...but all that did was increase the side effects. It's been 1 1/2 days now since I took any, and I still have some of the effects, like nausea and flushing. I don't know how long it stays in the body, but I hope that the effects will go away soon. In the future I'm not sure what to do when I need pain relief. I guess I will have to endure the flushing and other side effects for the sake of pain relief? Anyways, thanks again for the advice. We'll see how the next couple days go. Breanna"

Artist replied: "What a terrible choice to have to make. I'm so sorry. There are adjunct meds like valium you can take to possibly lower the need for the opioid. Also, sometimes neurogenic pain meds like neurontin and lyrica help chronic pain. May be worth looking in to...All the best, Artist"


June 5th 2014

Mirtazapine success

A friend of mine who recently developed painful facial flushing and burning, emailed me to say that the clonidine she started on is helping her, but not enough. She then asked her GP for mirtazapine and reports: "Things with me are still up and down. After a few weeks on the Clonidine, I felt that it was helping but not enough – I was still not sleeping at all well, waking up flushed more or less every day and felt like rosacea was taking over my life, was crying most days and in pain. So I went to a GP, luckily I found a really understanding female one who listened to me and took into account the research I had done, and managed to get her to prescribe me mirtazapine. I’ve been on it two weeks now and it does seem to be helping a lot. The main thing is it helps me sleep which makes such a huge difference to my life – I feel much more able to function and go to work etc. Not having side effects at all really except increased appetite (most people say it makes them drowsy but I find it just makes me sleep 7-8 hours a night which is perfect!). Also, the flushing has greatly reduced I think. It still happens almost every day, but seems to be only now in the night rather than to triggers during the day like it was before, not as severe, and it goes down very quickly after I wake up. Did you find the mirtazapine becomes more effective over the first few months?"

I am reading on some facebook rosacea groups lately and notice -as well onb the forums- a new (?) tendency to disencourage others to start with medication, and to deal with rosacea the natural way. This seems to equal homeopathy, acupuncture, liver cleansing and other types of detoxification, diet etc. I don't think its nice to almost demonize medication (someone there literally tells new posters to stay away from medication as it will make them much worse), simply because of a personal belief about this. There is not much information out there and with doctors about medication to tackle facial flushing and burning, and it can be notoriously difficult to treat. Therefore I like to have it out there what helped me in the end; not as some miraculous ultimate cure, I'm far from cured and when a detox session 'cured' someones's rosacea I am more inclined to wonder if that person had rosacea in the first place, as it tends to be a multifunction, complex, stubborn condition and it interests me how a cleanse (something the liver and kidneys are build for to do on a daily basis themselves) could cure it. But if it works for someone, then that is great. But I don't find it fair for such people to influence others, with perhaps a different type of rosacea, which might not respond to toxic cleanses, to stay well clear of medication.

I always compare it with telling someone with a heart defect to stop taking his betablockers or other heart aids. Who would do that? Yet it seems normal to consider rosacea a condition which one should deal with the 'natural' way, or you are poisoning your system even more apparently.
When someone deals with severe rosacea symptoms, and when these are far more than an annoyance to the patient, and we take into consideration that rosacea can be a chronic and progressive illness, then I don't see why someone who is desperate for relief shouldn't go and talk with his or her GP or dermatologist to try out anti flushing medication. It comes with some potential side effects (but to be frank, so did the Chinese traditional medical concussions I tried), but if it keeps you sane and in less pain, and if it breaks the flushing cycle, giving your poor blood vessels and facial nerves some rest to recover, than go for it. Facial flushing needs to be stopped in it's track, no matter what way, to help stabilize your rosacea and prevent it from getting worse. That's my view at least and that of the few good professors/derms I have as doctors. But whatever works for you, keep doing it, whether herbs, teas, cleanses, creams or drugs. Just don't demonize a perfectly scientific treatment option for others who are asking for help on the social media platforms, out of a personal belief.

I replied to this friend, some parts from it that might interest someone else here:
Good hearing from you. Its really good hearing that the clonidine worked a little bit at least and that the mirtazapine seems to help too. I don't find them to be cures to be honest, they just bring my flushing level back down and flushing threshold back up, and I can stay in an acceptable state now, whereas before  I flushed from everything and anything. But my derm Dr Chu beliefs that when you stop the flushing in its tracks early, you can still bring everything back to normality sometimes, so if its working, keep using it :) Mirtazapine, please take this serious dear, it will make you heavier. And more hungry, and everything tastes better, so be very aware to not overeat, as normally I got away with it but not anymore since using mirtazapine. Its a fab drug I think (in terms of medication being able to possess such a quality, nobody likes them in the end or would take them unless really needed), it helped me with 4 problems at one go (flushing, depression, anxiety and sleep deprivation), but the price is the weight issues. It will take some time to creep up on you but be careful ok?
I felt the mirtazapine started working after about 3 days for me and it did build up, but you will hit a roof at some point. I also sleep great on it, 8-9 hours usually, and dream very vidily, which i dont mind at all. I also feel that diet plays a big role for me, for instance, had a very good week, then sinned with sweet stuff from the bakery and been flushed for a day and night ever since. Its very personal, those triggers, but for me its defo yoghurt, dairy, wheat, corn and cheese mostly. So what I eat are lots of vegetables, in a wok or stir fry, organic chicken and beef, fruits, rice flour products like self made pancakes or fruit pie, salads, some sweet potatoes or normal potatoe occasionally, skin seems to do best on these foods for me.

Oh great, wow you are good, already managed to see dr Chu in June? I find him extremely nice, a very modest man but a true scientist, no hocus pocus, sure you'll like him as well. Chocolate and coffee, they are like poison for me, I can't eat them although I do sin on chocolate at times :) Yep I sleep that way too, double pillows, head a bit upwards, I have the normal thicker blanket pulled up until the chest and an empty sheet for the top part of chest till chin, that helps me a lot. Trapping the heat below midriff so to speak and not letting it build up all the way to my face. I also use a small fan at night and usually wake up pale and stay pale all through the night this way. Its just that I have to turn sides often cause the cheek I sleep on is paler than the one turned upwards and need to alternate or one gets really deep red further down the week. I also have some allergies so I have special allergy free, mite trapping covers for my mattress and pillows, they used to be incredibly expensive back in the days, but I found very good and affordable ones recently, it helps me a lot, and I make sure the house and especially bedroom are dust free. I use a chemical free, natural shampoo which helps too I find. Idem for washing powder. Wow that was a good experiment, to sleep elsewhere for a night :) I do think its the mechanism of sleep itself that makes many rosaceans flushed at night, the heat of the covers, the lying down, food digestion at night triggering internal heat and what not. But keeping your bedroom dust free and as mite free as possible is a good move anyway, or a good trial at least when you have this flushing problem. I also always have the window open for fresh air, unless there is some killer pollen attack going on outside. If you do manage to see an immunologist, don't forget to ask if they will test you on your ANA blood markers, and inflammation markers (like Regulatory T cells and some others)? They can indicate auto immune related inflammation and possibly underlying conditions. They can also do blood tests for allergy levels and markers in the body. I hope to go to Budapest in the fall :)
best wishes Nat

March 4th 2015

I got some emails from rosaceans of which I will use a little bit of the bare facts and my responses.. perhaps they can help others. It feels a bit hypocritical now, after criticizing the poor Jess Ainscough for advising other cancer patients about her treatment regime. I advice others based on what works for me and it might not work for others, or it might cause terrible side effects for them and that would make me semi co-responsible. But I can't help but tell what helps me, to a degree. No experimental make believe, but medications and lifestyle adaptations which visibly and noticeably improved my rosacea. Unfortunately every rosacean is different though and as my dermatologist already said last month; rosacea seems to stem from a myriad of underlying causes. What a mess..
Hi there I appreciate your openness, honesty,  and advice for rosacea and facial flushing. I have recently developed debilitating facial flushing episodes that make going to even the grocery store difficult. I use to get a little flushed if I had to speak to large groups, but nothing to this extent.  The flushing doesn’t seem to leave it just stays now and is becoming more permanent. I have had laser treatments done on two occasions, but this has seemed to be a real waste of money with little to no improvements. I honestly feel I made a major mistake in having the vbeam laser treatment done some months ago.  Before the treatments I had a just a few telangisiticas (sp) and that was that.  I am not sure if the procedures could have caused the chronic facial flushing and increased telangisticias. It seems like the more I focus and obsess about my face the worse it gets. Unfortunately I have as lot on my plate. The facial flushing now happens at just the thought.  I am currently taking .05 clonidine in the morning and  .2 in the evening. I have been diagnosed with extreme low levels of serotonin- do u think this could contribute? I have read your posts about the antidepressant medication mirtazapine. I recently picked up the medication and am having a difficult time getting myself to take them,  as I've always struggled with taking meds. Honestly,  the only reason I asked my doctor about this med, was because of your post and success.  Do u still feel the same way about mirtazapine as u did in your original posts? Thank u so much for your help. I would be taking clonidine and mirtazapine simultaneously.

Part of my reply:
"I'm sorry for the late reply, thanks for your nice words. Am sorry you are also dealing with the terrible facial flushing. I would try to up the clonidine to 3 times a day. I take also 50 mg but spread out every 8 hours. I find after 8 hours I get red again without it. I also take 40 mg of propranolol at night, but if you could try to use it and find it beneficial you could also take it more often. Yes I also take mirtazapine and find it very effective and good for my facial flushing and burning. But it comes with some side effects unfortunately. Mostly increased appetite and some weight gain but for me the pay off is huge as mirtazapine cuts down on my flushing and redness, and also on anxiety, depression and insomnia. I can control the weight with a healthy diet and walking every day. With the remeron, I found that it takes a good few weeks to see the real anti flushing effects, but a good 6 weeks at least for side effects to wear off. They usually do wear off though.. It's similar to people taking them for depression, the first 6 weeks are terror as you don't see the beneficial effct yet but get a truck load of side effects as your body and brain adjust to this new chemical. For instance, I had nerve twitches in my legs and arms every single night and brain zaps while trying to sleep. Lightning flashes before your eyes, like your brain is getting electrical overload. They all went away. The tiredness and desire to sleep non stop is infamous for remeron but I found that they also wear off. I now sleep 8 or 9 hours straight but feel very energized during the day. That took some time, initially it was hard to get out of bed at all and indeed I felt drugged and so drowsy all day. It will get a lot better in that respect, but I can't judge how much a time and capacity you have to sit those out, especially with your profession.. There are other antidepressants who seem to help people with flushing, Zoloft, Effexor, a few other SSRI's I think. Celexa is mostly mentioned I think as a beneficial one, apart from remeron. 

But there are other meds which might help you and give way less side effects, I would try propranolol, as I said above, perhaps take 40 mg a day or if needed up to 3 times a day. It should help a little bit at least with the flushing. An antihistamine like Xyzal helps me a lot too and perhaps upping your clonidine dose will help too?  It is hard yes to work with this illness. I taught for half a year at university and already had rosacea back then and brought my little fan into the college rooms, it was very difficult.. I said even no to a teaching opportunity later on because my flushing just was too much. I now work as an art historian for uni but as a researcher and writer, so I can do most of that from my rosacea fortress haha. But it's a bit of a missed chance, I'd have loved to teach. 
Perhaps red light therapy might be beneficial for you? there is a rosacea forum that is pretty good, they have a section on red light therapy, perhaps it is something that might help, although I am not raving about it myself.. http://www.rosaceagroup.org/The_Rosacea_Forum/index.php
I do not know about clonidine affecting serotonin. I know a male friend with rosacea and low serotonin levels but I am not sure that would affect your flushing in any way to be honest. Hope this helps?"

February 29th 2016

I read this good and comprehensive overview on rosacea and its treatment options;

Skin Therapy Letter, Systemic Therapy for Rosacea                H. E. Baldwin, MD, Disclosures                                        Skin Therapy Letter. 2007;12(2)                                                                               \Rosacea is a common condition that affects people of all races. In addition to the visible aspects of this disease, it can have a psychosocial impact that must be evaluated when considering the treatment options. More aggressive and innovative uses of existing oral agents have resulted in novel therapeutic approaches, which can provide long-term therapy and sustained remission. Rosacea is a common disorder that is thought to affect 13-14 million people in the US alone.[1,2] It is likely that the actual number is substantially higher. Rosacea affects all races, although erythema may be less prevalent in patients with skin types IV and V. The rate of occurrence appears to be higher in women; however, men are more likely to develop phymas. Patients are most often diagnosed with this condition in their 30s-50s. To truly understand the effects of rosacea on patients, the psychosocial impact must be evaluated along with the visible aspects of this disease. For many of our patients, the stigma of a 'drinker's nose' and the social and professional isolation that can result from low self-esteem is far more significant than the clinical reality. Contributing to the frustration experienced by patients with rosacea is the fact that as clinicians, we do not truly treat rosacea, but rather manage it. We cannot offer patients cures, simply improvements. As with all chronic conditions, continual therapy inevitably leads to non-adherence. The benefits derived from a combination of both medical and psychological approaches cannot be overemphasized. The overall objective is the improvement of the quality of life of patients, and in 2007, this goal is easier to attain thanks to topical medications that reduce skin irritation. Furthermore, with the advent of safer, once-daily systemic medications, it is possible to liberate patients from the use of topical products. Rosacea is a condition characterized by a constellation of symptoms including central facial erythema and telangiectasias, papules and pustules, granulomatous nodules, phyma formation, and ocular changes. The disorder is capricious with flares and remissions occurring without rationale. For the task of discussing therapy, rosacea is best viewed as a collection of several conditions with a common name. Although many patients have polymorphic disease, most have one predominating feature.

The most commonly used classification system is based on predominant lesion morphology and was developed by a committee of the National Rosacea Society and published in 2002.[3] Patients are classified as having one of four types of rosacea: erythematotelangiectatic, papulopustular, phymatous, or ocular with a variant form referred to as granulomatous. Individual patients may straddle one or more subtypes, but this system allows us to determine therapy based on similar lesion types. Therapeutic options for the various lesion types are easily categorized and there are few medications or modalities that are significantly effective in more than one category. Our lack of understanding with regard to the pathogenesis of rosacea hampers our therapeutic efforts. Still unclear at this time is the fundamental issue of whether or not the papules and pustules are based in the follicle. There is a growing consensus that bacterial infection does not play a role in rosacea etiology. The neurologic or hormonal mechanisms that may generate the flushing reaction and phyma formation are similarly unknown. It is also unclear if accumulated sun damage, which bears many biochemical and clinical similarities to vascular rosacea, is involved in its pathogenesis. What is known is that inflammation plays an important role in lesion formation. Inflammatory cells release proinflammatory cytokines and degradative enzymes that induce angiogenesis and damage dermal constituents.[4]

The outcome of our poor understanding of its pathogenesis is that treatment has been traditionally based on disease endpoints rather than targeting the underlying anomalies. Inflammation is treated with anti-inflammatory agents, flushing with vasoconstrictors, and telangiectasias with laser and light therapy. Until recently, papules and pustules were treated with antibiotics and no target organism Oral antibiotics have been used off-label for the treatment of rosacea since the 1950s because it was believed that microorganisms were causative. We now know that there is little to no evidence supporting this premise. Although not curative, the observed benefits of oral antibiotic treatment in patients with rosacea have made clinicians and patients reluctant to exclude these agents from their therapeutic armamentarium, much less to downgrade them from their first-line status.

Due to the chronicity of this disease, antibiotic use is often long-term and can produce side-effects. Furthermore, overuse of antibiotics is associated with the emergence of resistant strains of bacteria that have the potential to result in adverse global health consequences. Tetracycline received US FDA approval in 1952 and the derivatives doxycycline and minocycline soon followed in 1966 and 1972, respectively. At the time of their introduction, they were known to be bacteriostatic and have broad-spectrum action. Since then, we have come to recognize the anti-inflammatory properties of the tetracycline class of antibiotics. Tetracyclines are known to down-regulate the production of proinflammatory cytokines such as IL-1 and TNF-alpha.[5] They also inhibit neutrophil chemotaxis and the production of nitric oxide, reactive oxygen species, and matrix metalloproteinases (MMP).[6,7] This ability of tetracyclines to modulate the inflammatory response pathway, reducing the inflammatory response, is believed to be the rationale for its effectiveness in treating rosacea.[5] Tetracyclines are highly effective for papulopustular rosacea, requiring only 3-4 weeks of treatment for substantial improvement. Tetracycline 250-1000mg q.d., doxycycline 100-200mg q.d., and minocycline 100-200mg q.d. are most common. Use of oral tetracyclines until clinical improvement is seen, followed by a transition to topical antibiotics offers an alternative therapeutic regimen. There are patients for whom low-dose, long-term use of antibiotics are necessary to maintain control of their rosacea.

Long-term treatment with antibiotics is problematic for numerous reasons including significant side-effects.[8-10] Oral use of tetracyclines can result in disorders such as candidal vulvovaginitis, gastrointestinal distress, and even pseudotumor cerebri. Treatment with doxycycline can result in photosensitivity, and minocycline in vertigo and blue dyspigmentation. Minocycline has also been implicated in the development of lupus-like syndromes and hypersensitivity reactions. Of world-wide importance is the concern regarding emerging antibiotic resistance due to over/ misuse of antibiotics.

Anti-inflammatory dose doxycycline (20mg doxycycline hyclate) was FDA approved in 1998 for the treatment of adult periodontitis. The labeling permits continuous use for up to 12 months, and as such it is the only tetracycline approved for long-term use. It has been shown to be effective in treating papulopustular rosacea with a low incidence of adverse effects. Bikowski treated 50 patients with all types of rosacea and, at 4 weeks, noted an 80%-100% improvement in inflammatory lesions, and a 50% reduction in erythema.[10] Although doxycycline has been shown to be highly effective, perhaps its major contribution is that dosage at 20mg results in sub-antimicrobial blood levels. Several studies have reported no effect on antibiotic susceptibility patterns in up to 18 months of continuous therapy and in 9 months post-treatment.[12-14]

Golub, in 1998, showed that doxycycline hyclate (Periostat®, CollaGenex) had anti-chemotactic activity, was a scavenger of reactive oxygen species and inhibited the enzyme MMP from being released.[12] Of primary importance is the ability of doxycycline hyclate to inhibit activation of the MMP-2 and MMP-9 enzymes that break down the capillary vessel basement membrane.

In 2006, a once-daily controlled-release formulation of doxycycline monohydrate became available (Oracea®, CollaGenex Pharmaceuticals). As the first FDA-approved oral treatment for rosacea, the once-daily 40mg capsule combines 30mg immediate-release and 10mg delayed-release doxycycline. The low dose remains below the antibiotic threshold and the controlled release allows for once-daily dosing. Acting as an anti-inflammatory medication rather than an antibiotic, controlled-release doxycycline does not exert selective pressure on microorganisms and as such does not cause bacterial overgrowth (i.e., folliculitis, vaginal candidiasis) or encourage the development of bacterial resistance. Clinical studies have shown the formulation to be both efficacious and safe.[15] With once-daily dosing, compliance should also be improved.

Erythromycin is an effective antibiotic in the treatment of papulopustular rosacea, but its use is often limited by GI distress. Erythromycin in doses of 250-1000mg/day is generally used in patients who are intolerant to tetracyclines and in pregnant women in whom tetracyclines are contraindicated. Second generation macrolides such as clarithromycin and azithromycin have been shown to work faster and with less GI distress than erythromycin.[16] One study that followed patients for 3 years showed that subjects taking clarithromycin required less treatment time per year than those taking doxycycline (10.2 weeks/yr vs. 14.6 weeks/yr).[17] A 12-week trial of azithromycin in tapering doses showed an 89% reduction in inflammatory lesions.[18] The relatively small advantages of the second generation macrolides, however, need to be weighed against the cost differential in the US of a 30-pill supply: erythromycin enteric coated capsules $8.99, clarithromycin $107.49, and azithromycin $214.95.19 In the last decade, there has been increasing concern over the prevalence of antibiotic resistance. Dahl reported the rate of antibiotic-resistant Propionibacterium acnes (P. acnes) is up to 60%.[20] Globally, antibiotic-resistant P. acnes increased from 20% to 62% from 1978-1996.[21] European studies saw increases of 20% and 50% for tetracycline and erythromycin resistance respectively.[22,23] Consequently, there are concerns that increasing P. acnes resistance would result in a reduction in treatment success over time in rosacea patients.

Even greater cause for concern is the ability of P. acnes to transfer resistance to other, more pathogenic bacteria. Levy evaluated the long-term (>6 months) use of antibiotics in 105 acne patients.[24] He found that 85% of patients cultured positive for tetracycline resistant Streptococcus pyogenes in the oropharynx compared with 20% in the control group. Margolis, et al. suggested that this was not purely of academic interest, but translated into actual increase in disease.[25] In a large, retrospective study, an increase in upper respiratory infections in acne patients treated with either topical or oral antibiotics for greater than 6 weeks was seen. With the recent epidemic of methicillin-resistant Staphylococcus, tetracycline resistance has alarming implications.[26,27] Concerns about resistance have resulted in the suggestion by several authors that long-term use of antibiotics be discontinued in acne therapy;[21,28,29] and serves as an even more appropriate recommendation in rosacea where there is no evidence of a microbial pathogenesis. Because bacterial resistance is not as much of a concern, the use of anti-inflammatory dose doxycycline and other non-antibiotic alternatives in the treatment of rosacea is preferable whenever clinically appropriate.

Although effective in the treatment of rosacea, metronidazole has been associated with potential (although rare) side-effects such as neuropathy and seizures.[30] Alcohol abstinence is required during use to avoid a disulfiram-like reaction and headache.[31] Although rarely used in the US, oral metronidazole is prescribed frequently in Europe for long-term therapy of rosacea at doses of 200mg b.i.d.[31-34] In a double blind study of patients with papulopustular rosacea, it was shown to be as effective as oral oxytetracycline 250mg b.i.d.[35] Pregnancy category B labeling makes it an option for pregnant women. Isotretinoin is highly effective in the treatment of rosacea. It is one of the few medications that is capable of treating more than one subtype of disease. Onset of action is slower than that seen with the use of oral antibiotics.[36,37] In 1981, Nikolowski and Plewig showed that treatment resistant patients taking isotretinoin experienced fewer papules and pustules, a reduction in erythema, and decreased nasal volume.[38] Irvine, et al. demonstrated that this drug could halt rhinophyma by diminishing sebaceous gland size and number.[39]

More studies are needed to determine appropriate dosing schedules as well as optimal treatment duration. Unlike in acne vulgaris, it is not clear that isotretinoin can produce a permanent remission in rosacea. Schmidt and Raff documented remissions lasting up to 2 years after a course of isotretinoin.[40] More recently, Erdogan, et al. utilized low-dose isotretinoin at 10mg q.d. for 4 months and showed significant reduction in inflammatory lesions, erythema and telangiectasia at 9 weeks.[37] In our continuing search for a therapy that does not result in antibiotic resistance, isotretinoin may be a viable alternative, especially in males and older women past child-bearing years. Low dose (10mg q.d. or q.o.d.), long-term use of isotretinoin can result in minimal risks of side-effects. Birth defects, however, are possible at any dose of this drug; low dose does not mean low vigilance.

Reports in the literature support using dapsone in severe, refractory rosacea.[41] It is particularly helpful in patients for whom isotretinoin is contraindicated. Many anecdotal reports exist regarding the use of agents that antagonize the flushing reaction, including vasoconstricting agents, and drugs that alter flushing reactions in response to emotional stimuli.

Beta blockers in low doses (i.e., nadolol,[9] naloxone,[42] ondansetron,[43] aspirin,[44] and numerous selective serotonin reuptake inhibitors[19]) have been reported in isolated cases to be effective. However, there is no evidence-based research to support their use. Craige and Cohen recently revisited the use of propranolol in the control of flushing and blushing.[45] At starting doses of 10mg t.i.d., none of their nine patients improved. Six of nine patients improved when doses were escalated to 20-30 mg t.i.d. At such high doses, three patients withdrew from the study due to side-effects. This study shows that the perceived ineffectiveness of beta blockers may be due to inadequate dosing.

Clonidine has also been reported to improve flushing and blushing reactions at doses of 0.05mg b.i.d.[46] At this dose there was no reduction in blood pressure, but lower baseline malar temperature may have been reduced by peripheral vasoconstriction. Although some patients do remarkably well on clonidine, responders are not clinically identifiable before treatment. Since control of this feature of rosacea is so difficult, a trial course may be indicated.

The erythematotelangiectatic subtype of rosacea is the most difficult to treat. There is little evidence that topical or oral antibiotics have any role in the treatment of erythema, telangiectasias and flushing-blushing reactions. Isotretinoin may improve erythema resulting from inflammation, but this effect may be transient. Drugs that antagonize flushing may be helpful in some patients. Vascular laser and light therapy is the most effective modality in this subtype.

The papulopustular type of rosacea is the easiest subtype to treat. Most of these patients respond readily to topical medications such as metronidazole, benzoyl peroxide, clindamycin, erythromycin, and azelaic acid. In several studies, topical medications were shown to be equally effective to oral medications although therapy may take longer to be effective.

Since 2006 there has been a paradigm shift in the therapeutic decision-making process for treating rosacea. In the past, topical agents were considered as first-line therapy, and oral agents were introduced only when topical medications were ineffective, or were used in patients for whom immediate response was paramount. With the advent of once-daily, non-antibiotic dosing of doxycycline, oral therapy has become more commonly prescribed as first-line treatment. Often oral and topical antibiotics are used in combination; the resulting effect may be synergistic. Ultimately the patient may be converted to topical therapy alone for maintenance purposes. However long-term, anti-inflammatory dose doxycycline offers a viable alternative.

Isotretinoin is highly effective in this type of rosacea, especially given that low-dose, long-term therapy is an option particularly in men and women of nonchildbearing potential.

Dapsone may be necessary in refractory rosacea or in a patient for whom isotretinoin is contraindicated.

Surgical or laser ablation is often necessary to eradicate existing lesions of significant size. Isotretinoin has been reported to halt the progression of rhinophymata and to shrink overall volume of phymata by reducing the size of the sebaceous glands, but it does not appear to be curative.[37,39,40,47-50]

Mild, chronic ocular rosacea responds well to topical agents and eyelid hygiene. More significant disease responds promptly and substantially to virtually any oral antibiotic. Tetracyclines, because of their safety profile, are most often used.[51,52] Isotretinoin use may improve the more severe presentations of ocular rosacea, including coloboma formation and corneal erosions. Potential side-effects for this type of rosacea include dry eyes and gritty irritation during therapy.

The granulomatous variant of rosacea is treated in the same manner as papulopustular rosacea reviewed above. Severe disease also responds to the use of oral and intralesional corticosteroids.

Until recently, there had been little change in the systemic treatment options for rosacea over the last several decades. In 2007, more aggressive and innovative uses of existing oral agents have resulted in novel therapeutic approaches. The development of anti-inflammatory dose doxycycline monohydrate is an intriguing alternative to long-term or episodic use of full-dose antibiotics. Once-daily dosing with the controlled-release formulation of doxycycline monohydrate can be expected to improve compliance and therefore efficacy. Furthermore, anti-inflammatory dose doxycycline and isotretinoin are helpful modalities for preventing treatment failures. Agents with good or acceptable safety profiles allow for long-term therapy and provide sustained remission. More importantly, the use of oral agents that do not increase the likelihood of future bacterial resistance is of global importance

December 30th 2018

A fellow rosacea sufferer wrote me about his flushing, redness and burning issues. He has had laser treatments, but does not get sufficient results from them. He read this blog post and wants to try my anti flushing medication; clonidine, propranolol and perhaps also mirtazapine and an antihistamine like Xyzal. But primarily clonidine and propranolol. The problem is that he cannot find a dermatologist who is understanding of his flushing problem, and willing to let him try this meds. He asked my advise, and I think anyone in this same situation needs to offer his or her specialist or GP some research papers to convince them. If you scroll up in this post, you will find a list of research papers for each of the medication discussed. Pubmed articles are particularly handy to print out and to show, as medical specialists like to see in black and white that an off-label medication is actually effective for the symptom at hand. They are often worried to go off the beaten paths and away from the textbook treatment protocols. But it is important to explain that up until now, there is no official flushing treatment. Nothing. The only thing specifically designed to control flushing, Mirvaso gel, is a liability of a product that has made many users flush worse or made their rosacea worse even in some cases. Medication in pill form is much less risky and can actually really help controlling flushing. A doctor needs to compare it to hot flushes, but then ongoing ones that are not hormone driven often, but that nevertheless widen the blood vessels of the face regularly. Causing pain, heat and worsening of the dilation of the weakened vascular network in the face. Just like with untreated varicose veins. We need to control the flushing, in order to be able to control rosacea subtype 1 or neurogenic rosacea.

I am always worried about invasive treatments like laser or IPL for our subtype of rosacea, to be honest... If they stir up your rosacea and make it worse (which was the case for me), you are often stuck with the outcome! Whereas with medication, anything but steroids is a temporary thing. You try them and if you feel things are getting worse on them, you stop taking them and no long term harm is done. So it surprises me always that dermatologists are more easily swayed to offer laser or IPL treatments than they want to prescribe prescription medication. After all, flushing is a very difficult symptom to treat and if left untreated, it can worsen rosacea over the years and make the problem harder and harder to tackle.

He also asked about what medication to best use, or start with, to reduce facial flushing. My advise:
"I would start with clonidine if I were you. No doubt about it. 0,05 mg seems a very low dose.. I take 0,150 mg every 8 hours, so 3 times a day. You could start with 0,1 mg, three times a day. This is still a reasonably low dose, but I don't think going much lower will be doing much for the flushing tbh. It is very important to take clonidine 2 to 3 times a day, I'd say 3 times as after 8 hours it can give rebound redness and flushing. This medication needs to have a stable blood level dose, and if you want to stop, you slowly taper its use off.

I would try this for one month, then re-evaluate. And add propranolol then. I find it the best beta-blocker out of all the ones, for flushing and redness. But opinions differ on that one. Propranolol 40 mg pills can be taken as needed. You don't need to take them at specific intervals. No rebound issues. But I take 40 mg 3 times a day, together with the clonidine. When I have a bad flare, I take 80 mg (two pills) instead. Again, i would try this med for a month and then re-evaluate again."

Hope this helps someone :)


  1. I blush frequently, but I feel this is down to social anxiety as such. Have started on 15mg but felt no relief on the blushing front or social anxiety. Am up to 30mg now, only 2 days. Am waiting to give it time, was 2 weeks on 15mg. I am wondering though any experience or feedback on the feeling that you are blushing (the heat is there when in embarrassed situation) but when you have looked in the mirror you are not blushing, does this happen with Mirtrazapine? I am not sure if the blushing has triggered the social anxiety or the social anxiety has triggered the blushing to be honest! But days are very difficult at the moment. Fight or flight is in daily occurrence. Many thanks

    1. Hi, I assume you meant you are on 15 mg of mirtazapine? I felt it helping at that dose within a week; mostly I feel that it blocks part of the flushing. So it would take a lot more for me to get bright red and flushed while being on this medication. The antidepressant actions take a lot longer to kick in I found, at least 3 weeks, officially they state 5 weeks. I mostly feel less hot in the face and less blushing, but it doesn't stop it entirely for me. That being said, I flushed 24 hours a day before I started medication so it was hard to cut down given how bad things were to start with.
      Maybe a beta blocker like propranolol could help you too, given that you mention the fight or flight response. Propranolol lowers adrenaline release and also helps many blushers.

      Hope you are well


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