21 March, 2018

The Warm Room Theory, and how being in cold air could make your flushing and skin burning worse

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, according to Colin Dahl. He explains that 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.


The good news is that this process is reversible, according to the author of the Warm Room Theory, Colin Dahl. 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 factors. Neurotransmitters 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.

Understanding the warm room flush
When people with rosacea step from a cold environment into a warm room, we are likely to get a flush. Why is this? When we are in a cold environment, our bodies naturally has a built-in system to conserve heat. In the cooler environment, the body will constrict blood vessels in the skin. These blood vessels carry warm blood, and the wider the blood vessels are, the more body heat is released to the air, and thus the colder the body gets. In a cold environment, this is not wanted! So the body automatically constricts the blood vessels in the skin, giving the skin a more pale look and keeping the warm blood well inside, to contain and retain our body heat. We not only have more blood vessels in our facial skin than those with 'healthy skin', we also have more skin nerves to go with it, who can constrict all these extra blood vessels when it is cold. Normal skin builds up a small amount of inflammatory chemicals such as neuropeptides in the cold,  but because we have so many more blood vessels and nerves in our rosacea skin zones, these build up a large storage of neuropeptides. Our faces feel often cold to the touch now and the same goes for our hands and feet. But when blood vessels get too cold they begin to automatically dilate, because the blood vessels lose their ability to constrict, causing redness of the skin. This is why in the cold of winter, many (northern) people have a blushed face. It rarely burns however for them.

Neuropeptide storage
In cooler environments, chemicals the body uses to dilate blood vessels are no longer getting released much. If the person is in a cool environment for a long period of time, then these dilating chemicals such as neuropeptides, the major (inflammatory) dilating chemicals released by the body, begin to build up. Neuropeptides can only be made in small amounts by the body everyday. So the nerves have a way of storing these chemicals to use when needed. Similarly, other dilating chemicals are also building up their availability. Now research has shown that more neuropeptides are released in rosacea skin during flushes, and also that the body of a rosacea patient makes new neuropeptides faster than normal. They play a role in the warm room flush phenomenon. So when we walk from a cold environment into a warm room, as rosacea patients, we tend to flush. Our skin has more blood vessels and nerves, and therefore our skin gets more red and warm and sooner than normal too. But because our skin has been building up inflammatory neuropeptides while we were in the cold environment for some time, our skin has been building up inflammatory chemicals such as neuropeptides. We walk into the warm room, and our internal thermostat tells our skin that we are hot. The body quickly responds by initiating the release of heat. Nerves are activated in the skin to dilate blood vessels and trigger other nerves. These nerves can now release not just a small amount of neuropeptides, but ALL of the built up neuropeptides that we accumulated while being in the cold environment. Remember that more neuropeptides are released in rosacea skin, and also that the body of a rosacea patient makes new neuropeptides faster than normal. So while we are in the warm room, the nerves release their abundant neuropeptides in a big burst. As a result, we get a lot of blood vessel dilation in the skin, and this triggers the nerves in our skin even more, with the end result; a red hot burning facial flush. The extra blood flow stresses our blood vessels out, and in turn make them release more chemicals that keep the blood vessel dilation ongoing or even worse. If you get it bad enough, the flush can be very difficult to cool down, even when we go back into the cold outdoors again. Then after some time, for no apparent reason, the flush abruptly goes away. The skin has worked its way through the entire storage of the neuropeptide chemical and needs now time to rebuild the storage.

Colin Dahl has an important suggestion regarding how we can avoid these extreme flushes, triggered by moving from cold to warmer environments

Colin Dahl himself had rosacea flushing, and noticed that when he stayed abroad in a country with a stable warm climate, his rosacea flushing calmed down. Back home in his home country of Australia (where he did experience seasonal temperature changes), he tried to create a summer-like environment, by using heaters to prevent his face and body from getting cool (without getting too hot). He got through the winter and saw further improvement in his skin redness and flushing. He continued the experiment in the summer, but this time the cool environment was inside due to air conditioning. The warm room was now outdoor exposure to hot weather. he again tried to continually release neuropeptides throughout the day, by not allowing his skin to get too cold. He did use air conditioning sparingly during the summer, only to reduce very warm environments like hot cars. But he did not focus cool air directly on his face (flush zones) and did not get too cool. Again he noticed a great reduction in overall flushing and his facial redness was further improved. Over time he also noticed a greater tolerance to warm environments. When he had to go back to China, it was approaching winter there. He was spending eight hours a day in a cold lab that was only 15 degrees Celsius. After just a few days he began to experience warm room flushing again. Only once he started working in a heated room again, did the warm room flush stop. Even short periods in below zero weather did not cause the warm room flushing to re-appear. He wondered if the build up of neuropeptides and other inflammatory chemicals cause of all his rosacea flushing? Unfortunately the answer is no. However, this build up did play a major role in warm room flushing and warm environment flushing, both very common flushing triggers. Colin Dahl sees a correlation between cooler environments and rosacea. In tropical southern China there is little rosacea found, but as you travel north towards areas that experience cold winters (think of Mongolia!), rosacea is much more common.

The heat regulation process in rosacea skin, as described above, may have much to do with this ‘inflammatory cycle’ of rosacea. This is likely due to the fragile balance of heat conservation and heat release systems seen in people with rosacea. Even slightly cool environments will kick off the heat conservation phase in flush zones, enabling greater stores of neuropeptides, which when released in large amounts are likely to result in a flush. Many people with rosacea even try to stay in cool environments for long periods, trying to reduce facial flushes and redness that way. Let's face it; when your skin burns and feels and looks very hot, the natural thing to do is to find a cold area to find some relief. However, Colin Dahl states that this is counter productive in the end, because it can result in significant inflammatory neuropeptide storage. When you then eventually enter a warm environment, your skin has a build up of neuropeptides ready for release. In this situation a large flush will be difficult to prevent. he says that even slightly cool environments may cause neuropeptide storage to begin in your flush zones, as these areas begin to conserve heat very early. The impact of this neuropeptide storage may result in an increase in the number of warm room flushes and an increase in the severity in warm room flushes.

What is cool then and what is warm?

So how can you tell what is a cool environment and what is a warm environment? The answer according to Colin Dahl lies in your flush zones. If the flush zones of your face (cheeks, etc) are cool to the touch, then it is very likely that inflammatory chemicals such as neuropeptides are building up. Your flush zones don’t have to be red hot for these chemicals to be released. If you want to continually release neuropeptides gradually, then you want to have neutral to slightly warm skin (not hot and not cold). The longer you stay in a heat conservation phase (your flush zone feeling cold to the touch) then the longer the neuropeptide build up continues. If the room you are in is warm, then your flush zones will not be building up these inflammatory chemicals. Even slightly cool environments will set your flush zones into heat conservation mode and neuropeptide build up, and slightly warm environments are enough to enable continual neuropeptide release in flush zones. However, unless your rosacea is very mild, all this is often in itself not enough to get your rosacea back under control. If there is already an excessive flush zone and a lot of extra blood vessels have been formed over the years, then you need to reduce these blood vessel networks too. Colin Dahl  suggests IPL light therapy or laser treatments for this, to reduce the excessive amount of blood vessels in our skin. Read more about this here and here. He also stresses the importance of calming your rosacea flushing down in other ways. Avoid triggers like direct sunlight. Stop using irritating skin care products for instance, and switch to mild and neutral ones that sooth your skin (or in my own case, stop using all skin care products entirely. For the past 14 years I have only been washing my skin at night with bottled water and cotton pads and use jojoba oil around my mouth, leaving the rest of my skin alone. No wrinkles have been forming, despite the lack of anti ageing products and my skin is a lot less irritated because of it).

Anti flushing medication can also help to break the flushing cycle. This is very important according to Colin Dahl, and most dermatologists will stress the same thing; break the flushing cycle, and your skin and blood vessels get a break and a chance to normalize. If you reduce the over activity of the skin, you reduce the infrastructure required to maintain it. Less nutrients will be needed for supply, so less blood vessels are needed to get them there. Just as the body has a system to increase blood vessels and nerves in your skin to correlate with their activity, the body also has a system to reduce blood vessels and nerves in your skin when they are less active. The body uses growth factor regulation as one method of achieving this balance. This is why reducing flushing and skin irritation is so important. Read also up about the use of vitamins and supplements for the normalization of inflammatory skin cells. Colin Dahl mentions natural compounds such as silymarin, egcg and vitamin B12.

My own experience with the Warm Room Flush suggestions

The problem I have with the warm room flush mechanism, is that it is impossible to implement for me, unless I want to stay in a controlled environment all day. It's winter here now and I had to go in and out of hot trains, buses, airports, planes and back into the cold and wind the past weeks. The same for visiting people, how do you avoid the sharp transitions from warm to cold and back again in every day life? Living in a country with not the same mild or warm temperature all year round. It is a great theory and probably working for a lot of people. I have no doubt that in my mild/ moderate rosacea days, this was very useful. But these days I have such dense vascularity in my face and such vasodilation (also from all sorts of other triggers, despite keeping neuropeptides low or not) that it is impossible to sleep in a - say- 22 degree Celsius room. Even in summer when temperatures are consistently around or above 22 degrees, sleeping in such a temperature will ensure a beet red pulsating face during the night/next day. And the day after. And the week and months after, if I keep up with sleeping in such high temperatures. Sometimes the face is such a vascular mess that I don't believe in a few transition days before the skin gets used to sleeping in such a hot room. That one probably works better for people with transient and milder flushing and not a red face continuously due to decades of rosacea flushing.

Colin Dahl suggests IPL and laser in his theory text, but they are not for everyone unfortunately. Some rosacea patients react badly to them, or have the misfortune of having hypersensitive, photosensitive skin like me. I had 2 full face IPL treatments by different doctors and a dozen of small area IPL treatments, as well as laser test patches, and it virtually all made my rosacea worse or did nothing. Unfortunately I am a poor responding patient, but both IPL and laser have helped many rosacea patients tremendously, to the point of letting them go into rosacea remission, so worth exploring as a patient (but be sure to find a good practitioner, with rosacea skin treatment experience and up to date machinery, and insist on test patches first!). I am very happy when my skin feels cold to the touch. Because then I won't be burning and flushing. Ice cold is bad news (my skin gets very red from that sort of cold too, mainly in winter), but cool to the touch? Yayy! I take anti flushing medication and the cold feel of the facial skin is the sort of thing that anti flushing medication are aiming to achieve. To me, it feels counteractive to heat the place up to such a point that the skin feels warm again. Despite all efforts, there seem only three skin temperatures possible for me: cold to the touch, chilly to the touch, or burning hot to the touch. Like the skin lost the ability to just feel right. But when someone flushes not that often and has good periods of skin control, sticking to the warm room  flush theory might be the best non invasive thing around for now to avoid those awful temperature induced flares. But it does help me too in other ways; I'm not making it as cold as possible anymore in the house when I flare, but a mild temperature. Same in heat of summer, not too cold with the air-conditioning, or there will be rebound once going outside in the heat. I do keep
indoor temperatures higher than I used to, since understanding more about the warm room theory.
It used to be 16 degrees or below in my house (yikes.... but my face was so hot and sore), and these days I do well on 17- 18 degrees celsius, and even a bit higher when it is natural warmth outside instead of central heating. I think my skin is less inflamed actually then, and it might explain why so many people with rosacea flushing and redness do better in summer than in winter.. Not everyone with rosacea has the same severity of burning and flushing, and not everyone can handle temperatures as high as 22-23 degrees I'm afraid. This is what Colin Dahl also highlighted in his writings, the need to first and foremost control the amount of flushing and excess vascularity one has.

I agree with Colin Dahls Warm Room Theory, and that being in a cold environment, or cooling the skin too much does indeed give a neuropeptide fueled flushing (rebound also) inferno when entering a substantial warmer room. But he also stresses in both the middle of his treaty as at the end, the importance of reducing the vast vascular/nerval infrastructure that rosacea skin often has. Through IPL in his view. or otherwise through trigger avoidance, skin care adaptations etc. So if someone has moderate to severe rosacea and flushing, he acknowledges himself that his avoidance of cold air is not going to cut it. And that the aim is to reduce this vascular network, first with the heavy guns if rosacea is bad enough, then through avoiding the cold to warm environment stress. Unfortunately not everyone with rosacea has the same great experience with IPL. I had my mild rosacea sped to severe (24/7 flushing) after a botched IPL and it was literally the worst thing I have done in my entire life, probably due to the wrong practitioner and machine and also for having hyper reactive skin and being slightly photosensitive. I have only anti flushing medication now to make life bearable and curb the bad flushing. It s*cks but it is what it is. Saying that the vascular network needs to be eradicated first is an open door and not as easy said as done for many patients. If your rosacea is mild, the warm room theory alone and trigger avoidance on top might make rosacea very manageable, but I think it is just one piece of the puzzle, as Dahl himself openly acknowledged in his piece as well.

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 thevitamin-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).
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

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 :) 

Below is an impression of the experience from other rosaceans with the information gathered from the Warm Room Flush manual

Carly1981 wrote on November 7th, 2017: "Regarding the Warm room flush theory, I've read a little bit about it and I think I understand the concept, but how arduous is the path to improvement? I practically live in front of a small fan during the winter months because my cheeks flush so easily. If I ease up on using it, do I just have to push through the heat/ flushes until they lesson?  I went to the theater over the weekend and after about an hour, I could feel my cheeks start to burn (my friends actually thought the auditorium was too cold). Of course this made me feel embarrassed, so the flushing was made worse. *ugh* I have the acne more or less under control now, but I can't seem to shake the flushing."

Rednessator wrote on November 7th, 2017: "The whole premise of this theory is that only heat causes flushes, but as we know, people have many triggers, thus keeping environment warm all the time might actually lay the bed for the other triggers."

BraceYourself wrote on November 10th, 2017: "I've been to the tropics and the weather there was at a constant 20 °C with not much humidity. My skin must've been around a constant temperature and it was fantastic. Then again there are many different factors that would've changed, since I was on vacation, so my diet, sun exposure, stress and sleep pattern were not the same as usual. So it might not just be the temperature, but an array of things. Back to the title of the thread; walking into a warm room from the cold is probably my biggest nightmare honestly, because I can't control ANYTHING at that point. Then once I go red I feel embarrassed, which causes a deep blush and that makes it even more awful."

Violetsareblue wrote on November 17th, 2017: "Flushing, I guess, is very complex. In my case it is/was a combination of a damaged lipid barrier (sun damage, seb derm etc), hormonal fluctuations (my period, estrogen), body temperature over the day and menstrual cycle, Raynaud's syndrome (overactive vessels), bad physical shape in general (diet and blood circulation), depression and passivity. I still see a logic in the warm room theory but there is def more to it.. And def things we can effect even if we don't think so. I have managed to almost eradicate my flushing through an improved diet, skin barrier and avoidance of freezing or spending to much time in cold and dry environments, working out more (getting better blood circulation). Its winter here now and I barely have any flushing atm. I occasionally have some issues with what I believe is caused by my low blood pressure, but really, I am so so much better then I was a year ago. My rosacea also almost completely vanishes when I go to warm, humid places. I remember the doctor used to tell me that stress was a big factor in rosacea and I didn't understand it back then because I never flushed from stress. But the fact that long term stress and depression actually constricts your blood vessels all over your body, making your whole system tense and cold makes us more prone to flushing as well.. To be continued.."

Dzed1 wrote on November 17th, 2017: "Hi, I didn't meant that there are no other factors, you are right stress is huge thing same as hormones. What I meant was specifically for cold-warm exposure. Also you said Raynaud's syndrome, see there are conditions that overlap with rosacea, that's why I managed to learn quite a bit for this condition, and trust me many different chronic diseases are the same - I stand by my theory that rosacea is associated with CVD, blood clots, and insulin resistance destroyed digestive tract (immunity) this are the primary causes imho. Many people talk about demodex, let me tell you why they are not the issue. If you got good immunity, no demodex will ever do any harm to you, when i get on better diet - and started to use the methods i explained in the other threads, suddenly no demodex.....so no, they are not the cause, they come after."

Violetsareblue wrote on January 26th, 2018: "So I just wanted to report some of my latest findings regarding warm room theory etc. since I noticed the connection cold face, nose body and then flushing etc. I have tried to keep my body warm lately. I have started to keep a little electric radiator by my side at work for example so that I don't get into freeze mode anymore. My experience so far is really positive. Most of all, my body is much more relaxed which feels good and it feels like I build up less tension overall, tension that can possibly enhance flushing later in the day. My nose is also more even temperature all day which I think is beneficial. I rarely experience cheeks flushing nowadays however, if it happens its when I talk to cute guys haha (and that might be pretty normal). I have had continuous progress with my rosacea since I went paleo in April 2017. I have made several radical life style changes so its hard for me to say exactly what is making me better but maybe "every little helps". I know the diet was a big one, doing colon hydrotherapy in August 2017 was another and a good routine with nice skincare + metronidazole cream was yet another. The progress for me is  extremely slow, but if I look back a year, the progress is obvious. A year ago I couldn't even wear a turtle neck because it would make me over heat and flush, I had to keep my windows open all time to cool my face. If I went into a warm room my face would explode into flushing/swelling within five minutes. All of this is totally gone now and my life is back to normal. Instead I find I love the warm and do all I  can to stay warm.

I rent a flat and it has central heating that my landlord has decided. I have a few thermometers to keep my eye on the temp and it stays pretty even at 23 degrees celcius, which is warm for Sweden. My home is comfy temp and I rarely feel cold there. A year ago I couldn't handle this temperature at all and slept just with a thin cotton sheet on me but now I am fine and can sleep with a normal duvet. My body usually stays warm until around 11-12 am at work and then I need to put the radiator on as I start to get colder. I feel it in my hands and feets, nose but also pretty much my whole body. I have also changed in my office space so I have a standing desk because sitting makes me very cold, tired and enhances flushing. At around 4-6 pm I get warm again and tapper down the extra heating. I think for me the next thing to try to add is some of this old type of humidifiers to my flat. Regarding supplements I take a few: vitamin D3, C, zink, magnesium and iron. Every other day also cod liver oil and omega3. I also take antihistamines at night. To be continued.. And all my best to all of you /V"

Whiteshadows wrote on March 20th, 2018: "Its crazy to me that the warm room flush theory doesn't have more traction on this forum, I've used it and my flushing has all went away except for alcohol (which is just from a enzyme deficiency, look up asian flush). I remember when my rosacea started when I was around 13, I would go outside in -20 degree weather, waiting for the bus, going outside for hours with nothing covering my face. I would go inside an bam intense flush. Obviously the vicious cycle starts when I started to try to stay in cold rooms all the times only making things worse without knowing it. The theory makes so much sense and its also why so many people clear up when they go to the tropics. The opposite is also true if one lives in a hot climate but are in AC all day long, they will flush when they go out its just in reverse. Warm room flush theory should be tagged for every newcomer to see. I live in Canada and the theory worked super well for me also. From experience its not as much that you need to keep a consistent temperature, the trick is that you must not let your face get cold. When my rosacea was at its worst I would do the opposite and try to maintain cold temperatures, but I always flushed in warmer rooms because my face was accumulating neuropeptides. Hot trains, buses, and airports are not problems IF you make sure you're face doesn't accumulate neuropeptides by being cold for long periods of times. HOT environments will only be a problem is you let your neuropeptides accumulate by being in cold environments for to long. If you put your hand on you face and feel that it is cold it means your accumulating neuropeptides. When you go outside in the cold you wear a scarf to keep your face warm (preventing it from accumulating neuropeptides). When you are home and sleeping the temps must be 22 Celsius or above, if the temperature is less than that I feel me face is cold and accumulating.
Ever noticed how in the summer 22 degrees feels cold yet in the winter it feels warm and can make you flush? That's because in the summer your neuropeptides are not accumulating (unless you work in a very air conditioned environment. You will flush the first times though but you have to go through it, for me it lasted one night I slept with the temp at 23-24 I flushed like crazy (depleted my neuropeptide reserve). But the morning after I started to keep my face warm consistently and I pretty much never flushed again.(except for alcohol, and emotions but i feel these are normal and not rosacea caused). At this point I truly believe most peoples flushes are caused by this theory and some people have more severe rosacea the longer they have been stuck in the loop of keeping face cold which is the opposite of what one has to do. Ultimately this builds more and more blood vessels which makes skin even more sensitive. The less you flush the less blood vessels your skin will have long term."

Antwantsclear wrote on March 21st, 2018: "When my ear flushing was very bad before using the medications, I could not manage a warm room to sleep in, for example. However, now I prefer a moderately warm room (e.g. 23 C). But hydroxychloroquine/mepacrine made my flushing more tolerable. I think you do need to either have mild flushing or otherwise control moderate to severe rosacea flushing sufficiently in order to get the warm room syndrome theory to work. The other point here is that hydroxychloroquine and mepacrine are anti-parasitic drugs which I think do help control the demodex population. Demodex mites do respond to warm temperatures - in my experience they go crazy when you consistently have to deal with a temperature above about 25C-27C. There is broader evidence beyond rosacea to show that demodex mites respond to temperature in their levels of activity and breeding etc. So, I also do find that controlling the mites topically with almond oil and tea tree oil combined does help - that has to be on the hair and the face. I notice a lot less itching from the mites etc when I consistently use the oils. Again the warm room syndrome works better when the mite populations are under control - otherwise a hot room means increased demodex mite activity - flushing, burning and itching."

Whiteshadows wrote on March 21st, 2018: "Its true that for some people with too much "infrastructure'' or vascularity, like you said, the warm room flush may be hard to apply. The doctor that came up with the theory mentioned in the article that for some people they may require initial IPL or v-beam laser to reduce their infrastructure or vascularity as you said . He even says the more flushes one gets the more infrastructure ones builds and the less flushes one gets the body will reduce the infrastructure naturally. Yes rosacea meds make it a point to make the face feel cold but most of them cause a rebound effect similar to the release of neuropeptides. Essentially they work because they do the same thing a cold room does do your vessels which is constricting them. keeping the face warm may sound counter intuitive I remember thinking that was crazy back when it was bad but it truly makes sense now since now i make it a point to mostly never let my face become cold to touch since I know that although it may feel good my face is only accumulating neuropeptides to be released down the line.

This is an original forum discussion about the Warm Room Flush research at the time it first came out, and its author Colin Dahl also chimes in, answering some questions

Artist wrote on March 2nd, 2008: "WOW David this is an amazing read! I posted some excerpts and commented here and there, but I just think everyone should read this whole thing. VERY eye-opening. Please read The Warm Room Flush!!! I'm just going through it now. This reminds me of a camping trip one year. We went camping and it was only around 60-65 degrees most of the time. During the whole trip my skin looked amazing. My vessels were completely constricted at all times. On the way home, we went into a warm restaurant and I ate. I had the biggest "warm room" flush ever. It was very sudden, and awful. Now I realize that, while my skin was cool, dilating chemicals were not being used - so they built up. So, after such a long time building up, there was an abundant amount to be released. I think this also helps explain why many of us do worse in the winter going from warm to cold rooms.. Thanks for finding this. The author actually has rosacea. Perhaps this also explains why I do so well in tropical environments. I think a lot of us try and do this: "Many with rosacea even try to remain in cool environments for long periods in an attempt to reduce facial flushes from occurring. However, this is counter productive because it can result in significant inflammatory neuropeptide storage. When the person eventually enters a warm environment they have a build up of neuropeptides ready for release. In this situation a large flush will be difficult to prevent." Interesting!!!! Artist"

Quiller wrote on March 23rd, 2008: "I like the neuropeptide buildup idea because it's original, and testable. It looks like one of the neuropeptides is Substance P, which always interested me because it sounds so mysterious. Here's a nifty illustration of how it interacts with Nitric Oxide.

David Pascoe wrote on March 4th, 2008: "It is certainly an interesting thought that is worth exploring further to see if we can't understand how much this might help. The author did say it wasn't the cure, but did help. It is probably too hard for all to follow this sort of temperature regulation regime, but if it does help it is worth exploring and understanding it fully."

Melissa W. wrote on March 4th, 2008: "This is probably a silly question but what about people who can stay flushed for days? Doesn't the dilating chemical (neuropeptides) get depleted and shouldn't the flush die out sooner? I remember when I was first diagnosed I was fortunate enough to get to speak with Dr. Peter Crouch and he warned me not to sleep in too cool a room as that may require me to keep in cooler and cooler temps and harder to tolerate the warm room temps. I'm not sure he knew the mechanism behind this at the time but he was right! Best wishes, Melissa"

AustralianSciences (Colin Dahl) wrote on March 4th, 2008: "Hi Melissa, Regarding your question about those who stay flushed for long periods. The booklet does advise those in this situation to reduce their excessive heat regulation infrastructure (through IPL) before attempting some of the recommendations in the booklet. I can explain the reason for this a little further for you. In this situation, the person would obviously has an excessive heat regulation infrastructure (more nerves and blood vessels). This extra skin infrastructure is also involved in the generation of neuropeptides and inflammatory chemicals. So the flush won't die out faster, in fact it will last longer because more of these chemicals are being produced and released. If you have less of this heat regulation infrastructure in your skin, you will produce less of these inflammatory chemicals. Best regards, Colin Dahl"

Rusie wrote on March 4th, 2008: "Hello all, I have many questions regarding the warm room flush. First, thank you David for posting this info. I have had rosacea for three years now and for three years have been trying to keep my face cool or cold, even at night. I constantly have fans blowing on me and keep my house at 60 degrees in the winter (where I generally do better) and 69 degrees in the summer and spring (where I generally do worse). My general problem is facial flushing, not really p&p's. After three years of constantly trying to keep my face cool, with every trick you can imagine, how do I now stop and keep it warm? Should I use a gradual process? I should also mention that I get warm and hot easily, which results in a flush. Nighttime is especially hard for me, as it is difficult for me to sleep if I am not cool. Any suggestions?? I live in the Atlanta, Georgia area so it is hot in the summer and cool, but not extremely cold (most of the time) in the winter. Thank you for any help or advise any of you can offer. Rusie"

Eric123 wrote on March 4th, 2008: "I really enjoyed this booklet and think it will prove to be of great help. I had a couple questions; 1) Is there any way to release the neuropeptides, if you have stored them up, other than a flush? I noticed in Asia that topical application of L-Menthol on the back of my neck quickly resolved any flush, as did a proper neck/upper back massage.... could this be releasing or diverting the neuropeptides away from my flush zones to the neck/back areas?
2) Are there any neuropeptide inhibitors, topical or internal, which might be useful to achieve balance? 3) How does this affect how we regulate our temperature with things like hot drinks, chewing on ice chips, etc...? Chinese medicine always warns of drinking cold drinks, eating ice cream, etc... and I seemed to notice a marked decrease in my flushing episodes after I began to drink only room temperature water and other drinks."

AustralianSciences (Colin Dahl) wrote on March 7th, 2008: "Hi Rusie, I can totally relate to your situation. I kept myself in a cool environment for a few years too. It didn't help me and I can guess it is not working for you too. If you keep yourself in that cool environment you are setting yourself up for more flushes and longer flushes, which is likely to progress your rosacea even further. But what to do now? If I was you, I would find out how my body reacts to long periods of slightly warm temperatures. It doesn't really matter what happens the instant the air conditioner goes off, or when heater goes on. What matters is what is happening several days later. Don't be afraid to experience flushing during this initial period (think of this as a positive, you are reducing your build up of inflammatory chemicals in your flush zone, take advantage of this!). You are trying a medication free approach here, you really have nothing to lose and everything to gain. As the booklet states, if you just go from hot to hotter in even slightly warm environments (while restricting cool environments for a number of days) then it is possible that your heat regulation infrastructure is just too excessive to attempt this regime at this time, so IPL is recommended in the booklet. A good indication on excessive infrastructure is how much redness you have in your flush zone. Rosacea takes many years of flushing and skin excitation to progress. If you reduce the flushing and skin activity downwards every month, you are progressing towards the reversal of rosacea. For example purposes, you don't have to go from 10 flushes a week to zero in order to begin reversing rosacea. If you do experience 10 flushes a week for an extended period of time, then the infrastructure in your skin will be in proportion to 10 flushes/week. If you go down to 9 flushes a week for an extended period of time, then the infrastructure in your skin will be in proportion to 9 flushes/week. And so on. (I left out skin activity in the example, I didn't want to make it too complicated). Maybe I can discuss it next time. Best regards, Colin Dahl"

AustralianSciences (Colin Dahl) wrote on March 8th, 2008: "I typed ROSACEA into google, because for the last few years I haven't looked at what rosacea resources were on the internet. At the top of the list is rosacea.org I read their Winter 2008 Newsletter. A feature story is about research they funded on Demodex Mites. Are we still talking about this rubbish? To spend time and money on this kind of research is an insult to people with rosacea and anyone who donated to them. Am I the only one who feels like this? The other research isn't much better. Let me save them their research budget for the next few years with the following advice. At its most basic definition, Rosacea is an inflammatory condition. The severity of the condition is in relation to the inflammation/skin infrastructure. People with a basic understanding of rosacea should know that just about every kind of inflammatory chemical can play a role (vaso, nero, immuno). So isn't it then obvious that many of these chemicals will be elevated or over reactive in rosacea. Then why would you bother looking to see if one of these chemicals is increased or overactive? In my opinion, people with rosacea deserve much more innovative research than this! Maybe if people wrote to them and demanded better research then a positive may be achieved out of this. Best regards, Colin Dahl, Australian Sciences". Oops.. In light of the recent research on the role of demodex in (subtype 2) rosacea, this was a little misstep perhaps from Colin.

AustralianSciences (Colin Dahl) wrote on March 8th, 2008: "I no longer suffer from rosacea. I believe the key is flush minimization and reducing skin cell activity. I will try to post some messages on this over the next few weeks. One way to is to avoid flushing triggers, but you can't avoid all flushing triggers in the real world. So, together lets think of ways to minimize flushing (that doesn't involve avoidance of triggers). If you can't think of one you get an F (because the booklet talks about some ways). Best regards, Colin Dahl, Australian Sciences"

Artist wrote on March 8th, 2008: "Colin, Here's my idea on how to minimize flushing: Move to someplace tropical, where the temperature is pretty much the same all year round (absolutely fabulous), and no one has air conditioning! I think that would work like a charm for me:) I have a question. So, in your opinion, while we are down-regulating our facial skin infrastructure, should we be upset by slight pinkness from allowing our skin to be "slightly warm"? My thinking is that the deep flushes, or the ones that make you pretty red with a hot or burning feeling are the ones we need to worry about. I obsess about ALL pinkness, even if it's mild and I can only see it..not really feel it. I think "it's making my rosacea progress!" Should I stop worrying about that? I think I should, because when I see ANY pinkness, I immediately try to cool myself off. This would decrease my stress over my skin.. I'm thinking I only want to worry about decreasing the deep, hot, burning flushes I get maybe twice per week. Correct? I think your theory really makes complete sense. It follows basic physiology, and the notion that our bodies have natural compensating abilities - like negative feedback/positive feedback, hormones, blood pressure compensation, collateral blood vessel growth, heart rate, respirations, etc..it just makes sense. I'm very interested to see how folks do over time with the suggestions. Cheers! Artist"

AustralianSciences (Colin Dahl) wrote on March 9th, 2008: "Hi Artist and Quiller, Firstly Artist, you are correct. Concentrate on reducing the larger flushes. There's nothing wrong with being a little pink or red. Try not to obsess, you're increasing stress hormones, which cause more vasodilation and redness. Also, the deeper flushes (as you put it) tend to correspond with sympathetic nerves and the burning sensation with the more peripheral sensory nerves. They can act individually or together. But the burning component is a very troubling one. Maybe it will be easier to discuss ways of minimizing flushing and skin cell activity in real situations. Do you mind volunteering and telling us what causes your two flushes every week? Best regards, Colin Dahl Australian Sciences"

Artist wrote on March 9th, 2008: "Hi Colin: I'd say my big flushes occur for four reasons:
1) Early on many of my deep flushes were from "blushing" due to things like embarrassment, taking a test, interview, social situations, tense moments at work, etc. The beta blocker, Atenolol, has taken care of most of this problem. I still suffer from this type of "deep lasting blush" a few times a month maybe. I've considered talking to my doctor about increasing my dose of Atenolol, but I think it might lower my blood pressure too much. I do want blood going to my brain, after all ;) The Atenolol is amazing. I went from deep blushng every day, to just a few times a month or so.. Beta blockers curb the sympathetic "fight or flight" response. People often use them for "stage fright" for this very reason. They may feel anxious, but they don't appear anxious. No sweating or rapid heart rate, or blushing.. So, in my experience, beta blockers minimize sympathetic blushing.
2) Food. I flush badly to certain foods. Red wine, certain alcohols, aged cheese, most processed foods with large ingredient lists. I have to eat very basic. I had a semi-deep flush yesterday from the comination of a few drinks, lots of brie cheese, and slightly smoked chicken. We were also went on a long walk in 55 degree weather. I was talking socially with some new friends. The combination was what did it, I'm sure. So, avoiding food triggers helps prevent flushing, but it's a real pain and NO fun.
3) Skin being cool for a while, then going into a warm room, or especially eating at a warm restaurant. Last week I took my son to the park. It was about 55 degrees out. We were out for a few hours. We walked to a diner on the way home. It was probably about 75 degrees there. I didn't eat much while I was there, but I flushed big-time. It had been quite some time since that had happened. I had an IPL just a few days earlier, so my skin was still sensitive from that and I should have found someplace else to stop. Anyway, I held some cool wet napkins to my skin and the flush lasted maybe ten or fifteen minutes. When that happens, the flush does stop suddenly - just like you describe in your booklet. I wonder if attenuating that type of flush when it happens would help. Cooling the skin with a wet napkin might slow the release. Or, would it snuff out the release? Once the neuropeptide release starts, should you try to slow or stop it?
4) "Sudden Cool-Down" If I'm running around all morning, physically, while concentrating and focusing (I'm a nurse). After a morning like that, sometimes sitting in the lunch-room and eating my lunch brings on a deep flush. I think of it as the "sudden cool-down". That's been an issue for me off and on. Lately it's not bad, but there have been times when it happened every day. This will also occur if I do high-impact exercise - getting my heart rate up and sweating - something like running a few miles, etc. I don't flush during it - only afterwards while cooling down.

Of course, I flush if I get way too hot, but it has to be very hot. Maybe in the 90s and I'd have to be exerting myself at least moderately. Another one is deep concentration. I notice I breathe very shallow while concentrating deeply - reading, writing this email, etc. We know that, in general, you should avoid temperature extremes and wear a scarf on your face if the weather is cold. What we didn't know is what happens with skin infrastructure and that we may have the ability to reverse it. We didn't know that, by focusing too much on trying to stay cool all the time in order to avoid the acute trigger of "warmth", we could allow our infrastructure to build up over time. When we talk about improving rosacea long-term, the discussion centers around skin irritation. What can we do to decrease irritation and treat inflammation. Cheers! Artist"

AustralianSciences (Colin Dahl) wrote on March 12th, 2008: "Hi Artist, Thanks for your information. The flushing triggers you mentioned are all normal responses (just exaggerated in accordance with the level of your skin infrastructure). In regards to beta blockers, they can be very effective. In my own experience they initially did not give much benefit (due to my very excessive skin infrastructure). But later I was able to use them successfully when my skin infrastructure was less excessive. Apart from the dose or level of drug/neurotransmitter, I believe another reason for this comes back to how the body handles stress. The beta blocker drugs block one of the major stress induced vasodilation pathways. If your skin infrastructure is only moderately excessive then blocking this one pathway may be enough to prevent a stress related flush from occurring. However if your skin infrastructure is very excessive then blocking this one pathway may not be enough to prevent a flush. The body often has many ways of achieving important functions. One problem I found with beta blockers is that they caused dry eyes. I eventually replaced beta blockers with biological approaches to reduce the availability of blood to the facial region, thereby reducing flushing. In meetings where I thought a flush may occur, I initially tried to have the meetings in cool rooms. This in effect was constricting blood vessels in my skin and reducing the release of inflammatory chemicals (which can be a powerful opposing force to skin vasodilation). An additional approach was to have a large meal before the meeting. Regardless of which part of your body is experiencing vasodilation or vasoconstriction, overall you still have the same amount of blood in your body. So by having a meal before a meeting I was causing vasodilation in my digestive system, which forces vasoconstriction in the rest of the body (even muscles, which is why you feel tired after a meal meal). (Note Scarlet Nat: this is not the case for everyone! Digesting a large meal can for some rosacea flushers also create heat in the body by the digestion process and flare UP flushing in fact). 
Finally I adjusted the cool room approach by staying in a slightly warm environment prior to meetings, this automatically avoids large build ups of inflammatory chemicals including neuropeptides, so no matter what trigger was around the corner, you are well positioned to handle it better. By combining all of these flush reduction approaches (as well as others involving reducing skin cell activity) I no longer need to take beta blockers to prevent stress related flushes. Yes, it is good to cool the skin during a flush, especially early on to stop it progressing. Flushes cause changes to the skin (more blood vessels and nerves). However, I would like to make one point that is very important. Reducing flushes alone may not be enough to stop or reverse rosacea. Flushing is only one way the body uses to increase blood vessels and nerves. It has many others. For me additional factors were sunlight and skin irritation. You asked what you can do to reduce skin irritation and inflammation, well you can do a lot. Regardless of the actives or excipients, even the most basic moisturizer needs to have preservatives, which are irritants. I don't use topicals on my face, because I know they will irritate. The only thing I do is wash with soap (if you wanted to moisturize your skin you could use a moisturizing soap like Dove). If you use a moisturizing cream on the surface of your excessive skin infrastructure, then you will still have excessive skin infrastructure, but with softer skin. Best regards, Colin Dahl
Australian Sciences"

AustralianSciences (Colin Dahl) wrote on March 12th, 2008: "Australian Sciences has done tests to block individual neuropeptides (Substance P, CGRP, VIP, etc) to see what effect that has on reducing flushing. We saw that Substance P and CGRP greatly contribute to the burning sensation and delayed sensitivity. We've even done a lot of other non-neuropeptide tests, blocking Nitric Oxide and Nitric Oxide Synthase, etc. These tests were good to get a greater biological understanding of rosacea and flushing (and how the body works). However, a few years ago I felt (and still do) that this kind of approach is attractive to a pharmaceutical company but not to someone who wants to reverse rosacea. There are many neuropeptides to stop, and many other kinds of inflammatory chemicals to stop - you can't block them all, especially when you are producing more because of your excessive skin infrastructure. So we began to look into methods that could reverse the excessive blood vessel and nerve infrastructures, which contribute to the release of inflammatory chemicals in the skin. We tested about about two hundred growth factor inhibitors or anti-inflammatory compounds to see how well they worked against various stimuli, and did get some very good results. We also looked into blood vessel removal via IPL and further with flush minimization and reducing skin cell activity using the bodies own systems (such as heat regulation, neuropeptide storage/depletion and trigger avoidance). So I favor approaches that reduce skin infrastructure and skin activity (without specifically focusing on neuropeptide blocking drugs). I am not overly familiar with ND:Yag, I am with UV lights. But will have to talk about them next time. Best regards, Colin Dahl, Australian Sciences"

Stacey wrote on March 16th, 2008: "Hello Colin, Thanks for posting all the information. I can relate to a lot of what you wrote about. I was wondering if you would be able to answer my 2 questions: 1.I have read the post about the tingling sensation in your face/cheeks. I have this too. However, sometimes it gets even more uncomfortable than just tingling. This especially happens in cooler temperatures. The tingling is accompanied by a feeling cold sensation on my cheeks, as if you are aware of them being cold. It’s hard to describe but I hope I made sense. Is this related to the sensory nerves being overstimulated and reacting to the cold?? 2. Sometimes when I lay down on the bed or couch to rest or sleep I feel my face gets flushed (resting on an incline will still make me flush) . Sometimes it happens right away, sometimes in takes a few minutes, and sometimes it doesn’t happen at all. I didn't notice any relationship with temperature or time of day, just laying down or resting. Why does the act of resting or laying down induce a flush, any ideas? Thanks, Stacey"

AustralianSciences (Colin Dahl) wrote on May 24th, 2008: "Hi Stacey, The inner lining of blood vessels can sense extra blood flowing through them. The blood vessels respond by releasing chemicals (such as nitric oxide) to promote the blood flow. When you lay down, extra blood can flow through your head and face. This can then cause the extra release of these vasodilating chemicals to promote the flow, and may also lead to flushing. Reducing the excessive blood vessels structure in your flush zones through IPL/Laser should assist in reducing this kind of flush. The amount of flushing you experience is related to the amount of skin infrastructure you have. You're flushing less now because you have less of this infrastructure (especially less blood vessels after you IPL). You can continue to experience these light flushes and also continue improving your rosacea. In fact, activation of the skin infrastructure of your flush zones is normal and happens throughout the day in the form of heat regulation. So vasodilation of blood vessels in your flush zones is something that will continue to happen, whether you have rosacea or not. You may be noticing this vasodilation because your skin infrastructure is still excessive. As you reduce this skin infrastructure to normal (or close to normal) levels, the flushing/vasodilation becomes less apparent and you become unaware that vasodilation is actually happening (as with someone who doesn't have rosacea). This does take time and great effort to achieve, but it is very possible. So you can get to the stage where you no longer experience warm room flushes because your skin infrastructure has bee normalized. Or if you still have excessive infrastructure, then you can minimize warm room flush by avoiding neuropeptide & inflammatory chemicals build up. Having said that, if you continue to experience these warm room flushes, you should understand that your reversal of rosacea is likely to be slower. So try to take steps to prevent these kinds of flushes. These inflammatory chemicals can cause a flush but they also do good things for you too.
They even make up part of our immune system. So in one way you actually need these chemicals around. But the more you build up, the more gets released (like when a small trigger causes a large flush). It's difficult to quantify their release and storage because it depends on many factors (amount of skin infrastructure is a main one). If your flush zones stay in a cool environment for long periods (several hours), this will assist in inflammatory chemical build up in your flush zones. I think what you want to know is how long will this build up remain. The simple answer is that this is likely to be a contributing factor towards flushing for several hours after. The tingling sensation to cold (as with the extra blood flow when laying down) is a normal response, but in your case (and many others with Rosacea) it is a larger response. The response could even be described as a cool burning sensationThe reasons behind this tingling may involve the over-stimulation of sensory nerves, either directly or indirectly, or excessive sensory nerve innervation in your flush zones. Try to avoid/reduce cold environments. Generally you should try to prevent sensory nerve stimulation in your flush zones (due to cold, irritating topicals, sun, etc). By combining this approach with IPL/Laser to reduce blood vessel innervation of your flush zones, you will slowly notice a reduction in this kind of response. [..] We have had good success with natural ingredients such as Chinese Licorice Root and will soon be releasing a line of oral anti-inflammatory products to assist people with reversing Rosacea. Best regards, Colin Dahl, Australian Sciences."

Stringer1989 wrote on May 24th, 2008:
"Colin, thank you very much for your reply, it is very helpful. I have eliminated most other factors that can be bad for rosacea ( sun, foods,heavy exercise, mental side of things through propranolol etc) so the only factor of concern is really only temperature and temperature related flushing and symptoms. I am having difficulty determining whether I have too much infrastructure at the moment. I have already had 5 IPL treatments with the Lumenis one machine and I wouldn’t say that I've noticed too much improvement in my rosacea. The benefits from IPL tended to be only short term ones. You mention an indication of too much infrastructure is permanent redness. When I am normal (ie not hot and not cold) I have some permanent redness, but I have to be pretty close to the mirror to notice this redness, a few meters away from the mirror I cannot really see any visible redness. Would you say that this is not too much infrastructure or is it too difficult to say?
The reason I used to flush every day was because I was constantly putting cold water on my face and therefore during the day my face would be REALLY cold to touch and I would then flush in the latter hours of the evening, so I don’t know whether my flushing was caused by having way to much excessive infrastructure or just by the by the fact I was keeping my face way too cold during the day and this would result in an intense flush even if I had less infrastructure. Sometimes if I get really hot, I find that my nose and face are really hot, but it is not very red/flushed only slightly pinkish. Do you know what is happening here? Like is more blood vessels and nerves being developed and thus is it progressing my rosacea ? or should I not be worried about this? And lastly this is related to the question above, but i was wondering whether if you are constantly a bit hot and slightly red/pink in the face 24 hours a day, if this will help to reverse your rosaacea, compared to being cold during the day and then having an hour or two of intense red flushes later in the day?? Sorry to ask so many questions, it is just my rosacea has left me very confused and i have a lot of questions. Thanks heaps and best wishes"

AustralianSciences (Colin Dahl) wrote on January 20th, 2009: "Dear Stringer, I believe if someone becomes almost persistently flushed, then this is too much skin infrastructure to go directly into flush reduction programs (it's just too hard). In this situation IPL or laser treatment should deliver some much needed reduction in skin infrastructure and flushing. After this, following flush reduction programs become more realistic. Skin redness can change too rapidly to be a good indicator of Rosacea severity. Flushing gives a good indication of the level of skin infrastructure in flush zones. You don't sound like you are persistently flushed. And 5 IPL treatments sound like you gave it a good go. Keeping your face cold during the day could cause a flush at night even if you had slightly excessive skin infrastructure! (I'm not surprised your IPL benefits were short term). You don't need extremely excessive skin infrastructure for this to happen. You said previously that this no longer happens to you. So I would think you are well placed to continue with your flush reduction program and are on your way to slowly reversing rosacea on a daily basis, as opposed to the last few years where you were probably increasing your rosacea on a daily basis. The feeling of a flush relates directly to your skin nerves. The more they are activated, the more you FEEL the flush. The redness relates more directly to blood vessels and vasodilation. Although nerve and blood vessel activation often happen together and at similar intensity during a flush, it is not always the case.

Flushing is primarily responsible for progressing rosacea, but it's all relative to how much flushing & skin infrastructure you currently have! MORE flushing = more skin infrastructure, LESS flushing = less skin infrastructure. Sometimes it is difficult to avoid a flush. But as you gradually reduce your excessive skin infrastructure it does become easier. Don't worry whether one flush has progressed your rosacea. You have to think of reducing your overall flushing (duration and intensity). Say on a weekly basis or even a monthly basis. You don't need to go from 10 flushes a week to 0, in order for you to reverse Rosacea. But having said that, the more flushing (and inflammation) you can reduce the faster you will reverse rosacea. Also, one intense flush is not equal to a minor low intensity flush. If you could replace 10 major flushes a week with 10 minor flushes, you would be well on your way to reversing rosacea (less skin infrastructure in flush zones).
To answer the last part of your qn: YES. I believe that spacing out a flush (slightly hot, red) over a day would cause less angiogenesis than one big flush. If this were not true, then I would still be red as a tomato. Best regards, Colin Dahl, Australian Sciences"

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