Seborrhoeic dermatitis (seb derm) - in combination with rosacea

A lot of patients with rosacea, also have to deal with a coinciding skin condition called Seborrhoeic dermatitis, in short seb derm. I also have this annoying ailment and it primarily raises its ugly head in winter for me. I'd say I have no issues with it at all for 3/4 of the year; only during the cold periods. Which can be quite long lasting in Holland.

Seb derm is a common skin disorder

that mainly manifests itself on the scalp and facial T-zone (forehead, eyebrows very often, sides of nose and mouth), causing scaly, itchy, red skin and stubborn dandruff. Seborrheic dermatitis can also appear on the scalp or affect the upper chest, back and other areas of your body that have many oil (sebaceous) glands. On the scalp, seborrhoeic dermatitis usually causes roughly defined, dry, pink or skin colored patches with yellowish or white bran-like scales. Its shedding can resemble dandruff. In winter, I can bend my head forwards for instance and rub through my hair and over my scalp and it causes a lot of fine, white-grayish flakes to rain down. 

In the eyebrows and the creases beside the nose, seb derm can cause greasy textured, often yellowish flakes to build up. For me, these flakes start to look fatty and scaly when I don´t rub them off within a certain amount of time. In summer this isn't a big deal, but in winter the seb derm causes my (rosacea) skin to turn scaly and rough and red. This makes the skin around my mouth and on the inner cheeks and in the eyebrows stand out in color, and it looks quite sickly if you ask me. The cause of seb derm isn't fully understood yet, as far as I can tell from the information that´s out there online and from the dermatologists I´ve seen. What I understand is that seb derm might have an underlying autoimmune component to it. The skin responds badly to a common yeast that lives on it. This normal skin inhabitant is called Malassezia (formerly known as Pityrosporum ovale). Patients with seborrhoeic dermatitis appear to have a reduced resistance to the yeast and the toxic substances that it produces. Unlike in healthy people, it creates inflammation and skin irritation in us seb derm patients. An overproduction of sebum is also mentioned as a cause and there is an increased turnover of shedded skin (hence the flaking). In some cases, the seb derm is actually a precursor of psoriasis... 3-5% of the population has seb derm and it occurs more often in men than in women. Low immunity, stress, cold and dry weather and some foods can exacerbate the seb derm. It often runs in families.

Treatment options

• Ketoconazole cream or shampoo (1 or 2%)
• Nizoral cream or shampoo
• Zinc pyrithione shampoo
• 5% sulfur / 10% sulfacetamide lotion and or wash
• Lamisil cream
• Salicylic acid
• Ciclopirox cream / ciclopirox olamine
• Elidel or Protopic cream (pimecrolimus cream or tacrolimus ointment).  
• Hydrocortisone or steroid creams (Note: I would absolutely warn against this in case you also have rosacea, as it might stir up or worsen the rosacea).
• Tar cream can be applied to scaling areas and has to be removed several hours later by shampooing.
• Severe cases may receive a course of tetracycline antibiotics, oral antifungal medication, or sometimes ultraviolet radiation. 

Over-the-counter    
Dermol
Betadine
Selenium disulfide
Climbazole
Piroctone olamine
Clotrimazole
Sulfur

Prescription
Sodium sulfacetamide
Terbinafine
Fluconazole
Itraconazole

There are also more natural treatment options, including raw honey and virgin coconut oil. Some people use apple cider vinegar or tea tree oil on their seb derm and find it helpful. Watching your diet and avoiding foods with a lot of yeast (such as certain breads), high levels of simple sugars and certain fermented foods, also helps some patients. Dairy products might also add to the problem for some. On the other hand, some other foods have been mentioned to help combat the seb derm, including garlic (anti fungal and anti inflammatory), coconut oil (idem) and probiotics. I would personally forget about steroid creams and focus on antifungal creams. They are both available OCD and on prescription. Steroids can cause rosacea, thin your skin and on top of all that steroids don't tackle the yeast issue. A steroid cortisone cream set off my rosacea out of nowhere, so I wouldn't even touch it again personally. Also, the steroid cream might clear your seb derm initially, because the steroid is stopping your immune system from attacking the fungus that causes seb derm, plus it works as a strong anti-inflammatory. But once you stop the steroid, your immune system goes right back to work, creating inflammation to protect the body from further injury caused by pathogens so you are back to square one. A cream like ketoconazole is in my view safer and just as effective, if not more. It kills the Pityrosporum ovale.

Photos of seb derm

 

Selsun Blue

Some people with rosacea - especially those with redness and skin outbreaks and pimples - but also those with seb derm, mentioned that washing their face with Selsun Blue shampoo helped them control their skin symptoms. Selsun Blue is a line of shampoos used to treat dandruff and other skin conditions. It is available over the counter and in a prescription-strength version as well. It contains selenium sulfide as the active ingredient. Selenium sulfide is an antifungal agent, which may be helpful in treating the skin yeast infection tinea versicolor, scalp ringworm (tinea capitis) and athlete's foot (tinea pedis). Selenium sulfide is also effective in treating seborrheic dermatitis because it slows the overgrowth of skin cells involved in this condition. Selsun Blue's medicated formula contains not only selenium sulfide, but also menthol which is the main active ingredient in peppermint. Menthol has cooling, calming and numbing effects and may soothe irritated skin and stop itching, unless of course your skin is too sensitive for it (then it can irritate in fact). Trial and error..

Selsun Blue Naturals
Selsun Blue is available in a moisturizing formula as well as a shampoo, called Selsun Blue Naturals. It contains botanical ingredients to moisturize hair. Selsun Blue Naturals contains the active ingredient salicylic acid rather than selenium sulfide. Salicylic acid promotes shedding of the skin's top layer, so the shampoo can wash away the dead skin cells that make up dandruff. Botanical ingredients for moisturizing effect include aloe, chamomile and lavender extracts.

Selsun Salon
Selsun Salon is another anti-dandruff shampoo. This one contains the active ingredient pyrithione zinc, which slows the excess production of skin cells, thus relieving and preventing flaking and scaling of the scalp caused by dandruff or seborrhoea. Active Ingredient - Selenium Sulfide 1% - Purpose: anti-dandruff. Inactive Ingredients: Water, Ammonium Lauryl Sulfate, Distearyl Phthalic Acid Amide, Ammonium Laureth Sulfate, Sodium Chloride, Cocamide MEA, Dimethicone, Aloe Barbadensis Leaf Juice, Hydroxypropyl Methylcellulose, Sodium Isostearoyl Lactylate, DMDM Hydantoin, Fragrance, Citric Acid, Sodium Citrate, Titanium Dioxide, Blue 1.

For me, ketoconazole cream does the job

I use ketoconazole 2% and find it very effective in controlling (and in winter limiting) my seb derm rashes nowadays. Because of my very delicate and sensitive, flushing prone rosacea skin, I normally can't even tolerate a neutral base cream (I use nothing on my skin normally). However, my cheeks are the most sensitive and the seb derm usually shows up around my nose and mouth folds, where my skin can handle the ketoconazole 2% cream. My pharmacist makes a special cream however. Regular ketoconazole cream contains alcohol and a preservative, which both seem to irritate my skin. So my pharmacist makes a special cream with 2% ketoconazole in a cetomacrogol base cream (almost like a wax) without any preservative. It also contains no alcohol. I can store it in the fridge and get a new one every month. My cream contains the following ingredients (30 gram tube):

-Ketoconazolum 0,600 gram
-cera cetomacrogol emulsion 4,500 g.
-decylis oleas (cetiol V) 6,000 ML
-aqua purificata bag in box 17,700 ML
-Sorbitol 70% crist 1,200 ML

I only get the seb derm on my T-zone. I usually get flakes that look a bit greasy and that I can 'scrape out' of my eyebrows easily (yes, yuck!). They can also show up on the bridge of my nose and in the folds next to nose and mouth. I can usually remove it with a cotton pad. The seb derm flakes have a very light yellowish tone and greasy substance. I use this ketoconazole cream for most of the winter and it limits the seb derm for me once I start using it. It doesn't set off my rosacea either. I get no stinging from it. For those with both rosacea and seb derm, perhaps your pharmacy wants to make a similar type of cream as well. I use the cream every night or when needed on the affected areas on the T-zone, nowhere else on my face. Like steroids, the ketoconazole won´t address the entire cause of the seb derm, but it is a lot less harmful for our sensitive skin and it will limit the existing yeast in the treated areas, thereby limiting the subsequent skin response and stopping the vicious cycle. By doing this, I am able to be symptom free for most of the year (except for very stubborn eyebrow flakes) and I limit the seb derm outbreaks to the harsher months of winter now. The following pictures were taken during a bad seb derm year, the winter of 2010 when I didn't use the ketoconazole cream yet. The white dots are metronidazole cream and zinc cream; I was silly enough by then to think the metrocream would work for everything rosacea related. But it never worked for my rosacea and has the opposite effect of what we need in seb derm (we need an antifungal and this one does the opposite and kills certain bacteria, which will only make the yeast issue a bigger one).

Be careful with antibiotic creams or pills when you have seb derm

Treatment of seb derm is ideally a cream or shampoo or pill that kills off the yeast (fungi). Not kill off skin bacteria. Fungi and bacteria are normally living in harmony and balance with each other on the skin. Killing off one makes the other stronger. When you have seb derm, you have an overgrowth problem of yeast fungi; by attacking the skin bacteria with standard rosacea treatments such as metronidazole cream or doxycycline or lymecycline pills, you make the yeast even more disproportionately strong. And that is not what someone with a fungal problem needs, as it will make the seb derm problem probably worse. Because seb derm is a fungal-sort of yeast infection, you need to treat it with antifungal medication; ketoconazole cream is great, OTC Lamisil may already work (but ketoconazole is better) or Nizoral shampoo can help too. For bad cases derms can also on top of that prescribe an oral antifungal. For anti-inflammatory effects, I was prescribed the non-steroidal cream Elidel, instead of a cortisone cream (which I do not want to use, because of my underlying rosacea). 

Eyebrows versus seb derm

Ever since I developed rosacea and seb derm, I have slowly but surely lost a good part of my eyebrows. Mine got thinner and thinner over the years, and when I clean my eyebrows thoroughly with a cotton pad, I always see loose hairs from the eyebrow coming off too. But it's not as if they fall out with the slightest touch. I got my thyroid tested several times, but it s levels are fine and the eyebrow loss is not related to this. In fact, they found nothing else in blood tests to explain it, and blame it merely on the rosacea and seb derm (and possibly on some other autoimmune issues I have). Right now,  the outer parts of my brows are almost invisible. There are hairs there, but they are light in colour and not enough in quantity to make the brow look normal and continuing. I also lost a great amount of eyelashes. I don't use any make-up normally, but the past years I really started to get annoyed (and sad) with my bloated, red cheeks (from rosacea and medication) and the sickly looking bare eyes and half decent eyebrows. Mascara makes me flush badly (I know this sounds ridiculous as the mascara doesn't even touch my skin, but believe me, I love my mascara and there is no way anything but bad flushing and burning would keep me from using it). But I found a great solution. I now grind charcoal into a fine dusty substance, dip my finger into it, make sure I have a little bit left on the top of the finger. Then I bend forwards (so that the dust doesn't powder all over my cheeks), have a hand pocket mirror and use the black powder to make an eyeliner type of line on the eyelid and to fill in the eyebrows. Looks great!! And it has a great color; black but more natural than the synthetic shiny black from regular make-up. No flushing, no burning and I leave it on for a week, then remove what's left and redo it the next morning.

I think it's important to keep your skin clean when you have seb derm, but I am unable to tolerate any facial cleansers. So I wash my skin with glass bottled water with cotton pads and not even every evening, since my skin is very dry. I really wondered how it is possible to have a skin as dry as mine, yet to suffer from (local) sebum overproduction :/ I read that it happens to more people though. I have a very strange thing happening after some time, where the flushing threshold seems to go up when my epidermis builds up and becomes a bit thicker over time. But after some weeks, you can actually see the dead skin piling up on my face when looking closely. At some point I need to clean and scrub it clean. Which leaves my cheeks pink/red and scrubbed basically. And the cycle of rebuilding a dead skin layer starts all over again. My skin looks best and my flushing is least about midway this cycle. I´ll try to add some pictures to illustrate this, as it is an odd thing to explain. I am still unsure if this extra layer of dead skin is a good thing or not for me. But Professor Chu told me to scrub every month at least, as dead skin layers can cause skin outbreaks and inflammation.

Differentiating rosacea from seb derm

Differentiating rosacea from seb derm can be tough. Seb derm can aggravate rosacea when you have to deal with both of these charmers, so it might be a real catch 22 to sort the one out from the other. Both deal with red skin and rough skin texture. One of the real differentiating aspects of rosacea is the on and off redness. Rosacea tends to flare easily and when you feel flushed and hot from specific triggers (alcohol for instance, certain foods or hot rooms) then it is likely that rosacea is at play. Rosacea also takes quite a lot of years usually to cause the skin to become more permanently rough, red, raised and swollen. Rosacea tends to flare in the sun, whereas seb derm might benefit from it. The scaling, flaking and more persistent redness on the T-zone of the face, that can't be cooled down with cold temperatures within hours, might indicate seb derm. Seb derm is easier to treat than rosacea usually, and its symptoms can rapidly decrease with treatment. Seb derm favours the forehead, eyebrows, nose, mouth and inner cheeks. Whereas rosacea usually manifests itself all over the cheeks, and sometimes also on the nose and chin. Some doctors are quick to rule out rosacea in favor of seb derm, because of young age of a patient. But this is an outdated perception, as rosacea can hit patients at a young age in fact. Seb derm can also cause burning of the skin, but it's not common for that to happen, whereas rosacea definitely makes the skin feel sore and painful and hot and burning when it flares. Seb derm might itch and will feel and look irritated. For me, the seb derm also brings on some paps and little acne like bumps often. Especially on my forehead. 

One way to find out if you have active or underlying seb derm, is to apply ketoconazole cream to a small area of the affected skin for some time, and to see if it clears up. With both seb derm and rosacea, you should look into very gentle skin care products. Harsh ingredients and fragrances can irritate the skin even more and worsen both. Try to find something hypoallergenic and oil free (oily products tend to make both seb derm and rosacea worse). Oral or topical antibiotics help some rosacea patients (as they act as anti inflammatory meds) but usually make seb derm worse. The killing of bacteria will make the yeast population more powerful and the yeast is the culprit in seb derm. Both seb derm and rosacea can benefit from a diet low in sugar and processed foods. Picture left is seb derm, picture right is rosacea.

Here are some of the quite bleh looking close ups of the sebum/skin flake buildup I was talking about earlier

My skin doesn't shed dead skin cells normally. Dr. Chu (my derm.) also explained me this the last time I saw him; some rosaceans have compromised skin barrier function, meaning the dead skin cells don't just naturally fall off, but instead keep building up and up. For a while, this seems to make my rosacea less reactive, as it gives some sort of protective layer if you like. But after a certain time, I can notice the build up gets too much. It still looks kind of normal, but up close you can see there is too much of dead skin layer. And usually by then my skin starts to feel tight, starts to itch, traps heat and starts to burn and flush more therefore. And mostly; p&p's can start to form all over my cheeks. I normally do not have p&p's. Dr Chu said I need to scrub my skin, or clean it very thoroughly, because this dead skin cell build up can act as a breeding ground for inflammation. I do this eventually, but I kind of like the initial dead skin build up as it masks the redness and seems to protect my skin from strong wind etc. But after a given time, usually a week or 3, maximum 4, I notice p&p's and my skin feels tight and it needs a good scrubbing. I don't think normal skin gets that like this. This extreme I mean. The photos below show this process. See more pictures of my (seb derm/rosacea) skin in winter in this blog post. 

Before scrub

Before scrub

 Showing the skin buildup before 

and right after removing it

 Day after the skin cleaning

 Second day after skin cleaning 

Third day after skin cleaning

Patient testimonies on seb derm (versus rosacea)

Panasonic wrote: "I have very weak Seb Derm since one year now (I am 22 now). You can see nearly nothing from the outside. I have only very small scales around my nose, overlip beard (sorry I'm from Germany, I don't know every word) and in my eyebrows. But they are really small and not many. Only rarely some small parts of my skin get red. But most of the time, my skin looks totally normal. I am very thankful that my Seb Derm (two dermatologists diagnosed it) is so weak. BUT!!!! My hairs are falling out, although slightly. My eyebrow hairs are falling out regularly, which makes me sad and angry because I love my eyebrows. And my mustache also started falling out this winter. The hair grows  back but I desperately want to stop them falling out because I'm terrified that the bald parts get bigger. I don't understand. Why is my Seb Derm so weak [mild?] but my hairs are still falling out? I hate this so much because creams and cider vinegar only help for a short time. Then they start falling out again. I read that this virgin coconut oil and raw honey therapy works good?! Do you think it can stop my hair loss or do you have any other tips?"

Desperado wrote: "I have had this for 6 years now... What have the docs prescribed for you... hydrocortisone 1% or a more powerful steroid? Do you have white sebum plugs in the eyebrow pores as well??? When it first began for me I didn't have visible plugs, just little scaling as you mention. But with time the disease modified its form to thicker and drier scaling, from being oily scales initially. Also the plugs now are harder and drier, like rice grains and nearly all the pores of both the eyebrows are affected. This year I also notice it's spreading to the forehead where I'm getting bits of scales and the plugs. I have tried Zinc pyrithione... it controls it a bit by delaying the scaling, but does not touch the plugs!!! [...] I have tried oral antifungals and they have not helped. Selenium sulphide and ZNP just make the condition more dry and there is minimal difference, if any. Doctor did a skin scraping of the brow area and did not find demodex." 

And: "There are many theories behind why it does what it does... From it being an autoimmune disease and attacking healthy cells just as it would attack foreign anything, owing to wrong body signals being sent with possible links to high stress or anxiety levels, to genetic predisposition etc etc. Lot of skin diseases look alike and very often can get misdiagnosed. Even all derms do not concur on their diagnosis. Ex: sebopsoriasis and psoriasis are close cousins, yet different. Not to scare anyone, but there is theory that if seb derm is left untreated for long, it has the potential to turn into sebopsoriasis." "Focus on improving your diet so that your eyebrow roots can regain some strength or have possible regrowth. Lower your carbs intake and increase your green vegetable intake. Do you eat a lot of sweets?? Drink lots of water and since you are prone to Crohn's... definitely add probiotics to your daily routine. 80% of the immune system is controlled by the condition of the gut. Unfortunately there is no quick remedy for seb derm hair loss but doing the above things will control the condition much better."

Breanne wrote: "I was diagnosed with Crohn's Disease in August 2012. As of October 2012 my hair started to fall out, then in December my eyebrows and lashes began to fall out. I had blood work done and was diagnosed with a zinc deficiency so I have been taking supplements for that. I recently went to the dermatologist due to the hair loss and the severe dandruff I have in my hair and eyebrows. She diagnosed me with dermatitis. I am just wondering, can dermatitis make your hair, eyebrows and lashes fall out? My scalp hair loss has slowed down since starting the zinc supplements but not my eyebrows or lashes. When the brows and lashes fall out there is white on the tip of the hair. Is this permanent? The dermatologist prescribed me cream to put on my eyebrows twice a day. The dandruff in my eyebrows is very thick and yellowish. I read that coconut oil can help regrow eyebrows. I am so worried I'm going to lose all of my eyebrows!!"

And: "I am having the exact same problem!!! I was just diagnosed with seb derm. I get thick yellowish dandruff in my eyebrows and scalp. Eyebrows are drastically falling out when I wipe away the dandruff,, they even fall out without touching them. The root of the eyebrow has white on it. Dermatologist prescribed me the cortisone cream but I find it makes my brows even more itchy. Why does the seb derm cause the eyebrows to fall out???? I am so scared I'm going to lose all of mine as they have become so thin :( Has anyone tried the coconut oil? I am willing to try ANYTHING at this point. The hair on my scalp was also falling out really badly for months, it has seemed to slow down quite a bit but now I am left with only about 1/3 of the hair I used to have :( I am only 25 so this is taking quite a toll on me. Any help would be greatly appreciated!!"

I replied: "I have a similar problem. The hair on my head is not falling out and is normal, but over the years I have lost at least half of my eyebrows (only inner half is there, the rest I fill in with charcoal now, which looks pretty natural from a distance). Eyelashes have become much, much less as well. And I also get the dandruff-like issue with my eyebrows. In my case it's seborrheic dermatitis. I use a cream (ketoconazol) for it and it's probably also the rosacea and facial inflammation that plays a role for me. I have found no way yet to make the eyebrows grow back :( Have been tested many times for thyroid issues (as they can cause the same symptoms) but no. Don't have lupus either but I do have a bowel inflammatory disease, but not Crohn's (I have lymphocytic colitis)." 

Breanne later wrote: "Thank you for your reply Nat. I believe it is seborrheic dermatitis I have as well. The cream the dermatologist prescribed me is hydrocortisone, not sure on the spelling. My outer eyebrows are definitely falling out worse then my inner brows. I just touch them and they fall out. Sometimes they fall out without even touching them. Are yours like that? I am so scared I'm going to lose them all  :( I read online that seborrheic dermatitis can cause thinning. Do you have the dandruff on your scalp too? Mine is like a thick yellowish dandruff, its gross! I just had more blood work done last week to check my thyroid. I do have a zinc deficiency which can cause dandruff and hair loss. I've been taking supplements for over 2 months now but its still happening. Dermatologist said supplements can take up to 6 months to work, so fingers crossed! I don't think I have been tested for lupus.. is that done through blood work? I am paranoid I have alopecia and its really scaring me: ("

I replied: "If you have seb derm, you usually get flakes that look a bit greasy and that you can 'scrape out' of your eyebrows easily. They can also come on the bridge of your nose and next to your nose. You can usually remove it with a cotton pad and see a very light yellowish tone and greasy substance. If that's what you have, then hydrocortisone is not the right cream. The problem of seb derm is more of a yeast/fungal type of microbe and what helps is a cream called Nizoral or ketoconazole or Lamisil; all the same type of cream by the way, but slightly different. Hydrocortisone is a anti-inflammatory and lowers the immune response of the skin. Although seb derm does have an autoimmune component, it is the yeast aspect that you need to tackle. No, mine got thinner and thinner over the years, but when I clean my eyebrows thoroughly with a cotton pad, I always see lose hairs from the eyebrow coming off it. But it's not that they fall out with the slightest touch. Have you been tested yet on your thyroid? It's a simple blood test and they actually should always test you on this once you are losing eyebrows. Yep, I have dandruff on the scalp too. Not too bad but when I scratch my forehead or scalp, there are lots of white dry skin cells coming loose, lol it can look like snowy powdery sugar :) I don't have a problem with this and wash my hair every 3rd day with neutral anti-allergy shampoo. Overwashing (every day) usually worsens matters, oddly. There is special shampoo for this, called Nizoral shampoo, but I don't use it because I get flushed easily from it. But I have pretty bad rosacea. If you don't, I would definitely give it a try. I don't know about supplements, but the ketoconazole or Nizoral cream is really the thing to try when you have seb derm. Not hydrocortisone. And I wouldn't rely on supplements just yet, and first try the special creams for this problem. Also try to limit your sugar intake and try to avoid yeast products (bread for instance) for a while perhaps as they can worsen the seb derm."

Johnabetts replied: "There is a very common form of seborrhoeic dermatitis in infants colloquially called cradle cap. It can look quite severe and distressing to the child, but it does not seem to affect them much. The point of this post is to direct sufferers to the Wikipedia entry for Cradle Cap. where you can find a number of remedies for the condition. An old fashioned but effective anti-seborrhoea/ antifungal composition is Whitfield's Ointment (Compound Benzoic Acid Ointment) still available (at least in the UK) at very low cost. It does contain salicylic acid which will get the "anti-salicylists" here in a tizzy but it must be remembered that adverse reactions to salicylates are relatively unusual."

Judworth warned about the possibility of underlying thyroid problems: "I have hyperthyroidism and my partner has hypothyroidism, hair thinning (especially at the front) is very usual for hypothyroidism, as is losing the outer third of brows. You mention hoarseness (another symptom), do you feel as though you are 'wading through mud' emotionally & physically too? Extreme tiredness despite sleeping for hours on end is another."

Kelemvor replied: "I think I had a seb derm component and remember losing some eyebrow hair. Pyrithione zinc helps the seb derm component, but worsens my rosacea symptoms. I think it pretty much cleared up the seb derm component without worsening my rosacea (improving slightly) when I started using coal tar 2% ointment. I lather it on my face for a few minutes and wash it off twice about every 1.5 weeks. Skin is slightly pink the next day but helps put everything into remission and helps texture of skin. I'm pretty sure I stopped losing hair when I started that routine. I also use a coal tar shampoo on my scalp. Everybody is different but see if it helps."

Angelstar also has seb derm that makes her eyebrows fall out and writes about it here.  

Seb derm and having a burning face and red rashes at inner cheeks

Sparrow-legs suffered from seb derm and rosacea issues this winter and wrote: "Hi. I have had rosacea and seborrhoeic dermatitis for several years now (I'm 26) and it has been pretty well controlled with diet, antibiotics, occasional ipl and red light. However for the past 10 days or so I have woken up with really red, BURNING cheeks despite not having changed anything. I am getting really distraught. I am having a lot of trouble sleeping because I am so anxious about what is happening with my face. I thought I was finally moving in the right direction, and I was content in life... And now I feel like doing something stupid." 

And: "I thought that this started out as a seb derm flare, because I had the typical itching, burning and flaking down the creases by my nose, eyebrows, mouth, chin etc. Clotrimazole didn't do anything, so I put a little hydrocortisone on, and the flaking and rawness cleared up. But every morning for the past 10 days or so, I have been burning quite badly on both of my upper cheeks. I wondered if I was allergic to something in the clotrimazole cream, but I haven't used that for a week and no improvement. I tried sleeping with a fan, I think it just kept me awake and made it worse. I think the cold weather is the factor that started all this." 

Phlika also experienced worsened seb derm during the cold and wrote: "Sorry things have taken a downturn but you aren't alone. My skin turned really bad a few weeks ago, which I have put down to dreadful cold weather and too much sugar. For me the flair was seb derm related and it made me burn every afternoon at work for about two weeks. Could it be a seb derm flair for you too? It has been such a long cold winter/spring. But it will pass and it really shouldn't leave any permanent damage." 

Melissa W also experiences seb derm flares in winter and wrote: "Hi there Sparrow, so sorry you are experiencing a flare. It has been a rough winter/spring-so dry and cold. Hang in there and your flare in symptoms surely will pass. Try to take things one day at a time, be gentle with your skin and kind to yourself and I know your symptoms will ease. I know how you are feeling and sometimes our thoughts get away from us and go to scary dark places... don't be afraid to lean on your bf (and ofc us) at this difficult time. [..] Sparrow, forgive me because I cannot remember the details of what you might have tried in the past but have you ever tried Auburn's raw honey/virgin coconut oil treatment for seb derm? If not perhaps you can read her sticky here and see what you think."

Patient testimonials and tips to treat the seb derm

Jeff found that a combination of Butenafine, probiotics, garlic, Caprylic acid and Sovereign Silver helped with his deb derm. (Note, be careful with Colloidal silver). Johny battled his seb derm with an anti-candida, low carb diet. Dryfairskin also posted about his/her seb derm problems. There is a reference in this post to the Warm Room Flush (I also wrote a blog post about the Warm Room Flush theory). A very interesting read on how being in a room that's too cold, might stir up your flushing and lower your flushing threshold. Australian research.

These are pictures which show my seb derm, as well as the slight discoloration I developed around my mouth from the seb derm 

I didn't want to make pictures at the time, when it was a lot worse, but people actually commented on how yellow my mouth and chin area looked :( In the first picture you only see it slightly, and I also used to put a bit of pale powder on my chin and upper lip at the time to mask it. I remember also having very scaly, yellowish flakes and at some point I thought I would just damage my skin by scrubbing them off and I left them alone. I was waiting at the bus stop one day and a nice older man started talking to me and said I really had some skin problem going on. I was so shocked he said that and acted all laid back, as if I heard that all the time. He said my skin looked scaly. Internally I was so stressed out and as soon as I got back home I did a thorough scrub of my skin. Low and behold, I just had overdone the 'don't wash your face' phase. My dermatologist also unraveled the mystery of the orange tint of my skin back then: I was eating too many carrots! He suggested it and right away dismissed it, out loud. Stating that I would have to eat so many carrots for that to happen... not likely. I had to interject and ashamed admit that I ate green peas and carrots literally Every Single Day at the time haha. Once I heard this theory and stopped eating carrots, the orange/yellow tint slowly disappeared. 

 

 

Update May 21st 2014

Redfacegirl wrote on the Rosacea Forum:
"I hate going out outside, I always feel like people are staring at me and it just makes my anxiety so much worse. I also have light sensitivity, my computer screen/tv screen bothers my skin too. A couple months ago, every time I went on my computer the screen would make my face flare up so bad that I felt so sick and it was on a low setting of brightness. I went to the eye doctor last month and she told me my eyes are very dry. I have a heat intolerance too, which sucks because the weather is getting hot now. I would love to go back to school and be a normal teenager but my skin keeps getting worse. I never thought skin would have this big of a impact on my life and become my worst enemy. I have rosacea and seb derm but I can't find anything that helps really. My brother told me today my skin looks red, brown and yellow and I wanted to throw up just thinking about how disgusting I look all the time. I feel so embarrassed that I look like this and I don't feel like there's much hope. Even the tiniest bit of improvement would make me so happy and grateful."

I replied: "Poor Redfacegirl :( Just on a side note, have you ever tried ketoconazole for your seb derm? I have pretty severe rosacea on top (and only have seb derm issues in the cold winter months mostly), but my pharmacist makes an ultra neutral soft cream base for me, of cetomacrogol; a neutral pharmaceutical wax like substance. And they leave out any preservatives, so I can store it in the fridge for one month. They add 2% ketoconazole to it. The normal ketoconazole (for seb derm) has alcohols etc to preserve it and make it penetrate the skin easier, but I find my cream to be just as effective and it won't burn my skin. I only use it on the T-zone when needed, which is less sensitive than the cheeks anyway. If you want to try some let me know, I can spare one tube I think (it's sealed and the one month expiry date starts as soon as you puncture the sealing). Maybe it helps you to control the seb derm, which in turn might control the rosacea? And if so, maybe you can find a pharmacist who can follow this example? I remember being 22-25 and having the same issues as you describe; discolorations, brownish, yellow, orange even, around my entire mouth and T-zone. It looked bad and it burned. Now that I treat the seb derm, my skin tone is more even (albeit sometimes red, but when the flush has stopped, my skin looks fairly normal again). Let me know if I can help. Also, perhaps try to cut down on sugars and yeast, at least for a trial period? I find they really worsen my seb derm. On topic; I'm so sorry for each and everyone here who has to sit inside so much and often unwantedly :( It's fantastic that this forum exists and we can find people in a similar predicament. Best wishes Nat"

I found a good suggestion on The Rosacea Forum for the red rashes and falling out of eyebrows
"I went to my GP about it again last month and all we thought it could be was thyroid disease. I had been tested on them in the past already twice, always normal blood results, but we tested it again some weeks ago and again, all was normal. I still have about half my eye brows missing and what I find most typical about it is that the place where the eyebrows are supposed to be, there is a vague red rash. A red hue almost. The suggestion was made here that it can be Ulerythema ophryogenes. Its other name is Keratosis pilaris atrophicans faciei. I knew about that one, as a friend of mine has it on his arms: little small red dots, rashes, especially in summer. And there are a couple of long term members on the forum who have it as well, it gives a more constant redness to the cheeks. I discussed it in this blog post (or look below, I'll copy paste the part about KPRF).

So this is what eyebrows of such patients can look like 

My own eyebrows look exactly like that often! [Photo from 2023] Indeed with the red strip and rash in or above the missing part of the brow. I usually put zinc oxide on it, to mask the redness a bit. I am not sure if I could have KPRF... I have seen many good dermatologists and my symptoms are always attributed to rosacea. My skin can look pale, until a flush comes up, it's typical rosacea in many ways. But I do get the KPRf chicken pox thingies on my arms and legs at times. And the eyebrows look identical to mine! Which make me doubt again now, whether there might be a little overlap perhaps in those specific eyebrow symptoms. Both are inflammatory skin diseases, both might even have an autoimmune component to them, we don't know that yet but I personally suspect they can, in some cases. 

Keratosis Pilaris Rubra faceii

Keratosis pilaris (KP, also follicular keratosis, lichen pilaris) is a common genetic follicular condition, that produces  rough, slightly red bumps on the skin. It most often appears on the arms, but can also occur on the thighs, hands, and tops of legs, sides, buttocks, or on any body part except for the palms of the hands or the soles of the feet. Often the lesions will appear on the face, which may be mistaken for acne. Keratosis pilaris results in small bumps on the skin that feel like rough sandpaper. They are skin-colored bumps the size of a grain of sand, many of which are surrounded by a slight pink color. They are seldom sore or itchy. They occur when the human body produces excess keratin, a natural protein in the skin which is cream colored. It surrounds and entraps the hair follicles in the pore. This causes the formation of hard plugs. Doctors can often diagnose keratosis pilaris simply by examining the skin; tests are usually not needed. According to wiki, KP affects worldwide an estimated 40-50% of the adult population and approximately 50-80% of all adolescents. It is more common in women than in men, and is often present in otherwise healthy individuals. The skin condition is prevalent in persons of all races. Although keratosis pilaris may manifest in persons of any age, it usually appears within the first decade of life and is more common in young children. In most cases, the condition gradually improves before age 30, however it can persist longer. There are several different types of keratosis pilaris, including keratosis pilaris rubra (red, inflamed bumps which can be on arms, head, legs), keratosis pilaris alba (rough, bumpy skin with no irritation), keratosis pilaris rubra faceii (reddish rash on the cheeks), and related disorders. Because of the resemblance with rosacea, I will focus on this last subtype.

Treatment

Wiki states that keratosis pilaris is harmless and that medical treatment is not necessary. Many patients do however look for treatment, because of the cosmetic appearance of KP. Topical creams and lotions are currently the most commonly used treatment for keratosis pilaris, specifically those consisting of moisturizing or keratolytic treatments, including: urea, lactic acid, glycolic acid, salicylic acid, tretinoin, Vitamin D, or topical retinoids. Steroid creams can also be used to reduce redness. (NOT to be used when you have rosacea though!). However, the effectiveness of these treatments is limited and research to discover more effective treatments is ongoing. Improvement of the skin often takes months and the bumps are likely to return. Taking long, hot baths followed by exfoliating the affected areas with a coarse washcloth or stiff brush may help unplug pores and therefore can also be used as a treatment method. Some cases of keratosis pilaris have been successfully treated with laser therapy, which involves passing intense bursts of light into targeted areas of the skin. Depending on the body's response to the treatment, multiple sessions over the course of a few months may be necessary. Note that most of these treatments can be detrimental to underlying rosacea, in case you suffer from both conditions. Steroid creams are not recommended when you have rosacea and long hot baths neither. Some of the suggested creams here can worsen rosacea as well. This blogger with KP suggests for treatment: "For the majority of cases of Keratosis Pilaris, one can use moisturizers along with basic lubes that are non-prescription, such as Cetaphil and also Lubriderm, lactic acid lotions and for instance Lac-Hydrin. Your affected area ought to be washed with a mild moisturising soap twice a day. Use by no means unpleasant ingredients that can dry up your skin, since this can worsen the problem. Your skin specialist may also prescribe creams using alpha hydroxy acids, vitamin A lotions and immunomodulators. Even though not that effective in smoothing out Keratosis Pilaris, you can also use gentle exfoliant soap or facial scrubs."

KP or rosacea?

People with keratosis pilaris rubra faceii (KPRF) can have very red faces. The excess Keratin that KP patients have, here aggravates the blood vessels in the cheeks and causes them to be more visible from the surface. People with fair skin are more likely to suffer with this as it would be harder to see the blood vessels with people with darker skin. It can be very difficult to distinguish these red cheeks from rosacea. Especially when you read that KP is so common and widespread. I can hardly believe to be honest that about 60 to 80 % of youth are afflicted by the item, whereas just 40 per cent of grownups manifest some degree of the condition (source). Wiki estimates these percentage even higher as you could just read. I doubt these massive numbers of people have the keratosis pilaris rubra faceii, if so I hardly see them! I assume the majority of these people have the small red bumps on their arms and legs instead, at times.Update; KPRF is a lot more rare than regular KP. On this forum a member writes: "As keratin disorders affecting the face are rarer than rosacea it would be good to see a derm who is familiar with these to rule out KPRF or KPAF."

Keratosis pilaris rubra faceii (KPRF) is often misdiagnosed as rosacea (source), as it primarily affects the face and makes the cheeks also red and ruddy looking. However, KP can be accompanied by itching in the affected area, whereas rosacea rarely itches and often burns instead. Also, KP not only gives a bright rosy color, but this color can be very clearly marked from normal looking skin (and rosacea rarely has such a clear cut division line). Rosacea is usually quite blotchy while Rubra Faceii gives a much more even red skin tone (source). KPRF can look very smoothly red/rosy coloured, whereas rosacea rarely is as evenly red or pink (but again, there are exceptions for all this). KP can come with the typical KP bumps. However, to make matters more difficult: KPRF doesn't even have to have the chicken skin feel of normal KP. Also people who have Rubra Faceii usually also have a small bit of Keratosis Pilaris on other body parts, like the backs of their upper arms (however as 1/2 population has KP, this is probably not that great a test). Another difference is that rosacea can also affect the nose, chin and forehead. Rubra Faceii only affects the cheeks, the area just under the nose and just under the eyes. KPRF does not affect the eyes itself, unlike rosacea (causing ocular rosacea; dry, gritty, painful eyes). People with KPRF do blush and flush easily, something they share with a lot of rosacea patients. KPRF tends to hit at a young age, whereas rosacea usually starts after age 18. Some derms still say rosacea only affects people in their 30's, but this is most definitely incorrect. (Mine started age 19 and I know a lot of people from forums who had rosacea from their 20's, but I only heard of people getting affected with it as early as puberty (seldomly) and onwards). KP often seems to start in kids already, or during puberty. Some other KPRF indications are a paler patch right in the middle of the cheek redness area, or roughness or pitted areas (small depressions) in the redness, around the hair follicles on the cheek. Both KP and rosacea can run in families, so if any of your family members have one or the other, this can be another indication of which of the two you might have when you are dealing with these symptoms that can be both KP or rosacea.

For more information on KP, see this forum. Here and here a patient asks if he has KP or rosacea. See also this and this thread.

What does KPRF look like?

Update August 20th 2018

I have written before about how my skin doesn't seem to build up normally. My dermatologists think that the decade + of skin inflammation from the rosacea and flushing have disturbed normal skin barrier function. That my skin lacks a strong skin barrier therefore, making it very sensitive, easily disturbed (redness, burning, flushing) and that it does not really handle many topicals either (moisturizers or make-up). So I put nothing on my skin normally, just wash it with bottled water and cotton pads gently every evening. No skin care, aside from some diluted jojoba oil around my mouth and eyes maybe once a week. I have worn make-up 4 times in the past decade. Part of the issue seems to be that dead skin cells just build up and up, without naturally falling off. I also don't rub my face with a towel or scrub it like 'normal' people, and the old dead skin after a while becomes visible on my skin... But it is a delicate balance; after I scrub my skin and have red, flushed, fragile skin, it takes at least a month to be back at the stage where a layer of normal looking skin covers my face. I am honestly wondering at times if my redness and flushing issues are linked to this skin scrubbing once a month. It needs to be done (or else I end up with the scaling skin disorder look), but if done too thoroughly, my face looks like the epidermis is removed. The layer of dead skin also protects my face from a lot of stimuli it seems. But there always comes a point where the layer gets too much and darkens a bit and then I need to start rubbing or plucking again. Once I'm busy with that, it is very tempting to go overboard and keep going on and on, only to find out soon after that my skin is looking way too raw and was scrubbed off its protective layer entirely :(