Dr. Patricia Yarberry Allen is a collaborative physician. This week, she asks Dr. Monica Schadlow, a board certified dermatologist, to counsel a woman who is dismayed by the flushing and skin bumps of rosacea—a skin disease she suddenly developed in midlife.
Dear Dr. Pat:
I am 45 years old. Six months ago, I developed red, flushed cheeks with little pimples—and the same condition on my nose and chin. My GP did tests for lupus because my cheeks are so red. Fortunately, I don’t have that.
My periods have become very irregular, and this is the only thing that I can associate with this ugly change in my skin. I have very pale skin, blonde hair, and blue eyes. I rarely go out in the sun, but even driving in the car to and from work seems to make my face hot and redder. I seem to have developed a reaction to every sunblock, since when I use it, the skin burns a bit and then I get more of these small red bumps. I thought I had acne and tried some acne remedies, but everything seems to make my complexion worse.
I saw a dermatologist in a small city about an hour from my town. He said I had rosacea and prescribed ampicillin. It has made no difference. I don’t wear foundation for fear of making this condition worse. This is having an impact on my job as a sales rep, and is certainly affecting my self-esteem. I was a nice-looking woman before this. Is this caused by the hormonal change of menopause? What causes this? What works for this? Does laser work? At this point, I am ready to travel three hours to the city to see a specialist. I just don’t know who to see and how to know if what has been prescribed will start to make this better. What do women with this condition do to clear up their complexion?
Dr. Schadlow Responds:
Thank you for your question. This is something I have spoken about with many of my patients. Rosacea affects more than 16 million people in the United States, and the impact on people’s lives can be significant, as you describe in your letter. It can be one of the most frustrating conditions to treat. Even though it is not curable, it can be controlled.
Rosacea is usually diagnosed in both men and women between the ages of 30 and 60. The causes are not well understood and likely differ depending on the type of rosacea (some people have mostly redness and flushing, while others, like you, have the more classic form of redness along with bumps). Environmental factors, genetics, and hormones are all understood to be likely factors in the development of rosacea.
Although the cause of rosacea has not been definitively proven, there are some effective treatments. Controlling rosacea can initially take time, because the barrier function of the skin is not behaving properly. This explains the acute sensitivity you experienced with various topical creams, such as your sunscreen.
Here are some main principles I recommend to my patients in order to improve rosacea:
1) Avoid triggers that exacerbate flares of your rosacea. Although this can vary among patients, the most common triggers are sun exposure, very hot or very cold weather (including saunas or steam rooms), emotional stress, alcohol consumption, spicy foods, and heavy aerobic exercise.
2) Improve the barrier function of your skin with gentle cleansers and moisturizers. It may take time before the stinging/burning sensation disappears, but as the rosacea improves, so will your ability to tolerate simple products. I like non-soap gentle liquid cleansers with lukewarm water. Avoid exfoliating scrubs, washcloths, or cleansing brushes. Wait about 10 minutes after drying your face before applying a simple moisturizer. In the morning a sunscreen is essential. For my rosacea patients I usually recommend a mineral powder sunscreen because I find that mineral powders are generally well tolerated.
3) Treat the inflammatory pimples and pustules of rosacea. It is thought that the bumps of rosacea are mostly inflammatory in nature although certain microbes in the skin can contribute as well. My treatment focuses on both oral medication and topical. I usually recommend antibiotics—most commonly, doxycycline or minocycline—to help control flares more quickly. Recently, a lower-dose oral antibiotic was formulated (Oracea) to treat the inflammatory lesions without killing bacteria. This is thought to have fewer side effects than traditional higher-dose antibiotics and is considered safe for longer periods of time (six to twelve months) if needed. Topical antibiotics and anti-inflammatory creams are also an essential part of treatment. Given that rosacea is a chronic disease, topical therapy will likely be indefinite, and patience is key. I’m afraid there is no quick fix for rosacea. I think a realistic time frame to see any improvement is about six weeks.
4) Finally, treat the redness and superficial blood vessels of rosacea. This is where lasers and intense pulse light sources can be most useful. These treatments require some maintenance, and are best used as an adjunct to topical and oral therapy. In the next few months we will likely see an exciting new prescription medication for rosacea. It is a gel containing brimonidine tartrate, a substance that can constrict superficial blood vessels and improve the underlying redness in rosacea sufferers. This may provide a promising alternative to laser therapy, but only time will tell.
As always, please discuss your particular case with your personal physician, so that you can make sure you are making the right decisions for your health and wellbeing.
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