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Dr. Linda Sy, M.D.
Board
certified dermatologist, Linda Sy Fang, MD, originated Linda Sy
Skin Care in 1981.
In
1994 Linda Sy appeared on the World Wide Web, publishing articles
and conducting discussion forums as a means of educating the public
on the developments in the skin care profession. This is where collaboration between Dr. Geoffrey Nase and Dr. Sy started.
The
following article was published by Dr. Nase in Dr. Linda Sy's Dermatology Newsletter.
"The
Red Face of Rosacea"
by Dr. Geoffrey Nase, Ph.D.
Introduction to Rosacea
Rosacea
is a chronic, inflammatory skin disorder that affects an estimated
13 million Americans. It occurs in both sexes and may begin in the
teenage years. The most common symptoms include facial redness across
the nose, cheeks, chin and forehead, visibly damaged blood vessels
(telangiectasia), and small red inflammatory papules. The condition
develops gradually as mild episodes of facial blushing or flushing
lead to a permanent red face. Individuals with fair skin, particularly
those of Scottish, Irish or Celtic descent are more predisposed
to rosacea, although dark-skinned individuals are not spared.
Current medical opinion favors a multi-factorial mechanism where
the basic defect is due to facial vascular hyper-responsiveness
or dysfunction. Recurrent facial flushing or blushing is believed
to be one of the major causative factors. Anything that triggers
a facial flush or blush (an increase in blood flow through the facial
blood vessels) can worsen rosacea symptoms. Potential triggers for
flushing can be external or internal in origin. Common external
triggers include sun, wind, hot environments, cold environments,
vasodilator medications, physical irritation, irritating acne products,
sunscreens, cosmetics or skin care products. Additional external
triggers can come from various foods or beverages (thermally-hot
or spicy foods, and alcoholic beverages). Internal triggers include
stress, anxiety, strong emotions, hormone-related conditions (i.e.,
menstrual-, menopausal- and disease-mediated), and exercise-induced
overheating.
A general picture of rosacea can encompass different stages. It
varies from a pre-rosacea stage that is characterized by frequent
bouts of transient facial flushing, which dissipates quickly, to
an advanced stage as manifested by rhynophyma, a bulbous enlargement
of the nose. The intermediate stage of rosacea is characterized
by facial redness (with prominent dilated blood vessels) and swelling
that may persist for weeks or months and become permanent on the
nose and cheeks. During bad flares, patients may experience pulsating
facial pain and discomfort that lasts for days, disrupting their
normal lifestyles. Inflammatory outbreaks of papules and pustules
are a frequent occurrence at this stage. A most distressing symptom
is their intolerance to topical preparations. Their skin becomes
red, stings and burns upon application of certain products, particularly
acne preparations, cleansers, sunscreens and cosmetics. Rosacea
may also affect the eyes with symptoms including irritation, dryness,
crusting, tearing, foreign body sensation, swelling of eyelids,
conjunctivitis and light sensitivity. It is not uncommon to have
ocular rosacea undiagnosed or misdiagnosed.
Most physicians use a combination of oral and topical antibiotics
to treat rosacea patients. Antibiotic therapy is effective in treating
the mild cases and in decreasing papule and pustule formation in
the more severe cases. However, it is only minimally effective on
facial erythema and rarely affects the telangiectasia or flushing
aspects of the disorder. While on this treatment, most patients
have to continue to avoid all of their individual triggers. In many
of the cases, this may necessitate such changes in lifestyle as
to result in strained friendships and marriages, decreased job productivity,
and a generalized feeling of hopelessness and depression.
Dr. Nase's Battle with
Rosacea
In my case, during a
three-year period in my middle 20's, I was placed on various oral
and topical antibiotics and experienced no real improvement - in
fact, I continued to get worse. My face was literally changing before
my eyes. I was told that there was nothing else that could be done
and that I would have to live with my red, burning face. In addition,
my nose was slowly beginning to grow (mild stage rhinophyma), and
the only treatment suggested to me was surgery; but it would be
performed only after my nose grew quite large. Every day was an
extreme challenge because I had multiple triggers for facial flares,
which included:
- Most facial skincare products. I could not apply anything to
my face. For cleansing, I could only rinse my face with
water. Especially frustrating was the inability to put on a sunscreen
- I could not go out in the sun at all.
- Variations in temperature, such as getting into a warm car
in the summer, or going from the cold outdoors in the winter to
the warm indoors.
- Food and beverage triggers. As my facial rosacea worsened my
list of food and beverage triggers grew significantly, to the
point where I could only eat boiled chicken and salad. On this
diet, I lost 50 pounds in 6 months.
- Bending over to look through my microscope (an important part
of my job), any form of light exercise, and strong fluorescent
lighting were also moderate triggers.
- Emotions such as experienced when laughing at funny movies
or crying at sad ones (I am a sensitive male of the 90's) brought
about instantaneous facial flares. Mental calculations and mental
concentration exercises as well as stress from grant or scientific
article writing and professional deadlines were also not rosacea-friendly.
- Facial flushing also occurred spontaneously without any apparent
trigger; such as experienced on a stress-free weekend in a climate-controlled
environment. This was overwhelming!
- After years of getting worse and being pounded into submission,
I developed erythrophobia (the fear of being red).
These personal triggers
are not uncommon in other rosacea sufferers. To date, I have personally
spoken to many and have in-depth email correspondence from thousands
of rosaceans who are very unhappy with their current treatment regimen
and are also severely limited in what they can do or eat. Oral and
topical antibiotic therapy with the avoidance of all triggers is
not a very satisfying treatment strategy!
Treatment Options
for Rosacea: Dr. Nase & Dr. Sy Collaboration
From my own experience
and through years of searching for better treatments, I would like
to share several treatment options available to resistant cases.
When used in the right combination, they can result in substantial
improvement in most symptoms and in many cases may allow sufferers
to regain a normal lifestyle. It must be stressed that every rosacea
patient is unique and needs individualized treatment; however, there
are common treatment regimens that may be beneficial to the majority
of patients. For the purpose of this brief article, I would like
to discuss three options:
1. Laser - this treatment is effective at removing the structurally
damaged blood vessels and diminishing the constant facial redness.
For the past 5 years, the pulsed dye laser has been the 'gold standard'.
However, newer systems such as the Photoderm VL/PL (Intense Pulsed
Light Source) are now available. This treatment offers a greater
degree of selectivity for the treatment of the superficial facial
microvessels and can also target the larger and deeper blood vessels.
It also effectively treats more extensive areas of the face with
less pain and greater speed. Photoderm experts who specialize in
the treatment of rosacea are able to achieve good to excellent clearance
of telangiectasia and the chronic red face, as well as significantly
decrease the intensity and duration of the facial flush in many
patients.
Before Photoderm
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After Photoderm
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Before Photoderm
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After Photoderm
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2. Isotretinoin (Accutane)
- this is a vitamin A analog that has been used with much success
to treat severe nodulocystic acne, disorders of keratinization and
various other dermatological diseases. Isotretinoin works by inhibiting
sebaceous gland function and physically shrinking these problematic
glands. It also has potent anti-inflammatory properties, which make
isotretinoin a good option for the treatment of resistant rosacea
patients. It achieves long-term benefits and remission of papules,
pustules, rhinophyma and a decrease in facial burning. Another benefit
is that it allows patients to discontinue the use of acne products
resulting in less facial irritation. Some do experience a relapse,
but the symptoms are usually much milder. Many physicians find that
1 or 2 courses of low-dose isotretinoin may significantly decrease
the severity of the entire disease process. Side effects include
dry lips and skin, a transient elevation in cholesterol and triglyceride
levels, mild headaches and dry eyes. One serious side effect is
that it can cause severe deformities to the unborn fetus. Thus its
use is contraindicated for women who are trying to get pregnant
or who are not using birth control while sexually active. With this
said, the use of low-dose isotretinoin can be a godsend to many
rosacea sufferers.
 ACCUTANE
®
(isotretinoin) CAPSULES
3. A Gentle Protective
Barrier - It is speculated that the outer layer of facial skin
(epidermis), which forms a protective barrier from the outside elements,
may be physically or functionally abnormal in rosacea patients.
This could lead to greater penetration of topical products or abnormal
release of inflammatory mediators from epidermal cells, resulting
in a local inflammatory response with a resultant increase in facial
blood flow. Therefore, one goal in the treatment of rosacea is to
find a protective barrier that helps to normalize epidermal water-holding
properties, thus alleviating environmental and skincare mediated
facial flares. Two substances have been shown to exert such beneficial
actions - zinc oxide and dimethicone. Zinc oxide is approved by
the FDA as a Category I skin protectant. It is used as a soothing
preparation for facial redness and steroid-induced thinning of the
epidermis. Dimethicone is also a good skin protectant as well as
a non-greasy moisturizer. In a recently published clinical article,
physicians studying rosacea skin found that dimethicone significantly
decreased irritation to certain skincare products such as sunscreens.
The only problem with a zinc oxide-dimethicone protectant cream
is that it is usually not very elegant (i.e., it is thick and leaves
a white residue on the face). However, with newer technology, skincare
laboratories can now micronize zinc oxide into extremely fine particles
and then bind it to dimethicone - resulting in a very elegant formulation.
This new formulation has been found to be virtually transparent
to the naked eye, to have the broadest attenuation spectrum of all
transparent sunblocks, and is able to absorb sunlight and remain
photostable (i.e., it does not undergo any chemical or structural
changes that could decrease its effectiveness or cause facial irritation).
This special zinc oxide-dimethicone formulation could prove to be
very useful for the daily protection of rosacea skin against irritation
from sunlight, wind, makeup, and other various skincare products.
Hope for Rosacea Sufferers
Laser therapy, isotretinoin,
and protective barrier creams are just three of the many available
treatments for rosacea. There is hope. You do not have to live with
a red, burning face!
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