Rosacea and Emotions:
Depression

Topics Discussed Below

• Introduction
  
• Rosacea and depression
  
• Key symptoms of depression
  
• Additional symptoms of depression
  
• Rosacea can cause depression due to cosmetic disfigurement
  
• Rosacea can cause depression due to intense burning sensations
  
• Rosacea can cause depression due to substantial decreases in quality of life
  
• The quality of life of rosacea sufferers should not be overlooked
  
• Facial blushing and its impact on quality of life
  
• Questionnaire on facial blushing
  
• References

I.  Introduction

It is common for people with chronic inflammatory skin disorders to experience periods of depression and anxiety. (1) Depression and anxiety can be caused by any number of reasons, including cosmetic disfigurement, painful skin sensations, decreased quality of life, and avoidance of triggers. It must be stressed that depression and anxiety under these conditions is quite normal, and can occur in the healthiest, strongest-willed people. It does not mean that a person is "weak", "mentally unfit", or "emotionally unsound". It must also be emphasized that depression and anxiety are usually caused by the chronic skin disorder, and not vice versa. (2) In most cases, if the skin disorder is successfully treated or cured, the depression and anxiety disappear!

II.  Rosacea and Depression

Rosacea sufferers often report periods of depression stemming from cosmetic disfigurement, painful burning sensations, and decreases in quality of life. (2-4)   In the moderate to severe stages, medical experts emphasize, "Rosacea's psychological impact can be devastating". (5)  Other physicians stress, "Rosacea can be mutilating and devastating..... resulting in grotesque disfigurement". (6)  Medical experts also indicate that rosacea can, "Ruin lives", (7) and "Can inflict substantial damage to the quality of life". (8)  One rosacea specialist sadly states, "Many of them never go out of doors, but conceal themselves in their homes." (9) So, it should not be surprising that rosacea sufferers experience bouts of depression.

III.  Key Symptoms of Depression

• A sad, anxious, or empty mood that lasts for 2 weeks or more.
  
• A loss of interest or pleasure in most activities you once enjoyed.

IV.  Additional Symptoms of Depression

• Feelings of worthlessness, hopelessness, guilt.
  
• Difficulties in concentrating or making decisions.
  
• Changes in sleeping habits (such as insomnia or oversleeping).
  
• Significant change in weight or appetite.
  
• Fatigue, loss of energy, feeling "slowed down"
  
• Agitation, restlessness, and irritability.
  
• Frequent thoughts of death or suicide, or suicide attempts.

V.  Rosacea can cause Depression due to Cosmetic Disfigurement

Experts in the field of rosacea state, "Rosacea can be mutilating and devastating", and can, "Result in grotesque disfigurement". (6)

• Others describe rosacea as a disorder that can cause, "Severe cosmetic disability". (10)
  
  
• Drs. Garver and Wilkin emphasize, "Rosacea may cause permanent damage to the facial skin and eyes." (12)
  
  
• Several other experts indicate that rosacea can lead to, "Disfigurement",
  and, "Permanent damage to the face." (4,13,14)

VI.  Rosacea can cause Depression due to Intense Burning Sensations

• Facial burning sensations are reported in many rosacea sufferers in the moderate or severe stages. (15-17)
  
  
• Facial burning sensations can become disabling in some sufferers. (18)
  
  
• Facial burning sensations can be quite intense in a significant number of rosacea sufferers. (19, 20)
  
  
• Facial burning sensations can become chronic or permanent in some cases. (21, 22)
  
  
• Physicians also report that facial burning sensations frequently occur during flushing episodes, especially those induced by heat, environmental insults, and skin irritation. (15-17)
  
  
• A case report on a rosacea sufferer documents that the face can burn so much that, "Any gesture, even a laugh, is very painful." (23) Now, that's depressing!

VII.  Rosacea can cause Depression due to Substantial Decreases in the Sufferer's Quality of Life

• Dr. Jonathan Wilkin, one of the premiere experts in the field emphasizes, "Rosacea will never end lives, but it can ruin lives." (7)
  
  
• Experts who have spent quality time with their rosacea patients warn that this disease, "Can inflict substantial damage to the quality of life." (8)
  
  
• In agreement with the above reports, other physicians state, "Rosacea patients do suffer a negative impact on their quality-of-life." (24) In fact, a different expert sadly notes that while on the traditional therapies, "Many of them never go out of doors, but conceal themselves in their homes." (9)
  
  
• Physicians who have extensive experience with rosacea sufferers indicate that the effects of rosacea can be devastating and that, "Even the most outgoing individual may find he wants to hide in a closet during an outbreak of rosacea." (25)
  
  
• In a recent interview of 400 rosacea sufferers, the National Rosacea Society found that nearly 75% indicated that rosacea significantly lowered their self-esteem and self-confidence. Furthermore, 60% said that rosacea negatively affected their jobs. (26) Lastly, 60% reported that they avoided face-to-face contact because of their condition, and 56% said the disease had robbed them of pleasure and happiness!

Medical physicians have published descriptions on the effect of rosacea on their patients' quality of lives. Below are a few examples: (27-32)

1. One rosacea sufferer reports that it is, "A devastating condition.... I was so embarrassed that I retired as early as possible to avoid social contact."
   
   
2. Another sufferer states, "I quit my job because of how my face looked. One day I was helping handicapped kids board a bus headed for summer camp. After just an hour in the sun I came inside and my face was neon pink. My co-workers were so concerned they thought I was going to have a heart attack."
   
   
3. A different rosacea sufferer reports, "For me, rosacea is the most socially destroying disease I have ever experienced."
   
   
4. Other rosacea sufferers have reported, "There was such swelling and redness it actually changed the way I look."
   
   
5. A different sufferer states, "Rosacea is a heartache for people. This disease took over my life for two years."
   
   
6. Another sufferer emphasizes, "I take my rosacea into consideration when planning daily events."
   
   
7. A different rosacea victim reports, "I started to resemble Rudolph."
   
   
8. One sufferer states, "My face was burnt-looking.... I was tired of facing people who kept asking me what was wrong."
   
   
9. Others mention, "I was totally distraught, I had never had a complexion problem before. I was so depressed, I didn't want to leave the house."
   
   
10. There are also numerous reports in the medical literature of sufferers quitting jobs due to rosacea.

VIII.  The Quality of Life of Rosacea Sufferers should not be Overlooked

In a 1999 medical report in the Journal of the American Academy of Dermatology, Dr. Rapp boldly challenges physicians and pharmaceutical companies to strive for better treatment of patients with inflammatory skin disorders. (33) He indicates that these disorders can cause reductions in physical and mental functioning comparable to that seen in cancer, arthritis, hypertension, and heart disease. (33) He stresses that physicians must take into account the 'quality of life' of their patient (i.e., the patient's ability to achieve a level of overall functioning that allows the individual to pursue valued life goals, and that is reflected in general well being). Dr. Rapp states, "The historically narrow view of health care as efforts to reduce symptom severity or reverse the disease progression has given way to a more comprehensive view that effective treatment should also improve the patient's functional level and overall well being." (33) Furthermore, he states, "Measuring the impact of a disease on a person's life quality requires measuring its impact on disease-specific parameters (symptoms), as well as such global parameters of well-being as physical, psychological, and social functioning." (33) With the above said, traditional rosacea therapy falls far short of satisfying the above criteria because this therapy only decreases some of the superficial symptoms (i.e., it does not treat the underlying disorder and certainly does not allow most patients to get their quality of life back). Rosacea interferes with daily functioning, generates psychological distress, disrupts family and social relationships, and causes physical pain sensations.

IX.  Facial Blushing and its Impact on the Sufferer's Quality of Life

Almost everyone has blushed from embarrassment at one time or another. Blushing normally occurs during periods of embarrassment, perhaps from saying something incorrectly, spilling a drink, or leaving a zipper unzipped. In some individuals blushing can be unusually frequent or intense, occurring several times a day. (21) Medical experts point out that blushing (which is a form of pre-rosacea flushing), can be a potentially debilitating disorder. (4, 34) Dr. Drott, a medical expert who specializes in the treatment of facial blushing, stresses, "Many doctors are unaware of the impact of severe facial blushing on the quality of life, and trivialization is common. Most patients have been addressed with expressions like 'it is cute to blush', 'you will get used to it', or 'do not bother about it', by the medical profession. (35) However, the impact of facial blushing on the patient's quality of life can be devastating." (35) In a recent medical article, Dr. Drott and colleagues published a questionnaire to help the patient and physician determine the effect of facial blushing on the sufferer's quality of life. (35)

X.  Questionnaire -- Because of Facial Blushing Do You:

• Avoid meetings at work
  
• Avoid parties
  
• Avoid meeting someone you know on the street
  
• Not dare go out in daylight
  
• Have difficulties shopping
  
• Have difficulties in keeping a clear mind
  
• Fear being at the center of attention
  
• Have contact difficulties with the opposite sex
  
• Avoid studies
  
• Take periodic sick leave
  
• Use medication for facial blushing
  
• Have suicidal thoughts

I have received several dozen reports from rosacea sufferers who experience daily blushing episodes. Many of these sufferers describe these blushing episodes as debilitating, and all sufferers indicate that blushing has negatively impacted their lives. Some examples include:

• Several lawyers report quitting their profession because they could not speak in front of judges or jurors without intense facial blushing.
  
  
• Numerous salesmen/saleswomen have reported daily blushing attacks in front of customers.
  
  
• Two executives have reported daily blushing attacks that interfere with meetings and routine interpersonal communication. One has retired early, and the other now does all of his work from home via the computer.
  
  
• Three reporters have quit their jobs because they could not conduct interviews anymore because of their blushing attacks.
  
  
• Dozens of college students have reported dropping out of classes because of class presentations and seminars that were required of them.
  
  
• Dozens of sufferers have reported that they do not date anymore because of their blushing attacks.

XI.   References

1. Olff, M. Stress, depression and immunity: the role of defense and coping styles. Psychiatry Res 85: 7-15, 1999.
   
   
2. Koo, J.Y. and C.T. Pham. Psychodermatology. Practical guidelines on pharmacotherapy. Arch Dermatol 128: 381-388, 1992.
   
   
3. National Rosacea Society. "Rosacea Review". Summer. 1998. Drake,L.
   
   
4. Panconesi, E. Psychosomatic dermatology. Clin Dermatol 2: 94-179, 1984.
   
   
5. Gifford-Jones. "That rosy blush may be bad". Inside Health Column, 1998.
   
   
6. Plewig, G. and A.M. Klingman. Rosacea. In: Acne and Rosacea, edited by G. Plewig and A.M. Klingman. Berlin: Springer-Verlag, 1993, p. 433-475.
   
   
7. Yoffe, E. "Leading with his nose". http://www.usnews.com/usnews/issue/970331/31nose.htm . 2000. U.S. News Online: Health and Fitness.
   
   
8. National Rosacea Society. Drake, L. Rosacea Review. 2000. Spring.
   
   
9. Sobye, P. "Aetiology and pathogenesis of rosacea". Acta Derm Venereol 30: 137-157, 1950.
   
   
10. Marks, R. "Concepts in the pathogenesis of rosacea". Br J Dermatol 80: 170-177, 1968.
    
    
11. Garnis-Jones, S. Psychological aspects of rosacea. J Cutan Med Surg 2 Suppl 4: S4-S91998.
    
    
12. Garver, J.H. and J.K. Wilkin. Flushing and rosacea: overview and nursing interventions. Dermatol Nurs 4: 271-277, 1992.
    
    
13. Millikan, L. Recognizing rosacea. Postgrad Med 105: 149-8, 1999.
    
    
14. Anonymous. Rosacea: a chronic disease of the skin which, if not treated, can cause permanent damage. Sante Que 3: 17-18, 1992.
    
    
15. Marks, R. and D.S. Wilkinson. "Rosacea and perioral dermatitis". In: Textbook of Dermatology, edited by R. Marks and D.S. Wilkinson. Blackwell Scientific Publication, 1986, p. 1433-1438.
    
    
16. Neumann, E. and A. Frithz. Capillaropathy and capillaroneogenesis in the pathogenesis of rosacea. Int J Dermatol 37: 263-266, 1998.
    
    
17. Marks, R. and J.N. Harcourt-Webster. Histopathology of rosacea. Arch Dermatol 100: 683-691, 1969.
    
    
18. Kikuchi, I., B. Saita, and S. Inoue. Haber's syndrome. Report of a new family. Arch Dermatol 117: 321-324, 1981.
    
    
19. Erdogan, F.G., P. Yurtsever, D. Aksoy, and F. Eskioglu. Efficacy of low-dose isotretinoin in patients with treatment-resistant rosacea. Arch Dermatol 134: 884-885, 1998.
    
    
20. Holger, B. "Mepacrine and chloroquine in the treatment of rosacea". Br J Dermatol 67: 421-425, 1955.
    
    
21. Greaves, M.W. "Flushing, flushing syndromes, rosacea and perioral dermatitis". In: Textbook of Dermatology, edited by R.H. Champion, J.L. Burton, and et al. Malden: Blackwell Science, 1998, p. 2099-2112.
    
    
22. Macsai, M.S., M.J. Mannis, and A.C. Huntley. "Acne Rosacea". In: Eye and Skin Disease, edited by M.S. Macsai, M.J. Mannis, and A.C. Huntley. Philadelphia: Lippincott-Raven, 1996, p. 335-341.
    
    
23. National Rosacea Society. "Rosacea Review". Spring. 1998. Drake,L.
    
    
24. Shear, N.H. and C. Levine. Needs survey of Canadian rosacea patients. J Cutan Med Surg 3: 178-181, 1999.
    
    
25. National Rosacea Society. "Rosacea Review". Spring/Summer. 1992. Wilkin,J.K.
    
    
26. Erhard, M. "Rosacea: More americans now enter danger years for rosacea". 1999. http://medicalreporter.health.org/tmr0596/rosacea.html, National Rosacea Society.
    
    
27. National Rosacea Society. "Rosacea Review". Winter. 1994. Wilkin,J.K.
    
    
28. National Rosacea Society. "Rosacea Review". In: edited by J.K. Wilkin. 1994.
    
    
29. National Rosacea Society. "Rosacea Review". Summer. 1994. Wilkin,J.K.
    
    
30. National Rosacea Society. "Rosacea Review". (Winter). 1995. Drake,L.
    
    
31. National Rosacea Society. "Rosacea Review". Spring. 1997. Drake,L.
    
    
32. National Rosacea Society. "Rosacea Review". Spring. 1999. Drake,L.
    
    
33. Rapp, S.R., S.R. Feldman, L. Exum, A.B. Fleishcer, and D.M. Reboussin. "Psoriasis causes as much disability as other major diseases". J Am Acad Dermatol 41: 401-407, 1999.
    
    
34. Stein, D.J. and C. Bouwer. Blushing and social phobia: a neuroethological speculation. Med Hypotheses 49: 101-108, 1997.
    
    
35. Drott, C., G. Claes, L. Olsson-Rex, P. Dalman, T. Fahlen, and G. Gothberg. Successful treatment of facial blushing by endoscopic transthoracic sympathicotomy. Br J Dermatol 138: 639-643, 1998

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