March 18, 2024 • 21 mins
"What do Rembrandt, the Hollywood actor W. C. Fields and the former president Bill Clinton all have in common?"
The answer is rosacea, and in this first episode on this common skin condition, your hosts Dr George Moncrieff and Dr Roger Henderson explore how to identify rosacea in your patients, giving you clarity on the clinical presentations to avoid potential misdiagnosis.
They will also cover:
- How to differentiate rosacea from acne
- Rosacea in skin of colour
- The different subtypes in the rosacea spectrum and their severities
- The link between rosacea and eye symptoms, including how to work with opticians to help identify the condition quicker
- The impact rosacea has on a patient’s quality of life
- The importance of understanding different triggers to help patients effectively manage their condition
Rosacea affects around 1 in 10 people in the UK and can have a huge impact on their self-confidence and mental health. So, tune into this 20-minute episode, which is jam-packed with nuggets of wisdom from our hosts, allowing you to confidently help your patients manage their rosacea.
Thank you to our kind sponsor AproDerm, who provide a comprehensive range of quality emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
To simplify the process of finding the most suitable emollient for each patient, they have developed a remarkable solution: the AproDerm Emollient Starter Pack. This pack conveniently combines all four of their emollients in a single prescription, enabling patients to identify their ideal emollient more efficiently, aiding both compliance and adherence.
Find out more: https://aproderm.com/aproderm-emollient-starter-pack/
LI: https://www.linkedin.com/company/fontus-health-ltd/
We hope you find this podcast interesting and helpful. Please leave us a review or email info@aproderm.com with any feedback on this episode or suggestions on dermatology topics that you would like to hear about in future podcasts.
The views expressed in this podcast are of Dr George Moncrieff and Dr Roger Henderson. Fontus Health has not influenced, participated, or been involved in the programme, materials, or delivery of educational content.
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Transcript
Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
Dr Roger Henderson (00:09):
Hello and welcome to this Rash Decisions
podcast where we look at skin-relatedissues, conditions and treatments
in an interesting and informed way.
I'm Dr Roger Henderson, I'm a GPwith a long-standing interest in
this particular area of health
Dr George Moncrieff (00:24):
And I'm Dr George Moncrieff.
I too was a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:34):
Now today, George and I are going to be talking about the very
common skin condition rosacea, which wehave all seen many times in our surgeries.
I'm going to really talk [in] thispodcast about generalisations,
because the next podcast isgoing to be about its treatment.
(01:00):
Now I'm going to have a starter for tenhere, and for anyone listening, I've
probably given away the answer by thefact that you're listening to this podcast
on rosacea, but the pub quiz question,which I think is always a good one, is
"what do Rembrandt, the Hollywood actor W.C
Fields and the former president
Bill Clinton all have in common?"
(01:21):
And the answer, as you probablyguessed, is they all had, or have,
rosacea, to different degrees.
Now rosacea is often poorly understoodand many of us will have discovered
that when our patients actually tryand explain a little bit about what
they think is going on with their skin.
But that's surprising, it affectsabout 1 in 10 people in the UK,
(01:43):
particularly from middle age and onwards.
And I think we often forget that,don't we George, just how common it is.
Dr George Moncrieff (01:52):
Yeah, it really is common, isn't it?
It's probably the most commonskin condition, which is
saying something, isn't it?
1 in 10 adults have it.
I think the first thing to say, though,is we mustn't confuse it with acne.
Some people even call it rosacea acne,which just adds to the confusion.
So, like you, I think weshould just call it rosacea.
Dr Roger Henderson (02:13):
Yeah.
Dr George Moncrieff (02:13):
And then define it by the subtypes.
Obviously, both conditions causebumps and spots on the face,
but they are very different.
You get open comedones in acne.
You don't see those in rosacea,unless they're incidental, they're
not part of the pathogenesis.
And of course, rosacea affectsthe skin of the face and
(02:33):
occasionally up onto the scalp.
But acne is much more widespreadinvolving the chest, down to the
back, down to the buttocks sometimeseven, and the front of the chest.
But there are many differences and soI think don't call it rosacea acne.
Although more women seek advice for[rosacea than] men, I think studies
(02:54):
show it's equally common in both sexes.
I think it's just that womenare more likely to be distressed
by the changes and seek advice.
I'm not sure about you, but people sayit's not common in dark skin, I disagree.
I've seen a lot of it inpeople with skin of colour.
And it may just simply be that witha darker skin, the redness that you
get is less of a cosmetic problem.
Dr Roger Henderson (03:15):
Absolutely, completely concur with that.
And when you think about it, [if]you have someone with very pale skin,
even a mild flush can be apparent.
Someone with dark skin,they just don't see it.
Dr George Moncrieff (03:27):
I've taught that there's a bimodal prevalence
of rosacea, a peak in the early30s and another peak later on.
But a big study from Germany someyears ago, confirmed what I think we
all knew really, was that it just getsmore common as you get older and peaks
at around about 50 to 60 years of age.
So it starts around the sort of lateteens, early 20s, and peaks at 50ish.
(03:49):
Apart from phymatous disease,which seems to get progressively
worse into older years as well.
So, phymatous disease, Ithink, peaks a bit later.
And interestingly, it peaks, Ithink, a little earlier in women than
in men, but that's fairly subtle.
The mildest end of thespectrum is what we call
erythematotelangiectatic rosacea, or ETR.
(04:12):
This is due to increased flushingand blushing from triggers that
don't trouble other people.
So the individual with this finds thatthey get exposed to something and they
have a flush, whereas other peoplein that group, exposed to exactly the
same environment, don't have a flush.
So, this vasomotor instability causesthese flushes, which are not only
(04:34):
embarrassing, but they're uncomfortable.
They're unpleasant.
Typically they come on within about30 to 60 minutes of the trigger,
and can last for a couple of hours.
So, the skin eventually developsa permanent background redness,
classically with some sparing aroundthe eyes, which is quite useful.
(04:55):
And then eventually, that persistentdilatation and constriction of the
blood vessels results in telangiectasiadeveloping, and these are permanently
dilated vessels on the face.
I've already mentioned that patientswith rosacea find that their skin feels
sensitive and they report that they finddetergents and fragrances, particularly
(05:17):
those that contain alpha-hydroxy acidsor ascorbic acid, can sting the face.
So they learn to avoid those.
You can then move on to a moreinflammatory end of the spectrum,
which we call papulopustular rosacea.
Where you get whiteheads and painfulpustules and painful papules.
Again, mostly on the face, but up ontothe forehead and even onto the scalp.
(05:39):
And I think sometimes colleaguesare put off because they see scale
around these and they don't thinkof rosacea, they think of it as
being a greasy skin condition.
But no, it's a scaly skin conditionand you can get quite significant
scale due to rosacea, along withthis background permanent redness.
Around about 50% of patients withrosacea experience eye symptoms,
(06:02):
ranging from the mildest dry eyeproblem to a bit of blepharitis,
to styes, perhaps conjunctivitis oreven things like keratitis, where
the eyeball is much more inflamed.
One of the problems with eye diseaseis it often precedes rosacea.
So patients can have a problem withdry eyes, they know that they need to
(06:23):
use artificial tears and ointment atnight perhaps, and the penny hasn't
dropped that they've got rosacea.
So it can precede it.
Dr Roger Henderson (06:31):
Yeah and I don't know if any of our peers are doing this,
but this is something I just decided todo, was to speak to my local optician.
And say if any of my patients turnedup basically with dry eyes, irritated
eyes, or they were picked up in routineconsultation, about dry eyes, and if
(06:52):
they had facial flushing, red face, ifthey talked about problems with their
skin, was to say to that patient, "Oh,Dr Henderson is interested in this",
and they would come along and see me.
And there were definitely a handful,I wouldn't say more than that, but a
handful of patients, with very earlyrosacea, that I managed to pick up early,
(07:12):
simply because of those dry eye symptoms.
Now it's not many, but it's a nicelittle tip if you've got a good working
relationship with your local optician,it'd be worth just mentioning it to
them to ask them for any feedback,because you just might be surprised
at the patient that you pick up early,and that's always so gratifying.
Dr George Moncrieff (07:30):
I think that's a lovely tip, and
what a lovely doctor you are.
A more uncommon condition though, isthis gross thickening of the subcutaneous
tissues typically on the nose, butsometimes on the chin which we call
rhinophyma, literally meaning potato nose.
Aren't we rude?
Dr Roger Henderson (07:48):
We are.
Dr George Moncrieff (07:49):
And I don't know about you, but I've only ever seen this
in men, I've never seen it in a woman.
Dr Roger Henderson (07:54):
Absolutely.
I've never seen it in a woman.
And also compared to 40 years ago,I'm definitely seeing it significantly
less, which can only be a good thing.
And I think that's becauseof the treatments that have
recently become [available].
Dr George Moncrieff (08:04):
I think, though, having said that some dermatologists
don't believe rhinophyma is genuinelypart of the rosacea spectrum.
But I do, and I'm pretty sure thatif we can control, certainly the
more inflammatory end of the spectrumwe curtail the development of that.
But we do now, I mean, next time we'llbe talking about treatments, we do
have some very effective treatmentsfor it, so that may be the other
reason why we're seeing less of it.
Those treatments weren'tavailable in the past.
Dr Roger Henderson (08:27):
Today's podcast has once again been made possible
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(08:48):
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Dr George Moncrieff (09:03):
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(09:23):
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(09:44):
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(10:06):
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(10:26):
Thanks again to AproDerm® forsponsoring this groundbreaking
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The problem for a lot of our patientswith rosacea is, it's visible.
It affects the face and youknow, the one part of my body
you can see today is my face.
It's, what we show to people, it's whatwe remember about people when we think
(10:48):
about them, we think of their face.
So not only is it visible, it'sunpredictable, it's unpleasant, so
it's hardly surprising it can have adevastating impact on their confidence,
their self-esteem, their mood.
If they're worried that their face isgoing to go red, that worry can make
their face go red and then they'reinto a vicious cycle, which just
completely endorses their concernsand their loss of self-confidence.
(11:12):
So, we need to take that into accountand be very sensitive to that.
Dr Roger Henderson (11:17):
Oh, it dramatically affects people's quality of life.
Now, people will wonder why I'm suddenlygoing to start talking about insomnia.
If someone comes and sits in frontof me with insomnia, one of the first
things I do, is to have a long chatwith them about sleep hygiene and
the tips for good sleep hygiene.
The reason for that, simply by doing that,1 in 3 people with insomnia will be cured.
(11:43):
The same for rosacea.
There are so many factors.
There's so much myth.
There's so much disinformation.
Many patients with rosacea actuallydon't, or haven't twigged, the
triggers that can affect them.
So, I always make a point of spendinga lot of time going through the
factors that can trigger their rosacea.
(12:03):
And again, if you do that, thena pleasing number of people with
rosacea will find their qualityof life dramatically improves,
even before they get to treatment.
So let's have a think about thefactors we should be speaking
to our patients about perhaps.
Dr George Moncrieff (12:19):
Well, I think the first thing to do is
not to mention alcohol, first.
Dr Roger Henderson (12:22):
Yep.
Dr George Moncrieff (12:23):
Keep that down to the end of your list.
So, the most common, and I thinkthe most important trigger, for
rosacea is ultraviolet light.
Usually UVB, but alsoimportantly, sometimes UVA.
And the thing about UVA is it goesstraight through cloud, it goes straight
(12:45):
through glass, and it's almost asintense at dusk, as it is at noon.
And almost as intense inDecember, as it is in June.
So you, on a cloudy day, indoors, inDecember, are being exposed to UVA.
And if it's UVA that's driving theflushes, then it's really important to
(13:08):
be aware of that and to deal with it.
So, yes, UVB is the more important,but it can be UVA as well.
Obviously, embarrassing situations,speaking in public, for example, or
an awkward situation with your bossor something, going bright red is the
last thing you need in that situation.
And if you're worrying aboutthat, the emotional stress of
(13:30):
that, emotion can cause a flush.
You're into a vicious cycle, whereyou're going red because you're worried
you're going to go red, and then you'vegone red, and it's just dreadful.
Patients often avoid those situations.
I talk to patients about having very hotmeals, hot food as well as spicy food,
hot curries and things, can cause aflush in some individuals, not everyone.
(13:51):
For other people it's cheeseand certain cheeses or beer.
Sudden temperature changes, goinginto a hot sauna or into a hot room
or going, sometimes even going intoa cold room or going out for a cold
walk can cause the face to flush.
So, there are a large number ofdifferent potential triggers.
Yes, alcohol can, and I think in W.C
Field's case, he clearly enjoyed
(14:12):
his gin and enjoyed his alcohol,
and made quite a note about that.
But I think it's probably endorsed inour psyche, the link between rosacea and
alcohol, but it's much less strong thanthese other triggers in my experience.
And, in a big study, from in nurses fromSouthern Ireland, they found that it
was, white wine more than red wine, orbeer or spirits, that causes a flush.
(14:34):
But yeah I always inquire aboutthis last, after having gone
through all the other things.
Because if you've got somebody with atroublesome red face and all you talk
about is alcohol, they will think you'vegot the wrong end of the stick and they
will probably not be happy with that.
Very occasionally certainmedications taken by mouth or
on the skin can cause a flush.
For example, Protopic®, patientsput Protopic® on their eczema,
(14:55):
they then have some alcohol and acombination causes a flush on the face.
So, that can happen.
But, you can get it fromcalcium channel antagonists.
There's a large number ofdrugs that can cause flushing.
So, just consider themedications the patient's on.
I think the message that I want to getacross is that, everyone's an individual,
and what causes flushing for one patient,won't necessarily for somebody else.
(15:17):
So, what I recommend is they should, keepa diary, for two or three months, and they
will know they're having a flush becauseit happens quite quickly, and it comes
on much faster than sunburn, for example.
Sunburn, it's several hours later.
If it's causing a flush it'll happenwithin half an hour or two at most.
So, find out what is your trigger, orare your triggers, and then you know
(15:38):
what you need to do to try and keepthose at bay as much as possible.
Dr Roger Henderson (15:42):
Absolutely.
And I have, interesting whilst youwere talking there, it just brought
to mind, I have seen menopausal women,with early rosacea who have been having
menopausal flushing, but also havegot mixed in, rosacea flushing, and
they just, you know, it hasn't beenpicked up, because everything has just
been lumped in with the menopause.
(16:02):
So we have to just have thatlittle extra thinking cap on,
if you're seeing a menopausalwoman coming in with a flushing.
Yes, this is likely to be menopausal,but it could just as likely be, rosacea.
I've got two camps of peoplewith rosacea, in my experience.
There's the camp that says, youknow, they're the only one with it.
They're the only person who'sgot the symptoms and they're
(16:23):
dreadfully distressed by it.
And then there's the camp thatthinks, well, everybody sort of looks
the same and the same presentation.
But, one of the problems with rosacea,as you've alluded to, there's a massive
range, of not only presentation,there's also clinical findings as well.
And we just have to keep thatrosacea thinking cap on, don't we?
Dr George Moncrieff (16:44):
Absolutely.
I've described the range, but you canget all combinations of those subtypes.
In my experience, it usuallystarts, with eye symptoms.
And then the patient starts experiencingeasy flushing, blushing, with
increased facial skin sensitivity.
Then they go on to develop thatpermanent background redness with
the sparing around the eyelids.
(17:07):
And I haven't seen this in the books,but it's my impression that it's
that repeated blushing and flushingand there is a difference between a
blush and a flush, but that repeatedflushing that vasomotor instability,
I think drives the rosacea onto themore inflammatory end of the spectrum,
in a genetically prone individual.
So, I think the message there isif you can curtail that flushing
(17:29):
and limit it, you might be ableto prevent it progressing to the
more aggressive inflammatory endwith the papules and the pustules.
So, that's just an interesting concept.
Phymatous disease can occur on its own.
The patient has no significanthistory of rosacea, they've
just got phymatous disease.
Which is why I think somedermatologists wonder whether
it is part of the same spectrum.
(17:51):
And it's this extraordinary subcutaneousthickening of the sebaceous material.
But, it's a strange entity that seemsto run along, to some extent, parallel
to the erythematotelangiectatic andpapulopustular patterns that we see.
Dr Roger Henderson (18:05):
Yeah and just to me it just makes logical common sense.
If you've got a condition...
Dr George Moncrieff (18:10):
Sure.
Dr Roger Henderson (18:10):
...with repeated episodes of inflammation,
then you are going to put petrolon that fire, of that condition.
So like you, I mean, the books maynot be saying it, but I think in
the real world, it probably is.
Now, I can't remember the last time, onceI was certain of the diagnosis, and that's
an important point, but once I was certainof the diagnosis of rosacea that I ever
(18:31):
investigated, a patient with rosacea.
And I suppose that's one of the beautiesas a doctor, if I can use that term,
with patients with rosacea, becauseusually, we just have to sort of think,
and look, and most especially important,listen to the patient, and there's
a diagnosis that drops on our lap.
So, unless you're not 100%about the diagnosis, I don't
(18:56):
think I've ever investigated.
Have you much?
Dr George Moncrieff (18:59):
Very rarely.
I mean, as you say, it's a clinicaldiagnosis, based on listening to a
careful history, and a few signs onexamination, for example, the periocular
sparing of the background erythema.
But the history is usually very typical.
People are sometimes put off bythe scale, and aren't thinking of
rosacea being a scaly skin condition.
(19:20):
So they'll be thinking, couldthis be seborrhoeic dermatitis,
which is extremely common.
And of course, the two can co-exist.
Acne can be in the differential there,acne progressing later, but there you'd
be looking for comedones and diseaseelsewhere, because the two could co-exist.
The one that worries me, I suppose,just at the back of my mind, is
(19:40):
lupus, systemic lupus, for example.
They usually have much moreextreme photosensitivity.
So, the patient says that myface is going red in the sun.
With lupus you might expect perhaps tosee more than just a bit of redness.
You might expect to see someeven blistering, and so on.
So, I've done, occasionally donean ANA [Antinuclear Antibody], just
to be sure I'm not missing that.
(20:01):
But no, I'd say, 98% of thetime, it's going to be history
and examination, a good history.
But if they've got seborrhoeicdermatitis, you're going to be looking
in their scalp, you're gonna be lookingin their ear, behind their ear, maybe in
the front of the chest and the armpits.
And it's more into the nasolabial fold,rather than this redness and pustular
change on the cheeks and things.
Dr Roger Henderson (20:23):
Yeah, it's interesting you mention lupus, there.
I mean, the book, the textbookswould have us believe that, you know,
the butterfly rash was absolutelydemarcated like a butterfly.
We all know in practice it'soften a lot more vague...
Dr George Moncrieff (20:35):
Subtle.
Dr Roger Henderson: ...and subtle than that. (20:35):
undefined
So, it can look, just like ageneral reddening rather than
any kind of demarcated rash.
But yes that's probably theone to think of there, George.
Well, we're going to think abouttreatment, in the next podcast, but
George and I do hope that you foundthis chat about the most common of
skin problems interesting and that youfound this initial overview helpful.
(21:00):
And allow you to have more confidencewhen you're discussing rosacea with
patients when they sit in front of you.
Dr George Moncrieff (21:06):
So, we really hope you will join us again when we'll
go into much more detail as to how weapproach our management of rosacea.
Really emphasising the importance ofself-management and lifestyle tips
as well as some of the wonderfultreatments we have at our fingertips now.
We'd also like to thank, AproDerm®, oursponsor, for all their help in putting
these Rash Decisions podcasts together.
(21:27):
We couldn't have done it without them.
Dr Roger Henderson (21:29):
So until the next time, it's goodbye from George.
Dr George Moncrieff (21:32):
Goodbye.
Dr Roger Henderson (21:33):
And as always, it's goodbye from me.
Hello and welcome to this Rash Decisions
podcast where we look at skin-relatedissues, conditions and treatments
in an interesting and informed way.
I'm Dr Roger Henderson, I'm a GPwith a long-standing interest in
this particular area of health
Dr George Moncrieff (00:24):
And I'm Dr George Moncrieff.
I too was a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:34):
Now today, George and I are going to be talking about the very
common skin condition rosacea, which wehave all seen many times in our surgeries.
I'm going to really talk [in] thispodcast about generalisations,
because the next podcast isgoing to be about its treatment.
(01:00):
Now I'm going to have a starter for tenhere, and for anyone listening, I've
probably given away the answer by thefact that you're listening to this podcast
on rosacea, but the pub quiz question,which I think is always a good one, is
"what do Rembrandt, the Hollywood actor W.C
Fields and the former president
Bill Clinton all have in common?"
(01:21):
And the answer, as you probablyguessed, is they all had, or have,
rosacea, to different degrees.
Now rosacea is often poorly understoodand many of us will have discovered
that when our patients actually tryand explain a little bit about what
they think is going on with their skin.
But that's surprising, it affectsabout 1 in 10 people in the UK,
(01:43):
particularly from middle age and onwards.
And I think we often forget that,don't we George, just how common it is.
Dr George Moncrieff (01:52):
Yeah, it really is common, isn't it?
It's probably the most commonskin condition, which is
saying something, isn't it?
1 in 10 adults have it.
I think the first thing to say, though,is we mustn't confuse it with acne.
Some people even call it rosacea acne,which just adds to the confusion.
So, like you, I think weshould just call it rosacea.
Dr Roger Henderson (02:13):
Yeah.
Dr George Moncrieff (02:13):
And then define it by the subtypes.
Obviously, both conditions causebumps and spots on the face,
but they are very different.
You get open comedones in acne.
You don't see those in rosacea,unless they're incidental, they're
not part of the pathogenesis.
And of course, rosacea affectsthe skin of the face and
(02:33):
occasionally up onto the scalp.
But acne is much more widespreadinvolving the chest, down to the
back, down to the buttocks sometimeseven, and the front of the chest.
But there are many differences and soI think don't call it rosacea acne.
Although more women seek advice for[rosacea than] men, I think studies
(02:54):
show it's equally common in both sexes.
I think it's just that womenare more likely to be distressed
by the changes and seek advice.
I'm not sure about you, but people sayit's not common in dark skin, I disagree.
I've seen a lot of it inpeople with skin of colour.
And it may just simply be that witha darker skin, the redness that you
get is less of a cosmetic problem.
Dr Roger Henderson (03:15):
Absolutely, completely concur with that.
And when you think about it, [if]you have someone with very pale skin,
even a mild flush can be apparent.
Someone with dark skin,they just don't see it.
Dr George Moncrieff (03:27):
I've taught that there's a bimodal prevalence
of rosacea, a peak in the early30s and another peak later on.
But a big study from Germany someyears ago, confirmed what I think we
all knew really, was that it just getsmore common as you get older and peaks
at around about 50 to 60 years of age.
So it starts around the sort of lateteens, early 20s, and peaks at 50ish.
(03:49):
Apart from phymatous disease,which seems to get progressively
worse into older years as well.
So, phymatous disease, Ithink, peaks a bit later.
And interestingly, it peaks, Ithink, a little earlier in women than
in men, but that's fairly subtle.
The mildest end of thespectrum is what we call
erythematotelangiectatic rosacea, or ETR.
(04:12):
This is due to increased flushingand blushing from triggers that
don't trouble other people.
So the individual with this finds thatthey get exposed to something and they
have a flush, whereas other peoplein that group, exposed to exactly the
same environment, don't have a flush.
So, this vasomotor instability causesthese flushes, which are not only
(04:34):
embarrassing, but they're uncomfortable.
They're unpleasant.
Typically they come on within about30 to 60 minutes of the trigger,
and can last for a couple of hours.
So, the skin eventually developsa permanent background redness,
classically with some sparing aroundthe eyes, which is quite useful.
(04:55):
And then eventually, that persistentdilatation and constriction of the
blood vessels results in telangiectasiadeveloping, and these are permanently
dilated vessels on the face.
I've already mentioned that patientswith rosacea find that their skin feels
sensitive and they report that they finddetergents and fragrances, particularly
(05:17):
those that contain alpha-hydroxy acidsor ascorbic acid, can sting the face.
So they learn to avoid those.
You can then move on to a moreinflammatory end of the spectrum,
which we call papulopustular rosacea.
Where you get whiteheads and painfulpustules and painful papules.
Again, mostly on the face, but up ontothe forehead and even onto the scalp.
(05:39):
And I think sometimes colleaguesare put off because they see scale
around these and they don't thinkof rosacea, they think of it as
being a greasy skin condition.
But no, it's a scaly skin conditionand you can get quite significant
scale due to rosacea, along withthis background permanent redness.
Around about 50% of patients withrosacea experience eye symptoms,
(06:02):
ranging from the mildest dry eyeproblem to a bit of blepharitis,
to styes, perhaps conjunctivitis oreven things like keratitis, where
the eyeball is much more inflamed.
One of the problems with eye diseaseis it often precedes rosacea.
So patients can have a problem withdry eyes, they know that they need to
(06:23):
use artificial tears and ointment atnight perhaps, and the penny hasn't
dropped that they've got rosacea.
So it can precede it.
Dr Roger Henderson (06:31):
Yeah and I don't know if any of our peers are doing this,
but this is something I just decided todo, was to speak to my local optician.
And say if any of my patients turnedup basically with dry eyes, irritated
eyes, or they were picked up in routineconsultation, about dry eyes, and if
(06:52):
they had facial flushing, red face, ifthey talked about problems with their
skin, was to say to that patient, "Oh,Dr Henderson is interested in this",
and they would come along and see me.
And there were definitely a handful,I wouldn't say more than that, but a
handful of patients, with very earlyrosacea, that I managed to pick up early,
(07:12):
simply because of those dry eye symptoms.
Now it's not many, but it's a nicelittle tip if you've got a good working
relationship with your local optician,it'd be worth just mentioning it to
them to ask them for any feedback,because you just might be surprised
at the patient that you pick up early,and that's always so gratifying.
Dr George Moncrieff (07:30):
I think that's a lovely tip, and
what a lovely doctor you are.
A more uncommon condition though, isthis gross thickening of the subcutaneous
tissues typically on the nose, butsometimes on the chin which we call
rhinophyma, literally meaning potato nose.
Aren't we rude?
Dr Roger Henderson (07:48):
We are.
Dr George Moncrieff (07:49):
And I don't know about you, but I've only ever seen this
in men, I've never seen it in a woman.
Dr Roger Henderson (07:54):
Absolutely.
I've never seen it in a woman.
And also compared to 40 years ago,I'm definitely seeing it significantly
less, which can only be a good thing.
And I think that's becauseof the treatments that have
recently become [available].
Dr George Moncrieff (08:04):
I think, though, having said that some dermatologists
don't believe rhinophyma is genuinelypart of the rosacea spectrum.
But I do, and I'm pretty sure thatif we can control, certainly the
more inflammatory end of the spectrumwe curtail the development of that.
But we do now, I mean, next time we'llbe talking about treatments, we do
have some very effective treatmentsfor it, so that may be the other
reason why we're seeing less of it.
Those treatments weren'tavailable in the past.
Dr Roger Henderson (08:27):
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Dr George Moncrieff (09:03):
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Thanks again to AproDerm® forsponsoring this groundbreaking
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The problem for a lot of our patientswith rosacea is, it's visible.
It affects the face and youknow, the one part of my body
you can see today is my face.
It's, what we show to people, it's whatwe remember about people when we think
(10:48):
about them, we think of their face.
So not only is it visible, it'sunpredictable, it's unpleasant, so
it's hardly surprising it can have adevastating impact on their confidence,
their self-esteem, their mood.
If they're worried that their face isgoing to go red, that worry can make
their face go red and then they'reinto a vicious cycle, which just
completely endorses their concernsand their loss of self-confidence.
(11:12):
So, we need to take that into accountand be very sensitive to that.
Dr Roger Henderson (11:17):
Oh, it dramatically affects people's quality of life.
Now, people will wonder why I'm suddenlygoing to start talking about insomnia.
If someone comes and sits in frontof me with insomnia, one of the first
things I do, is to have a long chatwith them about sleep hygiene and
the tips for good sleep hygiene.
The reason for that, simply by doing that,1 in 3 people with insomnia will be cured.
(11:43):
The same for rosacea.
There are so many factors.
There's so much myth.
There's so much disinformation.
Many patients with rosacea actuallydon't, or haven't twigged, the
triggers that can affect them.
So, I always make a point of spendinga lot of time going through the
factors that can trigger their rosacea.
(12:03):
And again, if you do that, thena pleasing number of people with
rosacea will find their qualityof life dramatically improves,
even before they get to treatment.
So let's have a think about thefactors we should be speaking
to our patients about perhaps.
Dr George Moncrieff (12:19):
Well, I think the first thing to do is
not to mention alcohol, first.
Dr Roger Henderson (12:22):
Yep.
Dr George Moncrieff (12:23):
Keep that down to the end of your list.
So, the most common, and I thinkthe most important trigger, for
rosacea is ultraviolet light.
Usually UVB, but alsoimportantly, sometimes UVA.
And the thing about UVA is it goesstraight through cloud, it goes straight
(12:45):
through glass, and it's almost asintense at dusk, as it is at noon.
And almost as intense inDecember, as it is in June.
So you, on a cloudy day, indoors, inDecember, are being exposed to UVA.
And if it's UVA that's driving theflushes, then it's really important to
(13:08):
be aware of that and to deal with it.
So, yes, UVB is the more important,but it can be UVA as well.
Obviously, embarrassing situations,speaking in public, for example, or
an awkward situation with your bossor something, going bright red is the
last thing you need in that situation.
And if you're worrying aboutthat, the emotional stress of
(13:30):
that, emotion can cause a flush.
You're into a vicious cycle, whereyou're going red because you're worried
you're going to go red, and then you'vegone red, and it's just dreadful.
Patients often avoid those situations.
I talk to patients about having very hotmeals, hot food as well as spicy food,
hot curries and things, can cause aflush in some individuals, not everyone.
(13:51):
For other people it's cheeseand certain cheeses or beer.
Sudden temperature changes, goinginto a hot sauna or into a hot room
or going, sometimes even going intoa cold room or going out for a cold
walk can cause the face to flush.
So, there are a large number ofdifferent potential triggers.
Yes, alcohol can, and I think in W.C
Field's case, he clearly enjoyed
(14:12):
his gin and enjoyed his alcohol,
and made quite a note about that.
But I think it's probably endorsed inour psyche, the link between rosacea and
alcohol, but it's much less strong thanthese other triggers in my experience.
And, in a big study, from in nurses fromSouthern Ireland, they found that it
was, white wine more than red wine, orbeer or spirits, that causes a flush.
(14:34):
But yeah I always inquire aboutthis last, after having gone
through all the other things.
Because if you've got somebody with atroublesome red face and all you talk
about is alcohol, they will think you'vegot the wrong end of the stick and they
will probably not be happy with that.
Very occasionally certainmedications taken by mouth or
on the skin can cause a flush.
For example, Protopic®, patientsput Protopic® on their eczema,
(14:55):
they then have some alcohol and acombination causes a flush on the face.
So, that can happen.
But, you can get it fromcalcium channel antagonists.
There's a large number ofdrugs that can cause flushing.
So, just consider themedications the patient's on.
I think the message that I want to getacross is that, everyone's an individual,
and what causes flushing for one patient,won't necessarily for somebody else.
(15:17):
So, what I recommend is they should, keepa diary, for two or three months, and they
will know they're having a flush becauseit happens quite quickly, and it comes
on much faster than sunburn, for example.
Sunburn, it's several hours later.
If it's causing a flush it'll happenwithin half an hour or two at most.
So, find out what is your trigger, orare your triggers, and then you know
(15:38):
what you need to do to try and keepthose at bay as much as possible.
Dr Roger Henderson (15:42):
Absolutely.
And I have, interesting whilst youwere talking there, it just brought
to mind, I have seen menopausal women,with early rosacea who have been having
menopausal flushing, but also havegot mixed in, rosacea flushing, and
they just, you know, it hasn't beenpicked up, because everything has just
been lumped in with the menopause.
(16:02):
So we have to just have thatlittle extra thinking cap on,
if you're seeing a menopausalwoman coming in with a flushing.
Yes, this is likely to be menopausal,but it could just as likely be, rosacea.
I've got two camps of peoplewith rosacea, in my experience.
There's the camp that says, youknow, they're the only one with it.
They're the only person who'sgot the symptoms and they're
(16:23):
dreadfully distressed by it.
And then there's the camp thatthinks, well, everybody sort of looks
the same and the same presentation.
But, one of the problems with rosacea,as you've alluded to, there's a massive
range, of not only presentation,there's also clinical findings as well.
And we just have to keep thatrosacea thinking cap on, don't we?
Dr George Moncrieff (16:44):
Absolutely.
I've described the range, but you canget all combinations of those subtypes.
In my experience, it usuallystarts, with eye symptoms.
And then the patient starts experiencingeasy flushing, blushing, with
increased facial skin sensitivity.
Then they go on to develop thatpermanent background redness with
the sparing around the eyelids.
(17:07):
And I haven't seen this in the books,but it's my impression that it's
that repeated blushing and flushingand there is a difference between a
blush and a flush, but that repeatedflushing that vasomotor instability,
I think drives the rosacea onto themore inflammatory end of the spectrum,
in a genetically prone individual.
So, I think the message there isif you can curtail that flushing
(17:29):
and limit it, you might be ableto prevent it progressing to the
more aggressive inflammatory endwith the papules and the pustules.
So, that's just an interesting concept.
Phymatous disease can occur on its own.
The patient has no significanthistory of rosacea, they've
just got phymatous disease.
Which is why I think somedermatologists wonder whether
it is part of the same spectrum.
(17:51):
And it's this extraordinary subcutaneousthickening of the sebaceous material.
But, it's a strange entity that seemsto run along, to some extent, parallel
to the erythematotelangiectatic andpapulopustular patterns that we see.
Dr Roger Henderson (18:05):
Yeah and just to me it just makes logical common sense.
If you've got a condition...
Dr George Moncrieff (18:10):
Sure.
Dr Roger Henderson (18:10):
...with repeated episodes of inflammation,
then you are going to put petrolon that fire, of that condition.
So like you, I mean, the books maynot be saying it, but I think in
the real world, it probably is.
Now, I can't remember the last time, onceI was certain of the diagnosis, and that's
an important point, but once I was certainof the diagnosis of rosacea that I ever
(18:31):
investigated, a patient with rosacea.
And I suppose that's one of the beautiesas a doctor, if I can use that term,
with patients with rosacea, becauseusually, we just have to sort of think,
and look, and most especially important,listen to the patient, and there's
a diagnosis that drops on our lap.
So, unless you're not 100%about the diagnosis, I don't
(18:56):
think I've ever investigated.
Have you much?
Dr George Moncrieff (18:59):
Very rarely.
I mean, as you say, it's a clinicaldiagnosis, based on listening to a
careful history, and a few signs onexamination, for example, the periocular
sparing of the background erythema.
But the history is usually very typical.
People are sometimes put off bythe scale, and aren't thinking of
rosacea being a scaly skin condition.
(19:20):
So they'll be thinking, couldthis be seborrhoeic dermatitis,
which is extremely common.
And of course, the two can co-exist.
Acne can be in the differential there,acne progressing later, but there you'd
be looking for comedones and diseaseelsewhere, because the two could co-exist.
The one that worries me, I suppose,just at the back of my mind, is
(19:40):
lupus, systemic lupus, for example.
They usually have much moreextreme photosensitivity.
So, the patient says that myface is going red in the sun.
With lupus you might expect perhaps tosee more than just a bit of redness.
You might expect to see someeven blistering, and so on.
So, I've done, occasionally donean ANA [Antinuclear Antibody], just
to be sure I'm not missing that.
(20:01):
But no, I'd say, 98% of thetime, it's going to be history
and examination, a good history.
But if they've got seborrhoeicdermatitis, you're going to be looking
in their scalp, you're gonna be lookingin their ear, behind their ear, maybe in
the front of the chest and the armpits.
And it's more into the nasolabial fold,rather than this redness and pustular
change on the cheeks and things.
Dr Roger Henderson (20:23):
Yeah, it's interesting you mention lupus, there.
I mean, the book, the textbookswould have us believe that, you know,
the butterfly rash was absolutelydemarcated like a butterfly.
We all know in practice it'soften a lot more vague...
Dr George Moncrieff (20:35):
Subtle.
Dr Roger Henderson: ...and subtle than that. (20:35):
undefined
So, it can look, just like ageneral reddening rather than
any kind of demarcated rash.
But yes that's probably theone to think of there, George.
Well, we're going to think abouttreatment, in the next podcast, but
George and I do hope that you foundthis chat about the most common of
skin problems interesting and that youfound this initial overview helpful.
(21:00):
And allow you to have more confidencewhen you're discussing rosacea with
patients when they sit in front of you.
Dr George Moncrieff (21:06):
So, we really hope you will join us again when we'll
go into much more detail as to how weapproach our management of rosacea.
Really emphasising the importance ofself-management and lifestyle tips
as well as some of the wonderfultreatments we have at our fingertips now.
We'd also like to thank, AproDerm®, oursponsor, for all their help in putting
these Rash Decisions podcasts together.
(21:27):
We couldn't have done it without them.
Dr Roger Henderson (21:29):
So until the next time, it's goodbye from George.
Dr George Moncrieff (21:32):
Goodbye.
Dr Roger Henderson (21:33):
And as always, it's goodbye from me.
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