April 1, 2024 • 27 mins
“...when you then see the patient who comes in [with] rosacea and they [have] then got the broken capillaries, the blood vessels starting to appear. It's not that my heart sinks when I see those, compared to a patient with simple background flushing, but I start thinking, we're in for a slightly trickier time here to start pulling them back.” Dr Roger Henderson.
In this episode, your hosts, Dr George Moncrieff and Dr Roger Henderson discuss the treatment options available across the rosacea spectrum. From how to treat simple flushing and background redness through to ocular involvement and Rhinophyma.
With over 70 years' combined experience in primary care, listen in to learn from these two expert GPs as they share their knowledge and practical tips on rosacea treatments.
This episode includes:
- Discussing lifestyle changes and trigger avoidance with your patients
- The importance of emollients as part of a daily routine
- The variety of treatment options available, both on the NHS and privately, when to use them appropriately, including anti-inflammatory and camouflage products, as well as laser therapy
- The association between Demodex mites and rosacea
- The various ocular manifestations and their treatment options
- The advances of rhinophyma debulking
But, be warned, by the end of this podcast, you might just be walking around with the same thoughts as George... “...I see a lot of people walking around the streets who've still got very nasty inflammatory papulopustular rosacea. I'm just desperate to talk to them because, I know we've got such effective treatments.”
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/
Thank you for listening. 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.
(00:09):
Hello and welcome to this Rash Decisionspodcast, where we look at skin related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
(00:30):
of the Dermatology Council for England.
Now today, George and I are going to betalking about the treatment of rosacea,
and this is the second of two podcastsabout this very common skin problem.
And if you were with us for the firstone where we talked about the basics
of the condition, then George andI do hope you found that helpful.
(00:58):
So to kick off this week's podcast,George, let's not dive into medication
straight away, although that'sobviously crucial, but let's first
chat about some general treatmentprinciples here, which for rosacea
particularly, I think are so important.
I agree.
Lifestyle changes should play a hugepart in our approach to helping patients
(01:20):
with this distressing condition.
Trigger avoidance is key.
So, I talked about the diary lasttime, and I would suggest patients
keep a diary to find out what theirtriggers are, to show what, for their
individual case, what's happeningand why they're getting the triggers.
And then the patient can make a decision.
(01:40):
If they get home from a stressful day atwork and they're desperate for a glass
of wine and some cheese and a hot curry,and they know that that combination
is going to give them a trigger.
Well, that's their choice andthey may well feel that's what
they'd rather do tonight becausetoday was such a stressful day.
So trigger avoidance, knowing what yourtriggers are, can be very, very helpful.
(02:01):
But because UV light is such a commoncause of triggering in rosacea, I advise
that all patients with rosacea shoulduse a high factor UVB and UVA sunblock.
All year round, even on a cloudy day, evenif they're going to be staying indoors,
(02:21):
still use a sunblock on your face and theother areas where you're getting rosacea.
Generally try to keep out of directsunlight, and perhaps consider
wearing a wide-brimmed hat, to keepyour head in the shade and your face
in the shade would be a good idea.
And by high factor, I suppose it hasn'tgot to be that high a factor, but make
(02:42):
sure it's got a UVA block in it as well.
So ideally a three or four starrating UVA block, and to be honest,
actually, I think the, the sort ofsunblock that you have in, face creams
for, for women as their foundation.
So a factor 15 is probably okay,for most of the year anyway.
UVB is very weak in the winter and at theextremes of day and on cloudy days, so
(03:05):
you don't need a very strong UVB to giveyou the protection you need from UVB.
The second thing to say is thatthe skin in rosacea is sensitive.
So avoid detergents.
You know I hate soap but thisis a situation where I would
definitely say avoid soaps and otherdetergents and maybe wash instead
with a soap substitute emollient.
(03:26):
And the AproDerm® range here are ideal.
For example, I use AproDerm® Gel to wetshave through , but you can use AproDerm®
Gel as a soap substitute in the shower.
It will make the shower traya bit slippery, so you may
need to warn your patients.
But I think an emollient towash with, which we've discussed
before, is a great idea.
And don't forget that shampoois a powerful detergent.
(03:47):
So, by all means, wash your hair, butdon't let the shampoo wash down over
the rosacea affected areas of skin.
It will aggravate things.
So that's another powerfuldetergent to avoid.
Similarly, patients should generallytry and avoid fragrances on the face,
particularly those that contain alphahydroxy acids or ascorbic acids.
They will aggravate things, but patientsusually find that out for themselves.
(04:10):
Any exposure of the facial skin to atopical steroid can massively aggravate
things, and that can even be fromusing some Canesten® HC or Daktacort®.
Trivial amounts of 1% hydrocortisonecan make things dramatically worse.
I've even seen it aggravated bythe, the mist around a spray from a
(04:31):
hayfever spray or an asthma spray.
If that gets onto the face, it canmake rosacea worse as can putting a
steroid on another part of your body orperhaps treating your child's eczema.
You think you've washed your hand,you think you've got it all off,
but the tiny residue can then geton your face and that can make
things worse, so watch out for that.
(04:52):
Another little tip is, is using agreen-tinted makeup, that can go a
long way to masking that backgroundredness, and I even suggest men use
it, do you, do you, do you like that?
I do, I have said that and meninvoluntarily take about three
steps backwards when I say that.
And, and when they wearit you cannot tell.
It is not like putting, you know,what I'd call conventional makeup on.
(05:15):
You just cannot tell.
And usually they come back and go "youknow, well, that was a great tip, doc.
I don't tell anybody but my wife knows."
But, you know...
ha ha ha ha ha.
...this is really, really helpful.
It's got to be the green-tinted one, yes.
Yeah, absolutely.
The green tint will mask thatpermanent background redness.
Yes.
And particularly when you get to themore inflammatory end of the spectrum,
(05:36):
to the papulopustular sort of rosacea.
This is a dry skin condition.
Don't be put off by seeinga bit of scale there.
It's still rosacea.
So, this is a situation where I'd want torecommend a quality, leave on emollient,
something like the AproDerm® Colloidal.
Absolutely ideal there.
It has nice, I find it sort ofanti-inflammatory a bit as well.
(05:58):
So that would be an option I'd look for.
The other one I really like is,as an alternative, if you're
happy with gels, is Adex™ Gel.
That's Doublebase™ with nicotinamide, andnicotinamide is a remarkable ingredient.
It improves the productionof the skin barrier through
increasing lamellar action.
But it also hasanti-inflammatory properties.
(06:19):
So this
wonderful vitamin B3
can be very effective.
Although it's only licensed for eczema,I use Adex™ Gel for a number of other
skin conditions besides rosacea.
I use it for my patients on isotretinoinfor acne, patients with psoriasis,
patients with Grover's disease, andso on, and even pemphigoid, and so I
think nicotinamide has a very, veryimportant anti-inflammatory role, and
(06:41):
I love it in this topical product.
Yeah, it's fantastic.
I mean, when we, typically see patientsor patients decide to present in front
of us, one of the triggers, and no punintended, that has brought them to us,
is the facial flushing and the redness.
That's the thing that initially seemsto cause the most concern, affect
(07:02):
their quality of life the most.
They feel they've been driven in frontof us because they really are fed up with
the flush, the flushing, the redness.
So if we look at the, the flushing sideof things, in terms of treatment, what
sort of patterns of treatment should webe thinking about going through when we
[are] just thinking of treating the, theflushing and the redness there, George?
Well, obviously, apart from trying toavoid triggers, I think the first thing
(07:24):
to say is that I don't think topicalantibiotics have any role here at all, and
I haven't prescribed a topical antibioticfor this pattern of rosacea for decades.
So, you know, metronidazole gels or otherantibiotic options are not going to be
effective at helping the, the flushing.
By far, by far, the most effectivetopical treatment we have is brimonidine.
(07:48):
That's Mirvaso® Gel Now that,the brimonidine, is we've been
using it for years, as Alphagan®,as an eye drop for glaucoma.
So we've put it into the conjunctivalsac without any hesitation
for years and years and years.
It's not caused any problems and it worksa treat, so when they put it into a gel
for the face I was very relaxed abouttrying it, and it is powerful stuff.
(08:11):
The problem with it is, it does causesome stinging for patients when they first
start to use it, and if they perseverewith it, usually that stinging calms down.
But one little tip there, there's aproduct called Toleriane Ultra, made by
L'Oreal, and it's got an ingredient calledNeurosensine, and Neurosensine renders the
(08:33):
nerve endings a lot, lot less sensitive.
Unfortunately, Toleriane Ultra does causea little bit of stinging when you first
use it, so, but it's fairly minor andpatients can tolerate that, and they put
it on twice a day for a week or so andthen, then they'll find they can put the
Mirvaso® on without any problem at all.
So it's a useful way of getting themto tolerate Mirvaso® and once they're
(08:57):
using Mirvaso®, then they will find thatthey'll develop tolerance to that and
they don't get the stinging so much.
The other thing is to putit on cold from the fridge.
That can help.
The other problem with Mirvaso®is, it's just too effective, and it
can render their background rednesscompletely white, and you can even do
Noughts & Crosses if you want with it.
(09:19):
It's that dramatic, but itdoesn't constrict the vessels that
have lost their muscle control.
So those telangiectatic vessels are thenjust rendered much more visible, and
patients often are very upset by that.
They'd rather have thebackground redness masking that.
And so, it can be a bit too effective,and of course, there are not many parts
of the country where you can prescribeit, so it's not available on the NHS.
(09:41):
You have to give the patienta private prescription.
So Mirvaso® is my absolute favourite, if Ican persuade the patient to give it a go.
The other thing it can do is, it cancause rebound flushing when it wears
off, but it lasts a good 12 hours.
So, I'd normally recommend puttingMirvaso® on in the morning and then by the
end of the day, they're at home and it'sin bed and it's unlikely to be a problem.
And that usually isn't too big a problem.
(10:03):
Occasionally, provided they're notcontraindicated, your patient hasn't
got asthma or something, or Raynaud's,a beta-blocker can be very effective.
Taken by mouth just one in the morning.
The one I like is Carvedilol,so I'd recommend that.
And there's certain patients, I think, whomight benefit more from that than others,
particularly if it's not contraindicated.
Yeah, I have occasionally picked a patientwith rosacea who's highly anxious and
(10:29):
their anxiety and stress that seems to bedriving along, their repeated episodes of
flushing and redness, and I have found anoral beta-blocker really can work on both.
And it's a bit of a chicken and egg,which one's it treating the best, and I
suspect in those cases, it's treating theanxiety and the adrenaline and the stress,
that then has the impact on the rosacea.
You can very nicely get a double whammy.
(10:51):
I seem to remember, going back, and Ihaven't done this for, oh for forever
really, but I do seem to remember thatClonidine was touted around for rosacea,
but I can't remember seeing anyone onit for, for decades probably, George.
No, I haven't.
I remember thinking about it, sortof in the 1980s and as an option,
(11:11):
before we had things like Mirvaso®.
Well, that was certainly available10 years ago, but certainly in the
80s it was an option we considered.
But it's limited by nasty sideeffects, and you've got to
introduce it gently and things.
No, it's an old-fashioned treatmentoption, and I think being superseded.
I suppose if you had a patient withbad asthma who couldn't tolerate
Brimonidine, it would cross my mind.
Yeah, but we'd probably putthat one, that one to bed.
(11:34):
So if that's the, the facial flushing and,and, and the redness when you then see
the patient who comes in [with] rosaceaand they then got the broken capillaries,
the blood vessels starting to appear.
It's not that my heart sinks when I seethose, compared to a patient with simple
background flushing, but I start thinking,we're in for a slightly trickier time here
(11:57):
to, to start pulling, pulling them back.
Would you, in your experience, would yousay that's, that's, you know, fair to say?
Yes, I think so.
We haven't got any options availableto us in primary care for this.
Yeah.
That's the real problem and the NHSdoesn't provide the treatment for them.
But, so it's tricky from that pointof view, but you could offer them, you
(12:19):
could talk about camouflage creams.
That's definitely an option and putthem in touch with 'Changing Faces'.
That's certainly a thought, butit's not an ideal long-term option.
The only really effective treatmentsare available privately and I do
urge patients to go to a respecteddermatologist, not to a high street
laser clinic or anything like that.
(12:39):
Definitely go to a respected dermatologyspecialist who has an interest
in laser treatments and intensepulsed light or pulsed dye lasers.
These can be very effective indeed,and they're a permanent remedy.
So the patient has these, thesedilated vessels, the individual
(13:00):
vessels are treated, you cantreat small patches at a time.
It may need four or maybe fivetreatments, perhaps five at most, each
treatment costing a few hundred pounds.
And I agree that's a lot of moneyto ask someone to pay for, but
it's not available on the NHS.
It's a permanent remedy, for theirtelangiectasia, and I think for
some patients that's an option thatthey are prepared to consider, as
(13:22):
being perhaps more important thana holiday or changing their car.
Absolutely, when I've spoken to patientswho've had that, they all say, yes,
that's a big chunk of money I hadto find, but in terms of payback for
quality of life, they say, "I wouldhappily do it again", because it
revolutionises some of their lives.
It's on their face, it's sovisible, and the end result is
(13:46):
back to normal looking skin.
Absolutely.
And interestingly, they get a lotof positive feedback from people,
other people who see them and say"Oh, you look so much better, your
face looks...", and, and almostindirectly, they get complimented for
having the rosacea treatment, whichmakes them, makes them feel better.
But rosacea spots, again, once we'vegot the diagnosis, and we're happy with
(14:08):
the diagnosis, if you're unfortunateenough to suffer, from quite often,
quite nasty rosacea spots , there aresome really effective treatments, but
they, unless you know what they are,they can be tricky to treat, can't they?
Yeah, they can.
And I see a lot of people walking aroundthe streets who've still got very nasty
inflammatory papulopustular rosacea.
(14:29):
I'm just desperate to talkto them because, I know we've
got such effective treatments.
This is where antibiotics are used.
And they work, there's no doubt.
They do work.
And here I go with a Tetralysal®or Lymecycline type antibiotic.
Occasionally low dose Doxycycline.
What I do like is 40 milligramsof modified-release Doxycycline.
(14:50):
That's Efracea®, which doesn'tdisturb the microbiome, supposedly,
but I'm sure it probably does.
But antibiotics here are being used fortheir anti-inflammatory side effects.
We're not primarily using them asantibiotics, and I just think that's
a little bit extravagant to putsomebody onto long-term antibiotics.
(15:12):
They have an impact on their microbiomeand of course on antimicrobial resistance.
I actually haven't prescribedMetronidazole for rosacea for decades.
And I'll come on to why not a bitlater, but I don't use Metronidazole.
I don't know whether you like theregular Metronidazole preparations.
They have to be used twice a day.
(15:33):
They plateau after a couple of months.
They're not that effective.
I do use them for fungating tumours andthings like that, where there's an odour.
But I don't use them for rosacea.
So, if I'm going to use an antibiotic, I'dprobably go with an oral antibiotic, and
I wouldn't want to go on using it for morethan a few months, if I could help it.
If you've got fairly mild andlocalised inflammatory rosacea,
(15:58):
azelaic acid, is, can be fantastic.
We've used that in a cream preparation,at 20%, called Skinoren®, for acne,
for years, and they put it into agel formulation at 15%, so a bit
weaker, in about 2003 or 2004.
So it's been around for 20 years, andalthough it's significantly weaker
(16:18):
than other options, it's a lovelyold-fashioned, safe, anti-inflammatory
treatment that can work verywell at keeping mild PPR at bay.
Now in papulopustular rosacea,there's a preponderance of a mite.
There are only two mitesthat live on our skin.
One is scabies and the otheris the Demodex folliculorum
(16:42):
and Demodex brevis mites.
Other mites like Ixodesricinus, which carry Lyme
disease, they don't breed on us.
But those two groups of mites, theDemodex and the scabies Sarcoptes,
they breed on us, they live on us,and we all have Demodex mites on our
face as part of our facial microbiome.
They're there to digest thesquames and the, and the sebum
(17:05):
around our hair follicles.
And, normal skin has abouttwo to five per centimetre.
In rosacea, they have an abundance,over a hundred, sometimes, of these
Demodex mites per square centimetre.
And in their, they've got, they'vegot no anus, but in their gut, they
have a particularly noxious, nastybacteria called Bacillus oleronius,
(17:29):
which can really trigger nasty,innate, inflammatory immune responses.
And interestingly when the mitedies, the chitin that comes from
its gut wall, sorry, its bodywall is also hugely inflammatory.
For years, I had patients come to see mewith troublesome, difficult, inflammatory
(17:49):
rosacea, which wasn't really beingcontrolled by oral antibiotics, and I used
Permethrin, 5% Permethrin cream, like weuse for scabies, and it worked a treat.
It knocked things back, got thingsunder control, but generally, several
months later, their rosacea came back.
About 10 years ago, a creamcontaining Ivermectin became
(18:11):
available, that's called Soolantra®.
And look at you smiling.
It is my absolute, all timefavourite topical agent.
It is, it was originally licensedfor treating Strongyloides
stercoralis, and onchocerciasis,the cause of river blindness.
(18:31):
I've also used it on a namedpatient basis, just one capsule
orally, for crusted scabies.
Absolutely brilliant.
It's a very powerfulscabicide for killing mites.
But this completely kills the mite.
The problem is that when it killsthe mite, it releases lots of chitin
from their cell walls, and it alsoreleases lots of Bacillus oleronius.
So patients often get a bit of a flare.
(18:53):
And I, therefore, sometimes if they'vegot particularly aggressive inflammatory
rosacea, I might just cover that first fewweeks with some very low dose doxycycline.
But they just put thiscream on once a day.
Usually at bedtime, and withina month, their rosacea, in my
experience, has melted away andprobably by killing these mites.
(19:14):
And you can then drop it downto, eventually down to once a
week, even just once a month.
And I just say, just keep going,putting it on once a month for, I say,
for the rest of your natural life.
It's not licensed for that, but I'm veryhappy for patients to be doing that.
Interestingly, there's a study calledthe MOSAIC Study, where patients put
Soolantra® on their face at bedtime, andthe Mirvaso® on their face in the morning.
(19:40):
And in that study, normally about 50%of patients won't tolerate Brimonidine,
Mirvaso®, because of the stinging.
But when you combine it with theSoolantra®, the anti-inflammatory
effect of the Soolantra®, atbedtime, meant that over 95% of
patients in that study toleratedthe Mirvaso® without any stinging.
(20:00):
So, if you've got both, I say you cando both, and put Mirvaso® on in the
morning, so you don't flush during theday, and the Ivermectin on at bedtime.
There's a new agent come outrecently, one, become stabilised.
It's been around since the early part ofthe 19th century, called hypochlorous.
(20:20):
Not hypochlorite, that'sMilton® or bleach.
But hypochlorous is producednaturally by our neutrophils as
part of our innate immune system.
And the problem with hypochlorous wasgetting it into a product that was stable.
Initially, it would take them20 years to stabilise it.
But it used to go off within two days.
(20:43):
But now they've stabilised it for twoto three years, and this, wait for it,
is 80 times more potent than bleach.
Whoa.
It kills bacteria, 99.9% of bacteria,fungi, even spores, and viruses.
And is in a stable preparation nowcalled Clinisept+.: And, it's totally
(21:06):
non damaging to mammalian cells.
Mammalian cells make it.
It's part of our innate immune system.
But it is lethal to these microbes.
And, I think that might be anotheroption for maintaining the skin.
The only worry I have, well one ofthe worries I have with Clinisept+,
or hypochlorous, is it's too good, andit's going to knock out the microbiome.
(21:28):
So we may need to think abouthow we reseed the microbiome
to, to, to cope with that.
And then the final thing to mentionis, very rarely, I've used off-licence,
very low dose oral Isotretinoin.
It's, it's not licensed,but you need a tiny dose.
Not really suitable for women ofchildbearing years, because she may
need to be on it for a few years.
(21:50):
But if you've got somebody, say, 45, 50,or a man, it can be highly effective.
And I think what it's doing there is,it's working by starving the mites.
The little buggers haven'tgot anything to eat.
So there's no squames, there'sno grease, and so they, they,
they die from starvation.
But a highly effectiveold-fashioned treatment.
But to be honest, since Soolantra®became available, my patients with severe
(22:12):
inflammatory rosacea don't exist anymore.
It's, it's absolutely brilliant stuff.
It's one of the most amazing topicalpreparations to come on the market, this
century, certainly...or in my lifetime.
Absolutely, in my lifetime aswell, isn't, isn't it just.
Now obviously, we, we often thinkof purely skin linked conditional
rosacea, but we touch on eyesymptoms, and I think these are really
(22:35):
important not to, not to forget.
Now, you might not need any significantintervention in someone with, even
quite severe rosacea, if they've got noeye involvement, but if we're starting
to think about possible interventionsfor our rosacea patients who do have
eye symptoms, we're going, there's awhole spectrum, everything from simple
(22:56):
artificial tears on a PRN basis upto specialist referral, isn't there?
Yes, absolutely.
And the extraordinary thing about eyesymptoms is that patients with severe
eczema, so sorry, severe rosacea, mayhave no eye symptoms at all, and then
the next patient comes in and they got,they got, they've got severe chalazion,
and they've got terrible problems,and so it doesn't seem to be related
(23:18):
to the severity of the skin disease.
But yeah, if you've just got simpledry eyes, then artificial tears,
the one that they like, plus perhapssome simple eye ointment, to last
a bit longer through the nights.
Perhaps advising them notto use contact lenses.
Simple treatments like that are wise.
Blepharitis, I would say lid hygiene.
Occasionally a bit of shampoo,baby shampoo along the
(23:41):
eyelid margin can be helpful.
But I, to be honest, I prefer hotsaline soaks, as hot as the patient
can bear, and I also use thosefor patients with recurrent styes.
I think maybe myhypochlorous has a role here.
It's so safe it could go almost anywhere.
So the hypochlorous could go there,but you do need to use it as the
(24:02):
hypochlorous eye preparation,which is called Purifeyes™.
I wouldn't use Clinisept+in or near to the eye.
So, for blepharitis, it's lidhygiene treatment, essentially.
But yeah, you're absolutely right.
If it's more severe, you may need toconsider oral antibiotics, antibiotic
eye drops, or seeing an eye specialist.
(24:25):
And interestingly, they sometimes useeye steroid drops, steroid eye drops,
which, be jolly careful you don't getthose on the face, but if you've got
keratitis, for example, they may wellneed a steroid to calm that down.
Off-licence, I've seen Ivermectinused, and I've used it as well.
Ivermectin cream is not licensedfor around the eye, and the advice
(24:46):
is to avoid getting it in the eye.
But I sometimes suggest to patients, ifthey've got particularly nasty chalazion,
and eyelid involvement, rather thaneyeball involvement, if the eyelids are
very inflamed, very, very carefully, juststroking a little bit of Soolantra® cream
along the eyelid margin, off-licence,so you do need to discuss it with the
(25:07):
patient, can be highly effective as well.
So that's another option we have there.
Yeah, that's a really helpful tip.
Now, when we started the firstof these podcasts, we mentioned
Rembrandt, W. C. Fields.
And the reason we know they've had rosaceawas because of their unfortunate noses.
So I think it might be an appropriateend, end of this podcast to
(25:29):
perhaps look at that sort of area.
Now, the key thing, obviously,and I'm seeing this less and less.
In fact, I can't think of the lastcase of a new rhinophyma I saw.
We're seeing this less and lessbecause the treatments are getting
better and better, but the key thingis to actually prevent a rhinophyma
happening in, in the first place.
But if you do have someone whowalks in and they've got an obvious
(25:51):
rhinophyma that's developed, the,the blunt truth here is you've just
got to chop it off, haven't you?
That's really the onlytreatment we've got.
Having heard what you said there, I'm notabsolutely convinced that rhinophyma is
the end stage of uncontrolled rosacea.
I have seen rhinophyma withoutany rosacea , but it is my hunch.
(26:12):
I'd rather agree with you, yeah, that ifyou've got uncontrolled papulopustular
rosacea, you're likely to be a candidatefor going on to develop a rhinophyma.
But I'm not too sure how strong thatlink is between the two conditions.
But no, once you've got arhinophyma, basically it's debulking.
And in the old days, that wassurgical, which wasn't so good.
Now they use a CO2 cutting laser, and Ihave seen phenomenal results from that.
(26:36):
A normal skin regrowing andnot even looking scarred.
So not available usually on the NHS,but a CO2 cutting laser can be a very,
very effective way of debulking thissubcutaneous seborrhoeic material.
Yeah, that's a really optimistic note toend this, this treatment podcast on and I
(27:00):
think we've covered, you know, an enormousrange of treatments here, which does give
hope to us, and I do think that's a goodplace to bring this episode to a close,
and George and I actually do hope thatyou found this interesting and helpful,
the next time you, [are] seeing a patientsitting in front of you with rosacea.
And we hope you'll join usagain where we'll be discussing
another skin related condition.
(27:22):
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So as always, until the nexttime, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome to this Rash Decisionspodcast, where we look at skin related
issues, conditions and treatments inan interesting and informative way.
I'm Dr Roger Henderson.
I'm a GP with a long-standing interestin this particular area of health.
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
(00:30):
of the Dermatology Council for England.
Now today, George and I are going to betalking about the treatment of rosacea,
and this is the second of two podcastsabout this very common skin problem.
And if you were with us for the firstone where we talked about the basics
of the condition, then George andI do hope you found that helpful.
(00:58):
So to kick off this week's podcast,George, let's not dive into medication
straight away, although that'sobviously crucial, but let's first
chat about some general treatmentprinciples here, which for rosacea
particularly, I think are so important.
I agree.
Lifestyle changes should play a hugepart in our approach to helping patients
(01:20):
with this distressing condition.
Trigger avoidance is key.
So, I talked about the diary lasttime, and I would suggest patients
keep a diary to find out what theirtriggers are, to show what, for their
individual case, what's happeningand why they're getting the triggers.
And then the patient can make a decision.
(01:40):
If they get home from a stressful day atwork and they're desperate for a glass
of wine and some cheese and a hot curry,and they know that that combination
is going to give them a trigger.
Well, that's their choice andthey may well feel that's what
they'd rather do tonight becausetoday was such a stressful day.
So trigger avoidance, knowing what yourtriggers are, can be very, very helpful.
(02:01):
But because UV light is such a commoncause of triggering in rosacea, I advise
that all patients with rosacea shoulduse a high factor UVB and UVA sunblock.
All year round, even on a cloudy day, evenif they're going to be staying indoors,
(02:21):
still use a sunblock on your face and theother areas where you're getting rosacea.
Generally try to keep out of directsunlight, and perhaps consider
wearing a wide-brimmed hat, to keepyour head in the shade and your face
in the shade would be a good idea.
And by high factor, I suppose it hasn'tgot to be that high a factor, but make
(02:42):
sure it's got a UVA block in it as well.
So ideally a three or four starrating UVA block, and to be honest,
actually, I think the, the sort ofsunblock that you have in, face creams
for, for women as their foundation.
So a factor 15 is probably okay,for most of the year anyway.
UVB is very weak in the winter and at theextremes of day and on cloudy days, so
(03:05):
you don't need a very strong UVB to giveyou the protection you need from UVB.
The second thing to say is thatthe skin in rosacea is sensitive.
So avoid detergents.
You know I hate soap but thisis a situation where I would
definitely say avoid soaps and otherdetergents and maybe wash instead
with a soap substitute emollient.
(03:26):
And the AproDerm® range here are ideal.
For example, I use AproDerm® Gel to wetshave through , but you can use AproDerm®
Gel as a soap substitute in the shower.
It will make the shower traya bit slippery, so you may
need to warn your patients.
But I think an emollient towash with, which we've discussed
before, is a great idea.
And don't forget that shampoois a powerful detergent.
(03:47):
So, by all means, wash your hair, butdon't let the shampoo wash down over
the rosacea affected areas of skin.
It will aggravate things.
So that's another powerfuldetergent to avoid.
Similarly, patients should generallytry and avoid fragrances on the face,
particularly those that contain alphahydroxy acids or ascorbic acids.
They will aggravate things, but patientsusually find that out for themselves.
(04:10):
Any exposure of the facial skin to atopical steroid can massively aggravate
things, and that can even be fromusing some Canesten® HC or Daktacort®.
Trivial amounts of 1% hydrocortisonecan make things dramatically worse.
I've even seen it aggravated bythe, the mist around a spray from a
(04:31):
hayfever spray or an asthma spray.
If that gets onto the face, it canmake rosacea worse as can putting a
steroid on another part of your body orperhaps treating your child's eczema.
You think you've washed your hand,you think you've got it all off,
but the tiny residue can then geton your face and that can make
things worse, so watch out for that.
(04:52):
Another little tip is, is using agreen-tinted makeup, that can go a
long way to masking that backgroundredness, and I even suggest men use
it, do you, do you, do you like that?
I do, I have said that and meninvoluntarily take about three
steps backwards when I say that.
And, and when they wearit you cannot tell.
It is not like putting, you know,what I'd call conventional makeup on.
(05:15):
You just cannot tell.
And usually they come back and go "youknow, well, that was a great tip, doc.
I don't tell anybody but my wife knows."
But, you know...
ha ha ha ha ha.
...this is really, really helpful.
It's got to be the green-tinted one, yes.
Yeah, absolutely.
The green tint will mask thatpermanent background redness.
Yes.
And particularly when you get to themore inflammatory end of the spectrum,
(05:36):
to the papulopustular sort of rosacea.
This is a dry skin condition.
Don't be put off by seeinga bit of scale there.
It's still rosacea.
So, this is a situation where I'd want torecommend a quality, leave on emollient,
something like the AproDerm® Colloidal.
Absolutely ideal there.
It has nice, I find it sort ofanti-inflammatory a bit as well.
(05:58):
So that would be an option I'd look for.
The other one I really like is,as an alternative, if you're
happy with gels, is Adex™ Gel.
That's Doublebase™ with nicotinamide, andnicotinamide is a remarkable ingredient.
It improves the productionof the skin barrier through
increasing lamellar action.
But it also hasanti-inflammatory properties.
(06:19):
So this
wonderful vitamin B3
can be very effective.
Although it's only licensed for eczema,I use Adex™ Gel for a number of other
skin conditions besides rosacea.
I use it for my patients on isotretinoinfor acne, patients with psoriasis,
patients with Grover's disease, andso on, and even pemphigoid, and so I
think nicotinamide has a very, veryimportant anti-inflammatory role, and
(06:41):
I love it in this topical product.
Yeah, it's fantastic.
I mean, when we, typically see patientsor patients decide to present in front
of us, one of the triggers, and no punintended, that has brought them to us,
is the facial flushing and the redness.
That's the thing that initially seemsto cause the most concern, affect
(07:02):
their quality of life the most.
They feel they've been driven in frontof us because they really are fed up with
the flush, the flushing, the redness.
So if we look at the, the flushing sideof things, in terms of treatment, what
sort of patterns of treatment should webe thinking about going through when we
[are] just thinking of treating the, theflushing and the redness there, George?
Well, obviously, apart from trying toavoid triggers, I think the first thing
(07:24):
to say is that I don't think topicalantibiotics have any role here at all, and
I haven't prescribed a topical antibioticfor this pattern of rosacea for decades.
So, you know, metronidazole gels or otherantibiotic options are not going to be
effective at helping the, the flushing.
By far, by far, the most effectivetopical treatment we have is brimonidine.
(07:48):
That's Mirvaso® Gel Now that,the brimonidine, is we've been
using it for years, as Alphagan®,as an eye drop for glaucoma.
So we've put it into the conjunctivalsac without any hesitation
for years and years and years.
It's not caused any problems and it worksa treat, so when they put it into a gel
for the face I was very relaxed abouttrying it, and it is powerful stuff.
(08:11):
The problem with it is, it does causesome stinging for patients when they first
start to use it, and if they perseverewith it, usually that stinging calms down.
But one little tip there, there's aproduct called Toleriane Ultra, made by
L'Oreal, and it's got an ingredient calledNeurosensine, and Neurosensine renders the
(08:33):
nerve endings a lot, lot less sensitive.
Unfortunately, Toleriane Ultra does causea little bit of stinging when you first
use it, so, but it's fairly minor andpatients can tolerate that, and they put
it on twice a day for a week or so andthen, then they'll find they can put the
Mirvaso® on without any problem at all.
So it's a useful way of getting themto tolerate Mirvaso® and once they're
(08:57):
using Mirvaso®, then they will find thatthey'll develop tolerance to that and
they don't get the stinging so much.
The other thing is to putit on cold from the fridge.
That can help.
The other problem with Mirvaso®is, it's just too effective, and it
can render their background rednesscompletely white, and you can even do
Noughts & Crosses if you want with it.
(09:19):
It's that dramatic, but itdoesn't constrict the vessels that
have lost their muscle control.
So those telangiectatic vessels are thenjust rendered much more visible, and
patients often are very upset by that.
They'd rather have thebackground redness masking that.
And so, it can be a bit too effective,and of course, there are not many parts
of the country where you can prescribeit, so it's not available on the NHS.
(09:41):
You have to give the patienta private prescription.
So Mirvaso® is my absolute favourite, if Ican persuade the patient to give it a go.
The other thing it can do is, it cancause rebound flushing when it wears
off, but it lasts a good 12 hours.
So, I'd normally recommend puttingMirvaso® on in the morning and then by the
end of the day, they're at home and it'sin bed and it's unlikely to be a problem.
And that usually isn't too big a problem.
(10:03):
Occasionally, provided they're notcontraindicated, your patient hasn't
got asthma or something, or Raynaud's,a beta-blocker can be very effective.
Taken by mouth just one in the morning.
The one I like is Carvedilol,so I'd recommend that.
And there's certain patients, I think, whomight benefit more from that than others,
particularly if it's not contraindicated.
Yeah, I have occasionally picked a patientwith rosacea who's highly anxious and
(10:29):
their anxiety and stress that seems to bedriving along, their repeated episodes of
flushing and redness, and I have found anoral beta-blocker really can work on both.
And it's a bit of a chicken and egg,which one's it treating the best, and I
suspect in those cases, it's treating theanxiety and the adrenaline and the stress,
that then has the impact on the rosacea.
You can very nicely get a double whammy.
(10:51):
I seem to remember, going back, and Ihaven't done this for, oh for forever
really, but I do seem to remember thatClonidine was touted around for rosacea,
but I can't remember seeing anyone onit for, for decades probably, George.
No, I haven't.
I remember thinking about it, sortof in the 1980s and as an option,
(11:11):
before we had things like Mirvaso®.
Well, that was certainly available10 years ago, but certainly in the
80s it was an option we considered.
But it's limited by nasty sideeffects, and you've got to
introduce it gently and things.
No, it's an old-fashioned treatmentoption, and I think being superseded.
I suppose if you had a patient withbad asthma who couldn't tolerate
Brimonidine, it would cross my mind.
Yeah, but we'd probably putthat one, that one to bed.
(11:34):
So if that's the, the facial flushing and,and, and the redness when you then see
the patient who comes in [with] rosaceaand they then got the broken capillaries,
the blood vessels starting to appear.
It's not that my heart sinks when I seethose, compared to a patient with simple
background flushing, but I start thinking,we're in for a slightly trickier time here
(11:57):
to, to start pulling, pulling them back.
Would you, in your experience, would yousay that's, that's, you know, fair to say?
Yes, I think so.
We haven't got any options availableto us in primary care for this.
Yeah.
That's the real problem and the NHSdoesn't provide the treatment for them.
But, so it's tricky from that pointof view, but you could offer them, you
(12:19):
could talk about camouflage creams.
That's definitely an option and putthem in touch with 'Changing Faces'.
That's certainly a thought, butit's not an ideal long-term option.
The only really effective treatmentsare available privately and I do
urge patients to go to a respecteddermatologist, not to a high street
laser clinic or anything like that.
(12:39):
Definitely go to a respected dermatologyspecialist who has an interest
in laser treatments and intensepulsed light or pulsed dye lasers.
These can be very effective indeed,and they're a permanent remedy.
So the patient has these, thesedilated vessels, the individual
(13:00):
vessels are treated, you cantreat small patches at a time.
It may need four or maybe fivetreatments, perhaps five at most, each
treatment costing a few hundred pounds.
And I agree that's a lot of moneyto ask someone to pay for, but
it's not available on the NHS.
It's a permanent remedy, for theirtelangiectasia, and I think for
some patients that's an option thatthey are prepared to consider, as
(13:22):
being perhaps more important thana holiday or changing their car.
Absolutely, when I've spoken to patientswho've had that, they all say, yes,
that's a big chunk of money I hadto find, but in terms of payback for
quality of life, they say, "I wouldhappily do it again", because it
revolutionises some of their lives.
It's on their face, it's sovisible, and the end result is
(13:46):
back to normal looking skin.
Absolutely.
And interestingly, they get a lotof positive feedback from people,
other people who see them and say"Oh, you look so much better, your
face looks...", and, and almostindirectly, they get complimented for
having the rosacea treatment, whichmakes them, makes them feel better.
But rosacea spots, again, once we'vegot the diagnosis, and we're happy with
(14:08):
the diagnosis, if you're unfortunateenough to suffer, from quite often,
quite nasty rosacea spots , there aresome really effective treatments, but
they, unless you know what they are,they can be tricky to treat, can't they?
Yeah, they can.
And I see a lot of people walking aroundthe streets who've still got very nasty
inflammatory papulopustular rosacea.
(14:29):
I'm just desperate to talkto them because, I know we've
got such effective treatments.
This is where antibiotics are used.
And they work, there's no doubt.
They do work.
And here I go with a Tetralysal®or Lymecycline type antibiotic.
Occasionally low dose Doxycycline.
What I do like is 40 milligramsof modified-release Doxycycline.
(14:50):
That's Efracea®, which doesn'tdisturb the microbiome, supposedly,
but I'm sure it probably does.
But antibiotics here are being used fortheir anti-inflammatory side effects.
We're not primarily using them asantibiotics, and I just think that's
a little bit extravagant to putsomebody onto long-term antibiotics.
(15:12):
They have an impact on their microbiomeand of course on antimicrobial resistance.
I actually haven't prescribedMetronidazole for rosacea for decades.
And I'll come on to why not a bitlater, but I don't use Metronidazole.
I don't know whether you like theregular Metronidazole preparations.
They have to be used twice a day.
(15:33):
They plateau after a couple of months.
They're not that effective.
I do use them for fungating tumours andthings like that, where there's an odour.
But I don't use them for rosacea.
So, if I'm going to use an antibiotic, I'dprobably go with an oral antibiotic, and
I wouldn't want to go on using it for morethan a few months, if I could help it.
If you've got fairly mild andlocalised inflammatory rosacea,
(15:58):
azelaic acid, is, can be fantastic.
We've used that in a cream preparation,at 20%, called Skinoren®, for acne,
for years, and they put it into agel formulation at 15%, so a bit
weaker, in about 2003 or 2004.
So it's been around for 20 years, andalthough it's significantly weaker
(16:18):
than other options, it's a lovelyold-fashioned, safe, anti-inflammatory
treatment that can work verywell at keeping mild PPR at bay.
Now in papulopustular rosacea,there's a preponderance of a mite.
There are only two mitesthat live on our skin.
One is scabies and the otheris the Demodex folliculorum
(16:42):
and Demodex brevis mites.
Other mites like Ixodesricinus, which carry Lyme
disease, they don't breed on us.
But those two groups of mites, theDemodex and the scabies Sarcoptes,
they breed on us, they live on us,and we all have Demodex mites on our
face as part of our facial microbiome.
They're there to digest thesquames and the, and the sebum
(17:05):
around our hair follicles.
And, normal skin has abouttwo to five per centimetre.
In rosacea, they have an abundance,over a hundred, sometimes, of these
Demodex mites per square centimetre.
And in their, they've got, they'vegot no anus, but in their gut, they
have a particularly noxious, nastybacteria called Bacillus oleronius,
(17:29):
which can really trigger nasty,innate, inflammatory immune responses.
And interestingly when the mitedies, the chitin that comes from
its gut wall, sorry, its bodywall is also hugely inflammatory.
For years, I had patients come to see mewith troublesome, difficult, inflammatory
(17:49):
rosacea, which wasn't really beingcontrolled by oral antibiotics, and I used
Permethrin, 5% Permethrin cream, like weuse for scabies, and it worked a treat.
It knocked things back, got thingsunder control, but generally, several
months later, their rosacea came back.
About 10 years ago, a creamcontaining Ivermectin became
(18:11):
available, that's called Soolantra®.
And look at you smiling.
It is my absolute, all timefavourite topical agent.
It is, it was originally licensedfor treating Strongyloides
stercoralis, and onchocerciasis,the cause of river blindness.
(18:31):
I've also used it on a namedpatient basis, just one capsule
orally, for crusted scabies.
Absolutely brilliant.
It's a very powerfulscabicide for killing mites.
But this completely kills the mite.
The problem is that when it killsthe mite, it releases lots of chitin
from their cell walls, and it alsoreleases lots of Bacillus oleronius.
So patients often get a bit of a flare.
(18:53):
And I, therefore, sometimes if they'vegot particularly aggressive inflammatory
rosacea, I might just cover that first fewweeks with some very low dose doxycycline.
But they just put thiscream on once a day.
Usually at bedtime, and withina month, their rosacea, in my
experience, has melted away andprobably by killing these mites.
(19:14):
And you can then drop it downto, eventually down to once a
week, even just once a month.
And I just say, just keep going,putting it on once a month for, I say,
for the rest of your natural life.
It's not licensed for that, but I'm veryhappy for patients to be doing that.
Interestingly, there's a study calledthe MOSAIC Study, where patients put
Soolantra® on their face at bedtime, andthe Mirvaso® on their face in the morning.
(19:40):
And in that study, normally about 50%of patients won't tolerate Brimonidine,
Mirvaso®, because of the stinging.
But when you combine it with theSoolantra®, the anti-inflammatory
effect of the Soolantra®, atbedtime, meant that over 95% of
patients in that study toleratedthe Mirvaso® without any stinging.
(20:00):
So, if you've got both, I say you cando both, and put Mirvaso® on in the
morning, so you don't flush during theday, and the Ivermectin on at bedtime.
There's a new agent come outrecently, one, become stabilised.
It's been around since the early part ofthe 19th century, called hypochlorous.
(20:20):
Not hypochlorite, that'sMilton® or bleach.
But hypochlorous is producednaturally by our neutrophils as
part of our innate immune system.
And the problem with hypochlorous wasgetting it into a product that was stable.
Initially, it would take them20 years to stabilise it.
But it used to go off within two days.
(20:43):
But now they've stabilised it for twoto three years, and this, wait for it,
is 80 times more potent than bleach.
Whoa.
It kills bacteria, 99.9% of bacteria,fungi, even spores, and viruses.
And is in a stable preparation nowcalled Clinisept+.: And, it's totally
(21:06):
non damaging to mammalian cells.
Mammalian cells make it.
It's part of our innate immune system.
But it is lethal to these microbes.
And, I think that might be anotheroption for maintaining the skin.
The only worry I have, well one ofthe worries I have with Clinisept+,
or hypochlorous, is it's too good, andit's going to knock out the microbiome.
(21:28):
So we may need to think abouthow we reseed the microbiome
to, to, to cope with that.
And then the final thing to mentionis, very rarely, I've used off-licence,
very low dose oral Isotretinoin.
It's, it's not licensed,but you need a tiny dose.
Not really suitable for women ofchildbearing years, because she may
need to be on it for a few years.
(21:50):
But if you've got somebody, say, 45, 50,or a man, it can be highly effective.
And I think what it's doing there is,it's working by starving the mites.
The little buggers haven'tgot anything to eat.
So there's no squames, there'sno grease, and so they, they,
they die from starvation.
But a highly effectiveold-fashioned treatment.
But to be honest, since Soolantra®became available, my patients with severe
(22:12):
inflammatory rosacea don't exist anymore.
It's, it's absolutely brilliant stuff.
It's one of the most amazing topicalpreparations to come on the market, this
century, certainly...or in my lifetime.
Absolutely, in my lifetime aswell, isn't, isn't it just.
Now obviously, we, we often thinkof purely skin linked conditional
rosacea, but we touch on eyesymptoms, and I think these are really
(22:35):
important not to, not to forget.
Now, you might not need any significantintervention in someone with, even
quite severe rosacea, if they've got noeye involvement, but if we're starting
to think about possible interventionsfor our rosacea patients who do have
eye symptoms, we're going, there's awhole spectrum, everything from simple
(22:56):
artificial tears on a PRN basis upto specialist referral, isn't there?
Yes, absolutely.
And the extraordinary thing about eyesymptoms is that patients with severe
eczema, so sorry, severe rosacea, mayhave no eye symptoms at all, and then
the next patient comes in and they got,they got, they've got severe chalazion,
and they've got terrible problems,and so it doesn't seem to be related
(23:18):
to the severity of the skin disease.
But yeah, if you've just got simpledry eyes, then artificial tears,
the one that they like, plus perhapssome simple eye ointment, to last
a bit longer through the nights.
Perhaps advising them notto use contact lenses.
Simple treatments like that are wise.
Blepharitis, I would say lid hygiene.
Occasionally a bit of shampoo,baby shampoo along the
(23:41):
eyelid margin can be helpful.
But I, to be honest, I prefer hotsaline soaks, as hot as the patient
can bear, and I also use thosefor patients with recurrent styes.
I think maybe myhypochlorous has a role here.
It's so safe it could go almost anywhere.
So the hypochlorous could go there,but you do need to use it as the
(24:02):
hypochlorous eye preparation,which is called Purifeyes™.
I wouldn't use Clinisept+in or near to the eye.
So, for blepharitis, it's lidhygiene treatment, essentially.
But yeah, you're absolutely right.
If it's more severe, you may need toconsider oral antibiotics, antibiotic
eye drops, or seeing an eye specialist.
(24:25):
And interestingly, they sometimes useeye steroid drops, steroid eye drops,
which, be jolly careful you don't getthose on the face, but if you've got
keratitis, for example, they may wellneed a steroid to calm that down.
Off-licence, I've seen Ivermectinused, and I've used it as well.
Ivermectin cream is not licensedfor around the eye, and the advice
(24:46):
is to avoid getting it in the eye.
But I sometimes suggest to patients, ifthey've got particularly nasty chalazion,
and eyelid involvement, rather thaneyeball involvement, if the eyelids are
very inflamed, very, very carefully, juststroking a little bit of Soolantra® cream
along the eyelid margin, off-licence,so you do need to discuss it with the
(25:07):
patient, can be highly effective as well.
So that's another option we have there.
Yeah, that's a really helpful tip.
Now, when we started the firstof these podcasts, we mentioned
Rembrandt, W. C. Fields.
And the reason we know they've had rosaceawas because of their unfortunate noses.
So I think it might be an appropriateend, end of this podcast to
(25:29):
perhaps look at that sort of area.
Now, the key thing, obviously,and I'm seeing this less and less.
In fact, I can't think of the lastcase of a new rhinophyma I saw.
We're seeing this less and lessbecause the treatments are getting
better and better, but the key thingis to actually prevent a rhinophyma
happening in, in the first place.
But if you do have someone whowalks in and they've got an obvious
(25:51):
rhinophyma that's developed, the,the blunt truth here is you've just
got to chop it off, haven't you?
That's really the onlytreatment we've got.
Having heard what you said there, I'm notabsolutely convinced that rhinophyma is
the end stage of uncontrolled rosacea.
I have seen rhinophyma withoutany rosacea , but it is my hunch.
(26:12):
I'd rather agree with you, yeah, that ifyou've got uncontrolled papulopustular
rosacea, you're likely to be a candidatefor going on to develop a rhinophyma.
But I'm not too sure how strong thatlink is between the two conditions.
But no, once you've got arhinophyma, basically it's debulking.
And in the old days, that wassurgical, which wasn't so good.
Now they use a CO2 cutting laser, and Ihave seen phenomenal results from that.
(26:36):
A normal skin regrowing andnot even looking scarred.
So not available usually on the NHS,but a CO2 cutting laser can be a very,
very effective way of debulking thissubcutaneous seborrhoeic material.
Yeah, that's a really optimistic note toend this, this treatment podcast on and I
(27:00):
think we've covered, you know, an enormousrange of treatments here, which does give
hope to us, and I do think that's a goodplace to bring this episode to a close,
and George and I actually do hope thatyou found this interesting and helpful,
the next time you, [are] seeing a patientsitting in front of you with rosacea.
And we hope you'll join usagain where we'll be discussing
another skin related condition.
(27:22):
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Rash Decisions podcasts together.
We couldn't have done it without them.
So as always, until the nexttime, it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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