April 22, 2024 • 23 mins
"What have Rembrandt, the Hollywood actor, W. C. Fields and former president of the United States, Bill Clinton, all got in common?"
The answer is rosacea, which affects around 1 in 10 people in the UK. Typically characterised by a flushed face, this common skin condition can have a huge impact on an individual’s mental health and self-esteem.
So, in this episode our skin experts Dr George Moncrieff and Dr Roger Henderson will be discussing:
- The science behind the flushing
- The four different types of rosacea and their symptoms
- What the common triggers are
- Practical tips and advice on how to manage your unique triggers
Thank you to our kind sponsor AproDerm, who provide a range of emollients designed for the management of dry skin conditions, including eczema, psoriasis and ichthyosis.
Everyone’s skin is unique and what works for one person, may not work for another. That’s why AproDerm has developed the AproDerm Emollient Starter Pack. This pack contains all four of their emollients varying in their formulation, consistency and hydration, giving you the choice to find a routine which suits you.
Find out more here.
IG: https://www.instagram.com/aproderm/
FB: https://www.facebook.com/AproDerm
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 (00:11):
Hello and welcome to this Skin Deep podcast
where we look at skin relatedissues, conditions and treatments
in an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a longstandinginterest in this area of health.
Dr George Moncrieff (00:25):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:33):
Now today, George and I will be talking about
the common skin condition, rosacea,and what we should know about it.
Now the treatment of rosacea will bethe subject of our next podcast so
do make sure you check that one out.
And, I think what I'm going to do, George,today, is start with a pub quiz question,
(00:54):
which I think is a really good one, ifyou weren't already on this podcast,
because you'll know the answer to thisby being on this podcast, but if you
chuck this into a pub quiz, I suspect notmany people would get it, which is "What
have Rembrandt, the Hollywood actor,
W.C. Fields
and former president of the UnitedStates, Bill Clinton, all got in common?"
(01:16):
Well, as you might expect, theanswer is they had, or have, rosacea.
And interestingly, if you take a look atthe self-portraits that Rembrandt painted
throughout his life, his face changesquite markedly, to when he is an old man.
And those are essentiallythe changes of rosacea.
But, I think it's a good ideato start off by talking exactly
(01:38):
what rosacea is, obviously.
It's often poorlyunderstood, in my experience.
Patients that come to see me inpractice with it, unfortunately, seem
to know relatively little about itand I always find that surprising
as it affects about 1 in 10 people.
That's a significant number of peoplehere in the UK, especially, in the middle
age and I think that's probably yourexperience as well, isn't it, George?
Dr George Moncrieff (02:01):
I agree, absolutely.
It is one of the most commonskin conditions that we see.
I suppose the first thing I'd want to sayis, we shouldn't confuse it with acne.
Some people even call it, rosaceaacne, which just adds to the confusion.
So like you, I prefer simplyjust to call it rosacea.
Both conditions happen to causered bumps and spots on the face,
(02:26):
but they are very, very different.
For example, rosacea affects theskin of the face and occasionally a
bit up onto the forehead and scalp,whereas acne commonly involves the
front of the chest and the back.
But there are many differences, and Iwon't go into those differences here,
but don't confuse rosacea with acne, andcertainly don't call it rosacea acne.
(02:48):
Interestingly, although more women seekadvice and help for rosacea than men,
when we do population studies, it seemsto be equally common in both sexes, and
I'm intrigued that all those examplesyou gave were men who had rosacea.
Interestingly, with Rembrandt and
W.C. Fields,
they had the condition, which wecall rhinophyma, which I'll come on to.
(03:11):
Also, people often think it's nota condition of dark skin, and I
think that's simply that people withdark skin are less likely to seek
advice, possibly because going redin the face is less of a cosmetic
problem on a dark skin background.
However, I've certainly seen, andI'm sure you have too Roger,
lots of rosacea in people with skin of colour.
(03:33):
So we need to consider it there,although there's a differential of
other things that can cause changeson the skin, particularly in dark
skin, that need to be thought about.
As you say, the number of peoplewith rosacea just increases with age.
It seems to start becoming morecommon from about the age of 20 and it
probably peaks around about 50 to 60years, for most patterns of rosacea.
(03:57):
The change that Rembrandt and
W.C. Fields
had, where the nose grows,that generally is a condition of
older men and it gets worse, asyou said, with advancing years.
Dr Roger Henderson (04:08):
Now, have you found in your experience, George,
there is any kind of family history?
Can it run in families, or isit just so relatively common
that it can sometimes appear to?
Dr George Moncrieff (04:19):
Well, it certainly seems to be more common
in very fair skin types, doesn't it?
Dr Roger Henderson (04:24):
Yeah.
Dr George Moncrieff (04:24):
So, I think a lot of rosacea being in Celtic skin, so,
if you've got a fair skin background,that's going to mean you're more likely
particularly, to get the flushing and redface end of the spectrum, rather than the
more inflammatory pustular end, but I'venot actually noted anything specifically
on family association with it.
(04:45):
Have you?
Dr Roger Henderson (04:46):
No, I haven't, which is why I ask, the
question, with your experience.
I don't think I've ever seen a family withconsistent rosacea running through it.
In fact, the most I've probably seenis two family members, of different
ages, and they were siblings.
But no, I would never say thatthere is a strong family link.
Dr George Moncrieff (05:05):
But it's so common, that you commonly see two individuals
with it in the same family, don't you?
Dr Roger Henderson (05:10):
Exactly.
Dr George Moncrieff (05:12):
The mildest end of the spectrum of rosacea, and this is
a spectrum of disease, it's got a bigname, erythrotelangiectatic rosacea,
or for short, ETR, and so I'll use ETR.
Erythro means redness to doctors,and telangiectasia is a big,
complicated medical word, basicallydescribing a dilated blood vessel.
So, you get background rednessand you get dilated blood vessels.
(05:35):
And this is due to increasedflushing and blushing.
The flushes are caused by triggers, whichgenerally don't trouble other people.
So, these patients have, whatwe call, vasomotor instability.
Their tendency to flush ismuch more easily triggered.
And that's not only embarrassing forthem, but it's very unpleasant, they
(05:57):
describe these flushes as unpleasant.
And the flush typically comes onwithin 30 to 60 minutes of a trigger,
and can last for a couple of hours.
And, one thing can trigger thisin one individual and not in
another, so it's a very individualand personal set of triggers.
(06:17):
The skin then gradually developsa permanent background redness,
that erythema we're talkingabout, with, interestingly,
some sparing around the eyes.
Classically, in rosacea you don'tget that redness around the eyes.
And then this repeated dilatation ofthe blood vessels, followed by them
constricting back down again, youeventually get these tiny, permanently
(06:38):
dilated blood vessels, on the face, ratherlike weather beaten vessels, as this
background, hence the telangiectasia.
What patients with rosacea tell meis that their skin feels sensitive.
It's, often aggravated by detergents orfragrances, especially fragrances that
(06:58):
contain alpha-hydroxy acids or ascorbicacid, and they say that putting these
on their face, it actually stings.
Their skin feels much more sensitive.
There's a more inflammatory pattern,which we call, again another big word,
papulopustular rosacea, or PPR, whereyou get papules, that's red bumps,
and pustules, which is whiteheads.
(07:21):
These are mostly on the face, but they canoccur up onto the forehead and the scalp.
And they can be quite scaly.
I think doctors are often putoff by the fact that you see
scale around these pustules.
And as with the erythrotelangiectaticpattern, there's often some background,
or there's typically, you look forthe background permanent redness.
(07:43):
Well over half of patients who haverosacea, or go on to get rosacea,
experience some eye symptoms.
And they can be ranging from verymild, just dryness to scaly eyelashes,
blepharitis in other words, torecurrent styes or conjunctivitis,
or even occasionally much moreinflammatory conditions of the eyeball.
(08:03):
And I've had patients who'vecomplained of dry eyes, sometimes
for a year or two, before they startto get the skin manifestations.
So, these eye symptomscan precede, rosacea.
Dr Roger Henderson (08:15):
Yes, I just remembered when you were talking there, I remember
speaking to one of my local opticiansabout this and I asked them if they
had anyone coming in complaining ofdry eyes, irritant eyes, if they seem
to have a high colour in their face.
Or if the optician thought, gosh,you look like you're flushed.
Let me know.
And, it was only a couple of patientsI picked up early, but I definitely
(08:38):
picked up a couple early, just by askingthe optician to look out for those.
Dr George Moncrieff (08:45):
What a clever thing to do.
Excellent.
Yes.
But these eye symptoms are useful tous because if you've got a patient
with a red face, and there's adifferential, there are a number of
conditions that can cause a red facethat we need to be thinking about.
If they've got eye symptoms as well,which over half of patients with rosacea
will have, nearly always, then you'regoing to be airing towards the diagnosis.
(09:07):
But I think that's a great tip.
I love it.
I might go talk to myoptician and do the same.
A much more uncommon condition, iswhere the patient develops considerable
thickening of the tissues under the skin.
Typically on the nose, but it can occur onthe forehead and on the chin, and rather
rudely, doctors call this rhinophyma.
(09:28):
Rhino, meaning nose, and rather thanbeing a rhinoceros or bone on the
nose, it's a phyma, which is a potato.
So, we're basically sayingyou've got a potato nose, which
I always think is a bit rude.
And I don't know about you,I've only ever seen this in men.
I've never seen this in women.
Dr Roger Henderson (09:43):
Absolutely agreed.
And, we touched on Rembrandt
and W.C. Fields,
and as you say, that's whyit was picked up, and we'll touch
on this in a bit more detail later.
I'm certainly seeing less of that than Iwas 40 years ago, and I think maybe it's
because we're getting better at stoppingpeople with rosacea getting to that point.
But I know the misery, and the tauntseven, that some people with a rhinophyma
(10:07):
have had to endure, for a very long time.
It can be socially crippling.
So, I'm glad we're seeingless of that than we used to.
Dr George Moncrieff (10:14):
Yes, it's intriguing.
There are dermatologists I speakto who don't actually believe
it's part of the rosacea spectrum.
But I do, and I do think it isuncontrolled rosacea that drives it.
The other reason why we may be seeingless is that we have now, and we'll
talk about this next time, we havegot some fairly effective treatments.
So, particularly at the mildend of the spectrum, we can
calm it down and control it.
(10:36):
So, it may be that we're better atcontrolling rosacea or it may be that
we're better at treating rhinophyma,which is why we're seeing less of it.
But I've certainly had some patientswith some pretty spectacular noses.
And it is hard not tolook at them, isn't it?
Dr Roger Henderson (10:49):
It is.
Dr George Moncrieff (10:50):
And that is the problem with rosacea, it's visible.
It's your face.
It's the bit of your body thatyou expect to be able to see.
The only bit of my body you can seehere today, for example, and it's
unpredictable, and it's unpleasant forthe patient, and it hurts, the flushes
are unpleasant, the skin feels unpleasant.
So, it's not to be trivialised at all,and it's hardly surprising that it
(11:13):
can have a, really, very devastatingimpact on the patient's confidence,
going into a meeting, giving a talk,going into a new situation, their
self-esteem is affected and it canhave a big impact on mood as well.
So, I think we do need to take it veryseriously with those thoughts in mind.
Dr Roger Henderson (11:30):
Absolutely.
And if we think about the factors thatcan make rosacea worse, and that leads
nicely into what you just said there,about public speaking, it can be a real
catch-22 because, not only are there areasof myths and disinformation about rosacea
and, you know, if I had a pound for everyold wives tale I've heard about rosacea,
I'd be sitting on a beach in Barbados now.
(11:52):
But, the lifestyle factors, the foodswe eat, the alcohol that we drink, the
temperatures that we're in, or, if we'reembarrassed or stressed or anxious or
nervous or walking out onto a stage, it'sa cruel disease in many ways, because
it makes it more visible at that time.
Dr George Moncrieff (12:10):
Absolutely.
The most common though, and probablythe most important, trigger for
a flush is ultraviolet light.
Dr Roger Henderson (12:20):
Yep.
Dr George Moncrieff (12:21):
That's usually UVB, but also, importantly, it's UVA.
And I say importantlybecause UVA doesn't burn.
You're much less aware of it, andUVA goes straight through cloud.
UVA goes straight through glass.
And it's just as strong in thewinter as it is in the summer.
(12:42):
And it's just as strong at eitherend of the day as it is at noon.
So, you're being exposed to UVA, and ifthat's what's triggering your rosacea,
and you don't protect yourself from that,you will be getting triggers from UVA.
Admittedly, it's usually UVB, butUVA can have an important role in
rosacea, and we'll discuss that a bitmore when we talk about treatment.
Dr Roger Henderson (13:04):
Well I think this is a perfect time to take the
opportunity to say a few words aboutour kind sponsor, AproDerm®, and their
range of emollients and barrier creams.
Now, as we know,everyone's skin is unique.
In my many years as a GP, it'soften been tricky to find an
emollient that immediately suitedone person and their one condition.
(13:25):
And we know it's not as simple asone condition, one type of emollient.
It's often the case of patients trying anemollient and then going back and forth
with several prescriptions, several visitsto the practice, which is far from ideal.
But fortunately, AproDerm® havedeveloped a genius solution to
simplify the whole process ofselecting the right emollient for you.
Dr George Moncrieff (13:46):
Their AproDerm® Emollient Starter Pack contains
all four of their emollients inone pack, each having a unique
consistency and level of hydration.
With just one prescription, you havethe opportunity to try each one and find
the one that works best for your skin.
This allows you to choose the one, ormore, that you prefer and that suits
your lifestyle, while saving money,time, and more importantly, fewer
(14:11):
visits to the GP, pharmacist, or nurse.
Sounds like the perfectanswer to me as a GP.
And if you can't make it to yourhealthcare professional, it's available to
buy from your local pharmacy and Amazon.
I've been a big advocate of theAproDerm® range for a while now.
It's such a great range of products.
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Dr Roger Henderson (14:32):
Yeah, and I have to say I love them even more
now and actually use them myself.
So, if you're affected by a dry skincondition and want to know which emollient
will be the best for you, then do trythe AproDerm® Emollient Starter Pack.
Which, incidentally, also comes witha handy self-care guide full of tips
on helping you manage your condition,including useful advice on applying
(14:55):
emollients and potential triggers.
It really is a game changerfor the world of dermatology.
And, as George said earlier, it'savailable on prescription or to buy
from your local pharmacy or Amazon.
Dr George Moncrieff (15:09):
Yeah, speaking in public is probably the next most,
embarrassing situations, going toa dinner party, or whatever, can
really cause a very awkward flush.
And as soon as you think you mightbe flushing, you're more embarrassed,
and then you're into a viciouscycle, and the whole thing is a mess.
Hot foods can do it.
They're hot in temperature, but alsospicy hot foods, so curries and things.
(15:32):
Cheese, sudden temperature changes, goinginto a sauna, going into a hot room.
Interestingly, alsogoing into a cold room.
If you go out in the cold, somepeople's face begins to go red, which
is counterintuitive rather, isn't it?
Exercise.
If you're exercising, particularly ifyou are overdressed, or going for a brisk
walk and wearing more than you should havebeen wearing, all these things can do it.
(15:55):
And even just simple emotional stress,if you're getting upset, it can cause
your face suddenly to go bright red,which can really compromise your
ability to deal with that situation.
I always think about those triggersfirst, before I talk about alcohol,
because if somebody comes to see me,worried they've got a red face, and
I think this is a
problem with W.C. Fields,
he definitely didenjoy his alcohol, didn't he?
(16:15):
And he made a big thing of it, butI think it's perhaps built into
our psyche, the link between redfaces and rosacea and alcohol,
because he certainly had all three.
But, if I ask a patient with a red face,do they find alcohol triggers it, it's the
last thing I ask about, after I've gonethrough all the other possible triggers.
Interestingly, it's white wine morethan red wine that, or spirits or,
(16:39):
or beer that causes more triggeringproblems, in a big study from Ireland.
But, I think it's important that wedon't embarrass our patients by talking
about alcohol too early in that.
Dr Roger Henderson (16:49):
Absolutely.
Dr George Moncrieff (16:49):
Sometimes the medications we prescribe can cause
flushing, and there are a number that arenotorious for that, including some skin
topical treatments, can cause flushing.
For example, Protopic®, tacrolimus.
That can certainly cause flushing,especially if the patient puts it on
their skin and then drinks alcohol.
But certain calcium channel antagonists,that we use for blood pressure sometimes,
(17:12):
and other things, they can cause it.
But the important thing about flushingis it's very individual, so, what
causes a flush for one patient won'tnecessarily cause it for somebody else.
So, what I suggest to somebody withthis is, go away and keep a diary for a
couple of months and record, you'll knowwhat causes a flush, you probably know
already, but if eating cheese causes aflush, it will happen probably within an
(17:34):
hour or so, two at the most, and you canthen know what your causes of flushes
are, and you can say, look, I actuallyreally have had an awful day at work.
I need a glass of wine.
I need a chunk of cheese.
I just need that to get, to get homeand so on, I'm going to tolerate
having a flush in a couple hourstime because I'll be on my own,
and you can negotiate with yourselfwhat you're going to put up with...
(17:55):
but know what your flushes are.
Dr Roger Henderson (17:57):
It's interesting, people with rosacea who have sat in
front of me, they almost slightlyfall into two camps in a way.
There's the camp that thinksthat they're the only person
with that particular problem.
And then there's the campthat believes that everyone
looks the same, with rosacea.
So, rosacea, is rosacea, is rosacea.
And as we've talked about, you know,there's this massive spectrum from those
(18:18):
who aren't aware they've got it, buthave got some dry eyes and they walk
into their opticians, to the chap walkingdown the street who doesn't want to
see anybody because his face looks sored and he's got a large, bulbous nose.
Dr George Moncrieff (18:31):
I think it usually starts off with this unusually
easy flushing and blushing, withincreased skin sensitivity, developing
this permanent background redness.
And I haven't seen this in the books,but I actually believe it's that
flushing and blushing, that flushingand blushing definitely then causes
the dilated, permanently dilated, bloodvessels, which can be quite troublesome.
(18:55):
But I think it's that flushing andblushing, the vasomotor instability
then drives matters on, to the moreinflammatory end of the spectrum where you
get those sore red bumps and those spots.
And that creates the environmentthat is ideal for that to develop.
So, I actually believe that if you canlimit the amount of triggers that you
(19:18):
have, not only will it be more pleasantfor you as a patient, but it might
curtail the progression of this diseaseto the more severe end of the spectrum.
I don't know what happens witheye disease, and eye disease is
fascinating, and I don't know whetherwe can do anything to curtail that.
It seems to run alongside this,and I've seen very severe eye
disease with relatively mildskin disease, and vice versa.
(19:41):
And of course, half of the patients haveeye disease, but the other half don't.
So, it's extraordinary howthat association is there.
Phymatous disease, whichis this, bulbous nose.
I suspect it's due to chronically undertreated rosacea, but not necessarily, but
they're all very definitely interlinked.
Dr Roger Henderson (20:02):
What I often say to patients with rosacea is that,
just like you, I don't think we'vegot any hard evidence that repeated
flushing drives it along, although Ido genuinely think that is the case.
What I often say to patients withrosacea is, it's petrol on the fire.
The fire is just there quietlygoing along underneath.
But you then have repeated flushing,and it's just petrol on that fire,
(20:23):
and it's common sense, isn't it?
That's only going to increase,rather than decrease, inflammation.
If I'm happy with the diagnosis ofrosacea, in other words, if I've
excluded other possible diagnoses,I generally cannot ever remember
investigating a patient with rosacea.
I'm happy with the diagnosis and I canjust get on with advice and treatment.
(20:46):
Do you think that's fair?
Dr George Moncrieff (20:49):
I do actually, yes.
I'd say 90% of medicine iswhat the patient tells me.
It's their history, whatdoctors call their history.
90% is what they tell me.
8% is probably what I find on examination,and investigations are very, very rarely
important, particularly in this situation.
(21:10):
No, I, there are one or twothings I might want to exclude
if it's looking a bit unusual.
So I would think outside the box,but no, I couldn't agree more.
It's a clinical diagnosis madein the consulting room, based on
what the patient tells me and alittle bit about what I can see.
The distribution and thepattern
and things like that. Yeah.
Dr Roger Henderson (21:29):
Yeah. I mean,
from a medical point of view,it's one of the nicer, if I can use
that term, dermatological conditions,because it is so readily diagnosed.
It's not a no brainer, you'vegot to be thinking about it, but
it is something where you canfairly quickly be content with.
Dr George Moncrieff (21:45):
And it's nicer because we can definitely
make life better for the patients.
We've got some fabuloustreatments, which we're going to
come onto in our next podcast.
Dr Roger Henderson (21:52):
Exactly, and many of those patients will have tried all
sorts of over-the-counter preparations,or tried old wives tales and this, and
it's often quite late in the day theyactually come to see us in surgery, when
they get into a point where it's impactingon them, and I sometimes wish that they
came a little bit sooner, but I, youknow, would never, never say that to them.
As you say, we're going to talk about thetreatment of rosacea in the next podcast.
(22:17):
So, with this one, I do hope that youfound this chat from George and I really
helpful, about this most common of skinconditions, and that it has allowed
you to have more confidence if you dohave rosacea, in not only understanding
it a little bit better, but also abouthow we may be looking to treat it.
Dr George Moncrieff (22:36):
So, we hope you'll join us next time when we'll
be discussing that, along with selfmanagement tips and other lifestyle tips.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (22:54):
So, until next time, it's goodbye from George.
Dr George Moncrieff (22:58):
Goodbye.
Dr Roger Henderson (22:59):
And as always, it's goodbye from me.
Goodbye.
Hello and welcome to this Skin Deep podcast
where we look at skin relatedissues, conditions and treatments
in an interesting and informed way.
I'm Dr Roger Henderson.
I'm a GP with a longstandinginterest in this area of health.
Dr George Moncrieff (00:25):
And I'm Dr George Moncrieff.
I was also a GP, although I've now retiredfrom my practice, and I was the Chair
of the Dermatology Council for England.
Dr Roger Henderson (00:33):
Now today, George and I will be talking about
the common skin condition, rosacea,and what we should know about it.
Now the treatment of rosacea will bethe subject of our next podcast so
do make sure you check that one out.
And, I think what I'm going to do, George,today, is start with a pub quiz question,
(00:54):
which I think is a really good one, ifyou weren't already on this podcast,
because you'll know the answer to thisby being on this podcast, but if you
chuck this into a pub quiz, I suspect notmany people would get it, which is "What
have Rembrandt, the Hollywood actor,
W.C. Fields
and former president of the UnitedStates, Bill Clinton, all got in common?"
(01:16):
Well, as you might expect, theanswer is they had, or have, rosacea.
And interestingly, if you take a look atthe self-portraits that Rembrandt painted
throughout his life, his face changesquite markedly, to when he is an old man.
And those are essentiallythe changes of rosacea.
But, I think it's a good ideato start off by talking exactly
(01:38):
what rosacea is, obviously.
It's often poorlyunderstood, in my experience.
Patients that come to see me inpractice with it, unfortunately, seem
to know relatively little about itand I always find that surprising
as it affects about 1 in 10 people.
That's a significant number of peoplehere in the UK, especially, in the middle
age and I think that's probably yourexperience as well, isn't it, George?
Dr George Moncrieff (02:01):
I agree, absolutely.
It is one of the most commonskin conditions that we see.
I suppose the first thing I'd want to sayis, we shouldn't confuse it with acne.
Some people even call it, rosaceaacne, which just adds to the confusion.
So like you, I prefer simplyjust to call it rosacea.
Both conditions happen to causered bumps and spots on the face,
(02:26):
but they are very, very different.
For example, rosacea affects theskin of the face and occasionally a
bit up onto the forehead and scalp,whereas acne commonly involves the
front of the chest and the back.
But there are many differences, and Iwon't go into those differences here,
but don't confuse rosacea with acne, andcertainly don't call it rosacea acne.
(02:48):
Interestingly, although more women seekadvice and help for rosacea than men,
when we do population studies, it seemsto be equally common in both sexes, and
I'm intrigued that all those examplesyou gave were men who had rosacea.
Interestingly, with Rembrandt and
W.C. Fields,
they had the condition, which wecall rhinophyma, which I'll come on to.
(03:11):
Also, people often think it's nota condition of dark skin, and I
think that's simply that people withdark skin are less likely to seek
advice, possibly because going redin the face is less of a cosmetic
problem on a dark skin background.
However, I've certainly seen, andI'm sure you have too Roger,
lots of rosacea in people with skin of colour.
(03:33):
So we need to consider it there,although there's a differential of
other things that can cause changeson the skin, particularly in dark
skin, that need to be thought about.
As you say, the number of peoplewith rosacea just increases with age.
It seems to start becoming morecommon from about the age of 20 and it
probably peaks around about 50 to 60years, for most patterns of rosacea.
(03:57):
The change that Rembrandt and
W.C. Fields
had, where the nose grows,that generally is a condition of
older men and it gets worse, asyou said, with advancing years.
Dr Roger Henderson (04:08):
Now, have you found in your experience, George,
there is any kind of family history?
Can it run in families, or isit just so relatively common
that it can sometimes appear to?
Dr George Moncrieff (04:19):
Well, it certainly seems to be more common
in very fair skin types, doesn't it?
Dr Roger Henderson (04:24):
Yeah.
Dr George Moncrieff (04:24):
So, I think a lot of rosacea being in Celtic skin, so,
if you've got a fair skin background,that's going to mean you're more likely
particularly, to get the flushing and redface end of the spectrum, rather than the
more inflammatory pustular end, but I'venot actually noted anything specifically
on family association with it.
(04:45):
Have you?
Dr Roger Henderson (04:46):
No, I haven't, which is why I ask, the
question, with your experience.
I don't think I've ever seen a family withconsistent rosacea running through it.
In fact, the most I've probably seenis two family members, of different
ages, and they were siblings.
But no, I would never say thatthere is a strong family link.
Dr George Moncrieff (05:05):
But it's so common, that you commonly see two individuals
with it in the same family, don't you?
Dr Roger Henderson (05:10):
Exactly.
Dr George Moncrieff (05:12):
The mildest end of the spectrum of rosacea, and this is
a spectrum of disease, it's got a bigname, erythrotelangiectatic rosacea,
or for short, ETR, and so I'll use ETR.
Erythro means redness to doctors,and telangiectasia is a big,
complicated medical word, basicallydescribing a dilated blood vessel.
So, you get background rednessand you get dilated blood vessels.
(05:35):
And this is due to increasedflushing and blushing.
The flushes are caused by triggers, whichgenerally don't trouble other people.
So, these patients have, whatwe call, vasomotor instability.
Their tendency to flush ismuch more easily triggered.
And that's not only embarrassing forthem, but it's very unpleasant, they
(05:57):
describe these flushes as unpleasant.
And the flush typically comes onwithin 30 to 60 minutes of a trigger,
and can last for a couple of hours.
And, one thing can trigger thisin one individual and not in
another, so it's a very individualand personal set of triggers.
(06:17):
The skin then gradually developsa permanent background redness,
that erythema we're talkingabout, with, interestingly,
some sparing around the eyes.
Classically, in rosacea you don'tget that redness around the eyes.
And then this repeated dilatation ofthe blood vessels, followed by them
constricting back down again, youeventually get these tiny, permanently
(06:38):
dilated blood vessels, on the face, ratherlike weather beaten vessels, as this
background, hence the telangiectasia.
What patients with rosacea tell meis that their skin feels sensitive.
It's, often aggravated by detergents orfragrances, especially fragrances that
(06:58):
contain alpha-hydroxy acids or ascorbicacid, and they say that putting these
on their face, it actually stings.
Their skin feels much more sensitive.
There's a more inflammatory pattern,which we call, again another big word,
papulopustular rosacea, or PPR, whereyou get papules, that's red bumps,
and pustules, which is whiteheads.
(07:21):
These are mostly on the face, but they canoccur up onto the forehead and the scalp.
And they can be quite scaly.
I think doctors are often putoff by the fact that you see
scale around these pustules.
And as with the erythrotelangiectaticpattern, there's often some background,
or there's typically, you look forthe background permanent redness.
(07:43):
Well over half of patients who haverosacea, or go on to get rosacea,
experience some eye symptoms.
And they can be ranging from verymild, just dryness to scaly eyelashes,
blepharitis in other words, torecurrent styes or conjunctivitis,
or even occasionally much moreinflammatory conditions of the eyeball.
(08:03):
And I've had patients who'vecomplained of dry eyes, sometimes
for a year or two, before they startto get the skin manifestations.
So, these eye symptomscan precede, rosacea.
Dr Roger Henderson (08:15):
Yes, I just remembered when you were talking there, I remember
speaking to one of my local opticiansabout this and I asked them if they
had anyone coming in complaining ofdry eyes, irritant eyes, if they seem
to have a high colour in their face.
Or if the optician thought, gosh,you look like you're flushed.
Let me know.
And, it was only a couple of patientsI picked up early, but I definitely
(08:38):
picked up a couple early, just by askingthe optician to look out for those.
Dr George Moncrieff (08:45):
What a clever thing to do.
Excellent.
Yes.
But these eye symptoms are useful tous because if you've got a patient
with a red face, and there's adifferential, there are a number of
conditions that can cause a red facethat we need to be thinking about.
If they've got eye symptoms as well,which over half of patients with rosacea
will have, nearly always, then you'regoing to be airing towards the diagnosis.
(09:07):
But I think that's a great tip.
I love it.
I might go talk to myoptician and do the same.
A much more uncommon condition, iswhere the patient develops considerable
thickening of the tissues under the skin.
Typically on the nose, but it can occur onthe forehead and on the chin, and rather
rudely, doctors call this rhinophyma.
(09:28):
Rhino, meaning nose, and rather thanbeing a rhinoceros or bone on the
nose, it's a phyma, which is a potato.
So, we're basically sayingyou've got a potato nose, which
I always think is a bit rude.
And I don't know about you,I've only ever seen this in men.
I've never seen this in women.
Dr Roger Henderson (09:43):
Absolutely agreed.
And, we touched on Rembrandt
and W.C. Fields,
and as you say, that's whyit was picked up, and we'll touch
on this in a bit more detail later.
I'm certainly seeing less of that than Iwas 40 years ago, and I think maybe it's
because we're getting better at stoppingpeople with rosacea getting to that point.
But I know the misery, and the tauntseven, that some people with a rhinophyma
(10:07):
have had to endure, for a very long time.
It can be socially crippling.
So, I'm glad we're seeingless of that than we used to.
Dr George Moncrieff (10:14):
Yes, it's intriguing.
There are dermatologists I speakto who don't actually believe
it's part of the rosacea spectrum.
But I do, and I do think it isuncontrolled rosacea that drives it.
The other reason why we may be seeingless is that we have now, and we'll
talk about this next time, we havegot some fairly effective treatments.
So, particularly at the mildend of the spectrum, we can
calm it down and control it.
(10:36):
So, it may be that we're better atcontrolling rosacea or it may be that
we're better at treating rhinophyma,which is why we're seeing less of it.
But I've certainly had some patientswith some pretty spectacular noses.
And it is hard not tolook at them, isn't it?
Dr Roger Henderson (10:49):
It is.
Dr George Moncrieff (10:50):
And that is the problem with rosacea, it's visible.
It's your face.
It's the bit of your body thatyou expect to be able to see.
The only bit of my body you can seehere today, for example, and it's
unpredictable, and it's unpleasant forthe patient, and it hurts, the flushes
are unpleasant, the skin feels unpleasant.
So, it's not to be trivialised at all,and it's hardly surprising that it
(11:13):
can have a, really, very devastatingimpact on the patient's confidence,
going into a meeting, giving a talk,going into a new situation, their
self-esteem is affected and it canhave a big impact on mood as well.
So, I think we do need to take it veryseriously with those thoughts in mind.
Dr Roger Henderson (11:30):
Absolutely.
And if we think about the factors thatcan make rosacea worse, and that leads
nicely into what you just said there,about public speaking, it can be a real
catch-22 because, not only are there areasof myths and disinformation about rosacea
and, you know, if I had a pound for everyold wives tale I've heard about rosacea,
I'd be sitting on a beach in Barbados now.
(11:52):
But, the lifestyle factors, the foodswe eat, the alcohol that we drink, the
temperatures that we're in, or, if we'reembarrassed or stressed or anxious or
nervous or walking out onto a stage, it'sa cruel disease in many ways, because
it makes it more visible at that time.
Dr George Moncrieff (12:10):
Absolutely.
The most common though, and probablythe most important, trigger for
a flush is ultraviolet light.
Dr Roger Henderson (12:20):
Yep.
Dr George Moncrieff (12:21):
That's usually UVB, but also, importantly, it's UVA.
And I say importantlybecause UVA doesn't burn.
You're much less aware of it, andUVA goes straight through cloud.
UVA goes straight through glass.
And it's just as strong in thewinter as it is in the summer.
(12:42):
And it's just as strong at eitherend of the day as it is at noon.
So, you're being exposed to UVA, and ifthat's what's triggering your rosacea,
and you don't protect yourself from that,you will be getting triggers from UVA.
Admittedly, it's usually UVB, butUVA can have an important role in
rosacea, and we'll discuss that a bitmore when we talk about treatment.
Dr Roger Henderson (13:04):
Well I think this is a perfect time to take the
opportunity to say a few words aboutour kind sponsor, AproDerm®, and their
range of emollients and barrier creams.
Now, as we know,everyone's skin is unique.
In my many years as a GP, it'soften been tricky to find an
emollient that immediately suitedone person and their one condition.
(13:25):
And we know it's not as simple asone condition, one type of emollient.
It's often the case of patients trying anemollient and then going back and forth
with several prescriptions, several visitsto the practice, which is far from ideal.
But fortunately, AproDerm® havedeveloped a genius solution to
simplify the whole process ofselecting the right emollient for you.
Dr George Moncrieff (13:46):
Their AproDerm® Emollient Starter Pack contains
all four of their emollients inone pack, each having a unique
consistency and level of hydration.
With just one prescription, you havethe opportunity to try each one and find
the one that works best for your skin.
This allows you to choose the one, ormore, that you prefer and that suits
your lifestyle, while saving money,time, and more importantly, fewer
(14:11):
visits to the GP, pharmacist, or nurse.
Sounds like the perfectanswer to me as a GP.
And if you can't make it to yourhealthcare professional, it's available to
buy from your local pharmacy and Amazon.
I've been a big advocate of theAproDerm® range for a while now.
It's such a great range of products.
All are suitable from birth and freefrom common irritants and sensitisers.
Dr Roger Henderson (14:32):
Yeah, and I have to say I love them even more
now and actually use them myself.
So, if you're affected by a dry skincondition and want to know which emollient
will be the best for you, then do trythe AproDerm® Emollient Starter Pack.
Which, incidentally, also comes witha handy self-care guide full of tips
on helping you manage your condition,including useful advice on applying
(14:55):
emollients and potential triggers.
It really is a game changerfor the world of dermatology.
And, as George said earlier, it'savailable on prescription or to buy
from your local pharmacy or Amazon.
Dr George Moncrieff (15:09):
Yeah, speaking in public is probably the next most,
embarrassing situations, going toa dinner party, or whatever, can
really cause a very awkward flush.
And as soon as you think you mightbe flushing, you're more embarrassed,
and then you're into a viciouscycle, and the whole thing is a mess.
Hot foods can do it.
They're hot in temperature, but alsospicy hot foods, so curries and things.
(15:32):
Cheese, sudden temperature changes, goinginto a sauna, going into a hot room.
Interestingly, alsogoing into a cold room.
If you go out in the cold, somepeople's face begins to go red, which
is counterintuitive rather, isn't it?
Exercise.
If you're exercising, particularly ifyou are overdressed, or going for a brisk
walk and wearing more than you should havebeen wearing, all these things can do it.
(15:55):
And even just simple emotional stress,if you're getting upset, it can cause
your face suddenly to go bright red,which can really compromise your
ability to deal with that situation.
I always think about those triggersfirst, before I talk about alcohol,
because if somebody comes to see me,worried they've got a red face, and
I think this is a
problem with W.C. Fields,
he definitely didenjoy his alcohol, didn't he?
(16:15):
And he made a big thing of it, butI think it's perhaps built into
our psyche, the link between redfaces and rosacea and alcohol,
because he certainly had all three.
But, if I ask a patient with a red face,do they find alcohol triggers it, it's the
last thing I ask about, after I've gonethrough all the other possible triggers.
Interestingly, it's white wine morethan red wine that, or spirits or,
(16:39):
or beer that causes more triggeringproblems, in a big study from Ireland.
But, I think it's important that wedon't embarrass our patients by talking
about alcohol too early in that.
Dr Roger Henderson (16:49):
Absolutely.
Dr George Moncrieff (16:49):
Sometimes the medications we prescribe can cause
flushing, and there are a number that arenotorious for that, including some skin
topical treatments, can cause flushing.
For example, Protopic®, tacrolimus.
That can certainly cause flushing,especially if the patient puts it on
their skin and then drinks alcohol.
But certain calcium channel antagonists,that we use for blood pressure sometimes,
(17:12):
and other things, they can cause it.
But the important thing about flushingis it's very individual, so, what
causes a flush for one patient won'tnecessarily cause it for somebody else.
So, what I suggest to somebody withthis is, go away and keep a diary for a
couple of months and record, you'll knowwhat causes a flush, you probably know
already, but if eating cheese causes aflush, it will happen probably within an
(17:34):
hour or so, two at the most, and you canthen know what your causes of flushes
are, and you can say, look, I actuallyreally have had an awful day at work.
I need a glass of wine.
I need a chunk of cheese.
I just need that to get, to get homeand so on, I'm going to tolerate
having a flush in a couple hourstime because I'll be on my own,
and you can negotiate with yourselfwhat you're going to put up with...
(17:55):
but know what your flushes are.
Dr Roger Henderson (17:57):
It's interesting, people with rosacea who have sat in
front of me, they almost slightlyfall into two camps in a way.
There's the camp that thinksthat they're the only person
with that particular problem.
And then there's the campthat believes that everyone
looks the same, with rosacea.
So, rosacea, is rosacea, is rosacea.
And as we've talked about, you know,there's this massive spectrum from those
(18:18):
who aren't aware they've got it, buthave got some dry eyes and they walk
into their opticians, to the chap walkingdown the street who doesn't want to
see anybody because his face looks sored and he's got a large, bulbous nose.
Dr George Moncrieff (18:31):
I think it usually starts off with this unusually
easy flushing and blushing, withincreased skin sensitivity, developing
this permanent background redness.
And I haven't seen this in the books,but I actually believe it's that
flushing and blushing, that flushingand blushing definitely then causes
the dilated, permanently dilated, bloodvessels, which can be quite troublesome.
(18:55):
But I think it's that flushing andblushing, the vasomotor instability
then drives matters on, to the moreinflammatory end of the spectrum where you
get those sore red bumps and those spots.
And that creates the environmentthat is ideal for that to develop.
So, I actually believe that if you canlimit the amount of triggers that you
(19:18):
have, not only will it be more pleasantfor you as a patient, but it might
curtail the progression of this diseaseto the more severe end of the spectrum.
I don't know what happens witheye disease, and eye disease is
fascinating, and I don't know whetherwe can do anything to curtail that.
It seems to run alongside this,and I've seen very severe eye
disease with relatively mildskin disease, and vice versa.
(19:41):
And of course, half of the patients haveeye disease, but the other half don't.
So, it's extraordinary howthat association is there.
Phymatous disease, whichis this, bulbous nose.
I suspect it's due to chronically undertreated rosacea, but not necessarily, but
they're all very definitely interlinked.
Dr Roger Henderson (20:02):
What I often say to patients with rosacea is that,
just like you, I don't think we'vegot any hard evidence that repeated
flushing drives it along, although Ido genuinely think that is the case.
What I often say to patients withrosacea is, it's petrol on the fire.
The fire is just there quietlygoing along underneath.
But you then have repeated flushing,and it's just petrol on that fire,
(20:23):
and it's common sense, isn't it?
That's only going to increase,rather than decrease, inflammation.
If I'm happy with the diagnosis ofrosacea, in other words, if I've
excluded other possible diagnoses,I generally cannot ever remember
investigating a patient with rosacea.
I'm happy with the diagnosis and I canjust get on with advice and treatment.
(20:46):
Do you think that's fair?
Dr George Moncrieff (20:49):
I do actually, yes.
I'd say 90% of medicine iswhat the patient tells me.
It's their history, whatdoctors call their history.
90% is what they tell me.
8% is probably what I find on examination,and investigations are very, very rarely
important, particularly in this situation.
(21:10):
No, I, there are one or twothings I might want to exclude
if it's looking a bit unusual.
So I would think outside the box,but no, I couldn't agree more.
It's a clinical diagnosis madein the consulting room, based on
what the patient tells me and alittle bit about what I can see.
The distribution and thepattern
and things like that. Yeah.
Dr Roger Henderson (21:29):
Yeah. I mean,
from a medical point of view,it's one of the nicer, if I can use
that term, dermatological conditions,because it is so readily diagnosed.
It's not a no brainer, you'vegot to be thinking about it, but
it is something where you canfairly quickly be content with.
Dr George Moncrieff (21:45):
And it's nicer because we can definitely
make life better for the patients.
We've got some fabuloustreatments, which we're going to
come onto in our next podcast.
Dr Roger Henderson (21:52):
Exactly, and many of those patients will have tried all
sorts of over-the-counter preparations,or tried old wives tales and this, and
it's often quite late in the day theyactually come to see us in surgery, when
they get into a point where it's impactingon them, and I sometimes wish that they
came a little bit sooner, but I, youknow, would never, never say that to them.
As you say, we're going to talk about thetreatment of rosacea in the next podcast.
(22:17):
So, with this one, I do hope that youfound this chat from George and I really
helpful, about this most common of skinconditions, and that it has allowed
you to have more confidence if you dohave rosacea, in not only understanding
it a little bit better, but also abouthow we may be looking to treat it.
Dr George Moncrieff (22:36):
So, we hope you'll join us next time when we'll
be discussing that, along with selfmanagement tips and other lifestyle tips.
We'd also like to thank our sponsor,AproDerm®, for all their help in putting
these Skin Deep podcasts together.
We couldn't have done it without them.
Dr Roger Henderson (22:54):
So, until next time, it's goodbye from George.
Dr George Moncrieff (22:58):
Goodbye.
Dr Roger Henderson (22:59):
And as always, it's goodbye from me.
Goodbye.
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