April 22, 2024 • 24 mins
Rosacea can be a potentially distressing condition, so in this episode your hosts, Dr George Moncrieff and Dr Roger Henderson delve straight into lifestyle changes, providing simple yet effective tips to help you manage your condition.
Drawing on their extensive experience as GP’s, spanning over 70 years combined, these dermatology experts also discuss the various treatment options available across the rosacea spectrum, from simple redness and flushing to eye involvement and Rhinophyma.
Listen along to hear:
- Guidance on how to identify your unique triggers
- Advice on what lifestyle adjustments you can make and how to manage symptoms effectively
- The importance of incorporating emollients into your daily skincare routine
- The diverse treatment options available, both through the NHS and privately, including anti-inflammatory medications, camouflage products, and laser therapy
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.
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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.
(00:10):
Hello and welcome again to this Skin Deeppodcast 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-standinginterest in this area of health.
And I'm Dr George Moncrieff, I wasalso a GP, although I've now retired
from my practice and I was the Chairof the Dermatology Council for England.
(00:34):
Now, today George and I are going to betalking about the treatment of rosacea.
This is the second of two podcasts aboutthis very common skin problem and if you
were with us for the first one, wherewe talked about the basics of rosacea,
we do hope that you found it helpful.
(00:59):
So to kick off this week's podcast,let's not dive into medication straight
away because that's the second areato look at rather than the first when
I'm talking to patients with rosacea.
But let's chat about what I call generaltreatment principles here and lifestyle
changes, which are so important.
I couldn't agree more.
Lifestyle changes should play ahuge part in our approach to this
(01:22):
potentially distressing condition.
And the first thing there tosay is trigger avoidance is key.
So I've talked last time aboutkeeping a diary to find out
what your personal triggers are.
And once you know what tends to causeyour face to go red and flush and be
uncomfortable, then you can negotiatewith yourself, and decide whether
you're going to experience that triggerbecause you are particularly keen to
(01:45):
have that hot curry or whatever it is.
So it's a choice that you can make.
I mentioned last time that UV light isprobably the most important trigger.
And most people I've met with rosaceado find that when they go out in the
sun, it's not sunburn, they're actuallyflushing much sooner than that.
Sunburn will be a few hours later.
They go red when they're out in the sun.
(02:07):
And so, I advise that all patients,and I mean all patients with rosacea,
should really use a high factor UVBand UVA sunblock all year round.
Often we don't worry about the sunin the middle of the winter, but
if you're getting a problem, it canbe due to UVA, and UVA is just as
(02:28):
strong indoors, even on a cloudy day.
When you wouldn't be thinking aboutthe sun, you may be getting exposed to
enough UV light to be causing a trigger.
So, generally try and keep yourface out of direct sunlight.
Consider wearing a hat,a wide brimmed hat.
That would be another good idea.
When we say high factor, would you belooking at factor 30, factor 50, is that
(02:50):
the sort of level you'd be at, George?
There you're talking about UVB factors,and a factor 30 used at the right
concentration gives you 30 times longerin the sun before you get burning.
But no, I don't think you needanything quite as strong as that.
I'd go for a three plus UVAstar rating for sunblock.
(03:14):
But I'd have thought a 15, 20, infact, most women who use foundation
creams on their face, those contain asunblock and that's probably enough.
It doesn't need to be too strongunless you're planning to go out into
very direct sunlight on a day whenthe sun's going to be more intense.
I'd say that UVA is as strong inthe winter and at dawn and dusk,
(03:37):
it isn't quite as strong, but it'snot that different to noon at June,
comparing to dusk at December.
But there's a difference, butit's not anything like as dramatic
as the difference with UVB.
It's UVB that changes dramaticallywith the seasons and the time of
day and the cloud intensity andwhether you're indoors or not.
And it's UVB that burns and causes,I think, a lot of the damage.
(04:00):
So, no, I would say a factor 15 UVB wouldprobably be adequate, unless you have
particularly sensitive skin to sunlight.
And a good 3, 4 star ratingfor UVA, that'd be ideal.
I mentioned last time that theskin in rosacea feels sensitive.
I hate soaps and detergents, and I thinkit's a situation where I really do think
(04:25):
you ought to avoid exposure to detergentsand wash with a soap substitute emollient.
And here the AproDerm®range is absolutely ideal.
You could use AproDerm® Gel.
I actually use that to shave through.
I wet shave through AproDerm®Gel, but you could use AproDerm®
Gel or AproDerm® cream.
And remember, shampoo isa very powerful detergent.
(04:47):
If you let that wash over your face,you will be having a detergent effect
on the face, so be careful there.
I would just say avoid detergentsas much as you possibly can.
Soaps, shower gels which forma foam shampoos, bubble baths.
Don't get those on your face.
Equally avoid fragrances on theface, particularly if they make
(05:07):
your face go red or cause stinging.
And I mentioned last time the alphahydroxy acids in a lot of fragrance, or
ascorbic acid, can aggravate things forsome patients, so avoid those if you can.
A big important message is don't lettopical steroids get on your face.
Sometimes mistakenly doctors see aninflamed looking red face and may
(05:28):
inadvertently prescribe a steroid.
Sometimes it's in combinationwith another treatment.
So if the wrong diagnosis is made thatyou might get given a treatment that has
a little bit of hydrocortisone in it.
And steroids can massivelyaggravate rosacea...
Yeah.
...even trivial amounts.
And I have, for example, had apatient who was treating her son's
(05:50):
eczema with a steroid, appropriately.
She carefully washed her hands afterwards.
Soon after that, went to bed, andher hand got next to her face as
she was lying in bed at night.
And there was a tiny residue ofsteroid on her hand, and that was
enough to aggravate her rosacea.
But I've also seen it from inhaledsteroids for hay fever or asthma.
The small mist from the spray that getsonto their face can actually aggravate it.
(06:14):
So, think about steroids anddon't let them get onto it, they
can definitely make things worse.
I don't know about you, butI found that you can get some
rather nice green-tinted makeup.
A number of companies make that and Ifind that can go a long way to masking
that permanent background redness andmake it much easier to be going out in
public and even suggest that men whohave a red face should consider getting
(06:37):
a green-tinted makeup just to mask thatredness a bit, it can be very effective.
Inflammatory rosacea, where youget papules and pustules, can
be quite a dry skin condition.
So not only should you avoid detergents,but you may need to add on a quality
leave-on emollient and one I particularlylike is AproDerm® Colloidal Oat Cream.
Another one you might want to consideris Adex™ Gel, which is Doublebase™,
(07:01):
but with the addition of nicotinamide.
Nicotinamide is vitamin B3, but it happensto be my all time favourite ingredient
in many products, orally and topically.
It has remarkable propertiesand it's anti-inflammatory.
So, that's a very sensible option to use.
You've got inflamed red skin.
(07:22):
It's actually licensed for eczema, butI use it for a number of other skin
conditions and it's the nicotinamideI think that is highly effective.
Yeah really, really good tips and thegreen tinted makeup's an interesting one.
When I've suggested that to somechaps, with rosacea, they sort of
take about three steps backwards andlook at you as if you're slightly mad.
But once they've tried it andbecause you can't tell, you've got
(07:44):
anything on, you just don't know.
It just really dulls down that redness.
That's a really good tip.
Now, if we're talking about the facialflushing and the redness, which the
majority of our patients presenting tous would fall into that camp as to why
they come and sit in front of us andit's the one thing that they really
would want to start to lose becausethat's what's really embarrassing them.
(08:06):
How should we start thinking about how totreat that particular area, the flushing
and the redness that we see in rosacea?
Well this is where we're gettingon to actually being a doctor
and prescribing our treatments.
Clearly trigger avoidance is keyand that is the most important part.
I often see doctors prescribingtopical antibiotics for this but in my
(08:27):
experience, topical antibiotics are prettyuseless for the flushing and blushing.
And I haven't actually recommended thoseor prescribed those now for decades,
for this particular pattern of rosacea.
So I think if you're, if you've been givensomething like metronidazole gels or other
antibiotics, they just don't really dovery much for this end of the spectrum.
(08:52):
Occasionally, provided they'renot contraindicated, we do
prescribe beta-blockers by mouthand they can be very helpful.
They need to be taken regularly.
So there are tablets that you can takeprovided you don't have asthma, for
example, or extremely cold fingers thatgo white in the cold or other reasons
for which they're contraindicated.
If you can tolerate abeta-blocker, they can be very
(09:13):
effective, so that's an option.
But by far, the most effectivetopical treatment we have, only
became available about 10 yearsago, is a drug called brimonidine.
Brimonidine has been around foryears as an eye drop for glaucoma.
We've put it into the conjunctivalarea to treat glaucoma.
So, something that's safe going in theeye, being put into a gel and then put on
(09:37):
the face, is very, very unlikely to comeup with some unexpected side effects.
And that's been the case.
But, it's not without its problems.
One of its problems, it works too well.
And it causes dramatic constrictionof the blood vessels, and it doesn't
unfortunately constrict those dilatedblood vessels that have been damaged by
(09:57):
being constantly dilated up and goingdown and getting dilated up again.
So those telangiectasia I talkedabout last time become more
visible, which can be distressing.
But it can cause the faceto go completely white.
I had somebody I saw at a meeting,and I didn't know that she had
put this on her face, and I said,"goodness, are you all right?
You look awfully pale."
She said, "I'm fine, absolutely fine."
(10:18):
I said, "well, you look as thoughyou're really, really pale, I think
you need to do something about it."
At the end of the meeting, she cameup to me and said, I just realised I'd
put some Mirvaso® on my face and youcould do noughts and crosses with it.
It's that dramatic.
But, it can cause reboundvasodilatation, which can be quite
unpleasant and a lot of patients findit very stingy when they put it on.
(10:39):
But there are some tips thatwe can talk to them about.
Put it on cold from the fridge.
Start off by treating a smallarea and you do gradually develop
tolerance to that stinging.
And there is a product you can buy overthe counter called Toleriane Ultra,
which L’Oréal make and if you use thatfirst, that can sting a little bit when
you put it on initially, but you put iton for a few days that can render the
(11:02):
skin much less sensitive and then youcan tolerate the Mirvaso® much better.
So that's another option.
But one of the main problems with Mirvaso®is it's not available on NHS prescription.
You've got to pay for it.
Yeah.
And it's interesting, thebeta-blocker that you mentioned,
they can be really be helpful,and I found them perhaps the best.
If you've got someone who's generallyvery anxious and you might even
(11:22):
be thinking about a very low dosebeta-blocker just as a way of helping
their anxiety, or if their rosacea justtends to really flare at times of high
anxiety or stress, the beta-blockercan work really well in that case.
So if we've got, if you like, thefacial flushing and the redness covered,
and if someone sits down in front ofme, I'm fairly relaxed about that.
(11:44):
If they're starting to get the brokenblood vessels and the capillaries if
you like, that's moved on from that, Iwouldn't say my heart sinks, but we're
getting into a trickier area to treat.
This is much less easy, isn't it?
Well, it is, especially for us in generalpractice because the problem with the
treatments for flushing, they only workon the vessels that can constrict, and
(12:06):
these vessels have lost that ability,they've lost the muscle structure.
So, yeah, we could talk aboutcamouflage creams, but that's not great.
There is a very effective treatment,but it's not available on the
NHS and that needs to be done bya specialist and I would only go
to a really good dermatologist.
(12:27):
I wouldn't just go to any highstreet person who's offering laser
therapies but pulsed dye lasers orintense pulsed light treatments can
permanently destroy those blood vesselswith a fantastic cosmetic result.
And it would probably for the averagepatient need, I don't know, three to four
or five sessions of treatment to treatthe different areas of the face, each
(12:51):
session costing several hundred pounds.
But for a sum of money, you canprivately have those dealt with on
a pretty permanent long-term basis.
And once they've been treated, thosevessels won't come back, and so you
can have a one-off set of treatments.
And so you've got somebody who's, youknow, wants to know what they want
for their 50th wedding anniversary ortheir 25th wedding anniversary, have a
(13:14):
collection to build up for that, becausethat could be a very effective treatment.
So that's the only treatmentI know that really works.
There's nothing topical, nothing by mouth.
It's only camouflage or thesephysical treatments with intense
pulsed light or pulsed dye laser.
Yeah and I found that even though thereis a financial cost to that treatment
(13:35):
for people that have had it done, theydo say their improvement in their quality
of life as a result far outweighs youknow, their financial cost to them.
Even, you know, during this time ofeconomic squeeze, they do still say
I would still have it done again.
Rosacea spots, I don't want to sortof go into too much detail with this
(13:56):
because we can get really bogged down inthe minutiae of medical treatment here.
But perhaps I would just mentionbecause I have seen this and it does
make my non-existent hair stand onend, people slapping olive oil on
their face to try and treat spotsand that's a real no-no isn't it?
I couldn't agree more.
I love olive oil, in mydiet, but not on my skin.
(14:18):
It's got the wrong ratio ofoleic acid to linoleic acid.
It's got too much oleic acid and oleicacid is damaging to the skin barrier.
So, no, olive oil shouldnot go on the skin anywhere.
I like coconut oil.
Actually, I love coconut oil.
At room temperature, it's just solidbut to put on the skin, it becomes
(14:39):
a liquid and coconut oil helps.
Most of the other vegetable oilsfeed the little mites, now wait for
it, we have little mites as part ofour microbiome living on the face.
And you're actually justnourishing those mites.
And those mites cause the moreinflammatory end of the spectrum, I think.
So I wouldn't use olive oil, butI would consider some coconut oil.
(15:02):
That would be a very reasonableemollient alternative, if you wanted.
And I have had patients who'vementioned sea buckthorn oil.
Because you know, people do like tryingto use natural treatments, and some of
them swear by sea buckthorn oil, anduntil I went away and looked it up, I
have to say that was a new one on me.
(15:23):
Yep, it kills the mite and it definitelysoothes, so it's, I'm told effective.
I have to say I've got no personalexperience of patients who've used it.
No one's discussed it with me, butsimilar to you, I've read about sea
buckthorn oil and I'm told it kills themites, which is quite a nice thing to do.
I'm coming on to these mites.
People also try tea tree oil and that toowould help, but I think it's generally
(15:48):
too irritant on this sort of skin.
People have tried it and yes, itwould help if they can tolerate
it, but generally they mightfind it too irritant for that.
Yeah, I agree with that one.
Eye symptoms we touched on this inour first podcast about trying to
pick up very early symptoms at theopticians with people with dry eyes.
(16:09):
You might not actually needany treatment if people are not
particularly bothered by their dry eyes.
But you can, you know, treat eyesymptoms if need be pretty easily
most of the time, can't you?
It's a big, big spectrum from minordry eyes for which artificial tears
and some simple eye ointment at bedtimeperhaps may be all that's needed.
(16:31):
And thinking about whether youknow, your contact lenses are
aggravating the problem there.
So, some simple over the counter remedies.
If you're getting problems withblepharitis, which is grittiness and
sandiness in the eyelashes, that's asituation ophthalmologists talk about
using shampoo along the eyelashes.
I always sort of have to take a secondthought at that but just massaging
(16:53):
some eye shampoo along that or usingvery, as hot water as you can bear
without risking scalding yourself.
And maybe some salt water.
That's another tip thatI certainly recommend.
Get some hot water, dissolve some saltin it and then when you can safely
put your fingers into that previouslyboiling water, when it's cooled down
enough, get a bit of cotton wooland hold that against your closed
(17:13):
eyelid and just wash the eyelids.
A simple eyelid hygienelike that can help.
There's a product called hypochlorous,which I've come across recently.
Not hypochlorite, which is inbleach or Milton® and very damaging
to the skin, it's very alkaline.
Hypochlorous is a natural product,produced naturally by our own white
(17:38):
blood cells as part of our immuneattack on bacteria and things and
is totally safe for human cells.
There's an eye preparation ofhypochlorous called Purifeyes™.
And this is, wait for it,it's 80 times more potent than
bleach, which is hypochlorite.
(17:58):
Wow.
And it kills 99.9% of bacteria,fungi, spores, and even viruses,
and is totally safe on human skinand doesn't cause allergic reactions
and doesn't damage the environment.
It's magic.
It's unbelievable.
And so if I had a problem with chronicstyes or blepharitis, I'd probably
(18:22):
be putting some hypochlorous aroundmy eye and even into my eye, this
ophthalmic preparation, just to keepthe hygiene level really good there
and to support the immune system.
And this is produced naturallyby the body's own white cells as
part of our own immune response.
But it's taken us years, takenthem, not me, but taken years to
put it into a stable preparation.
When they first started making it, itonly lasted for a couple of days, and
(18:46):
then lost its effect, but now they'vegot it into a stable preparation that
lasts on the shelf two to three years.
So, hypochlorous in Clinicept+is, I think, a game changer.
But this is a situation whereophthalmologists often recommend.
Eye drops can be in steroids.
Interestingly, I wouldn't getthem on the face, but in the
eye, sometimes they need those,sometimes they need oral antibiotics.
(19:11):
And often you do need to involvean ophthalmologist if it's the
more severe end of the spectrumof the inflammatory problems.
So there are some things thatcan be done for eye disease.
But it's often needs the careof a specialist in that field.
We haven't talked about the managementof the pustular end of the spectrum.
And just to cover that briefly,part of our normal skin microbiome
(19:34):
includes on the face a mite.
A little animal with horriblelittle legs and things, and
it's horrible to think about.
It's less than 0.1 of a millimetre,so you can't quite see it, but
it's there to clean up the deadcells and the grease on the skin.
It's there to sort of digaround the open hair follicles.
It dives into those andit cleans things up a bit.
(19:56):
Now, most of us have betweentwo and five per centimetre.
If you've got rosacea,you've got over a hundred.
And in the gut of this little miteis a very unpleasant bacteria,
which drives and triggers rosacea.
As does when the mite dies, the cellwall, which is made of chitin, breaks
(20:18):
down and that too is highly inflammatory.
So, this is what I think is causingthe inflammatory end of the spectrum.
Doctors often use oral antibiotics forthis inflammatory end of the spectrum.
Highly effectively, the antibiotickills the bacteria, but predominantly
we're using these antibiotics fortheir anti-inflammatory side effects,
(20:41):
which I think is a bit extravagant.
Taking an antibiotic for months onend will not only do major harm for
antimicrobial resistance and encouragebacterial resistance, which is going
to be a big problem for us all, butit also has catastrophic effects
on your own microbiome and yourgut and on the rest of your skin.
So I'm not terribly enthusiasticfor long courses of antibiotics.
(21:04):
And in recent years, a wonderful treatmenthas come out which kills this mite.
It's been around for years and years.
I've used it for treatinganother mite, scabies.
But it's been put into a creamcalled Soolantra® and the
active ingredient is ivermectin.
And I don't know whether you'vegot any experience of using that,
but it is possibly my all timefavourite topical prescription
(21:27):
because it works so amazingly well.
Occasionally it works too well at firstbecause it kills lots of mites, you get
a release of a lot of chitin and a lotof bacteria, and you get a sudden flare.
And I say rejoice, we're onthe right tracks, persevere.
But it knocks that micropopulationright down, and when that's right
down, the inflammatory end of thespectrum, dramatically improves.
(21:49):
And you can then keep it atbay by just using it, perhaps,
you just put it on once a day.
It's available on NHS prescription, andthen after a month or two, you can usually
drop down to alternate days, or even downto just once a week, or once a month.
to keep that mite population atbay for years and years on end and
a very effective treatment there.
So that's another option we haveand there are other options that are
(22:10):
more old fashioned which do work.
But, perhaps not relevantin this situation.
Yeah.
Now right at the start of these twopodcasts we were talking about the
potato noses of Rembrandt and
W.C. Fields,
and they would have looked verydifferent if they had access to treatments
like ivermectin which is one of thereasons why we don't see it so much.
(22:33):
Now obviously, the important thingabout, you know, rhinophyma, is to stop
it happening in the first place, but ifyou do have the unusual case of someone
who is walking around with a rhinophymabecause they haven't been able to access
modern treatments or they're elderlyand it's just built up over decades,
it is really difficult, unfortunately.
(22:54):
I wish there was some more positivenews about treating that but we're
looking really at fundamentallychopping bits off it, aren't we?
Yeah.
There's excess tissue under the skin, andthat excess tissue needs to be removed.
And, so it's a debulking procedure,essentially, and that can be
done with a knife and surgery.
(23:14):
But in fact nowadays the way it's doneis usually with a CO2 cutting laser, and
that's prevents bleeding at the same time,and it can be done under anaesthetic,
but it's pretty unpleasant at the time,but it can give fantastic, I've seen
remarkable cosmetic results from that.
People who after they've had it a month,a few months later when the skin settled
(23:34):
back down to normal skin colour, youwould never know that they've had a
rhinophyma there in the first place.
So it's definitely a good option.
But again, that's not availableusually in the UK on the NHS.
I think it's a privateprocedure in my experience.
Yeah, but fortunately that'sgetting less and less needed
because of the treatments we've got.
(23:54):
And that's an optimisticnote, I suppose, to end on, to
bring this episode to a close.
So George and I do hope youfound it interesting and helpful.
So, Roger and I hope you'll joinus again when we'll be discussing
more skin related conditions.
We'd also, once again, like to thank oursponsor, AproDerm®, for all their help in
putting these Skin Deep podcasts together.
(24:15):
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
Hello and welcome again to this Skin Deeppodcast 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-standinginterest in this area of health.
And I'm Dr George Moncrieff, I wasalso a GP, although I've now retired
from my practice and I was the Chairof the Dermatology Council for England.
(00:34):
Now, today George and I are going to betalking about the treatment of rosacea.
This is the second of two podcasts aboutthis very common skin problem and if you
were with us for the first one, wherewe talked about the basics of rosacea,
we do hope that you found it helpful.
(00:59):
So to kick off this week's podcast,let's not dive into medication straight
away because that's the second areato look at rather than the first when
I'm talking to patients with rosacea.
But let's chat about what I call generaltreatment principles here and lifestyle
changes, which are so important.
I couldn't agree more.
Lifestyle changes should play ahuge part in our approach to this
(01:22):
potentially distressing condition.
And the first thing there tosay is trigger avoidance is key.
So I've talked last time aboutkeeping a diary to find out
what your personal triggers are.
And once you know what tends to causeyour face to go red and flush and be
uncomfortable, then you can negotiatewith yourself, and decide whether
you're going to experience that triggerbecause you are particularly keen to
(01:45):
have that hot curry or whatever it is.
So it's a choice that you can make.
I mentioned last time that UV light isprobably the most important trigger.
And most people I've met with rosaceado find that when they go out in the
sun, it's not sunburn, they're actuallyflushing much sooner than that.
Sunburn will be a few hours later.
They go red when they're out in the sun.
(02:07):
And so, I advise that all patients,and I mean all patients with rosacea,
should really use a high factor UVBand UVA sunblock all year round.
Often we don't worry about the sunin the middle of the winter, but
if you're getting a problem, it canbe due to UVA, and UVA is just as
(02:28):
strong indoors, even on a cloudy day.
When you wouldn't be thinking aboutthe sun, you may be getting exposed to
enough UV light to be causing a trigger.
So, generally try and keep yourface out of direct sunlight.
Consider wearing a hat,a wide brimmed hat.
That would be another good idea.
When we say high factor, would you belooking at factor 30, factor 50, is that
(02:50):
the sort of level you'd be at, George?
There you're talking about UVB factors,and a factor 30 used at the right
concentration gives you 30 times longerin the sun before you get burning.
But no, I don't think you needanything quite as strong as that.
I'd go for a three plus UVAstar rating for sunblock.
(03:14):
But I'd have thought a 15, 20, infact, most women who use foundation
creams on their face, those contain asunblock and that's probably enough.
It doesn't need to be too strongunless you're planning to go out into
very direct sunlight on a day whenthe sun's going to be more intense.
I'd say that UVA is as strong inthe winter and at dawn and dusk,
(03:37):
it isn't quite as strong, but it'snot that different to noon at June,
comparing to dusk at December.
But there's a difference, butit's not anything like as dramatic
as the difference with UVB.
It's UVB that changes dramaticallywith the seasons and the time of
day and the cloud intensity andwhether you're indoors or not.
And it's UVB that burns and causes,I think, a lot of the damage.
(04:00):
So, no, I would say a factor 15 UVB wouldprobably be adequate, unless you have
particularly sensitive skin to sunlight.
And a good 3, 4 star ratingfor UVA, that'd be ideal.
I mentioned last time that theskin in rosacea feels sensitive.
I hate soaps and detergents, and I thinkit's a situation where I really do think
(04:25):
you ought to avoid exposure to detergentsand wash with a soap substitute emollient.
And here the AproDerm®range is absolutely ideal.
You could use AproDerm® Gel.
I actually use that to shave through.
I wet shave through AproDerm®Gel, but you could use AproDerm®
Gel or AproDerm® cream.
And remember, shampoo isa very powerful detergent.
(04:47):
If you let that wash over your face,you will be having a detergent effect
on the face, so be careful there.
I would just say avoid detergentsas much as you possibly can.
Soaps, shower gels which forma foam shampoos, bubble baths.
Don't get those on your face.
Equally avoid fragrances on theface, particularly if they make
(05:07):
your face go red or cause stinging.
And I mentioned last time the alphahydroxy acids in a lot of fragrance, or
ascorbic acid, can aggravate things forsome patients, so avoid those if you can.
A big important message is don't lettopical steroids get on your face.
Sometimes mistakenly doctors see aninflamed looking red face and may
(05:28):
inadvertently prescribe a steroid.
Sometimes it's in combinationwith another treatment.
So if the wrong diagnosis is made thatyou might get given a treatment that has
a little bit of hydrocortisone in it.
And steroids can massivelyaggravate rosacea...
Yeah.
...even trivial amounts.
And I have, for example, had apatient who was treating her son's
(05:50):
eczema with a steroid, appropriately.
She carefully washed her hands afterwards.
Soon after that, went to bed, andher hand got next to her face as
she was lying in bed at night.
And there was a tiny residue ofsteroid on her hand, and that was
enough to aggravate her rosacea.
But I've also seen it from inhaledsteroids for hay fever or asthma.
The small mist from the spray that getsonto their face can actually aggravate it.
(06:14):
So, think about steroids anddon't let them get onto it, they
can definitely make things worse.
I don't know about you, butI found that you can get some
rather nice green-tinted makeup.
A number of companies make that and Ifind that can go a long way to masking
that permanent background redness andmake it much easier to be going out in
public and even suggest that men whohave a red face should consider getting
(06:37):
a green-tinted makeup just to mask thatredness a bit, it can be very effective.
Inflammatory rosacea, where youget papules and pustules, can
be quite a dry skin condition.
So not only should you avoid detergents,but you may need to add on a quality
leave-on emollient and one I particularlylike is AproDerm® Colloidal Oat Cream.
Another one you might want to consideris Adex™ Gel, which is Doublebase™,
(07:01):
but with the addition of nicotinamide.
Nicotinamide is vitamin B3, but it happensto be my all time favourite ingredient
in many products, orally and topically.
It has remarkable propertiesand it's anti-inflammatory.
So, that's a very sensible option to use.
You've got inflamed red skin.
(07:22):
It's actually licensed for eczema, butI use it for a number of other skin
conditions and it's the nicotinamideI think that is highly effective.
Yeah really, really good tips and thegreen tinted makeup's an interesting one.
When I've suggested that to somechaps, with rosacea, they sort of
take about three steps backwards andlook at you as if you're slightly mad.
But once they've tried it andbecause you can't tell, you've got
(07:44):
anything on, you just don't know.
It just really dulls down that redness.
That's a really good tip.
Now, if we're talking about the facialflushing and the redness, which the
majority of our patients presenting tous would fall into that camp as to why
they come and sit in front of us andit's the one thing that they really
would want to start to lose becausethat's what's really embarrassing them.
(08:06):
How should we start thinking about how totreat that particular area, the flushing
and the redness that we see in rosacea?
Well this is where we're gettingon to actually being a doctor
and prescribing our treatments.
Clearly trigger avoidance is keyand that is the most important part.
I often see doctors prescribingtopical antibiotics for this but in my
(08:27):
experience, topical antibiotics are prettyuseless for the flushing and blushing.
And I haven't actually recommended thoseor prescribed those now for decades,
for this particular pattern of rosacea.
So I think if you're, if you've been givensomething like metronidazole gels or other
antibiotics, they just don't really dovery much for this end of the spectrum.
(08:52):
Occasionally, provided they'renot contraindicated, we do
prescribe beta-blockers by mouthand they can be very helpful.
They need to be taken regularly.
So there are tablets that you can takeprovided you don't have asthma, for
example, or extremely cold fingers thatgo white in the cold or other reasons
for which they're contraindicated.
If you can tolerate abeta-blocker, they can be very
(09:13):
effective, so that's an option.
But by far, the most effectivetopical treatment we have, only
became available about 10 yearsago, is a drug called brimonidine.
Brimonidine has been around foryears as an eye drop for glaucoma.
We've put it into the conjunctivalarea to treat glaucoma.
So, something that's safe going in theeye, being put into a gel and then put on
(09:37):
the face, is very, very unlikely to comeup with some unexpected side effects.
And that's been the case.
But, it's not without its problems.
One of its problems, it works too well.
And it causes dramatic constrictionof the blood vessels, and it doesn't
unfortunately constrict those dilatedblood vessels that have been damaged by
(09:57):
being constantly dilated up and goingdown and getting dilated up again.
So those telangiectasia I talkedabout last time become more
visible, which can be distressing.
But it can cause the faceto go completely white.
I had somebody I saw at a meeting,and I didn't know that she had
put this on her face, and I said,"goodness, are you all right?
You look awfully pale."
She said, "I'm fine, absolutely fine."
(10:18):
I said, "well, you look as thoughyou're really, really pale, I think
you need to do something about it."
At the end of the meeting, she cameup to me and said, I just realised I'd
put some Mirvaso® on my face and youcould do noughts and crosses with it.
It's that dramatic.
But, it can cause reboundvasodilatation, which can be quite
unpleasant and a lot of patients findit very stingy when they put it on.
(10:39):
But there are some tips thatwe can talk to them about.
Put it on cold from the fridge.
Start off by treating a smallarea and you do gradually develop
tolerance to that stinging.
And there is a product you can buy overthe counter called Toleriane Ultra,
which L’Oréal make and if you use thatfirst, that can sting a little bit when
you put it on initially, but you put iton for a few days that can render the
(11:02):
skin much less sensitive and then youcan tolerate the Mirvaso® much better.
So that's another option.
But one of the main problems with Mirvaso®is it's not available on NHS prescription.
You've got to pay for it.
Yeah.
And it's interesting, thebeta-blocker that you mentioned,
they can be really be helpful,and I found them perhaps the best.
If you've got someone who's generallyvery anxious and you might even
(11:22):
be thinking about a very low dosebeta-blocker just as a way of helping
their anxiety, or if their rosacea justtends to really flare at times of high
anxiety or stress, the beta-blockercan work really well in that case.
So if we've got, if you like, thefacial flushing and the redness covered,
and if someone sits down in front ofme, I'm fairly relaxed about that.
(11:44):
If they're starting to get the brokenblood vessels and the capillaries if
you like, that's moved on from that, Iwouldn't say my heart sinks, but we're
getting into a trickier area to treat.
This is much less easy, isn't it?
Well, it is, especially for us in generalpractice because the problem with the
treatments for flushing, they only workon the vessels that can constrict, and
(12:06):
these vessels have lost that ability,they've lost the muscle structure.
So, yeah, we could talk aboutcamouflage creams, but that's not great.
There is a very effective treatment,but it's not available on the
NHS and that needs to be done bya specialist and I would only go
to a really good dermatologist.
(12:27):
I wouldn't just go to any highstreet person who's offering laser
therapies but pulsed dye lasers orintense pulsed light treatments can
permanently destroy those blood vesselswith a fantastic cosmetic result.
And it would probably for the averagepatient need, I don't know, three to four
or five sessions of treatment to treatthe different areas of the face, each
(12:51):
session costing several hundred pounds.
But for a sum of money, you canprivately have those dealt with on
a pretty permanent long-term basis.
And once they've been treated, thosevessels won't come back, and so you
can have a one-off set of treatments.
And so you've got somebody who's, youknow, wants to know what they want
for their 50th wedding anniversary ortheir 25th wedding anniversary, have a
(13:14):
collection to build up for that, becausethat could be a very effective treatment.
So that's the only treatmentI know that really works.
There's nothing topical, nothing by mouth.
It's only camouflage or thesephysical treatments with intense
pulsed light or pulsed dye laser.
Yeah and I found that even though thereis a financial cost to that treatment
(13:35):
for people that have had it done, theydo say their improvement in their quality
of life as a result far outweighs youknow, their financial cost to them.
Even, you know, during this time ofeconomic squeeze, they do still say
I would still have it done again.
Rosacea spots, I don't want to sortof go into too much detail with this
(13:56):
because we can get really bogged down inthe minutiae of medical treatment here.
But perhaps I would just mentionbecause I have seen this and it does
make my non-existent hair stand onend, people slapping olive oil on
their face to try and treat spotsand that's a real no-no isn't it?
I couldn't agree more.
I love olive oil, in mydiet, but not on my skin.
(14:18):
It's got the wrong ratio ofoleic acid to linoleic acid.
It's got too much oleic acid and oleicacid is damaging to the skin barrier.
So, no, olive oil shouldnot go on the skin anywhere.
I like coconut oil.
Actually, I love coconut oil.
At room temperature, it's just solidbut to put on the skin, it becomes
(14:39):
a liquid and coconut oil helps.
Most of the other vegetable oilsfeed the little mites, now wait for
it, we have little mites as part ofour microbiome living on the face.
And you're actually justnourishing those mites.
And those mites cause the moreinflammatory end of the spectrum, I think.
So I wouldn't use olive oil, butI would consider some coconut oil.
(15:02):
That would be a very reasonableemollient alternative, if you wanted.
And I have had patients who'vementioned sea buckthorn oil.
Because you know, people do like tryingto use natural treatments, and some of
them swear by sea buckthorn oil, anduntil I went away and looked it up, I
have to say that was a new one on me.
(15:23):
Yep, it kills the mite and it definitelysoothes, so it's, I'm told effective.
I have to say I've got no personalexperience of patients who've used it.
No one's discussed it with me, butsimilar to you, I've read about sea
buckthorn oil and I'm told it kills themites, which is quite a nice thing to do.
I'm coming on to these mites.
People also try tea tree oil and that toowould help, but I think it's generally
(15:48):
too irritant on this sort of skin.
People have tried it and yes, itwould help if they can tolerate
it, but generally they mightfind it too irritant for that.
Yeah, I agree with that one.
Eye symptoms we touched on this inour first podcast about trying to
pick up very early symptoms at theopticians with people with dry eyes.
(16:09):
You might not actually needany treatment if people are not
particularly bothered by their dry eyes.
But you can, you know, treat eyesymptoms if need be pretty easily
most of the time, can't you?
It's a big, big spectrum from minordry eyes for which artificial tears
and some simple eye ointment at bedtimeperhaps may be all that's needed.
(16:31):
And thinking about whether youknow, your contact lenses are
aggravating the problem there.
So, some simple over the counter remedies.
If you're getting problems withblepharitis, which is grittiness and
sandiness in the eyelashes, that's asituation ophthalmologists talk about
using shampoo along the eyelashes.
I always sort of have to take a secondthought at that but just massaging
(16:53):
some eye shampoo along that or usingvery, as hot water as you can bear
without risking scalding yourself.
And maybe some salt water.
That's another tip thatI certainly recommend.
Get some hot water, dissolve some saltin it and then when you can safely
put your fingers into that previouslyboiling water, when it's cooled down
enough, get a bit of cotton wooland hold that against your closed
(17:13):
eyelid and just wash the eyelids.
A simple eyelid hygienelike that can help.
There's a product called hypochlorous,which I've come across recently.
Not hypochlorite, which is inbleach or Milton® and very damaging
to the skin, it's very alkaline.
Hypochlorous is a natural product,produced naturally by our own white
(17:38):
blood cells as part of our immuneattack on bacteria and things and
is totally safe for human cells.
There's an eye preparation ofhypochlorous called Purifeyes™.
And this is, wait for it,it's 80 times more potent than
bleach, which is hypochlorite.
(17:58):
Wow.
And it kills 99.9% of bacteria,fungi, spores, and even viruses,
and is totally safe on human skinand doesn't cause allergic reactions
and doesn't damage the environment.
It's magic.
It's unbelievable.
And so if I had a problem with chronicstyes or blepharitis, I'd probably
(18:22):
be putting some hypochlorous aroundmy eye and even into my eye, this
ophthalmic preparation, just to keepthe hygiene level really good there
and to support the immune system.
And this is produced naturallyby the body's own white cells as
part of our own immune response.
But it's taken us years, takenthem, not me, but taken years to
put it into a stable preparation.
When they first started making it, itonly lasted for a couple of days, and
(18:46):
then lost its effect, but now they'vegot it into a stable preparation that
lasts on the shelf two to three years.
So, hypochlorous in Clinicept+is, I think, a game changer.
But this is a situation whereophthalmologists often recommend.
Eye drops can be in steroids.
Interestingly, I wouldn't getthem on the face, but in the
eye, sometimes they need those,sometimes they need oral antibiotics.
(19:11):
And often you do need to involvean ophthalmologist if it's the
more severe end of the spectrumof the inflammatory problems.
So there are some things thatcan be done for eye disease.
But it's often needs the careof a specialist in that field.
We haven't talked about the managementof the pustular end of the spectrum.
And just to cover that briefly,part of our normal skin microbiome
(19:34):
includes on the face a mite.
A little animal with horriblelittle legs and things, and
it's horrible to think about.
It's less than 0.1 of a millimetre,so you can't quite see it, but
it's there to clean up the deadcells and the grease on the skin.
It's there to sort of digaround the open hair follicles.
It dives into those andit cleans things up a bit.
(19:56):
Now, most of us have betweentwo and five per centimetre.
If you've got rosacea,you've got over a hundred.
And in the gut of this little miteis a very unpleasant bacteria,
which drives and triggers rosacea.
As does when the mite dies, the cellwall, which is made of chitin, breaks
(20:18):
down and that too is highly inflammatory.
So, this is what I think is causingthe inflammatory end of the spectrum.
Doctors often use oral antibiotics forthis inflammatory end of the spectrum.
Highly effectively, the antibiotickills the bacteria, but predominantly
we're using these antibiotics fortheir anti-inflammatory side effects,
(20:41):
which I think is a bit extravagant.
Taking an antibiotic for months onend will not only do major harm for
antimicrobial resistance and encouragebacterial resistance, which is going
to be a big problem for us all, butit also has catastrophic effects
on your own microbiome and yourgut and on the rest of your skin.
So I'm not terribly enthusiasticfor long courses of antibiotics.
(21:04):
And in recent years, a wonderful treatmenthas come out which kills this mite.
It's been around for years and years.
I've used it for treatinganother mite, scabies.
But it's been put into a creamcalled Soolantra® and the
active ingredient is ivermectin.
And I don't know whether you'vegot any experience of using that,
but it is possibly my all timefavourite topical prescription
(21:27):
because it works so amazingly well.
Occasionally it works too well at firstbecause it kills lots of mites, you get
a release of a lot of chitin and a lotof bacteria, and you get a sudden flare.
And I say rejoice, we're onthe right tracks, persevere.
But it knocks that micropopulationright down, and when that's right
down, the inflammatory end of thespectrum, dramatically improves.
(21:49):
And you can then keep it atbay by just using it, perhaps,
you just put it on once a day.
It's available on NHS prescription, andthen after a month or two, you can usually
drop down to alternate days, or even downto just once a week, or once a month.
to keep that mite population atbay for years and years on end and
a very effective treatment there.
So that's another option we haveand there are other options that are
(22:10):
more old fashioned which do work.
But, perhaps not relevantin this situation.
Yeah.
Now right at the start of these twopodcasts we were talking about the
potato noses of Rembrandt and
W.C. Fields,
and they would have looked verydifferent if they had access to treatments
like ivermectin which is one of thereasons why we don't see it so much.
(22:33):
Now obviously, the important thingabout, you know, rhinophyma, is to stop
it happening in the first place, but ifyou do have the unusual case of someone
who is walking around with a rhinophymabecause they haven't been able to access
modern treatments or they're elderlyand it's just built up over decades,
it is really difficult, unfortunately.
(22:54):
I wish there was some more positivenews about treating that but we're
looking really at fundamentallychopping bits off it, aren't we?
Yeah.
There's excess tissue under the skin, andthat excess tissue needs to be removed.
And, so it's a debulking procedure,essentially, and that can be
done with a knife and surgery.
(23:14):
But in fact nowadays the way it's doneis usually with a CO2 cutting laser, and
that's prevents bleeding at the same time,and it can be done under anaesthetic,
but it's pretty unpleasant at the time,but it can give fantastic, I've seen
remarkable cosmetic results from that.
People who after they've had it a month,a few months later when the skin settled
(23:34):
back down to normal skin colour, youwould never know that they've had a
rhinophyma there in the first place.
So it's definitely a good option.
But again, that's not availableusually in the UK on the NHS.
I think it's a privateprocedure in my experience.
Yeah, but fortunately that'sgetting less and less needed
because of the treatments we've got.
(23:54):
And that's an optimisticnote, I suppose, to end on, to
bring this episode to a close.
So George and I do hope youfound it interesting and helpful.
So, Roger and I hope you'll joinus again when we'll be discussing
more skin related conditions.
We'd also, once again, like to thank oursponsor, AproDerm®, for all their help in
putting these Skin Deep podcasts together.
(24:15):
We couldn't have done it without them.
So, until the next time,it's goodbye from George.
Goodbye.
And it's goodbye from me.
Goodbye.
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