Hello and welcome to this Skin Deep podcast where we look at skin related issues, conditions and treatments in an interesting and informed way. I'm Dr Roger Henderson. I'm a GP with a longstanding interest in this area of health.
And I'm Dr George Moncrieff. I was also a GP, although I've now retired from my practice, and I was the Chair of the Dermatology Council for England.
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 be the 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, which I think is a really good one, if you weren't already on this podcast, because you'll know the answer to this by being on this podcast, but if you chuck this into a pub quiz, I suspect not many people would get it, which is "What have Rembrandt, the Hollywood actor,
W.C. Fields and former president of the United States, Bill Clinton, all got in common?" Well, as you might expect, the answer is they had, or have, rosacea. And interestingly, if you take a look at the self-portraits that Rembrandt painted throughout his life, his face changes quite markedly, to when he is an old man. And those are essentially the changes of rosacea. But, I think it's a good idea to start off by talking exactly what rosacea is, obviously.
It's often poorly understood, in my experience. Patients that come to see me in practice with it, unfortunately, seem to know relatively little about it and I always find that surprising as it affects about 1 in 10 people. That's a significant number of people here in the UK, especially, in the middle age and I think that's probably your experience as well, isn't it, George?
I agree, absolutely. It is one of the most common skin conditions that we see. I suppose the first thing I'd want to say is, we shouldn't confuse it with acne. Some people even call it, rosacea acne, which just adds to the confusion. So like you, I prefer simply just to call it rosacea. Both conditions happen to cause red bumps and spots on the face, but they are very, very different.
For example, rosacea affects the skin 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 I won't go into those differences here, but don't confuse rosacea with acne, and certainly don't call it rosacea acne.
Interestingly, although more women seek advice and help for rosacea than men, when we do population studies, it seems to be equally common in both sexes, and I'm intrigued that all those examples you gave were men who had rosacea. Interestingly, with Rembrandt and W.C. Fields, they had the condition, which we call rhinophyma, which I'll come on to.
Also, people often think it's not a condition of dark skin, and I think that's simply that people with dark skin are less likely to seek advice, possibly because going red in the face is less of a cosmetic problem on a dark skin background. However, I've certainly seen, and I'm sure you have too Roger, lots of rosacea in people with skin of colour.
So we need to consider it there, although there's a differential of other things that can cause changes on the skin, particularly in dark skin, that need to be thought about. As you say, the number of people with rosacea just increases with age. It seems to start becoming more common from about the age of 20 and it probably peaks around about 50 to 60 years, for most patterns of rosacea. 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, as you said, with advancing years.
Now, have you found in your experience, George, there is any kind of family history? Can it run in families, or is it just so relatively common that it can sometimes appear to?
Well, it certainly seems to be more common in very fair skin types, doesn't it?
Yeah.
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 red face end of the spectrum, rather than the more inflammatory pustular end, but I've not actually noted anything specifically on family association with it. Have you?
No, I haven't, which is why I ask, the question, with your experience. I don't think I've ever seen a family with consistent rosacea running through it. In fact, the most I've probably seen is two family members, of different ages, and they were siblings. But no, I would never say that there is a strong family link.
But it's so common, that you commonly see two individuals with it in the same family, don't you?
Exactly.
The mildest end of the spectrum of rosacea, and this is a spectrum of disease, it's got a big name, 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, basically describing a dilated blood vessel. So, you get background redness and you get dilated blood vessels. And this is due to increased flushing and blushing.
The flushes are caused by triggers, which generally don't trouble other people. So, these patients have, what we call, vasomotor instability. Their tendency to flush is much more easily triggered. And that's not only embarrassing for them, but it's very unpleasant, they describe these flushes as unpleasant. And the flush typically comes on within 30 to 60 minutes of a trigger, and can last for a couple of hours.
And, one thing can trigger this in one individual and not in another, so it's a very individual and personal set of triggers. The skin then gradually develops a permanent background redness, that erythema we're talking about, with, interestingly, some sparing around the eyes. Classically, in rosacea you don't get that redness around the eyes.
And then this repeated dilatation of the blood vessels, followed by them constricting back down again, you eventually get these tiny, permanently dilated blood vessels, on the face, rather like weather beaten vessels, as this background, hence the telangiectasia. What patients with rosacea tell me is that their skin feels sensitive.
It's, often aggravated by detergents or fragrances, especially fragrances that contain alpha-hydroxy acids or ascorbic acid, 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, where you get papules, that's red bumps, and pustules, which is whiteheads. These are mostly on the face, but they can occur up onto the forehead and the scalp.
And they can be quite scaly. I think doctors are often put off by the fact that you see scale around these pustules. And as with the erythrotelangiectatic pattern, there's often some background, or there's typically, you look for the background permanent redness. Well over half of patients who have rosacea, or go on to get rosacea, experience some eye symptoms.
And they can be ranging from very mild, just dryness to scaly eyelashes, blepharitis in other words, to recurrent styes or conjunctivitis, or even occasionally much more inflammatory conditions of the eyeball. And I've had patients who've complained of dry eyes, sometimes for a year or two, before they start to get the skin manifestations. So, these eye symptoms can precede, rosacea.
Yes, I just remembered when you were talking there, I remember speaking to one of my local opticians about this and I asked them if they had anyone coming in complaining of dry 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 patients I picked up early, but I definitely picked up a couple early, just by asking the optician to look out for those.
What a clever thing to do. Excellent. Yes. But these eye symptoms are useful to us because if you've got a patient with a red face, and there's a differential, there are a number of conditions that can cause a red face that 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're going to be airing towards the diagnosis. But I think that's a great tip. I love it.
I might go talk to my optician and do the same. A much more uncommon condition, is where the patient develops considerable thickening of the tissues under the skin. Typically on the nose, but it can occur on the forehead and on the chin, and rather rudely, doctors call this rhinophyma. Rhino, meaning nose, and rather than being a rhinoceros or bone on the nose, it's a phyma, which is a potato. So, we're basically saying you'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.
Absolutely agreed. And, we touched on Rembrandt and W.C. Fields, and as you say, that's why it was picked up, and we'll touch on this in a bit more detail later. I'm certainly seeing less of that than I was 40 years ago, and I think maybe it's because we're getting better at stopping people with rosacea getting to that point. But I know the misery, and the taunts even, that some people with a rhinophyma have had to endure, for a very long time. It can be socially crippling.
So, I'm glad we're seeing less of that than we used to.
Yes, it's intriguing. There are dermatologists I speak to who don't actually believe it's part of the rosacea spectrum. But I do, and I do think it is uncontrolled rosacea that drives it. The other reason why we may be seeing less is that we have now, and we'll talk about this next time, we have got some fairly effective treatments. So, particularly at the mild end of the spectrum, we can calm it down and control it.
So, it may be that we're better at controlling 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 patients with some pretty spectacular noses. And it is hard not to look at them, isn't it?
It is.
And that is the problem with rosacea, it's visible. It's your face. It's the bit of your body that you expect to be able to see. The only bit of my body you can see here today, for example, and it's unpredictable, and it's unpleasant for the 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 can have a, really, very devastating impact on the patient's confidence, going into a meeting, giving a talk, going into a new situation, their self-esteem is affected and it can have a big impact on mood as well. So, I think we do need to take it very seriously with those thoughts in mind.
Absolutely. And if we think about the factors that can 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 areas of myths and disinformation about rosacea and, you know, if I had a pound for every old wives tale I've heard about rosacea, I'd be sitting on a beach in Barbados now.
But, the lifestyle factors, the foods we eat, the alcohol that we drink, the temperatures that we're in, or, if we're embarrassed or stressed or anxious or nervous or walking out onto a stage, it's a cruel disease in many ways, because it makes it more visible at that time.
Absolutely. The most common though, and probably the most important, trigger for a flush is ultraviolet light.
Yep.
That's usually UVB, but also, importantly, it's UVA. And I say importantly because UVA doesn't burn. You're much less aware of it, and UVA goes straight through cloud. UVA goes straight through glass. And it's just as strong in the winter as it is in the summer. And it's just as strong at either end of the day as it is at noon. So, you're being exposed to UVA, and if that'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, but UVA can have an important role in rosacea, and we'll discuss that a bit more when we talk about treatment.
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Yeah, speaking in public is probably the next most, embarrassing situations, going to a dinner party, or whatever, can really cause a very awkward flush. And as soon as you think you might be flushing, you're more embarrassed, and then you're into a vicious cycle, and the whole thing is a mess. Hot foods can do it. They're hot in temperature, but also spicy hot foods, so curries and things. Cheese, sudden temperature changes, going into a sauna, going into a hot room.
Interestingly, also going into a cold room. If you go out in the cold, some people's face begins to go red, which is counterintuitive rather, isn't it? Exercise. If you're exercising, particularly if you are overdressed, or going for a brisk walk and wearing more than you should have been wearing, all these things can do it.
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 triggers first, 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 did enjoy his alcohol, didn't he?
And he made a big thing of it, but I think it's perhaps built into our psyche, the link between red faces 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 gone through all the other possible triggers. Interestingly, it's white wine more than red wine that, or spirits or, or beer that causes more triggering problems, in a big study from Ireland.
But, I think it's important that we don't embarrass our patients by talking about alcohol too early in that.
Absolutely.
Sometimes the medications we prescribe can cause flushing, and there are a number that are notorious 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, and other things, they can cause it.
But the important thing about flushing is it's very individual, so, what causes a flush for one patient won't necessarily cause it for somebody else.
So, what I suggest to somebody with this is, go away and keep a diary for a couple of months and record, you'll know what causes a flush, you probably know already, but if eating cheese causes a flush, it will happen probably within an hour or so, two at the most, and you can then know what your causes of flushes are, and you can say, look, I actually really 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 home and so on, I'm going to tolerate having a flush in a couple hours time because I'll be on my own, and you can negotiate with yourself what you're going to put up with... but know what your flushes are.
It's interesting, people with rosacea who have sat in front of me, they almost slightly fall into two camps in a way. There's the camp that thinks that they're the only person with that particular problem. And then there's the camp that 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 who aren't aware they've got it, but have got some dry eyes and they walk into their opticians, to the chap walking down the street who doesn't want to see anybody because his face looks so red and he's got a large, bulbous nose.
I think it usually starts off with this unusually easy flushing and blushing, with increased 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 flushing and blushing definitely then causes the dilated, permanently dilated, blood vessels, which can be quite troublesome.
But I think it's that flushing and blushing, the vasomotor instability then drives matters on, to the more inflammatory end of the spectrum where you get those sore red bumps and those spots. And that creates the environment that is ideal for that to develop. So, I actually believe that if you can limit the amount of triggers that you have, not only will it be more pleasant for you as a patient, but it might curtail the progression of this disease to the more severe end of the spectrum.
I don't know what happens with eye disease, and eye disease is fascinating, and I don't know whether we can do anything to curtail that. It seems to run alongside this, and I've seen very severe eye disease with relatively mild skin disease, and vice versa. And of course, half of the patients have eye disease, but the other half don't. So, it's extraordinary how that association is there. Phymatous disease, which is this, bulbous nose.
I suspect it's due to chronically under treated rosacea, but not necessarily, but they're all very definitely interlinked.
What I often say to patients with rosacea is that, just like you, I don't think we've got any hard evidence that repeated flushing drives it along, although I do genuinely think that is the case. What I often say to patients with rosacea is, it's petrol on the fire. The fire is just there quietly going along underneath. But you then have repeated flushing, and it's just petrol on that fire, 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 of rosacea, 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 can just get on with advice and treatment. Do you think that's fair?
I do actually, yes. I'd say 90% of medicine is what the patient tells me. It's their history, what doctors 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. No, I, there are one or two things 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 made in the consulting room, based on what the patient tells me and a little bit about what I can see. The distribution and the pattern and things like that. Yeah.
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've got to be thinking about it, but it is something where you can fairly quickly be content with.
And it's nicer because we can definitely make life better for the patients. We've got some fabulous treatments, which we're going to come onto in our next podcast.
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 they actually come to see us in surgery, when they get into a point where it's impacting on them, and I sometimes wish that they came a little bit sooner, but I, you know, would never, never say that to them. As you say, we're going to talk about the treatment of rosacea in the next podcast.
So, with this one, I do hope that you found this chat from George and I really helpful, about this most common of skin conditions, and that it has allowed you to have more confidence if you do have rosacea, in not only understanding it a little bit better, but also about how we may be looking to treat it.
So, we hope you'll join us next time when we'll be discussing that, along with self management 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.
So, until next time, it's goodbye from George.
Goodbye.
And as always, it's goodbye from me. Goodbye.