Hello and welcome again to this Skin Deep podcast where we look at skin related issues, conditions and treatments in an interesting and informative way. I'm Dr Roger Henderson. I'm a GP with a long-standing 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 are going to be talking about the treatment of rosacea.
This is the second of two podcasts about this very common skin problem and if you were with us for the first one, where we talked about the basics of rosacea, we do hope that you found it helpful. So to kick off this week's podcast, let's not dive into medication straight away because that's the second area to look at rather than the first when I'm talking to patients with rosacea. But let's chat about what I call general treatment principles here and lifestyle changes, which are so important.
I couldn't agree more. Lifestyle changes should play a huge part in our approach to this potentially distressing condition. And the first thing there to say is trigger avoidance is key. So I've talked last time about keeping a diary to find out what your personal triggers are.
And once you know what tends to cause your face to go red and flush and be uncomfortable, then you can negotiate with yourself, and decide whether you're going to experience that trigger because you are particularly keen to have that hot curry or whatever it is. So it's a choice that you can make. I mentioned last time that UV light is probably the most important trigger.
And most people I've met with rosacea do find that when they go out in the sun, it's not sunburn, they're actually flushing much sooner than that. Sunburn will be a few hours later. They go red when they're out in the sun. And so, I advise that all patients, and I mean all patients with rosacea, should really use a high factor UVB and UVA sunblock all year round.
Often we don't worry about the sun in the middle of the winter, but if you're getting a problem, it can be due to UVA, and UVA is just as strong indoors, even on a cloudy day. When you wouldn't be thinking about the sun, you may be getting exposed to enough UV light to be causing a trigger. So, generally try and keep your face 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 be looking at factor 30, factor 50, is that 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 longer in the sun before you get burning. But no, I don't think you need anything quite as strong as that. I'd go for a three plus UVA star rating for sunblock.
But I'd have thought a 15, 20, in fact, most women who use foundation creams on their face, those contain a sunblock and that's probably enough. It doesn't need to be too strong unless you're planning to go out into very direct sunlight on a day when the sun's going to be more intense. I'd say that UVA is as strong in the winter and at dawn and dusk, it isn't quite as strong, but it's not that different to noon at June, comparing to dusk at December.
But there's a difference, but it's not anything like as dramatic as the difference with UVB. It's UVB that changes dramatically with the seasons and the time of day and the cloud intensity and whether you're indoors or not. And it's UVB that burns and causes, I think, a lot of the damage. So, no, I would say a factor 15 UVB would probably be adequate, unless you have particularly sensitive skin to sunlight. And a good 3, 4 star rating for UVA, that'd be ideal.
I mentioned last time that the skin in rosacea feels sensitive. I hate soaps and detergents, and I think it's a situation where I really do think you ought to avoid exposure to detergents and 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 is a very powerful detergent.
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 detergents as much as you possibly can. Soaps, shower gels which form a foam shampoos, bubble baths. Don't get those on your face. Equally avoid fragrances on the face, particularly if they make your face go red or cause stinging.
And I mentioned last time the alpha hydroxy acids in a lot of fragrance, or ascorbic acid, can aggravate things for some patients, so avoid those if you can. A big important message is don't let topical steroids get on your face. Sometimes mistakenly doctors see an inflamed looking red face and may inadvertently prescribe a steroid. Sometimes it's in combination with another treatment.
So if the wrong diagnosis is made that you might get given a treatment that has a little bit of hydrocortisone in it. And steroids can massively aggravate rosacea... Yeah. ...even trivial amounts. And I have, for example, had a patient who was treating her son's eczema with a steroid, appropriately. She carefully washed her hands afterwards. Soon after that, went to bed, and her hand got next to her face as she was lying in bed at night.
And there was a tiny residue of steroid on her hand, and that was enough to aggravate her rosacea. But I've also seen it from inhaled steroids for hay fever or asthma. The small mist from the spray that gets onto their face can actually aggravate it. So, think about steroids and don't let them get onto it, they can definitely make things worse. I don't know about you, but I found that you can get some rather nice green-tinted makeup.
A number of companies make that and I find that can go a long way to masking that permanent background redness and make it much easier to be going out in public and even suggest that men who have a red face should consider getting a green-tinted makeup just to mask that redness a bit, it can be very effective. Inflammatory rosacea, where you get 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 particularly like is AproDerm® Colloidal Oat Cream. Another one you might want to consider is Adex™ Gel, which is Doublebase™, but with the addition of nicotinamide. Nicotinamide is vitamin B3, but it happens to be my all time favourite ingredient in many products, orally and topically. It has remarkable properties and it's anti-inflammatory. So, that's a very sensible option to use.
You've got inflamed red skin. It's actually licensed for eczema, but I use it for a number of other skin conditions and it's the nicotinamide I think that is highly effective. Yeah really, really good tips and the green tinted makeup's an interesting one. When I've suggested that to some chaps, with rosacea, they sort of take about three steps backwards and look at you as if you're slightly mad. But once they've tried it and because you can't tell, you've got 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 facial flushing and the redness, which the majority of our patients presenting to us would fall into that camp as to why they come and sit in front of us and it's the one thing that they really would want to start to lose because that's what's really embarrassing them. How should we start thinking about how to treat that particular area, the flushing and the redness that we see in rosacea?
Well this is where we're getting on to actually being a doctor and prescribing our treatments. Clearly trigger avoidance is key and that is the most important part. I often see doctors prescribing topical antibiotics for this but in my experience, topical antibiotics are pretty useless for the flushing and blushing. And I haven't actually recommended those or prescribed those now for decades, for this particular pattern of rosacea.
So I think if you're, if you've been given something like metronidazole gels or other antibiotics, they just don't really do very much for this end of the spectrum. Occasionally, provided they're not contraindicated, we do prescribe beta-blockers by mouth and they can be very helpful. They need to be taken regularly.
So there are tablets that you can take provided you don't have asthma, for example, or extremely cold fingers that go white in the cold or other reasons for which they're contraindicated. If you can tolerate a beta-blocker, they can be very effective, so that's an option. But by far, the most effective topical treatment we have, only became available about 10 years ago, is a drug called brimonidine. Brimonidine has been around for years as an eye drop for glaucoma.
We've put it into the conjunctival area to treat glaucoma. So, something that's safe going in the eye, being put into a gel and then put on the face, is very, very unlikely to come up 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 constriction of the blood vessels, and it doesn't unfortunately constrict those dilated blood vessels that have been damaged by being constantly dilated up and going down and getting dilated up again. So those telangiectasia I talked about last time become more visible, which can be distressing. But it can cause the face to 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." I said, "well, you look as though you're really, really pale, I think you need to do something about it." At the end of the meeting, she came up to me and said, I just realised I'd put some Mirvaso® on my face and you could do noughts and crosses with it. It's that dramatic. But, it can cause rebound vasodilatation, which can be quite unpleasant and a lot of patients find it very stingy when they put it on.
But there are some tips that we can talk to them about. Put it on cold from the fridge. Start off by treating a small area and you do gradually develop tolerance to that stinging. And there is a product you can buy over the counter called Toleriane Ultra, which L’Oréal make and if you use that first, that can sting a little bit when you put it on initially, but you put it on for a few days that can render the skin much less sensitive and then you can 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, the beta-blocker that you mentioned, they can be really be helpful, and I found them perhaps the best.
If you've got someone who's generally very anxious and you might even be thinking about a very low dose beta-blocker just as a way of helping their anxiety, or if their rosacea just tends to really flare at times of high anxiety or stress, the beta-blocker can work really well in that case. So if we've got, if you like, the facial flushing and the redness covered, and if someone sits down in front of me, I'm fairly relaxed about that.
If they're starting to get the broken blood vessels and the capillaries if you like, that's moved on from that, I wouldn'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 general practice because the problem with the treatments for flushing, they only work on the vessels that can constrict, and these vessels have lost that ability, they've lost the muscle structure.
So, yeah, we could talk about camouflage 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 by a specialist and I would only go to a really good dermatologist. I wouldn't just go to any high street person who's offering laser therapies but pulsed dye lasers or intense pulsed light treatments can permanently destroy those blood vessels with a fantastic cosmetic result.
And it would probably for the average patient need, I don't know, three to four or five sessions of treatment to treat the different areas of the face, each session costing several hundred pounds. But for a sum of money, you can privately have those dealt with on a pretty permanent long-term basis. And once they've been treated, those vessels won't come back, and so you can have a one-off set of treatments.
And so you've got somebody who's, you know, wants to know what they want for their 50th wedding anniversary or their 25th wedding anniversary, have a collection to build up for that, because that could be a very effective treatment. So that's the only treatment I know that really works. There's nothing topical, nothing by mouth. It's only camouflage or these physical treatments with intense pulsed light or pulsed dye laser.
Yeah and I found that even though there is a financial cost to that treatment for people that have had it done, they do say their improvement in their quality of life as a result far outweighs you know, their financial cost to them. Even, you know, during this time of economic squeeze, they do still say I would still have it done again. Rosacea spots, I don't want to sort of go into too much detail with this because we can get really bogged down in the minutiae of medical treatment here.
But perhaps I would just mention because I have seen this and it does make my non-existent hair stand on end, people slapping olive oil on their face to try and treat spots and that's a real no-no isn't it? I couldn't agree more. I love olive oil, in my diet, but not on my skin. It's got the wrong ratio of oleic acid to linoleic acid. It's got too much oleic acid and oleic acid is damaging to the skin barrier. So, no, olive oil should not go on the skin anywhere. I like coconut oil.
Actually, I love coconut oil. At room temperature, it's just solid but to put on the skin, it becomes a liquid and coconut oil helps. Most of the other vegetable oils feed the little mites, now wait for it, we have little mites as part of our microbiome living on the face. And you're actually just nourishing those mites. And those mites cause the more inflammatory end of the spectrum, I think. So I wouldn't use olive oil, but I would consider some coconut oil.
That would be a very reasonable emollient alternative, if you wanted. And I have had patients who've mentioned sea buckthorn oil. Because you know, people do like trying to use natural treatments, and some of them swear by sea buckthorn oil, and until I went away and looked it up, I have to say that was a new one on me. Yep, it kills the mite and it definitely soothes, so it's, I'm told effective. I have to say I've got no personal experience of patients who've used it.
No one's discussed it with me, but similar to you, I've read about sea buckthorn oil and I'm told it kills the mites, which is quite a nice thing to do. I'm coming on to these mites. People also try tea tree oil and that too would help, but I think it's generally too irritant on this sort of skin. People have tried it and yes, it would help if they can tolerate it, but generally they might find it too irritant for that. Yeah, I agree with that one.
Eye symptoms we touched on this in our first podcast about trying to pick up very early symptoms at the opticians with people with dry eyes. You might not actually need any treatment if people are not particularly bothered by their dry eyes. But you can, you know, treat eye symptoms if need be pretty easily most of the time, can't you? It's a big, big spectrum from minor dry eyes for which artificial tears and some simple eye ointment at bedtime perhaps may be all that's needed.
And thinking about whether you know, your contact lenses are aggravating the problem there. So, some simple over the counter remedies. If you're getting problems with blepharitis, which is grittiness and sandiness in the eyelashes, that's a situation ophthalmologists talk about using shampoo along the eyelashes. I always sort of have to take a second thought at that but just massaging some eye shampoo along that or using very, as hot water as you can bear without risking scalding yourself.
And maybe some salt water. That's another tip that I certainly recommend. Get some hot water, dissolve some salt in it and then when you can safely put your fingers into that previously boiling water, when it's cooled down enough, get a bit of cotton wool and hold that against your closed eyelid and just wash the eyelids. A simple eyelid hygiene like that can help. There's a product called hypochlorous, which I've come across recently.
Not hypochlorite, which is in bleach or Milton® and very damaging to the skin, it's very alkaline. Hypochlorous is a natural product, produced naturally by our own white blood cells as part of our immune attack on bacteria and things and is totally safe for human cells. There's an eye preparation of hypochlorous called Purifeyes™. And this is, wait for it, it's 80 times more potent than bleach, which is hypochlorite.
Wow. And it kills 99.9% of bacteria, fungi, spores, and even viruses, and is totally safe on human skin and 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 chronic styes or blepharitis, I'd probably be putting some hypochlorous around my eye and even into my eye, this ophthalmic preparation, just to keep the hygiene level really good there and to support the immune system.
And this is produced naturally by the body's own white cells as part of our own immune response. But it's taken us years, taken them, not me, but taken years to put it into a stable preparation. When they first started making it, it only lasted for a couple of days, and then lost its effect, but now they've got 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 where ophthalmologists often recommend. Eye drops can be in steroids. Interestingly, I wouldn't get them on the face, but in the eye, sometimes they need those, sometimes they need oral antibiotics. And often you do need to involve an ophthalmologist if it's the more severe end of the spectrum of the inflammatory problems. So there are some things that can be done for eye disease. But it's often needs the care of a specialist in that field.
We haven't talked about the management of the pustular end of the spectrum. And just to cover that briefly, part of our normal skin microbiome includes on the face a mite. A little animal with horrible little 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 dead cells and the grease on the skin. It's there to sort of dig around the open hair follicles.
It dives into those and it cleans things up a bit. Now, most of us have between two and five per centimetre. If you've got rosacea, you've got over a hundred. And in the gut of this little mite is a very unpleasant bacteria, which drives and triggers rosacea. As does when the mite dies, the cell wall, which is made of chitin, breaks down and that too is highly inflammatory. So, this is what I think is causing the inflammatory end of the spectrum.
Doctors often use oral antibiotics for this inflammatory end of the spectrum. Highly effectively, the antibiotic kills the bacteria, but predominantly we're using these antibiotics for their anti-inflammatory side effects, which I think is a bit extravagant.
Taking an antibiotic for months on end will not only do major harm for antimicrobial resistance and encourage bacterial resistance, which is going to be a big problem for us all, but it also has catastrophic effects on your own microbiome and your gut and on the rest of your skin. So I'm not terribly enthusiastic for long courses of antibiotics. And in recent years, a wonderful treatment has come out which kills this mite. It's been around for years and years.
I've used it for treating another mite, scabies. But it's been put into a cream called Soolantra® and the active ingredient is ivermectin. And I don't know whether you've got any experience of using that, but it is possibly my all time favourite topical prescription because it works so amazingly well. Occasionally it works too well at first because it kills lots of mites, you get a release of a lot of chitin and a lot of bacteria, and you get a sudden flare.
And I say rejoice, we're on the right tracks, persevere. But it knocks that micropopulation right down, and when that's right down, the inflammatory end of the spectrum, dramatically improves. And you can then keep it at bay by just using it, perhaps, you just put it on once a day. It's available on NHS prescription, and then after a month or two, you can usually drop down to alternate days, or even down to just once a week, or once a month.
to keep that mite population at bay for years and years on end and a very effective treatment there. So that's another option we have and there are other options that are more old fashioned which do work. But, perhaps not relevant in this situation. Yeah. Now right at the start of these two podcasts we were talking about the potato noses of Rembrandt and
W.C. Fields, and they would have looked very different if they had access to treatments like ivermectin which is one of the reasons why we don't see it so much.
Now obviously, the important thing about, you know, rhinophyma, is to stop it happening in the first place, but if you do have the unusual case of someone who is walking around with a rhinophyma because they haven't been able to access modern treatments or they're elderly and it's just built up over decades, it is really difficult, unfortunately. I wish there was some more positive news about treating that but we're looking really at fundamentally chopping bits off it, aren't we?
Yeah. There's excess tissue under the skin, and that excess tissue needs to be removed. And, so it's a debulking procedure, essentially, and that can be done with a knife and surgery. But in fact nowadays the way it's done is 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 back down to normal skin colour, you would 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 available usually in the UK on the NHS. I think it's a private procedure in my experience. Yeah, but fortunately that's getting less and less needed because of the treatments we've got.
And that's an optimistic note, I suppose, to end on, to bring this episode to a close. So George and I do hope you found it interesting and helpful. So, Roger and I hope you'll join us again when we'll be discussing more skin related conditions. We'd also, once again, 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 the next time, it's goodbye from George. Goodbye. And it's goodbye from me.
Goodbye.