Do you have a favourite over the counter treatment for your rosacea ? Depending on your health insurance and access to doctors and pharmacies, prescription treatments are out of the reach of many rosacea sufferers. So what can you try as a rosacea treatment that is easy to source, cheap and available without a prescription ? Is there anything ?

Please help your fellow rosacea sufferers with your best discoveries of treatments that you can get without a prescription or without visiting a doctor.

Here are some suggestions that I have collected that seem to be popular with members of the rosacea support group;

Prosacea

Prosacea is a topical gel, available over the counter at stores like Walgreens. It is also available on the internet at cvs.com. It contains 10% sulphur. The jury is still out, but reading prosacea user reviews, it looks to me like we should include prosacea as a bona fide rosacea treatment.

Rosacea-LTD

Rosacea-LTD is a topical treatment made of various compressed salts. It worked well for me to reduce papules and pustules and it is available only over the internet (which I guess counts as over the counter). This treatment is not cheap like many of the other suggestions in this listing, but I thought it definitely should be included as an over the counter treatment. For more information have a read of Rosacea-LTD User Reviews

Disclosure: rosacea-ltd is a site sponsor of rosacea-support.org

Aspirin

There has been some introductory research suggesting that a daily low dose of aspirin may help with rosacea swelling and flushing. For some it may lead to more flushing, but as an easily available and cheap over the counter treatment, aspirin may be worth a try.

Rosacea Swelling Relief Regime

Dr. Linda Sy has suggested in her rosacea swelling relief regimen, that there are some OTC meds that are easier (than prescription drugs) on the system such as: aspirin (blocks prostaglandin synthetase), antihistamines – ex. Chlor-trimeton which blocks H1 receptors; Cimetidine (Tagamet) which blocks H2 receptors. Pyridoxine (vit.B-6) has also been found to be helpful as a prophylaxis. She has sugested the following over the counter regime;

at Bedtime;

• 1 baby aspirin
• 1 Chlor-Trimeton (an antihistamine)
• 1 Tums (to offset the gastro effects of the aspirin)

and in the AM;

• a B complex vitamin with 50mg of B-6, but without Niacin (niacinamide is ok).
• 1 Tagamet

during a flush;

• apply a cool (not cold) compress to the face
• do deep breathing 10 times slowly.

Flaxseed Oil

Studies have shown that flaxseed oil may help improve acne and for some other Omega 3 sources like Fish Oil may offer additional benefits.

When Dr. Eric Jones was asked about the possibility of any nutritional link to ocular rosacea symptoms he responded “that here are studies with just dry eye, where flaxseed oil and omega 3s are quite effective. Foodwise, everyone is individual. There have been some surveys, and everyone was different. Some said spicy foods, others said hot drinks, alcohol, cold drinks. People have to find their individual triggers, I think.”

Nasalcrom

As an alternative to the steroid based nasal sprays, something like Rynacrom or Nasalcrom may help with allergic rhinitis and relieve other allergic symptoms. Certainly if you think your rosacea symptoms are allergy related this is worth trying. Even if it only relieves other chronic symptoms is might help you get your head around the other symptoms that occupy your thinking.

Afrin / Oxymetazoline

It is early days yet, but some preliminary research and some rosacea sufferers are reporting reductions in redness from using topicals such as Afrin. Rosacea sufferers are cautioned against applying Afrin directly to their skin as it is actually for allergic rhinitis so contains ingredients which may be irritating to rosacea sufferers.

Keep an eye out for updates related to Oxymetazoline based treatments like Afrin. See this forum posting Afrin cure ? for some more information. There are many over the counter products that contain oxymetazoline.

Cleansers and Moisturizers

OK officially cleansers and moisturizers aren’t rosacea treatments. This is a bit of a step backwards for rosacea sufferers. Once you understand that a gentle cleansing and moisturising regime is a good basis for beating rosacea, you are already off to a good start.

Make your own Cleanser

We know from a recent rosacea news article that colloidal oatmeal (Avena sativa) has interesting cleansing, moisturizing, buffering, soothing, protecting and anti-inflammatory properties.

Want to try something natural, perhaps something that you know exactly what it contains because you have made it yourself ? Some of the highlights from the Homemade Mixes community forum include simple natural sunscreens, licorice treatments, a honey cleanser and more.

Colloidal Oatmeal

Officially `Colloidal’ oatmeal is defined as a product made from grinding and processing whole oat grain with strict requirements on the particle size and fat content. In the past rosacea support group members have made their own cleansing masks with oatmeal and water. An extra bonus is that it can sop up flakes associated with seborrheic dermatitis.

Jojoba Oil

I have found that a small amount of jojoba oil blends in really well on wet skin and gives an excellent moisturized feel to my skin. Jojoba oil is cheap and easy to find in health food stores. We do know that jojoba oil has anti-inflammatory properties so it could be an ideal over the counter product.

A final warning

Please do be careful with products that you can get over the counter. Just because something is available without a prescription doesn’t mean it is even safe for rosacea skin. For example some OTC products might secretly (or quietly) contain steroids. As we now know, over the counter steroids can cause steroid induced rosacea.

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Go for It !

OK, so I have made my list, please give some more suggestions below in the comments.

Related Articles

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• choosing a rosacea moisturizer
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Showing just how important the internet is becoming for marketing new cosmetics, Pyratine XR has recently launched with a lot of press activity. As well as Senetek’s press releases on the internet I was also contacted by 2 PR representatives trying to get me to cover the release of this `new’ product. Pyratine XR was launched at the South Beach Dermatology Symposium in Miami on Feb 14 and also on March 6 at the AAD Annual Meeting in San Francisco.

The press release activity is based on an as-yet unpublished study of 18 mild to moderate rosacea over a period of 48 weeks.

So what is the difference between Kinerase, Pyratine-6 and Pyratine XR ? Well firstly they are all expensive over the counter cosmetics. The active ingredient in these products is furfuryl tetrahydropyranyladenine. As cosmetic products none of these can make claims to treat any particular disease.

Kinerase

Kinerase Cream contains 0.1% N6-furfuryladenine.

The ingredients of Kinerase are listed as: purified water, glyceryl stearate and laureth-23, isopropyl palmitate, propylene glycol, stearic acid, cetyl alcohol, carthamus tinctorius (safflower) seed oil, soya sterol, stearyl alcohol, dimethicone, imidazolidinyl urea, citric acid, sodium hydroxide, methylparaben, soluble collagen, carbomer, N6-furfuryladenine, panthenol, propylparaben, triethanolamine, ascorbic acid, hydrolyzed elastin, and aloe barbadensis leaf juice.

Pyratine-6

Pyratine 6 contains 0.1% N6-furfuryladenine and is marketed as an anti-aging product and as Senetek’s `second-generation patented cytokinin’

Pyratine XR

Pyratine XR contains 0.125% N6-furfuryladenine and is marketed as a rosacea product once Senetek increased the amount of the active ingredient and initiated the unpublished study mentioned in this article. It looks to me that the Red R in the labelling is also trying to suggest that this product is for rosacea sufferers.

Product Feedback

There is some strong skepticism about Pyratine XR over at the Rosacea Forum

I agree with Melissa:

1. The stuff is ridiculously expensive
2. It went “cosmetic” as to avoid having to conduct rigorous testing
3. It’s claims are yet to be approved by the FDA as far as I could find
4. There are no 3rd party tests of this product, only in house research done by the company
5. In the tests that were done the claim was that it was tested on people with mild to moderate rosacea, but the test data itself remains largely unpublished.
   Further: http://www.dermatology.uci.edu/IID%2…er%20final.pdf
   Are you kidding me? If the two test subjects pictured are the best examples to sell this product then it appears to only work well for those with really, really, really mild Rosacea.
6. I haven’t heard one good thing about Pyratine 6 from a real Rosacea sufferer, it is hard to imagine why this is going to be that much better
7. Spamming Rosacea web boards for business suggests a $ grab
8. I don’t know why this plant derivative substance is significantly different from others that have been around for some time that claim to also be anti-inflammatory and effective on ROS.
   Bottom line, there is no real reason to believe this product will work imo, but the jury is out. Once is comes out, if some reliable people post good results it might be worth a try. I would prefer seeing a large scale 3rd party double blind study on it.

Pyratine XR was due to be launched at the SF AAD Meeting. An interesting post from badhairday gives some insight into what this launch actually meant ;

Hi all,

Thought this would be helpful info re: Pyratine XR. I realize I don’t regularly post but I thought this was important. My sister in-law is a Derm. She attended the National Dermatology Conference in San Francisco this past weekend. I asked her to find this product and try to get me the inside scoop – like all of us I am cautiously hopeful of anything new but also skeptical. Here’s what she found.

The Pyratine XR booth – was a VERY hard to find tiny booth. There were two women representing the product (she said the ladies seemed a little sketchy – not necessarily important info but I trust my sisters judgement ). Just a few before and after pictures of people who had trialed it for 48 weeks – but NO real data on how the product works and the women wouldn’t get into any detail. They would only conditionally commit to give her 6 free samples (enough for the 48 months per patient) BUT the Dr. had to commit to recording results of their patients (data and pictures) through the period of the trial and report back to the company. If the Dr. didn’t want to commit to the following though on data gathering they would need to pay $400 + per patient (for an 48 month trial). This product will be sold over the counter only in physician offices (no pharmacies). My sister-in-law was concerned that this company was trying to solicit Doctors to do the research for them for free rather than setting up an actual study where patients are paid. Further she was sceptical that they wouldn’t give any free samples (it is $150 per tube!)

She reported that b/c it’s over the counter it doesn’t have to go though any “real” testing (a lot easier to get approved). Just need to prove that it doesn’t harm anyone. It seems to be a glorified anti aging product with natural plant exact ingredients which probably will be ok for many of us to use as most of the ingredients looked fairly benign. But it’s hard to say if it will have any effect on rosacea at this point. Her recommendation was to wait a year and not spend the money as it didn’t look promising enough and it didn’t have enough to back it up that would make it a worth while product at this point. Sorry to burst any bubbles – and again what doesn’t work for one may work for another and obviously a few people on this sight have had some luck. The product representation just seemed a little sketchy for me.

Good luck all – hope this helps a few of us to save a few bucks and… Jen

Paula Begoun has this to say about Kinetin.

Kinetin is a plant-growth hormone, and its technical name is N6-furfuryladenine. What makes kinetin interesting are the in vitro and animal studies demonstrating its effect as a growth factor.

…

I suspect that when it’s applied topically, kinetin isn’t of much use to the skin cell, and even if it could be utilized, there probably isn’t enough kinetin in any product to have a negative or positive impact but that is only a guess, no one knows for sure (Source: Dermatologic Clinics, October 2000, pages 609-615).

User Reviews & Feedback

As Pyratine XR has only recently launched there aren’t many testimonials available yet. Here are some thoughts from users of the related product Pyratine 6.

From DukeCity; I still am using the creme and think it’s the best moisturizer I’ve ever had, as far as toning down redness it’s so subjective, as I’ve had multiple IPL/Laser TX and am taking Oracea daily. But it is the only topical I’ve been using since last Feb./March. I will definitly be buying the Pyratine/RX as soon as it comes to public sale…

From dallascowgirl; On March 14, 2009, I will have completed a year using Pyratine- 6 lotion. (I tried the cream but it made my skin break out.) I still like it as much as ever– the first moisterizer I’ve ever been able to use. In this year, I have only used two 2.5 oz. tubes. I use a pea size glop twice a day while my face is slightly damp. I have had acne rosacea since I was 13 years old. Today, I have no breakout and my face skin is smooth, a little pink on my chin. Though it is expensive, I think I’ve actually saved money this year from not running out and buying the newest cream every month. Will I try the the new one? I really haven’t decided yet.

From sophie; I started using Pyratine last sept or oct, and loved my skin more after only a week or two. There has been a SMALL reduction in P&Ps [I still have them]. Likewise a SMALL reduction in redness [I'm still red]. The BIG difference was in the overall smoothness of my skin. Its still rougher than your average persons, but I’m quite sure that its the smoothest its been since pre-puberty [I'm now 33]. Funnily enough, I wonder whether my spider veins are now more defined now cause my skin is clearer. The other downside is that prolonged use hasn’t made my skin any better i.e. the almost immediate improvement has remained but not increased.

Over to You

So now that you have read all this background information, do you plan on trying Pyratine XR ?

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• Discuss it in the forums at Pyratine-6 Avail Feb 9th – Claims 60% Redness Reduction

Distressed with the expense of exotic rosacea treatments ? The stress of rosacea is enough without also having to worry about how to afford treatments. Finding affordable rosacea treatments is a real challenge.

So here we go; my top 5 suggestions to help you find cheap rosacea treatments.

1. Make your own cleanser

Colloidal Oatmeal has promise as natural product because of it’s cleansing, moisturizing, buffering, soothing, protecting and anti-inflammatory properties.

While products like Linda Sy’s Mild Oatmeal Facial Cleanser and Aveeno Oatmeal Anti-Itch are not cheap recommendations, you should be able to source colloidal oatmeal easily from a health food store. Colloidal Oatmeal is defined as a product made from grinding and processing whole oat grain with strict requirements on the particle size and fat content. The small particle size and the way that it disperses in water means that when it deposits on the skin it forms an occlusive barrier.

Try mixing a small amount of Colloidal Oatmeal with warm water and lathering it on your face. Gently remove it with cool water.

See also the Homemade Mixes Forum and the Custom Topical Formulations resources page for more suggestions on making your own super cheap topicals.

2. Use generic prescriptions

Newer releases of antibiotics like Oracea and Solodyn can be extremely expensive, especially without medical insurance. One alternative is to discuss with your doctor the possibility of trying generic doxycycline instead.

Doses of 50mg a day of doxycycline will closely match the amount of active antibiotic in Oracea and Solodyn. Higher doses many also be of benefit until the inflammation of rosacea subsides. Generic doxycycline is far more affordable that these 2 newly released re-packaged antibiotics.

Another possibility is to ask your doctor about generic metronidazole. The patent for metrogel (the 0.75% version specifically) has expired so generic equivalents are now available in several countries around the world. For more information see generic metrogel.

3. Hunt for Bargain Suggestions

Many of the `regular’ treatments for rosacea such as systemic and topical antibiotics are quite expensive. Be on the hunt for things you can try that are more reasonably priced. Here are some suggestions

• Prosacea: this can be sourced over the counter at places like Walgreens and Rite Aid for around $10. It seems to be an ok treatment for rosacea. Prosacea is based on a sulphur preparation.
• Cetaphil Gentle Skin Cleanser and Cetaphil Moisturizing Cream or Lotion are two under-rated skincare products. They are cheap, mild and easily available. If you can incorporate these in to your daily skincare regime then you are off to a good start to cheaply caring for your rosacea skin.
• Try to source a cheap zinc oxide based sunscreen. Some countries have cancer foundations that are good at providing affordable, simple sunscreens. You might be fortunate enough to find a low irritant formulation free of chemical sunscreens.

4. Manufacturer Rebates

Drug manufacturers recognise that their products can still be quite expensive by the time they get to the consumer. To try to mitigate this impost, rebates or coupons are sometimes offered.

A quick search revealed the following ; $10 Mail-In Rebate for Metrogel, and Save $10 on Finacea Instantly.

The very expensive Oracea also offers a Savings Card where you could save $25 per prescription for those without prescription insurance and help some insured patients pay no more than $25 per month. The similarly expensive Solodyn is also offering a $35 rebate.

One program that you may not be aware of is offered by Galderma. Galderma will provide Oracea and Metrogel FREE for low income and no insurance sufferers of rosacea.

While these manufacturer rebates come and go, keep an eye out for promotions offered by the manufacturers. Be aware of all the small print also as refunds can take many weeks to arrive, and promotions can be revoked at any time.

5. Ask for Physician Samples

When new drugs are being promoted, the sales team are desperate to find as many outlets as possible. This might mean that your doctor or specialist has drug samples just waiting to be handed out. Check with your local doctor’s surgery, and maybe even ring a few dermatologist to see if they ever get samples from the drug companys’ sales teams.

You might be lucky enough to find a good source for free samples. This is one asset that is worth trying to chase down and link up with.

Please Help

`Cheap’ and `Rosacea Treatment’ don’t often appear together in the same sentence. Treatments, especially prescription treatments that have been developed and marketed for rosacea sufferers are notoriously expensive – to the point of being unobtainable for many.

Do you have any recommendations for your fellow rosacea sufferers that are on a budget ?

Related Articles

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• Rosacea Support Community:  Homemade Mixes
• RSRP: Custom Topical Formulations

What are the best known naturopathic treatments for rosacea, and how well have they been shown to work ? Naturopathy is a medical philosophy that tries to improve our health by helping the body’s own ability to recover from illness and injury.

Those who practice naturopathic medicine promote a holistic approach to health and would steer away from synthetic treatments such as antibiotics and metronidazole for example.

If you ever wanted to get to the bottom of the mumbo jumbo that sometimes surrounds naturopathic treatments, then read on.

Herbs

There are now several products on the market to treat rosacea that promote their genesis in natural products. Additionally it may be possible to use some herbs in their natural form. Some of the commercially available products include the Aveeno Ultra Calming range that contains feverfew, and the Eucerin Redness Relief range that contains Licochalcone A, an extract of licorice. One other `naturally based’ topical worth considering is Rosacure which contains MSM and silymarin (Lady Thistle Extract). Although not a herb, colloidal oatmeal containing products from Aveeno are also based on a natural ingredients and my be useful in treating the itch of rosacea.

One herb that stands out (in theory at least) for me is arnica montana. This herb does have a long history of being used to treat swelling and bruising. If this can be extended to include the inflammation of rosacea then arnica might be worth exploring further. One other interesting approach is the Califlora and aloe vera based anti flushing protocol to control angiogenesis between IPL treatments.

It seems to me that products that are sourced from natural ingredients, that also have been tested and developed into commercial products, and are easily available; hold a lot of promise for rosacea sufferers.

Acupuncture

Although acupuncture has been a subject of active research since the late 20th century, accupuncture’s effects are not well understood. It is considered safe when administered by well trained practitioners using sterile needles, but probably like most of these sorts of therapies, needs more research.

See the following acupuncture thread over at the Rosacea Support Community for thoughts from other rosacea sufferers. It seems that acupuncture may be good for overall health, help you relax and might just help you cope with rosacea. Another thread at The Rosacea Forum from a member’s acupuncture trial is also worth reading, although there doesn’t seem to be a conclusion just yet.

Aromatherapy

Aromatherapy uses what are called essential oils and other aromatic compounds to affect one’s mood or health. Note that the `essential’ in essential oils only refers to the oils being concentrated from the plant they were extracted from. Thus the usage of `essential’ here should not be confused with uses of the term such as essential fatty acids for example.

According to wikipedia, the scientific evidence for aromatherapy is weak and could only be considered as mildly encouraging for a limited set of possible uses. Proponents of aromatherapy suggest that there are 2 main ways that the therapy works; firstly by the influence of the aroma on the brain, and secondly by the pharmacological effects of the essential oils.

Unlike acupuncture, aromatherapy is considered a largely Western treatment regime. The delivery of aromatherapy can be via aerial diffusion, inhalation or directly on the body. Many of the potentially interesting essential oils, like lavender oil, eucalyptus oil for eg. may also be useful as a topical treatment in their own right.

As aromatherapy preparations are often concentrated, dilution with a suitable solvent would be advised.

Homeopathy

Does homeopathy rise about the mumbo jumbo sounding statement of `treating like with like’ ?  Can it offer something useful for rosacea sufferers ? While the formal description of homeopathy; “an ill person can be treated using a substance that can produce, in a healthy person, symptoms similar to those of the illness” doesn’t sound too bad, sadly the research has never been able to escape the placebo effect. When you consider that many homeopathic remedies are diluted such that the active ingredient is undetectable in the diluent, it isn’t surprising that any benefits are hard to prove.

What about the Placebo Effect ?

For those not familiar with the placebo effect, it might be worth exploring that further here. When a new medication is trialled, researchers need to prove the efficacy of the medication when compared to placebo. The mind is a powerful influence in any treatment, especially when the patient has an expectation of improving. When trialists expect that they are receiving the active ingredient, but are only receiving the inactive placebo, and do perceive a benefit – this benefit is known as the placebo effect. Thus a blind study is more convincing; where trialists do not know if they are receiving an active ingredient, and the response can be measured objectively.

There are several theories about why the placebo effect exists. A disease may have its own natural cycle, or some people may be predisposed to the power of suggestion.

Despite being hard to prove, homeopathy is one of the most wide spread non conventional treatment approaches alongside Chinese medicine, herbal medicine and osteopathy.

There is a lot of discussion about the merits of homeopathy as treatment regime. One robust criticism of the whole approach that is worth a read Quackwatch: Homeopathy The Ultimate Fake. The author, Stephen Barrett, M.D. asserts that the FDA has not held homeopathic products to the same standards as other drugs and that at best the remedies are just placebos.

Nutrition

We all of course know that what we eat influences our health. Just how much does diet affect our rosacea though ?

Some foods are known to be common rosacea triggers. It can be quite complicated to understand one’s own allergies and food intolerances, especially if there are rosacea flareups related to intake of unknown foods. One good source for further reading is the resource page Dietary Influence.

Beyond some directly traceable intolerance to a particular food, what about a particular style of diet ? Rosacea Diets have been around for several years. Can avoiding processed foods or eating an alkaline diet help your rosacea ? Anecdotal reports suggest that this may be the case.

One paper that looks to be heading an an interesting direction is summarised here; could rosacea be caused by diet ?

Pursuing a whole foods, plant-based diet is also something worth considering when thinking about your general health and longevity. My belief is that we would all benefit from seeking the advice of a dietician for our rosacea and indeed for our general health and wellbeing. With so many chronic diseases having links to diet, it makes good sense to explore good nutrition with a dietician.

Physical Therapies

This sort of therapy includes hydrotherapy, physiotherapy, sports medicine and soft tissue manipulative therapy. While it might be hard to imagine how physical therapies can help rosacea, they may well improve your quality of life. We also know that moderate exercise may help your rosacea.

Psychological Counselling

There has been little direct research between the effects of stress and rosacea. It appears that emotional flushing in rosacea sufferers may be maintained by a combination of both cognitive and physiological factors. What comes first though ? does stress  make rosacea worse, or does rosacea induce its own stress, and feed off itself.

While we wait for more research, those who do suffer from anxiety or depression will likely benefit from meditation, relaxation, and stress management.

Another result from some recent research linking rosacea and flushing found that `The stress and fear of blushing can be mitigated by psychological intervention such as Cognitive Behavioural Therapy and Task Concentration Training.’ These are 2 more options that may be worth exploring to help rosacea sufferers copy with flushing and anxiety.

Over to you.

OK, so I have tried my best to outline the depth of naturopathic treatments and frame them with some relevance to treating rosacea. What successes can you report ? Do these sorts of treatments hold much promise for rosacea sufferers ?

Related Articles

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• Rosacea Support Community: A naturopathic physician’s take on treating rosacea
• RSRP: Dietary Influence
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• could rosacea be caused by diet ?
• natural anti-inflammatory therapies
• lavender, arnica, aloe vera, tea tree oil, and calendula ; do they work ?

Dr. Wu published a paper in 2006 on treating rosacea with herbs. This paper highlighted the properties and potential rosacea treatment modalities of licorice, feverfew, green tea, oatmeal, lavender, chamomile, tea tree oil and camphor oil. This just published paper concentrates more on the anti-inflammatory properties of several natural products and reviews the evidence supporting their use in inflammatory skin conditions.

Many rosacea sufferers want to treat their symptoms with natural therapies. This pursuit can be tricky as many natural ingredients are not easily obtained in a useable form. In the end it is sometimes just down to using commercial preparations that contain the active ingredient – and hopefully at the same time no other potentially irritating components. Another option is to try natural ingredients using a homemade mix.

Colloidal Oatmeal

We know from a recent rosacea news article that colloidal oatmeal (Avena sativa) has interesting cleansing, moisturizing, buffering, soothing, protecting and anti-inflammatory properties.

This paper especially highlights one of the active phytochemicals found in colloidal oatmeal – avenanthramides. These have been shown to have strong anti-inflammatory effects. At a concentration of 3%, avanthramides have a similar effect to hydrocortisone 1%.

suggested products: Linda Sy Mild Oatmeal Facial Cleanser, aveeno anti-itch.

Feverfew

Feverfew (Tanacetum parthenium) has a long history as a natural medicine and has potent anti-inflammatory, antioxidant and anti-irritant properties.

One point that I didn’t pick up on when previously writing about aveeno ultra calming with feverfew is that feverfew contains parthenolides which are highly irritating. Thus if you are interested in trying feverfew topically, be sure to look for products that contain Feverfew PFE (Parthenolide-free extract) – such as Aveeno for eg..

Studies show that Feverfew PFE is able to reduce UV induced redness and is beneficial for individuals with sensitive skin; offering improvement in facial redness, blotchiness, overall irritation and the feeling of rough skin and shaving irritation.

The paper cites a 2005 AAD Poster session that states that feverfew has greater inhibitory effect compared to other botanical compounds including green, black and white tea, echinacea, licorice, chamomile and aloe vera by factors of 35 to 1000-fold.

I had missed noting the (7!) posters sessions in 2005 that dealt with Feverfew PFE, but did highlight a more recent session from the 2008 AAD meeting that targeted rosacea more directly ; see Facial tolerance of a feverfew-PFE containing daily moisturizer regimen in mild to moderate rosacea patient.

suggested products: aveeno ultra calming with feverfew

Licorice

The active ingredients in licorice are well known to rosacea sufferers, epescially since the Eucerin Redness Relief range was introduced by Beiersdorf.  The two main actives from licorice are glabridin and licochalcone A which both have anti-irritant and anti-inflammatory properties. The paper cites studies that show that a lotion containing licochalcone A showed improvements in facial redness for those with and without rosacea, shaving induced irritation and UV induced redness.

From Anti-inflammatory Herbs

The dose of licorice is 5 to 15 g daily of cut or powdered roots and should contain 200 to 600 mg of glycyrrhizin. Licorice use is contraindicated in patients with high blood pressure, cardiac diseases, or liver cirrhosis.

suggested products: eucerin redness relief.

Aloe Vera

The active ingredients of interest in Aloe Vera are salicyclic acid, magnesium lactate and gel polysaccharides. Typical properties include aloe vera’s anti-inflammatory, analgesic, antipruritic (see AAD: pruritus), wound healing and anti-oxidant effects.

In clinical trials a 0.5% aloe vera cream was found to statistically improve psoriatic plaques (a symptom of psoriasis) and in other case reports is was found to be effective in reducing burning itching, and scarring that resulted from radiation dermatitis.

suggested products: pure aloe vera gel kept in the refrigerator.

Chamomile

Chamomile is a member of the daisy family – Matricaria recutita. The paper mentions properties of the volatile oil of chamomile as being able to inhibit cyclooxygenase and lipoxeygenase as well as the flavonoids pigenin, luteolin and quercetin which inhibit histamine release.

Topical chamomile is mostly used for the treatment of atopic dermatitis and skin irritation. One study found that the anti-inflammatory effect of topical chamomile was approximately 60% as effective as 0.25% hydrocortisone.

From Anti-inflammatory Herbs

The recommended dose of Matricaria recutita flowers is 3 g three times daily; Matricaria is available as an infusion, a fluid extract, and a tincture (1:5). Allergic hypersensitivity to this herb may occur in rare cases, and the herb can irritate the eyes if applied near them

Turmeric

Circumin is the active compound in Turmeric, and is responsible for the yellow pigment. Circumin has anti-oxidant, anti-inflammatory and chemoprotective properties that means it is is suitable for topcial inflammatory conditions and wound healing. Sadly, even though circumin improves epithelialization and wound contraction, the colour and odour limits its applicability to topicals, especially those applied to the face.

From Anti-inflammatory Herbs

According to Commission E in Germany (the German authority on evaluating herbal preparations), the recommended dose is 1.5 to 3 g of cut root daily; preparations of Curcuma longa are infusion powders, tinctures (1:5), and fluid extracts. The use of curcumin is contraindicated in bile duct obstruction because it enhances the secretion of bile.

Finally, here is the abstract of the paper that inspired this article.

Anti-inflammatory ingredients, Wu J., J Drugs Dermatol. 2008 Jul;7(7 Suppl):s13-6., University of Southern California-Los Angeles, Los Angeles, CA, USA.

There is a growing public awareness and concern among individuals regarding the condition of their skin, with a concomitant desire to use natural products to treat skin conditions. The increased interest in these products has spurred scientific and clinical studies evaluating the composition and clinical usefulness of natural products in the treatment of inflammatory skin dermatoses.

There are numerous natural ingredients that have been demonstrated to possess anti-inflammatory properties that make formulations containing these ingredients attractive treatment options.

This article summarizes the active ingredients, anti-inflammatory properties, clinical effects, and therapeutic potential of colloidal oatmeal, feverfew, licorice, aloe vera, chamomile, and turmeric. Potential therapeutic indications include erythema induced by ultraviolet light, rosacea, atopic dermatitis, sensitive and irritated skin, drug-induced skin eruptions, and psoriasis. These products may be particularly well suited as alternatives to pharmacologic therapies in chronic conditions for which long-term use is required.

Over to you: what related products have you tried ? please leave us all a comment below.

Related Articles

• colloidal oatmeal: a dream ingredient for rosacea sufferers
• Treating Rosacea with Herbs
• Aveeno Ultra Calming with Feverfew
• aveeno ultra calming with feverfew well tolerated
• ocular demodex, tea tree oil as a treatment
• golden chamomile
• lavender, arnica, aloe vera, tea tree oil, and calendula ; do they work ?
• US Pharmacist: Anti-inflammatory Herbs discussed here.

So reading that aim you will understand that the AARS will promote and discuss the well established and proven mainstream treatment options for rosacea.

These guidelines have also been published as American Acne & Rosacea Society rosacea medical management guidelines, J Drugs Dermatol. 2008 Jun;7(6):531-3

The AARS have a distinguished group of professionals listed as their Officers, Directors and Chairmen. Their stated overall aim is to provide information about the quality of life of rosacea sufferers and to promote the available research-supported treatments.

An interesting quote from their Disease State Fundamentals: “There is no definitive evidence that rosacea is caused by a microbial pathogen, such as a bacterium, parasite or virus.”

The topical treatment listing contains the usual suspects: sulfacetamide/sulfur, metronidazole, azelaic acid – but also mentions benzoyl peroxide/clindamycin 1% as well as the controversial topical permethrin as a treatment for rosacea that was diagnosed as demodex folliciulitis based.

The discussed oral treatments mention the well known agents anti-inflammatory dose doxycycline, the tetracycline family, and accutane. Skin care such as a gentle cleanser and moisturizer along with a sunscreen also gets a mention.

So the guidelines are a good description of what the published research supports as rosacea treatments. Whilst many rosacea suffers may want to look outside the standard regime for rosacea treatments, this management guideline will be useful for establishing a baseline to educate sufferers and practitioners.

There are plenty of other rosacea treatment regimes that do show promise such as IPL and laser. Given that the AARS will only promote treatments that FDA approved (and based on phase 3 trials), I think it is unlikely that we will see these sorts of alternative therapies discussed by the AARS.

Related Articles

• AARS: New American Acne and Rosacea Society

Many rosacea sufferers are looking for help to reduce the redness of their face. This is one of the first rosacea symptoms that people might notice. It is also one of the symptoms of rosacea that is sadly hardest to treat. What treatments have fellow rosacea sufferers used to hide the ruddiness and angry face that sometimes accompanies rosacea ? Read on where I’ll go through what I see as your current best options.

Feel free to leave a comment at the bottom with your top tips too.

eucerin redness relief

Eucerin Redness Relief is a new range of products from Beiersdorf that contains an extract from Licorice called Licochalcone. The reviews from members of the Rosacea Support Group are generally pretty good. There is also some published evidence that it might help with reducing the appearance of a red face.

acne cover lotion

This particular product is really an acne product, but my personal experience is really positive. It contains sulphur and has a strong ability to cover lesions. I’d see this product as best suited to outbreaks of papules and pustules and possibly also for general larger areas of redness. For more information see Linda Sy’s Acne Cover Lotion. This product might not be suitable for the more sensitive skin types.

[update:] sadly Linda Sy has gone out of business and ACL is no longer available. If you find something suitable as a replacement please let everyone know in the comments below.

tinted sunscreens

It seems to me that tinted sunscreens are still underrated as a rosacea treatment. My favourite, that I continue to use every day is Linda Sy’s (now made by RosaceaCare) Tinted ZincO Cream. As well as offering protection from the sun and elements it can cover redness quite well. Even a small amount of flesh coloring in a sunscreen can really lift your self esteem. All red faced rosacea rosacea sufferers would love to feel that their face blends in with the crowd !

More reading on sunscreens here: Rosacea & Sunscreen articles.

short course steroid creams

In short stints, low dose steroids can help calm a red rosacea flareup. This should be viewed as a last resort, though.

However, I believe that when circumstance requires it, a short-term course of low potency non-fluorinated topical cortisone, on the face of non-rosacean, is not out of the question. There are times when it is important to control an acute condition as soon as possible, to prevent progression or complication and to give relief to the patient. Once this is achieved, a responsible physician will: 1) attempt to find the cause of the condition and treat it accordingly and 2) convey the message that cortisone cream should be discontinued and not be used long-term due to its many side effects such as peri-oral dermatitis, steroid addiction, steroid induced rosacea, skin atrophy etc.

As for rosacean skin, it is definitely a good idea to use all other
alternative topicals or oral medications available, rather than use
cortisone. This is, as you know, due to the highly excitable reactive skin and vasomotor instability of rosaceans.

Dr. Linda Sy, RSG Message 22628

You’ll get different answers from different doctors AND group members! My own experience with patients has been that if you use a low potency non-fluorinated topical steroid, short term to alleviate symptoms, it is ok.

Dr. Linda Sy, RSG Message 14960

Steroids should be used with care as over the counter steroids can cause steroid induced rosacea.

If you think you are suffering from steroid induced rosacea you might find this post from Dr. Linda Sy MD helpful: treating steroid induced rosacea.

IPL

IPL, or Intense Pulsed Light is perhaps the best known treatment for a red face. Recently there have been a couple of studies published that were able to prove that IPL is effective in reducing rosacea associated erythema (redness). A couple of great papers are Measuring Erythema (red face) after IPL and IPL is excellent for rosacea (and inded a 2007 followup also IPL excellent for treating red face and broken blood vessels).

I’ve collected a set of 16 items (at the time of writing this article) that are a great place to start if you are interested in IPL. See the IPL Articles category.

KTP Laser

There is some good published articles suggesting that the KTP Laser (KTP stands for Potassium Titanyl Phosphate) is also a good choice for a facial redness. This laser is not talked about much in the online rosacea groups, but the published articles look promising. Have you had experience with this laser ? Please leave a comment below.

• ktp laser good for red face and facial vessels
• treating rosacea with the KTP Laser
• KTP Laser and facial telangiectasias

eredicane

How about if your redness is related to flushing ?

Eredicane is an OTC non-FDA approved treatment containing Magnesium, Passion Flower, Valerian, Vit B6, Glycine, Glutamine, Primula Officinalis and Taurine. According to their web site, eredicane works thusly ;

Fight Blushing With the Body’s Own Building Blocks

Eredicane’s main ingredient, GABA, is one of the nine essential amino acids found in the brain. GABA inhibits neurons in the cells from firing, thus diminishing the excitatory messages reaching the frontal cortex of the brain.

In essence, GABA lowers the excitatory level of the cell that is about to receive the incoming information, therefore helping to prevent the onset of the sensation that causes blushing.

But does it work ? A long thread over at ESFB, `Has anyone tried “Eredicane??”‘ is inconclusive, showing mixed results.

cutanix drl

Unfortunately Cutanix is not currently available. Some members of rosacea-support have found DRL to help their facial redness. It is believed that the FDA has objected to the claims made by the packaging. No information is yet available on if or when DRL will return to the market. I love this product so personally I’m looking forward to it becoming available again. As some background you might like to read the Cutanix Articles on Rosacea News.

sansrosa

This option is speculative, but is worth mentioning here in this list. Galderma is in one of the final stages of developing a product that is showing promise as a treatment for the flushing redness of rosacea. The product is informally known as Sansrosa and is also called COL-118 by Galderma. The information currently available suggests that this topical can be used safely for long periods and can reduce the appearance of a red flushed face. I have covered this product extensively, so feel free to look through the sanrosa articles. There is no guarantee that Sansrosa will be approved for general use, but if and when it does get approved, it will offer a treatment option that is not currently available from any other topical.

When it isn’t Rosacea

Finally, before launching into some treatment for rosacea, it might also be worth exploring the possibility that your red face isn’t actually rosacea. One good place to explore this further is red face: when flushing isn?t rosacea.

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How have you tackled your red face ? Leave a comment a below and let everyone know your top tips.

Evaluation of the efficacy of topical caffeine in the treatment of psoriasis vulgaris. J Dermatolog Treat. 2005;16(4):234-7, Vali A, Asilian A, Khalesi E, Khoddami L, Shahtalebi M, Mohammady M.

BACKGROUND: Psoriasis is a common disease which often requires long-term maintenance therapy. In psoriatic epidermis, the level of cyclic adenosine monophosphate (cAMP) decreases. It has been reported that beta-blockers exacerbate existing psoriatic plaque and decrease the concentration of intracellular cAMP. Caffeine is a methylxanthine that inhibits phosphodiesterase enzyme and results in a higher concentration of intracellular cAMP.

OBJECTIVE: Evaluation of the efficacy of topical caffeine 10% in the treatment of psoriasis.

…

CONCLUSION: Based on the results of the trial, topical caffeine is an effective, safe and inexpensive treatment for psoriasis, with a delay in action.

Caffeic acid suppresses UVB radiation-induced expression of interleukin-10 and activation of mitogen-activated protein kinases in mouse. Carcinogenesis. 2006 Sep;27(9):1803-11. Epub 2006 Mar 8, Staniforth V, Chiu LT, Yang NS.

Ultraviolet B (UVB) radiation present in sunlight causes sustained immune suppression, photocarcinogenesis and photoaging in humans. Interleukin-10 (IL-10) plays a critical role in UVB-induced immune suppression by inhibiting cell-mediated immune reactions. Mitogen-activated protein kinases (MAPKs) have been implicated in UVB-induced skin carcinogenesis. Caffeic acid (CA), a phenolic acid present in many dietary plants has been shown to confer antioxidant, anti-inflammatory and anticancer activities. In this study, we evaluated the protective effects of CA against UVB radiation-induced IL-10 expression and phosphorylation of MAPKs in mouse skin. An in vivo transgenic IL-10 promoter-luciferase-reporter gene based assay revealed that CA inhibits the transcriptional activation of UVB-induced IL-10 promoter. This was further confirmed by significant inhibition of UVB radiation-induced IL-10 mRNA expression and protein production by CA in mouse skin. Contact hypersensitivity assay showed that CA could attenuate the local immune suppression induced by UVB radiation against a hapten, dinitrofluorobenzene. Our results indicated that CA might inhibit IL-10 production by interfering with an early step, prostaglandin E(2) synthesis, in the activation of UVB-induced immune suppressive cytokine cascade. CA also significantly inhibited the UVB-induced activation of MAPK signal transduction pathways, such as extracellular signal-regulated protein kinase, c-Jun N-terminal protein kinase and p38 mitogen-activated protein kinase, and the downstream transcription factors activator protein-1 and nuclear factor-kappa B. The findings of our study suggest that CA may confer significant protection against UVB-induced immune suppression and photocarcinogenesis in vivo and provide the possible underlying molecular basis for its actions. Therefore, CA may have therapeutic potential as a topical protective agent against the deleterious effects of UVB radiation.

Caffeine and caffeine sodium benzoate have a sunscreen effect, enhance UVB-induced apoptosis, and inhibit UVB-induced skin carcinogenesis in SKH-1 mice, Carcinogenesis. 2006 Jul 24, Lu YP, Lou YR, Xie JG, Peng QY, Zhou S, Lin Y, Shih WJ, Conney AH.

Topical application of caffeine sodium benzoate immediately after UVB irradiation of SKH-1 mice enhanced UVB-induced apoptosis by a 2- to 3- fold greater extent than occurred after the topical application of an equimolar amount of caffeine. Although topical application of caffeine sodium benzoate or caffeine enhanced UVB-induced apoptosis, both substances were inactive on non-UVB-treated normal skin. Topical application of caffeine sodium benzoate or caffeine (each has UVB absorption properties) 0.5 hr before irradiation with a high dose of UVB decreased UVB-induced thymine dimer formation and sunburn lesions (sunscreen effect). Caffeine sodium benzoate was more active than an equimolar amount of caffeine in exerting a sunscreen effect. In additional studies, caffeine sodium benzoate strongly inhibited the formation of tumors in UVB-pretreated high risk mice and in tumor-bearing mice, and the growth of UVB-induced tumors was also inhibited. Caffeine sodium benzoate and caffeine are the first examples of compounds that have both a sunscreen effect and enhance UVB-induced apoptosis. Our studies suggest that caffeine sodium benzoate and caffeine may be good agents for inhibiting the formation of sunlight-induced skin cancer. (Supported in part by NIH Grants No. CA80759 and CA88961, as well as a State of New Jersey Commission on Cancer Research Grant 05-1976-CCR-EO).

See Also:

• RSRP: Green Tea Topicals
• Topix Replenix CF (topical with green tea + caffeine)
• Green Tea Extract may benefit rosacea
• Green tea extract (polyphenone) Phase 2, shows promise
• grape seed extract + quercetin and vascular function
• reapply sunscreen to avoid skin damage
• micronized zinc oxide dimethicone a safe sunscreen

Macrolide Antibiotics offer alternative treatment options to the well known tetracycline antibiotics. In recent years good studies have shown that some of these macrolides are safe and effective in treating rosacea.

Commonly prescribed Macrolides include: erythromycin, azithromycin (Zithromax), clarithromycin (Biaxin), dirithromycin (Dynabac), roxithromycin (Rulid, Surlid)

Here is a brief introduction from Linda Sy’s `Skin411 Digest January 2005‘, Summaries and commentaries from recent dermatologic journals: Rosacea Therapy. Medical editor: Margaret S. Choa M.D.

ORAL MEDICATIONS

2. Macrolides – Oral erythromycin is given to rosacea patients when there are contraindications such as allergy, intolerance or resistance to tetracyclines and in pregnancy, lactation and patients younger than 12 years of age. Erythromycin is in pregnancy category B.

The second-generation macrolides, clarithromycin and azithromycin, have been found in recent studies to be effective in reducing erythema and rosacea papules/pustules. Benefits of second-generation macrolides are improved bioavailability and lack of gastrointestinal side effects in comparison with erythromycin.

The following paper gives some background to the use of macrolides and disease such as acne, rosacea and blepharitis.

Use of macrolides and tetracyclines for chronic inflammatory diseases. Ann Pharmacother. 2005 Jan;39(1):86-94. Epub 2004 Nov 23

OBJECTIVE: To review the efficacy of macrolides and tetracyclines in several chronic inflammatory conditions.

DATA SOURCES: Searches of MEDLINE (1966-March 2004) and an extensive bibliography search were undertaken. Key terms included acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis.

STUDY SELECTION AND DATA EXTRACTION: Data were obtained primarily from randomized placebo-controlled trials upon which key recommendations are based.

DATA SYNTHESIS: Antibiotics are often prescribed for months or even years for treatment of chronic inflammatory conditions such as acne, blepharitis, cardiovascular disease, cystic fibrosis, periodontitis, rosacea, and rheumatoid arthritis. Randomized controlled trials have shown that azithromycin is useful in the management of cystic fibrosis and the tetracyclines are beneficial in the management of rheumatoid arthritis, acne, blepharitis, and periodontitis. Several large, randomized controlled trials have failed to show any benefit of macrolides in the secondary prevention of cardiovascular disease. No randomized placebo-controlled clinical trials have been performed to assess the efficacy of macrolides or tetracyclines in patients with rosacea.

CONCLUSIONS: The use of tetracyclines and macrolides for rosacea is based primarily on anecdotal reports or open-label trials. Limited clinical trials support the use of tetracyclines or macrolides in acne, blepharitis, periodontitis, rheumatoid arthritis, and cystic fibrosis. Trials to date do not support the use of antibiotics for secondary prevention of cardiovascular disease.

A follow-on the the above article is a question and answer article that gives some useful high level comments ; For Our Patients (PDF).

Macrolides and Tetracyclines for Chronic Inflammatory Diseases

What diseases are macrolides and tetracyclines used for?

Macrolides (for example, erythromycin, clindamycin) and tetracyclines are antibiotics used to treat infections. They are also increasing being studied or used for chronic conditions such as acne, rosacea (a skin disorder that causes flushing of the face, neck and upper chest), blepharitis (inflammation of the eyelids), periodontitis (inflammation of the gums), rheumatoid arthritis, coronary artery disease, and cystic fibrosis. These drugs have anti-inflammatory properties, as well as the ability to inhibit or kill pathogens that may cause these diseases.

Why is there a concern about these drugs in the treatment of chronic inflammatory diseases?

Doxycycline and the newer macrolides are now recommended for the treatment of some types of pneumonia. Overuse of these antibiotics may decrease their effectiveness against respiratory pathogens that cause short-term illnesses, such as pneumonia.

Which antibiotics should be chosen for chronic inflammatory diseases?

Antibiotics are often prescribed for months or even years for acne. Researchers recommend low-dose doxycycline for extended time periods. Current recommendations for rosacea include long-term doxycycline, minocycline, tetracycline, or erythromycin. However, no major clinical trials have been performed to assess their effectiveness.

The American Academy of Ophthalmology recommends the chronic use of either doxycycline or tetracycline for the management of blepharitis.

Periodontitis can be treated for long periods with low doses of doxycycline. Larger clinical trials are needed to confirm the role of macrolides in periodontitis.

Azithromycin, a macrolide, has been used in patients with cystic fibrosis because of its antibacterial and antiinflammatory properties. Patients receiving this drug maintain better lung function, require fewer courses of intravenous antibiotics, and have improved quality of life. However, there are no data demonstrating a stronger survival benefit in patients who have taken macrolides.

Results from published clinical trials do not support the use of macrolides or other antibiotics for the prevention of a repeat heart attack or stroke. Of note, two trials are continuing to study the role of macrolides in the prevention of cardiovascular disease. For patients suffering from rheumatoid arthritis, it appears that minocycline has some effect on the progression of the disease. However, measures of improvement were often difficult to measure with certainty. Further studies are needed to better define the role of minocycline in the treatment of this disease.

How serious is the resistance to antibiotics becoming?

Resistance to one or more antibiotics increased from 35% in 1991 to 56% in 2000. Resistance to erythromycin, clindamycin, and tetracycline approximately doubled over this period. Resistance to the macrolides is increasing and may have reached rates up to 43%.

What approaches should be followed to preserve the effectiveness of antibiotics against acute infectious diseases?

Alternative antiinflammatory medications should be used for chronic inflammatory conditions whenever possible. For instance, high-dose ibuprofen and oral corticosteroids may be beneficial for patients with cystic fibrosis. Clinical trials comparing the effectiveness of antiinflammatory agents with antibiotics should be performed.

Following are links to more studies relating to the use of systemic and topical antibiotics to treat rosacea.

Related Articles:

• is macrolide antibiotic resistance a problem ?
• macrolides and inflammatory pathways
• treating rosacea with clarithromycin (biaxin)
• biaxin (clarithromycin) vs. vibramycin (doxycycline)
• pulse dosing with azithromycin
• azithromycin and rosacea
• treating rosacea with azithromycin
• topical azithromycin same as clarithromycin
• Low dose doxycycline hyclate (SDD)
• Oracea approved by FDA for oral rosacea treatment
• Subantimicrobial Dose Doxycycline for Acne and Rosacea
• Periostat (doxycycline) goes generic, get ready for Oracea
• preventing antibiotic resistance
• Tetracyclines: their non-antibiotic properties
• RSRP: Antibiotics / Anti-Inflammatories

This paper explores the different problems that may be causing flushing. The list of possible reasons other than rosacea is extensive. It is worth consider what other conditions may be causing your red face before embarking on any treatment regime. Treatments that are good for some of the conditions listed here may make your rosacea worse, so read as widely as you can.

The author was kind enough provide a full copy of this paper, so contact me if you’d like to read it.

If you would like some ideas about about how to treat a red face, see another popular article I wrote titled how to treat a red face

The flushing patient: Differential diagnosis, workup, and treatment, Journal of the American Academy of Dermatology, Volume 55, Issue 2 , August 2006, Pages 193-208. Leonid Izikson MD, Joseph C. English III MD and Matthew J. Zirwas MD, Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.

Abstract: Cutaneous flushing—a common presenting complaint to dermatologists, allergists, internists, and family practitioners—results from changes in cutaneous blood flow triggered by multiple conditions. Most cases are caused by very common, benign diseases, such as rosacea or climacterum, that are readily apparent after a thorough taking of history and physical examination. However, in some cases, accurate diagnosis requires further laboratory, radiologic, or histopathologic studies to differentiate several important clinicopathologic entities. In particular, the serious diagnoses of carcinoid syndrome, pheochromocytoma, mastocytosis, and anaphylaxis need to be excluded by laboratory studies. If this work-up is unrevealing, rare causes, such as medullary carcinoma of the thyroid, pancreatic cell tumor, renal carcinoma, and others, should be considered.

Learning objective: At the completion of this learning activity, participants should be familiar with the mechanisms of flushing, its clinical differential diagnosis, the approach to establish a definitive diagnosis, and management of various conditions that produce flushing.

Abbreviations: CS, carcinoid syndrome; 5-HIAA, 5-hydroxyindoleoacetic acid; 5-HT, 5-hydroxytryptamine; MCT, medullary carcinoma of the thyroid; NSAID, nonsteroidal anti-inflammatory drug; TMEP, telangiectasia macularis eruptiva perstans; VIP, vasoactive intestinal polypeptide

…
When evaluating patients with rosacea, it is important to exclude the diagnoses of polycythemia vera, photosensitive eruption, lupus erythematosus, mixed connective tissue disease, carcinoid syndrome, systemic mastocytosis, or side effects from long-termfacial application of topical steroids. Since rosacea is typically limited to the face, extra facial erythema is generally an exclusionary sign. Rosacea flushing is associated with burning or stinging but not sweating, lightheadedness, or palpitations. Erythematotelangiectatic rosacea, while considered by many to represent a separate entity, may in fact be difficult to distinguish from simple benign cutaneous flushing and sun-damaged skin. In attempting this distinction, it may be useful to assess the extent of baseline facial telangiectasia and the overall degree of poikiloderma. However, since these 3 conditions are all common, they may coexist in many patients. Also, since erythematotelangiectatic rosacea and benign cutaneous flushing may have common triggers for flushing, it may be reasonable to consider these 2 entities as different points on a single continuum, making distinction of academic value only.
…
Table II
Differential diagnosis of flushing

Common Causes

Benign cutaneous flushing

Emotion
Temperature
Food or beverage

Rosacea
Climacteric flushing
Fever
Alcohol

Uncommon, serious causes

Carcinoid
Pheochromocytoma
Mastocytosis
Anaphylaxis

Other causes

Medullary thyroid carcinoma
Pancreatic cell tumor (VIP tumor)
Renal cell carcinoma
Fish ingestion
Histamine
Ciguatera

Psychiatric or anxiety disorders
Idiopathic flushing
Neurologic

Parkinson’s
Migraine
Multiple sclerosis
Trigeminal nerve damage
Horner syndrome
Frey syndrome
Autonomic epilepsy
Autonomic hyperreflexia
Orthostatic hypotension
Streeten syndrome

Medications

Very rare causes

Sarcoid, mitral stenosis, dumping syndrome, male androgen deficiency, arsenic intoxication,
POEMS syndrome, basophilic granulocytic leukemia, bronchogenic carcinoma, malignant histiocytoma, malignant neuroblastoma, malignant, ganglioneuroma, peri-aortic surgery,
Leigh syndrome, Rovsing syndrome

Summary: The differential diagnosis of cutaneous flushing is extensive and encompasses a variety of benign and malignant entities. Most flushing reactions result from benign causes. However, since flushing may be the presenting sign or symptom of several life-threatening conditions, it should prompt a thorough investigation to exclude such possibilities as anaphylaxis, systemic mastocytosis, carcinoid syndrome and other malignant tumors, pheochromocytoma, and autonomic epilepsy after more common benign causes have been ruled out and if there is no response to treatment. In the absence of an identifiable benign organic cause of flushing, psychiatric illness must be suspected and the patient should undergo appropriate evaluation. History and physical examination are critical in the evaluation of the cause of flushing and should be supplemented with laboratory and other investigations based on the clinical suspicion of an underlying cause. The most common causes of flushing – fever, emotional flushing, climacterium, and rosacea are obvious to most physicians and thus are likely to be promptly recognized and treated appropriately. Dermatologists have a unique role in the management of patients with flushing, as referred patients may be unresponsive to conventional therapy and are more likely to have a serious or life-threatening underlying cause. Accordingly, proper workup, recognition, and management of conditions that cause cutaneous flushing may have a significant impact on the patients’ morbidity and mortality.

• Abstract Online
• PubMed Extract

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