Healthcare

JK: Jackie Kabler
Dr S: Dr. Ed Seaton
AB: Alison Bowser
JK: Hello and welcome to the Healthcare Show. I’m Jackie Kabler Now then a poor complexion and spotty skin is something that many hope to leave behind in their teenage years but unfortunately not everybody grows out of skin problems. In fact adults are more likely than young people to develop rosacea, a skin condition which causes flushing, redness and sometimes pimples in the central part of the face. Well joining me today to talk about this is dermatologist Ed Seaton and rosacea expert Alison Bowser. Good evening to you both. Thank you very much for joining us. Now Dr Seaton, you are a consultant dermatologist at The Royal Free Hospital. You see people with all sorts of skin conditions. First of all explain to us exactly what rosacea is.

Dr S: Rosacea is a surprisingly common skin condition. It probably affects about 1 in 15/20 people in this country and a lot of it is under recognised. As you said in your introduction, the two things it really does is it causes redness of the face, particularly the cheeks. It tends to spare the areas around the mouth and the eyes. It’s redness, but it also causes in some patients, spots, pimples, a little bit like acne spots which can be painful and quite uncomfortable. It’s a condition that tends to be seen more commonly in people with fair skin, people of Celtic origins or some north west European origins, but sometimes we do see it in Asian and black patients as well. It’s something that tends to come on in adult life, most typically after the age of 40 but some people develop rosacea in their 20s or even earlier.

JK: OK and what are the triggers? Is it to do with diet? Is it to do with the environment? What actually causes it to flare up?

Dr S: We don’t exactly know the cause of rosacea, people are looking at that and there are a number of theories as to why people develop it in the first place. If you look at the blood vessels in patients with rosacea, the blood vessels react slightly abnormally so that the blood supply to the face is increased and increases even more in response to things like hot weather, cold weather and so on. Some people think that sunlight is a factor, which probably explains why people with fair skin are more likely to develop rosacea and the effect of sunlight can sometimes damage the blood vessels in the skin and can start rosacea off. But when you have established rosacea, it’s actually that there are various triggers that can make flushing and blushing a lot worse. Things like weather: sunlight, if you go out on a windy or cold day; sometimes if you walk into a hot room from outside; sometimes food, particularly spicy foods; sometimes hot drinks, alcohol can make it worse or exercise, going to the gym, can cause a painful flushing attack.

JK: Gosh, and we think of it as just rosacea but there are different types aren’t there? There are different degrees of rosacea.

Dr S: Yes, that’s right. As dermatologists we now recognise four types and patients, people can move from one type to another, but there are four distinct types: the first one you can describe simply as flushing rosacea – we call it technically erythematotelangiectatic rosacea, which is a long word – flushing is probably easier. Flushing rosacea – those patients, they don’t tend to have spots but what they do get is easy flushing, blushing, persistent redness of the cheeks and discomfort and they also get little blood vessels that start to appear on the skin. So that’s one type of flushing rosacea.

Then you’ve got the sort of pimple rosacea, we call it papulopustular rosacea. So these patients, people not only have flushing and redness, but they also get spots, a bit like acne spots – firm red spots and also pustules which can be really disfiguring.
Then there is rosacea of the eyes which is called ocular rosacea and this is surprisingly common and probably under recognised even by doctors. About 50% of people with established rosacea will have some rosacea affecting the eyes and this can cause a number of symptoms. It can cause grittiness and discomfort, some of it causes redness on the white of eyes and can become more serious if it’s not treated. Then finally, there is something called ‘phymatous’ or ‘phymitous’ rosacea which means swelling really, and this is a rarer complication of rosacea which is much, much more common in men – about one in ten of the sufferers of this are men and they tend to get persistent craggy swellings of parts of their face, particularly the nose which is called rhinophyma which tends to develop later on in life and can be difficult to treat.

JK: It must be very distressing psychologically for people to have this. Alison, I know that you run the Acne Support Group for the past 15 years and you are used to helping people who have got these sorts of conditions. What advice do you give to people in dealing with it?

AB: Well the good news is that there is lots you can do and lots of people who came to me at the Acne Support Group used to say, “I don’t know what else to do, I’ve tried it all” and often people haven’t tried it all. So there are a couple of things that I’d like to remind people about today. There’s a lot that a doctor can offer you. You don’t necessarily have to go and see a dermatologist, you can go and see your own GP and the website is a fantastic source of information so myrosacea.co.uk is a great source of further support for people.

JK: It can be managed through treatment can’t it? It’s not a curable condition as such but it can be very well controlled. So talk us through some of the treatments.

Dr S: I think the key thing with rosacea number one is to get the diagnosis right and if you think you might have rosacea, it’s certainly worth seeing your doctor, seeing your GP in the first instance and if there’s any need for it, then to be referred on to a skin specialist, a dermatologist. You are right that we can’t cure rosacea but we can usually get it much, much better and make people much more comfortable and this is important because rosacea has a huge impact on self-esteem. About 70% of people with rosacea have symptoms of depression, people may avoid work because of their rosacea when they have flares. It can have a huge impact on the quality of life and treatment actually can make people feel psychologically much better and the studies are out there showing that. So medical treatments are important and by medical treatments, I mean topically applied creams, ointments and gels and also tablet treatments. They are particularly useful for the pimple type rosacea I was talking about earlier, the papular pastular rosacea where you get inflammatory spots a bit like acne spots.

So in general, we will often start with a cream or a gel or an ointment application and there are two major types of treatment out there, one is called Azelaic acid one is called Metronidazole Now Azelaic Acid is a medicine that is being used on the skin, it was first used 100 years ago but has been relatively recently rediscovered and it was found initially to be effective for acne but it is also very effective for rosacea as well. It is used once or twice daily on the skin and dramatically reduce the number of spots that you get on the skin. It is actually a naturally occurring product found in wheat and rye and barley, that has been developed for use on the skin, and particularly there is a new formulation of this which is a 15% formulation in New Hydrogel which is actually very effective.

Metronidazole is another treatment, which has been used a little bit longer in the treatment of rosacea from the mid 80s onwards and this is a synthetic antibiotic which is effective, can also reduce the number of spots as well and also is very effective in some patients. So topical treatments are useful. Unfortunately with rosacea a lot of people have trouble in applying – finding topical treatments that don’t cause stinging and burning. So often it’s a question as a doctor of working through different treatments.

JK: Let me just remind anyone watching at home, this is a live show so if you do have any more questions you would like me to put to either of the guests please do email in on the website and then we’ll get to some of your questions shortly.

Just going back to treatment briefly, obviously you should go to the doctor. Can you get over the counter things? If somebody says, “I just feel so embarrassed, I don’t want to go to the doctor”, because it is Alison, isn’t it, it is psychologically quite distressing. Especially maybe younger people who just don’t like going to the doctor.

AB: Absolutely, I mean I think we’ve got to get this into perspective because some people are very, very upset about their skin, have gone to their doctor and perhaps those creams or gels don’t seem to have worked very well, and I would normally suggest that they go back and look at how they are using those gels and creams. Sometimes they are putting too much on. Sometimes it’s not enough. They also do need to use good moisturiser and some protection so that they are actually helping the skin at the same time and I know that is something you [Dr S] would normally agree with as well, to keep the skin moisturised. Normally rosacea skin types are sensitive and they are dry. So that’s what we always suggest.

JK: And for women I suppose we’ve got the great advantage that make up can help.

AB: Ah, well, it can help but it can also make it worse. And in fact this is a very sticky point for some people because they say, “the make-up I’ve been using for 15 years, I suddenly can’t use it any more”. Or they might have been advised to not wear make up at all and if you can imagine that makes it probably feel a little bit more obvious than it was before. So in fact what I would normally suggest is going down the route of skin camouflage. Now through the National Health you can actually get skin camouflage prescribed for you from the British Red Cross.

JK: So you just go to your GP and ask for that do you?

AB: It will come through the dermatologist.

Dr S: It generally comes through the dermatology departments. A lot of dermatology departments around the country have Red Cross camouflage clinics which is a charitable organisation obviously, and they provide this fantastic service. It’s not just women who find this useful, it’s men as well.

JK: If you don’t mind me interrupting we’ve had a question on that very subject from Kay who has emailed in and she says, “I have rosacea and I’m feeling very self conscious about red marks around my nose. What can I do to make these less visible”. So obviously that’s what you are talking about, the camouflage stuff.

Dr S: Absolutely. She may find that normal foundations would be helpful but the Red Cross will actually blend it exactly to her skin type so that it looks fantastic.

AB: And it’s so good it can stay on for up to three days. I mean this goes beyond make-up. This has a very heavy pigment in it and you can apply it to the area. You can put a setting powder on the top and it doesn’t look like make-up. That’s the whole idea. So we are trying to get away from the concept of it being makeup. We want more men to know they can use it because you can cover the redness, you can almost make people feel completely normal again.

JK: That’s fantastic. So as well as covering it up and everything and managing it with treatment, what about lifestyle changes? How does that impact? If somebody gets less stressed, maybe, will that help? How does that work?

AB: Well, I think this is the time to mention this diary that we’ve been working on.

JK: And you can download this from myrosacea.co.uk.

AB: Yes and it’s brilliant. Do that because it’s an opportunity for you to look at how this works. It does need a little bit of reading to understand how best to use it and the bottom line is we are going each day at a time. The idea is you are keeping a log of things that are happening in your life that you may not realise are actually connected to your rosacea. So it may not just be the weather; it may not just be the medication that you are on. It could be the skin care products. People say for example that they’ve taken up things like golf, or gardening and find that their skin flares up, or skiing….

JK: Which normally you would think would make you healthier and fitter but obviously not with rosacea..

AB: No it’s often the enemy for people with rosacea.

Dr S: It’s also foodstuffs as well: spicy foods, hot drinks. It’s not the caffeine in the hot drinks that causes flushing, it’s actually the heat of the drink.

AB: Yes, somebody I spoke to once said that they never ate a hot meal ever. They let their meal go cold. So some people do go to the most extraordinary lengths.

Dr S: The issue about alcohol and rosacea is important to address as well because the general public often assumes people with rosacea drink too much, particularly people with rhinophyma – swelling of the nose, that’s seen to be caused by drinking – is not. I have a 19th century textbook of dermatology in my office and it said even in that text book, it’s often assumed that rosacea is caused by drinking and it’s not. People still assume it is. What alcohol can do if you have established rosacea is cause flushing, it exacerbates rosacea in some people, but it’s not actually the cause.

JK: Right. Do certain types of alcohol have more impact than others? Wine or spirits or beer?

Dr S: It varies, and again this is exactly why a diary is a fantastic idea because some people will find it’s red wine, while other people will find it’s other drinks.

AB: They may not realise what it could be. But going back to the original point about being in control of your skin, sometimes people really cut back on their lifestyle, cut back on everything, because they think it’s going to make their life better, but in fact they are miserable because at Christmas they don’t have a drink, or they don’t go out, so use it in moderation – OK, so you may have red wine and you find it makes your skin bad for the next couple of days, but people have got to weigh that up. So I wouldn’t be too strict with yourself on it.
JK: OK, we have another question here. Alice wants to know – she says “I find a lot of department store skin care products burn or sting my skin. What care of skin care regime do you recommend?” This is a problem isn’t it, because it must be quite difficult to find things gentle enough that won’t exacerbate it.

Dr S: Definitely. I think in general, I don’t know if you agree Alison, it’s probably best to wash with luke warm water, try and avoid soaps and things if you can, especially if your are using cleanser or anything with alcohol based cleansers. It’s often best to use your fingers rather than a flannel when you are washing your face, blot the face dry rather than rubbing it dry with a towel and then wait about 30 minutes before putting on any topical treatments.

JK: You must be very gentle.

AB: Yes, and once you’ve got the topical treatment on, then you can put your moisturiser over the top and allow that about 15 minutes to absorb into the skin. Put your moisturiser over the top but something which of course hasn’t been around a dermatologist for a long time, and I appreciate the need, especially for rosacea skin types to protect them from the sun as well. So I would normally say minimum SPF15 and you can normally find skin care products that have got that in, but you don’t have to spend a lot on products. ‘More’ does not equal ‘better’.

JK: Indeed.

Dr S: The only problem with the SPF 15 cosmetics, to actually get that level of sun protection you have to apply it like wallpaper paste, so if you want to use a sun cream, it’s probably best to use an actual sun cream with an SPF of 30. Again, the problem with rosacea is that a lot of people have trouble finding a sun cream that doesn’t cause stinging and burning. It’s trial and error.

AB: Once again I think the website should be addressing those sort of issues and I would suggest you go back to the website and have a look at that for information on it.

JK: Ok. Sure. Another question from Sarah, this is one of those annoying things. Your car is making a noise, you go to the garage and it stops doesn’t it? She is saying, “Sometimes I have bad symptoms but it clears up by the time I get to the doctor”. What could she do? I suppose the diary would help with that.

AB: The diary is good and I would certainly say that photographic evidence is an ideal way. Take a photograph of your skin on a typical bad day and take that with you and then with the diary which you have downloaded from the website, and you have filled in, take them along to the doctor and I challenge any doctor to say that you are not to be taken seriously.

Dr S: I think this is an area where it’s important that seeing a dermatologist is useful, if you have a condition that’s difficult to diagnose. There are certain things that can mimic rosacea and a dermatologist by talking to a patient and hearing the history will be able to make a diagnosis, usually.

AB: Because sometimes even GPs find it difficult to accurately diagnose it.

Dr S: It’s amazing how often my patients say, “Oh my skin problem has cleared up because I’ve got this appointment with you”. It happens all the time and you sort of get used to it. If you take a proper history, and usually you can see something on the skin, you can make a diagnosis.

JK: We talked about psychologically it being very difficult, how do you help people to cope with it, because if you know this is something that really isn’t curable as such, that’s quite traumatic for people isn’t it?

AB: What I normally suggest is going back to the point I made about being in control of your skin, and there is a little bit about how you feel can also affect how your skin looks and we know that the two go together very closely. So being able to cover up the skin and treat the skin at the same time will probably help most people feel that they are back in the driving seat. I think it’s a feeling of the loss of control. “I’m out of control of my skin. I don’t know what to do about it and I think that perpetuates a very negative feeling and I think it’s about self-esteem issues as well. What would you suggest? (to Dr S)

Dr S: Absolutely. I think it’s important to give a patient control by giving them a diagnosis and explaining the condition to them so they know what they are dealing with but again, treatment is essential and we know it reduces psychological problems with rosacea. It reduces symptoms of depression. We talked about topical treatments but oral treatments are available as well, oral antibiotics which we tend to use for a few months at a time for patients who don’t respond to topical treatments, they can be used with topical treatments. You’ve got physical treatments, laser treatments and light based treatments are useful for people that have the flushing type of rosacea sometimes, although these aren’t widely available. But treatment does improve the way people feel about their skin.

AB: If you are getting married or something, you can pretty much make sure that maybe a lady wouldn’t have it on her wedding day, just a short period of control where possible. [all talking]

Dr S: Yes if you get appropriate treatment, you can get patients, people, 80% better.

JK: Another question, Gordon wants to know we’ve got a gentleman now, “What would you recommend to alleviate my rosacea in extreme hot and cold climates? My wife and I are keen skiers and also enjoy our summer holidays abroad”.. obviously we all like that don’t we, “in recent years my tolerance to these environments has become drastically impaired. Something from the chemist without prescription would be preferred.” That’s what we were talking about, generally men are the biggest culprits about not wanting to go to the doctor aren’t they? So what would you recommend for Gordon?

Dr S: It’s difficult to be honest. The easiest part of rosacea to treat are the spots and we are good at treating those and the flushing is harder to treat. We can treat the redness with light and laser based treatments, intense ?? light. The flushing is difficult to control and there is not much over the counter that will help. You may be able to use things like keeping a moisturising cream in the fridge and when you get flushing put that on, that can sometimes soothe symptoms, but it’s difficult to find things over the counter which really help with the control of flushing. People have looked at tablet treatments, dermatologists can use sometimes unlicensed in rosacea which can be effective; things like beta blockers sometimes people have tried, but these are best used by experts and the track record is not great.

JK: .. and his holiday, he was saying about his skiing and his summer holidays, I expect it’s that high factor sun cream we were talking about is a big help isn’t it?

AB: Absolutely the high factor sun cream, because you need to protect the face as much as possible. In the summer for example, I always say to people “Wear a wide brimmed hat”. Seek the shade, because most people will anyway because they feel uncomfortable and if needs be, carry a little hand held fan in your pocket. It’s about alleviating and those little steps can help to make you feel in control so like Ed was saying, you keep some things in the fridge, so when you put them on they feel cool and they are cooling. So it’s about managing, if you’re hot you need to cool down. If you are really cold…….. I would suggest for example, coming in from the cold wind in winter, if you’ve got a house that’s normally centrally heated, if you’ve got one room that you can keep the heating off, just to allow your body to acclimatise. It might not make a massive difference, but it can help to stop that sudden flush that you get as you go into a room.

JK: That’s a very good idea. One final question now, because we’re getting close to the end. Helen wants to know, she has emailed in, “What is the difference between flushing caused by the menopause and flushing caused by rosacea?” Well, that’s a good question because of course women do get these hot flushes don’t they which may look similar.

Dr S: Well the first thing to say is that age is important and if you are around the time of the menopause that’s clear I suppose, but with rosacea you often get persistent redness whereas with a menopausal flush you often get a symptom of discomfort affecting more than just the face. Whereas rosacea you tend to get redness which tends to be just the cheeks usually, so that’s one of the major differences. There is an easy way to pick up whether a person is going through the menopause, which is just a simple blood test which your GP can do to pick that up.

JK: It’s the sort of flushing isn’t it, you get different areas of the face as well.

Dr S: Yes and typically with rosacea it will be the convex areas of the face, so the cheeks, around the eyes and around the mouth whereas menopausal flushing can be extremely…. much more extensive.

JK: Just to sum up, let’s talk about the website again because that’s where people can get lots of information about everything we have talked about today. So it’s myrosacea.co.uk. Can you give us a quick summary of what you can see on there?

AB: You will find out more about the treatments and causes. You’ll find out more about lifestyle tips, once again the sort of things that we have talking about, the fabulous Skin Diary that you can download. I have to say I think it’s a definitive guide, the first really of its kind in the UK, so use it. I think it’s a great tool.

JK: Fantastic. OK. Well, I think that’s all we have time for today. Thank you very much. You’ve been extremely informative and if you’ve been watching at home I’m sure you’ve got lots of information there and hopefully it will take you a little bit closer to managing rosacea if that is what you are concerned about. Thank you so much for joining us. For more information of course you can visit that website. That’s myrosacea.co.uk. Myrosacea.co.uk but from all of us here for now, goodbye.