Recently we put some questions on the psychology of rosacea to Professor Peter Drummond, Ph.D., from the School of Psychology at Murdoch University in Perth, Western Australia, and his colleague Daphne Su, D.Psych, Clinical Psychologist (Registrar) with the Department of Health in Western Australia.

Professor Drummond’s research into the clinical psychophysiology of health-related conditions (pain, emotions, headaches including migraines, cardiovascular disorders) includes the neural control of facial blood flow, and the role of the sympathetic nervous system (SNS) in pain and inflammation. (See also Rosacea and the Sympathetic Nervous System: Dr. Peter D. Drummond, PhD )

Dr Su’s doctoral thesis entitled "Psychological stress and vascular disturbances in rosacea" can be accessed electronically from the Murdoch University library catalogue using the above link.

The Rosacea Support team would like to express our warmest thanks to Professor Drummond and Dr Su for generously sharing their time and knowledge with us.

Some of the questions we asked;

• Do you have any advice on how to cope with flushing caused by crippling shyness and social anxiety?
• Rosacea can have a major impact on self-esteem. Have you any advice for single people who fear dating in case they are rejected because of their rosacea
• Some rosaceans also suffer from depression and suicidal thoughts. At what stage should professional help be sought?

To see the full list of questions and answers please visit; Rosacea and Psychology: Peter D. Drummond, PhD, & Daphne Su, DPsych

Also feel free to check out our other Experts Questions and Answers;

• Ocular Rosacea: Dr. Eric Jones, MD
• Ocular Rosacea: Dr. Mark J. Mannis, MD
• Rosacea and the Sympathetic Nervous System: Dr. Peter D. Drummond, PhD
• Combining Light-Based Treatments and Topicals for Rosacea: Dr. David J. Goldberg, MD
• Laser & IPL: Dr. Peter Crouch, MB.BS, Dr Steve Johnson, MD, Dr. Nicholas Soldo, MD

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Quite a few news sites today are covering the filing of charges of and arraignment of rosacea identity “Dr. Syed”.

Known to rosacea sufferers as Tanweer A. Syed MD. PhD, 66 year old Timothy Syed Andersson is facing 51 felony charges including practicing medicine without a license, grand theft by deception and perjury.

Andersson has been found to have no formal training or license in the United States or abroad.

His web site has impressive sounding terminology such as “professional expertise in the field of extracting and synthesizing natural bioactive” and “incorporating biologically active natural ingredients into skin cream emulsions”, as well as “patent pending proprietary formulation” and also “powerful antioxidant is truly bio-available”.

Rosacea News has covered Dr. Syed and his products in the past. He was well known to rosacea sufferers for his very expensive Green Tea based cream. His cream was in fact found to contain hydrocortisone. The District Attorney Kamala Harris was quoted as saying the green tea cream was “a bunch of BS”. Users of his cream were found to be located all over the United States as well as several overseas countries.

Andersson has cleverly promoted his cream as appealing to rosacea sufferers. In 2007 he was listed as a member of the RRDi Medical Advisory Committee. His $125 Hypo-Allergenic Facial Cream (supposedly green tea  based) was not well received by rosacea sufferers as you can see in a few forum postings.

Be Careful out There

The charging of Andersson on serious charges is a great opportunity for rosacea sufferers to step back and think about what they read and accept and who they trust. Especially online, we all need to watch out for people who call themselves a doctor and have a web site full of gobbledegook.

Don’t trust someone who is not a licensed M.D. to offer you a consultation. Don’t buy products that promise results that appear suspicious.

Andersson has claimed to investigators that he does not practice medicine and just sells his facial cream from his home.

The District Attorney urges everyone to check the official registration of medical doctors and to not visit Andersson/Syed’s web site.

A recent segment on ABC-TV’s Good Morning America Health featured rosacea.

One slant put on this television story was promoted by a followup press release that highlights the use of Aesthera’s Isolaz technology.  In the past Aesthera’s combination of `pneumatic energy’ and broad band light has been used to treat the pustules and inflammation of acne.

Aesthera is now wanting to promote a `new tip’ on the Isolaz device which will allow it to target rosacea symptoms.

So the Isolaz treatment is IPL but with a suction head that reduces the pain usually associated with IPL treatments.

The Isolaz treatment hasn’t generated much discussion online. This is surprising considering such a high profile promotion on the ABC TV segment and that the treatment has been available since 2007. Dr. Day, a dermatologist from New York tells us that she herself has treated several hundred patients for acne and is now using the new treatment tip for rosacea.

User Reviews

If you are treated for rosacea with the Isolaz please do let us know how you got on in the comments below. How was the level of pain ? Did you see improvements ?

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On the table you can see Oracea, Metrogel and Cetaphil products, all from Galderma. One shot shows the new Cetaphil UVA/UVB Defence SPF 50 as well as Daily Advance Ultra Hydrating Lotion and the well known Cetaphil Gentle Skin Cleanser.

Apparently rosacea is called `the great disguiser’, not a term I have ever heard before, but obviously refers to the long list of possible differential diagnosis for rosacea symptoms.

The NRS supplied the familiar looking rosacea symptoms photos. This amount of detail given in the story is fantastic for the medium of broadcast television. Dr. Day touched on the confusion with adult acne and the reason we get rosacea as well as possible triggers.

Oracea gets a good plug for its low dose properties. Galderma will be very pleased indeed.

Finacea and Noritate also get a mention.

Other over the counter products on the table included

• Ageless Intensives Smooth Repair Control Deep Wrinkle Anti-Wrinkle Serum from Neutrogena (what a mouthful)
• Dopti Calm Anti-Fatigue and Diopti Anti-Wrinkle from Lierac
• Lipikar Baume Anti-Irritant Lipid Replenishing Body Balm from La Roche-Posay

Galderma’s `consumer promotional’ web site bestfaceforward.com as well the NRS’s rosacea.org get a mention at the end of the piece.

It was a well thought out and informative article. This is excellent for rosacea sufferers – such high quality information in the broadcast media.

Watch the full video here ;

http://abcnews.go.com/video/playerIndex?id=9626641

Featured Product

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When rosacea sufferers are first diagnosed it can be confusing to know how to include prescription topicals into their daily skincare regime. Rosacea patients want to know both that their expensive prescription medication has the best chance of working and that their current skin care system can still work.

In the most recent `Ask a Doctor’ column at the NRS web site Dr. Draelos confirms that rosacea topicals should be applied before any moisturizer or sunscreen or makeup.

Am I able to put a moisturizer over the topical therapy before I apply my makeup?

Yes, moisturizer may be used after applying topical medication without affecting the therapeutic outcome of your prescription. In fact, moisturizer may often be of help in preventing the burning, stinging, itching and irritation associated with rosacea.

I usually advise my patients to wait five to 10 minutes after applying a topical medication before applying a moisturizer, and then wait another five to 10 minutes before applying makeup. This will give your skin a chance to better absorb the medication and keep it from coming off on your fingers as you apply the moisturizer. Waiting before applying makeup may in turn improve cosmetic results.

This confirms the view held by Dr. Powell in his landmark book Rosacea: Diagnosis and Management. In Chapter 8 Dr. Powell tells us in italics that Drugs have priority-they go on first !

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Apremilast (CC-10004) has been trialled for use in psoriasis and psoriatic arthritis. It would seem that Celgene are now interested in seeing if Apremilast is useful for treating another inflammatory skin condition such as rosacea.

Open Label Pilot Study of Apremilast in Treatment of Rosacea

An Open Label, Pilot Study to Determine the Efficacy of Apremilast in the Treatment of Rosacea in Patients With Both Erythematotelangiectatic Rosacea and Papulopustular Rosacea

This is a single-center, open label trial of Apremilast in ten (10) subjects with moderate to severe inflammatory rosacea who will be treated with Apremilast 20 mg twice per day for 12 weeks. Following the screening period and baseline visit, study subjects will return at weeks 1, 2, 4, 6, 8, 10 and 12. There is a follow up study visit at week 16.

Recent research has shown an increase of specific proinflammatory cytokines in the biopsies of inflammatory lesions from rosacea and acne patients. The cytokines then trigger a chain of chemical responses in the body that likely result in the development of the papules an pustules that are seen in rosacea and acne patients. Apremilast is an oral agent that modulates multiple anti-inflammatory pathways and has pharmacodynamic properties with potential therapeutic benefit for treating inflammatory autoimmune disorders.

We therefore propose a pilot study to evaluate the potential for Apremilast to improve the signs and symptoms of moderate to severe inflammatory rosacea.

Note that the list of inclusion and exclusion is long and slightly scary looking. Celgene are obviously quite concerned about unintended side effects of their new drugs.

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Finding good advice on how to cope with the anxiety of rosacea can be hard to find.

Well now you have an opportunity to ask some questions of experts.

Psychology Question and Answer session

Professor Peter Drummond, Ph.D., from the School of Psychology at Murdoch University in Perth, Western Australia, has a particular sympathy for those suffering from rosacea and has been a good friend to the Support Group over the years. His research into the clinical psychophysiology of health-related conditions (pain, emotions, headaches including migraines, cardiovascular disorders) includes the neural control of facial blood flow, and the role of the sympathetic nervous system (SNS) in pain and inflammation, so we were thrilled when he allowed us to interview him a few years ago on possible links between rosacea and the SNS. In the interview article, Professor Drummond explained how "emotional responses can be controlled to some extent with stress management techniques and anti-anxiety drugs" including beta-blockers.
Rosacea and the Sympathetic Nervous System: Dr. Peter D. Drummond, PhD

Professor Drummond will be joined by a colleague, Daphne Su, D.Psych, a clinical psychologist whose doctoral thesis entitled "Psychological stress and vascular disturbances in rosacea" can be accessed electronically from the Murdoch University library catalogue.
Psychological stress and vascular disturbances in rosacea / Daphne Su

This is your chance to get some external insights into ways you can gain the upper hand against your rosacea stresses and anxieties. For example, you might also want to know what types of counselling or other therapies are proving particularly helpful for people with the kind of issues many rosaceans suffer from, or what kind of therapist to consult, or you might want recommendations for online or offline resources for self-help.

We would prefer that you ask your question over as the Rosacea Support Community forum site in the thread: Psychology Question and Answer session

Go For It !! Let us have your questions.

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Even though this condition is rare and it is a stretch to say that treating rosacea with this drug is a given, it is still interesting to follow the development of this drug.

Today’s press release relate to the continuing good results, this time from the Phase III (randomised, double blind, placebo controlled) clinical trials.

The Rosacea Question

For those who do suffer from PLE, simple events like venturing outside can be a trauma. Environmental trauma is experienced by some rosacea sufferers so for them, developments like afamelanotide are interesting.

Just to what extent those with severe sun triggers will experience relief from afamelanotide is completely up for question. How easily rosacea sufferers will be able to be prescribed this drug is another open question.

Clinuvel announces PLE Phase III preliminary results

Friday 18th December 2009, Melbourne, Australia

Trial in polymorphic light eruption (PLE) to support the final registration dossier of afamelanotide

Clinuvel Pharmaceuticals Limited (ASX: CUV; XETRA-DAX: UR9; ADR: CLVLY) today announced that it has
obtained preliminary results in its multicenter randomised double-blind placebo controlled PLE study (CUV015) evaluating the safety and efficacy of afamelanotide 20 mg implants. PLE is a recurrent seasonal UV-related skin disorder seen mostly in fair-skinned patients (10-20% incidence) in the northern hemisphere.

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This paper is Part 2 in the series of Standard Management Options for Rosacea. Part 1 was devoted to the Overview and Broad Spectrum of Care. Now, Part 2 will expand to discuss management options according to the rosacea subtype.

Lets do some quick revision. In 2002, the National Rosacea Society Expert Committee reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes. In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.

The standard classification system for rosacea breaks rosacea down in to 4 sub types.

• Subtype 1: Erythematotelangiectatic Rosacea (ETTR)
• Subtype 2: Papulopustular Rosacea (PPR)
• Subtype 3: Phymatous Rosacea (PR)
• Subtype 4: Ocular Rosacea (OR)

Understanding that some rosacea  sufferers may have multiple subtypes, the overall management of rosacea symptoms should be keyed to the rosacea subtype in question.

So below is a summary of the 2009 Standard management options for rosacea, part 2. I have given a quick view of each section. For further details, including several disclaimers about the information supplied, see the full text of the paper. The PDF can be purchased for $5 online at cutis.com. I can also email a copy if you would like to read a copy for your own rosacea treatment.

Many of the rosacea experts credited as authoring this paper have links to pharmaceutical companies, and their links are listed. Interestingly Dr. Wilkin is listed as “a scientific and regulatory affairs consultant for 145 companies, including some that products for rosacea.” Wow that is a lot of consulting !

See also Standard Management Options 1: overview and broad spectrum of care.

Erythematotelangiectatic Rosacea

The following therapeutic approaches are listed according to the grade of the redness and broken blood vessels of ETTR.

The committee notes that no drugs to reduce flushing have been approved by the FDA but off-label use may have some moderating effects for grade 2 and 3 flushing.

Papulopustular Rosacea

An approach of topical and oral therapies is detailed to bring the papules and pustules of rosacea into remission.

Additionally the following advice is offered for use a tetracycline other than the FDA approved-for-rosacea Oracea;

In some cases, oral drug therapy for grades 2 and 3 and/or in patients with ocular involvement may consist of off-label systemic tetracycline (or other members of the tetracycline family) administered as 1 g/d in divided doses for 2 to 3 weeks, followedby 0.5 g/d for 2 to 3 weeks.

Some physicians may prescribe higher doses, longer courses, or other tetracyclines
such as doxycycline or minocycline.

Further, here you will find some less common known oral and topical therapies ;

In refractory cases, off label oral trimethoprimsulfamethoxazole, trimethoprim alone, metronidazole, erythromycin, ampicillin, clindamycin, or dapsone may be prescribed. Off-label isotretinoin reportedly may be effective, especially in otherwise refractory cases or when the patulous follicles of incipient rhinophyma are present. Use of isotretinoin requires careful monitoring, and long-lasting remission is not common.

The possibility of some role for demodex, and the resulting therapy of topical permethrin and systemic ivermectin is also mentioned. Caution is suggested when using these potentially irritating agents.

This is the first time that I have seen the recommendation of demodex mite treatments in such a distinguished paper on rosacea.

Phymatous Rosacea

Grade 1 symptoms are treated with topical and systemic antibiotics.  We are told that Isotretinoin (accutane) has been shown to decrease nasal volume in younger patients with less advanced disease – although the volume may increase again after accutane is stopped. Topical retinoids may also reduce fibrosis, elastosis and sebaceous gland hypertrophy.

Ocular Rosacea

We are reminded that ocular symptoms may appear before skin symptoms and that more than 60% of patients with skin symptoms of rosacea also may have ocular symptoms.

Conclusion

As another stake in the ground, this paper will serve rosacea sufferers very well.

The committee suggests that the classification and grading of rosacea symptoms can help by subsequently leading to an effective management regime. Certainly attacking your rosacea symptoms by dividing and conquering the subtypes is a good place to start.

Those interested in a more thorough treatment of up to date rosacea treatment and diagnosis may be interested in my Book Review: Rosacea: Diagnosis and Management, Frank C. Powell which was written by one of the expert authors of this paper.

Standard management options for rosacea, part 2: options according to subtype.

Cutis. 2009 Aug;84(2):97-104.

Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J;

and further Collaborators

Bamford J, Berg M, Del Rosso J, Geronemus R, Goldberg D, Granstein R, James W, Kligman A, Mannis M, Marks R, Pelle M,Scheinfeld N, Sires B, Torok H, Wolf J, Yaar M

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss the standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) management options according to subtype. The menu of options is considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanisms of action of therapies are more definitively established.

Related Articles

• Standard Management Options 1: overview and broad spectrum of care
• Book Review: Rosacea Diagnosis and Management
• Standard Classification of Rosacea
• Rosacea Grading System

Briefly some history: In 2002, the National Rosacea Society Expert Committee reported on a standard classification system that identified primary and secondary features of rosacea and described 4 common patterns of signs and symptoms designated as subtypes. In 2004, the committee published a standard grading system for assessing the relative severity of rosacea to enhance the utility of the classification system for researchers and clinicians.

As we have always known, the classification system for rosacea is provisional and based on what can be observed rather than any common understanding of what causes rosacea (pathogenesis) or assumed progression of symptoms between the defined subtypes.

Now, the committee has developed standard management options for rosacea. The committee was expanded to include additional experts in dermatology, skin care, laser therapy and ophthalmology.

Many of the rosacea experts credited as authoring this paper have links to pharmaceutical companies, and their links are listed. Interestingly Dr. Wilkin is listed as “a scientific and regulatory affairs consultant for 145 companies, including some that products for rosacea.” Wow that is a lot of consulting !

See also Standard Management Options 2: according to subtype.

My Review

Below is a summary of the 2009 Standard management options for rosacea, part 1. I have given a quick view of each section. For further details, including several disclaimers about the information supplied, see the full text of the paper. The PDF can be purchased for $5 online at cutis.com. I can also email a copy if you would like to read a copy for your own rosacea treatment.

The committee is emphasizing the importance of how lifestyle changes and skincare and understanding the particular role of a treatment to achieving the best results for an individual patient.

The standard management options are a menu, you aren’t meant to do them all, just pick and choose what is relevant for your symptoms.

Medical History

A medical history is seen as necessary as some features of rosacea may not be visible when you front up at a doctor’s surgery. Also some tricky alternative diagnoses must be eliminated first.

A few paragraphs are very similar to that Dr. Powell says in his book Rosacea Diagnosis and Management, Frank C. Powell. eg. sun sensitive skin as in heliodermatitis can be confused with the redness and broken blood vessels  (ETTR) or rosacea. Undiagnosed ocular involvement is another reason for a detailed medical history.

Drug Therapy

The papules and pustules of rosacea can be effectively treated by well known drugs like Finacea and Oracea which have been officially approved by the FDA for treating rosacea. Options for off-label medications will be detailed in Part 2 of this series.

The committee acknowledges the need for research into and treatments for the background redness of rosacea as this is a great unmet clinical need.

Laser and Light Therapy

Most lasers that treat the vascular component of rosacea have wavelengths in the 500-600nm range. Also mentioned also is long-pulsed dye lasers, the 532nm KTP laser along with IPL. The er:YAG and 10,600nm CO2 ablative lasers are also given a mention for subtype 3 of rosacea.

Lifestyle Management

This is the bit of rosacea therapy that always seems wanting to me. The committee is suggesting that rosacea sufferers keep a record of or try to avoid their triggers. This just seems so impractical for real life.

Adjunctive Care

Skin Care is an important component of rosacea management because of the sensitive and easily irritated nature of rosacea skin. If chemical sunscreens cause irritation, physical sunblocks using zinc or titanium dioxide are recommended.

As stinging most often occurs when the skin is wet, rosacea sufferers are advised to apply wait 5 – 30 minutes for the face to dry after gentle cleansing, before applying topicals.

Avoid any product that causes burning, stinging itching etc. Good advice, but may be quite hard to follow if one cannot find the perfect moisturiser or cleanser for their regime.

“New cosmetics should be regularly purchased to minimize microbial contamination and degradation”. That advice sounds expensive !

Conclusion

Overall there is little here that is new to most rosacea sufferers. This paper does though serve well as a starting point when trying to find a regime that will relieve your symptoms.

Certainly the weight of authors involved in this paper will go a long way to help convince your doctor that the advice herein is well heeded.

Those interested in a more thorough treatment of up to date rosacea treatment and diagnosis may be interested in my Book Review: Rosacea: Diagnosis and Management, Frank C. Powell which was written by one of the expert authors of this paper.

Standard management options for rosacea, part 1: overview and broad spectrum of care.

Cutis. 2009 Jul;84(1):43-7.

Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J; National Rosacea Society Expert Committee on the Classification and Staging of Roasacea. ( <- yes pubmed does indeed mis-spell rosacea!)

The standard management options were developed by a consensus committee and review panel of 26 experts to assist in providing optimal patient care based on the standard classification and grading systems for rosacea that were developed to perform research; analyze results and compare data from different sources; and provide a common terminology and reference for the diagnosis, treatment, and assessment of results in clinical practice. We discuss standard management options for rosacea in 2 parts: (1) overview and broad spectrum of care, and (2) options according to subtype. The options are considered provisional and may be expanded and updated as appropriate. Managing the various potential signs and symptoms of rosacea calls for consideration of a broad spectrum of care, and a more precise selection of therapeutic options may become increasingly possible as the mechanism of action of therapies are more definitively established.

Related Articles

• Book Review: Rosacea Diagnosis and Management
• Standard Classification of Rosacea
• Rosacea Grading System
• Standard Management Options 2: according to subtype