Derm-it Trotter! Don't Swear About Skincare.
Feeling frustrated or overwhelmed with everything skin? Does the skinformation overload make you want to swear about skincare? Join Dr. Shannon C. Trotter, board certified dermatologist, as she talks with fellow dermatologists and colleagues in skincare to help separate fact from fiction and simplify the world of skin. After listening, you won’t swear about skincare anymore!
Derm-it Trotter! Don't Swear About Skincare.
Red Wine, Red Face: Taming the Rosacea Beast
Persistent facial redness isn’t always just sensitive skin. In this episode, Dr. Linda Stein-Gold unpacks rosacea — how it differs from acne, its wide range of symptoms, common triggers, and why it’s more than a cosmetic issue. She also shares practical skincare tips and highlights emerging links between rosacea and broader health conditions.
Whether you’re a patient, provider, or just curious, you’ll walk away with a clearer understanding of this complex condition.
Also, if you have the thymitis changes, that thickness that people can see on their nose where it gets thick and you can see the glands much more easily. That's also an independent diagnostic criteria for rosacea in rosacea patients, and some of them have burning, they have stinging, they have dryness, so these are all things and their skin tends to be overly sensitive. You know, people have a red face. People are wondering well, what's wrong with you? You have papules or pustules and you're a 45-year-old woman.
Speaker 2:Is it something that if people don't treat, can it have serious complications if they don't address it?
Speaker 3:Welcome to Dermot Trotter Don't swear about skincare when host Dr Shannon C Trotter, a board-certified dermatologist, sits down with fellow dermatologists and skincare experts to separate fact from fiction and simplify skincare. Let's get started.
Speaker 2:Welcome to the Dermatrotter Don't Swear About Skincare podcast. We've got a great episode lined up here for you today with Dr Linda Stein-Gold. She's Director of Dermatology Clinical Research for the Henry Ford Health System in Detroit, michigan. She is also Division Head of Dermatology for the Henry Ford Health System in West Bloomfield, michigan. Welcome to the podcast, dr Steingold. Thanks so much for having me. Of course, this is, I know, a topic that's near and dear to your heart. Unfortunately, I suffer with it as well. If I had a glass of red wine sitting next to me here on the podcast, you would see my flare occur. But we're going to talk more about rosacea tonight, and so one of the things I wanted to just talk about is kind of just really, what is it? Because I have patients come in and they're like my face has always looked this way. I'm just always a little pink and red. So I wanted to kind of give an idea of kind of what exactly is it and are there different types?
Speaker 1:That's a really good question because a lot of people think that rosacea is just another form of acne and the truth is it's not. It's actually its own distinct disease and we know at its core it's an abnormality of the innate immune system. Basically, things are revved up too much and our body's immune system overreacts and causes that redness and inflammation and bumps.
Speaker 2:And so when we talk about the acne standpoint, that's actually an excellent point, because people do come in and say, oh, I'm breaking out, I must have adult acne. And I don't think they even appreciate, maybe, how that's a little different. If somebody was trying to figure out, do I have adult acne or is this maybe more like along the lines of rosacea? How do you help them? Or what do you look at in the skin to kind of help make that distinction?
Speaker 1:It can be challenging, even for us, but there are a few keys to think about. First of all, when making the diagnosis of rosacea. If you have background redness, that's always there. That's an independent diagnostic criteria for rosacea. Also, if you have the thymitis changes, that thickness that people can see on their nose where it gets thick and you can see the glands much more easily, that's also an independent diagnostic criteria for rosacea. But not everybody has that. Sometimes people have some background erythema, but you can also have that flushing and blushing. You can have the papules and pustules, little blood vessels or telangiectasias, and you can also have eye involvement. So there are a lot of different characteristics of rosacea and we actually look at the individual patient and say, okay, you have rosacea and you have these individual features as well. Because it's important to identify what aspects of rosacea any patient has, because the treatment can be multifactorial and we actually look at the individual parts of the diagnosis and parts of what that patient has in order to make our game plan for treatment.
Speaker 2:Yes, I think that's where it gets confusing, right, because to a patient it might be normal, but then, when you think about they're coming in with the redness or the acne lesions, they're wondering okay, is this a part of the rosacea spectrum or acne spectrum? And then I think, also, too, people are wondering, you know, does everyone get rosacea? Is it something anyone could potentially get? Are there people that are more susceptible to it as well? You?
Speaker 1:know we think about especially women in their fifties who have European ancestry, and that's true. But you have to realize anybody can get it. I live in Detroit and I practice in Michigan and we have a lot of patients that have very diverse backgrounds. I see rosacea in patients with skin of color and it can look very different, but they still have fairly classic features, including the redness and the papules and the pustules. One key, though, in order to differentiate rosacea from acne is with rosacea you don't get comedones, so you don't see the blackheads and the whiteheads. So that's kind of interesting. And also, what's kind of different about the papules and pustules of rosacea, especially in a patient with skin of color? When those lesions heal, you don't see the post-inflammatory hyperpigmentation the same way you do in an acne patient. So it's kind of interesting, you can see it. But you know, if somebody has skin of color and they've got some papules and they go away, they're definitely going to have really pronounced hyperpigmentation and we just don't see it the same way in a rosacea patient.
Speaker 2:With these presentations and understanding just kind of why it happens. You mentioned the immune system kind of rubbed up and off balance. You know I had somebody come in and I read that I've got mites right. These mites are causing me to get rosacea or the bacteria on my skin. Can you talk a little bit more about sort of the theory behind? You know all the normal microorganisms that live on the skin that potentially might be contributing to rosacea?
Speaker 1:It is interesting. Years ago when people would bring up the idea of demodex and rosacea, a lot of people would say, oh, that's just not true, we don't really see that, it's not a major factor. But we're starting to understand and over the past many years we've come to understand. Yes, demodex are important in rosacea, everybody has some demodex that live on their skin. We know some rosacea patients have an increase in the demodex and these are little organisms that live kind of head down in their hair follicles and at night they kind of come out and migrate. They're normal. There's different types of demodex, though. They're different species and we know one of the species tends to be more inflammatory than the other one and we know in rosacea patients they tend to have more of that particular species. But it's something that is a contributing factor. It's not the cause, but it is something that contributes.
Speaker 2:And do you think the bacteria as well might play a role, or are they really? What is the theory? Is it all types of organisms or maybe more linked to the demodex mite? Is that the primary cause we're thinking you?
Speaker 1:know. It's interesting because with acne we know that cutibacterium acnes is at the center of the pathogenesis In rosacea. We don't have that organism. That really is the central key player. There's some supporting roles, we would say, but it's not really the center in the pathogenesis. So when we think about treatment options, for instance topical ivermectin, we know that this kills demodex and when we look at the numbers of demodex in patients who have used topical ivermectin, those numbers go down dramatically. But we also know that ivermectin has very potent anti-inflammatory properties. So it really works in both ways. So the organisms are important. The microbiome, you know, maintaining a healthy microbiome is important, but again, the organisms just aren't at the central core of the pathogenesis.
Speaker 2:Yeah, I like that you kind of point that out because that distinction, I think for a lot of people they always think you know things on the skin to a degree I think patients in general they can always think something's infectious or it's contagious and you know, maybe this is more reactive, but you know it sounds like it's definitely more complex. You know our understanding of kind of that pathophysiology, how that all kind of comes together and we talk about the physical, like we talked about you know, the redness, the background or erythema people get, the broken blood vessels or telangiectasia, the thickening of the nose, the inflammatory papules or pustules that people get. What about like physical symptoms? Do you feel like you have rosacea patients that can report changes beyond maybe just what you see in rosacea skin?
Speaker 1:That's such an important issue because a lot of people say my skin is so sensitive and we have these secondary criteria in rosacea patients and some of them have burning, they have stinging, they have dryness, so these are all things, and their skin tends to be overly sensitive. For some rosacea patients, they get irritated when they wash their face, they get irritated when they put moisturizer on. So there is this heightened sense of irritation on a lot of these patients. And it's interesting, when we look at the skin in a rosacea patient, it's more similar to an atopic dermatitis patient than to a normal patient. So there's abnormalities in the skin barrier in the rosacea patient as well. Dr Justin Marchegiani.
Speaker 2:I know we don't like to use the word abnormality sometimes a lot that kind of raises some eyebrows nowadays with just being sensitive to word choice. But I really like that you bring that up, because often I think rosacea is looked at or treated as simply this cosmetic condition. Right, people see the bumps, they see the redness, and you bringing up just the symptomatic nature how it can burn or it can be very sensitive I think it makes people feel like their rosacea is real. It's a true medical diagnosis condition. You know disease again and sometimes we don't like using that term as much anymore, but it truly is something that deserves to be treated. Is that something you feel like people kind of, you know, push back on a little bit and maybe more about not so much even the patient, but just in general that people feel like it's not like a real thing that needs to be prioritized?
Speaker 1:For a lot of patients. That's absolutely true, and some people don't even know that this is a condition. You know if you think about it, if you look at your parents and your siblings and they all have red faces and they tend to react if they have a glass of red wine or they're out in the sun or they eat hot foods. You just think that's how we're made, this is just the way we are. It's normal. But in fact, a lot of these patients have families that have a lot of rosacea and when you talk to patients who have significant rosacea, moderate or severe disease and you ask them about the psychosocial impact, it's devastating.
Speaker 1:You know, people have a red face. People are wondering well, what's wrong with you? You have papules or pustules and you're a 45-year-old woman. People look at you like well, what's wrong with you? Why do you have acne? Why didn't you take care of that stuff? And these are the things that. It is a skin disease. It's an inflammatory skin disease and if you take the whole picture of the mental health impact, the sensitivity of the skin, and put that all together, this is something that really deserves treatment.
Speaker 2:Rosacea is a condition I feel like just it deserves respect and sometimes it's not, given that you know, I think, in general in medicine, sometimes even by some of our colleagues, but then also on the side another discussion but you know insurances and looking at this, that it needs to be treated and addressed for our patients. When you were just talking to, you mentioned some of those things that might bring on a rosacea sort of flare. That red wine that I mentioned earlier on too, that's been craven at the end of the day. So I'd like to kind of just go over what types of triggers do you think are more common that people think about, and are there things that people don't really appreciate that might actually cause the rosacea to flare up?
Speaker 1:Triggers are different for every patient, but there are some things that we hear about more commonly. As you mentioned, alcohol is certainly one of them. Anything that can vasodilate the skin the sun, heat, we say, spicy foods, exercise these are all things that you know. We notice the skin becomes more red, flushes, people might notice a papular or pustular flare after exposure to these triggers. So there are things that you know. A lot of people don't want to avoid them completely, but when you can identify what causes you personally to flare up, it's easier to limit those triggers and kind of keep them in check.
Speaker 2:Yeah, and sometimes I know for mine that red wine could do it. But it can be worth it, sometimes worth it. I just got to get ready for it. So I think you know along those trigger lines we've talked about skin just like the symptoms and being a part of it. I wanted to get down to kind of how rosacea affects the eye because I do think for patients, listeners out there, people don't really appreciate kind of this extension beyond. You know just what we think of traditionally with skin. Can you just touch briefly upon like eye or ocular rosacea?
Speaker 1:Yes, ocular rosacea is certainly a type of rosacea, and sometimes patients have classic rosacea. Sometimes they really just have minimal cutaneous symptoms, but have very obvious ocular symptoms. Now patients will sometimes feel a gritty feel in their eye. Sometimes their eyes will look red, sometimes they tear a little bit, and this is something often patients will see an ophthalmologist for. What's interesting, though, is we don't have any FDA-approved treatments for ocular rosacea. We know that when we put people on systemic medications like systemic antibiotics or tetracycline-class antibiotics for the rosacea of their skin, often this will help their eyes as well.
Speaker 2:Is it something that if people don't treat, can it have serious complications if they don't address it?
Speaker 1:If it's more moderate or severe, it could. So I would say, if you have that gritty, uncomfortable feel in your eyes, if they look red, just certainly have an ophthalmologic evaluation just to really figure out what's going on and see is it rosacea or maybe it's something else, and there are treatments that certainly help this. There was an interesting study a small study but I thought interesting anyway topical ivermectin used on the face and then used on the eyelids for ocular rosacea and those patients actually did quite well and that was kind of easy to do and got both skin and eye improvement.
Speaker 2:Wow, that's well, killed two birds with one stone with that one. So that's good, cause I do the eye rosacea, ocular rosacea part. I'm glad that we talked a little bit about it, cause I do think it's sort of misunderstood. I've been sometimes impressed with how in extensive the eye or ocular involvement could be and then how little the skin appears to be and then vice versa sometimes too. You know, just you think the rosacea, the skin, is just terribly fine.
Speaker 2:You don't definitely don't see that correlation often clinically that they can kind of be a little mismatched, if you will. So I think that's also fascinating when people come in and you know, just kind of getting them to think you know twice about. Maybe maybe you do have eye involvement or you could develop it at some point down the line, and your skin doesn't necessarily have to be that impressive with rosacea involvement as well. But I think the one thing people are going to want to know is if you feel like you have rosacea you've been potentially diagnosed by your dermatologist. Are there particular skincare products or ingredients you recommend that could be useful? And then maybe potentially once you would say, hey, stay away from these, they're definitely going to probably make your rosacea worse.
Speaker 1:Yes, it's tough because if you have rosacea, your skin is overly sensitive. So when you walk into the drugstore and you see all these great products on the shelf, first of all, as we talked about earlier, it's not acne. So you can't just go pick up those acne medications and put them on your skin for your papules or your pustules and expect that's going to do okay. A lot of the acne medications are way too irritating for rosacea patients. I'll use benzoyl peroxide as an example. We have an encapsulated silica, encapsulated benzoyl peroxide. That's a prescription that actually calms the skin down in addition to reducing the papules and the pustules.
Speaker 1:But if you go to Target and you buy 5% benzoyl peroxide from over the counter just conventional benzoyl peroxide and put that on a patient with rosacea, you can probably hear them screaming from here. It's going to be just way too irritating. And then other things are just, you know, for especially women who are looking for products that might help with photoaging and the maintenance of healthy skin, some of those products are not going to be good for a rosacea patient. Topical retinoids might be a little bit too irritating. Over-the-counter retinoids or retinol, even like alpha or the glycolic acid products, might be a little bit irritating. So this is something you have to just really go gentle cleanser, gentle moisturizer, good sunscreen.
Speaker 2:And now that we've kind of tackled skincare, how would you describe kind of the treatment options? And again, that's a really obviously in-depth conversation, but if you kind of give an overview of how to approach potentially some options to treat rosacea, do you mind just kind of reviewing that with us a little bit? Sure?
Speaker 1:And the first thing I do when I have a patient standing before me is say okay, what are the features of rosacea that I see in this particular patient? If they have fixed background erythema that redness that's always kind of there we can use an alpha-adrenergic agonist like bromonidine or oxymetazoline. Those are applied in the morning and they usually last all day. Sometimes some of the devices will be helpful for that. If patients have telangiectasias they're the little blood vessels on the skin you can cream them all day and it's not going to take those blood vessels away. So they generally are going to need to have some kind of a device for that. If they have papules and pustules, they need either a topical and or an oral anti-inflammatory medication.
Speaker 1:Talked about topical ivermectin, encapsulated benzoyl peroxide. We have oral antibiotics, including submicrobial dose doxycycline. We have a low dose minocycline that was recently FDA approved. That's highly effective. The traditional drugs like azelaic acid and metronidazole maybe not quite as effective as some of the newer ones, but they still are FDA approved. And then if somebody has a thymidus lesion the thickness it depends on if it's still inflammatory, maybe you'll use a systemic antibiotic or oral isotretinoin. If it's more scarred, you're really going to need a surgical approach to that.
Speaker 2:You mentioned the oral antibiotics. They had a patient come in, probably now a few weeks ago, that had been on oral doxycycline for well over a year, higher dose, around 100 milligrams twice a day. I wanted to get your thoughts on, you know, with managing chronic inflammatory disease like a rosacea patient. What do you feel about long-term antibiotic use? Because I think that's some of the pushback I get often with rosacea patients is they're reserved or maybe cautious about antibiotic use, which we should be good users of that and not just throw it around. But what are your thoughts about sort of that long-term use, or do we have options to kind of get around that where you would feel comfortable having somebody take it in the long term?
Speaker 1:And that's really a critical issue that we face in dermatology every single day. And that's really a critical issue that we face in dermatology every single day. And I'll tell you, when I first started out in practice I might write oral antibiotics and see them in a year and maybe refill them. But we kind of know now that that's not the best approach in terms of the patient's overall health and our community's health because of the potential for resistant organisms to develop. So we now try to limit full-strength oral antibiotics to maybe three or four months.
Speaker 1:But with rosacea, because we're not using the antimicrobial property, we're really using more of the anti-inflammatory property, we use much lower doses and get great efficacy. So we see that with the submicrobial dose, doxycycline, that has anti-inflammatory effects but it doesn't go above the killing line. So you can use this for years at a time and we haven't seen the development of bacterial resistance. So that's great. And then we have the new minocycline. That's a low dose. Extended release also was studied and we didn't see the development of bacterial resistance and it didn't seem to affect the microbiome. We don't have as long data with the newer minocycline drugs, but preliminary data is good news that it looks like this is going to be effective and also safe for longer periods of time.
Speaker 2:I think it's a great option that we have that and to alleviate some of the concerns I know the patients have and you know ourselves obviously, how are we changing, you know, the gut, the microbiome, long-term with the antibiotic use we've done historically and now I think, the advent of these new products to kind of help and some that have been around a little bit longer, obviously with the doxycycline. But I think it's just a great option for patients to get them that understanding of there's some safety with this use if we have to do it on a more long-term basis. And I just think the concept is cool in explaining it to patients about anti-inflammatory benefits, because we all think about antibiotics, especially in the patient world oh, I got an infection, right, that's why we're using it but to capitalize on kind of the benefit they offer to control inflammation. I just think the concept itself is very fascinating and patients I think would appreciate that at the low dose.
Speaker 2:And I know one of my patients came in and asked about and I don't this is one of the things I wanted to talk with you. I know I sent this to you kind of earlier about this concept of the small intestinal bacterial overgrowth, like screening people and I was like well, this is something that I haven't thought about on a regular basis, and so I wanted to talk to you about what your thoughts were on it Like. First, what is it to kind of explain to people, and what do you think about this potential link to rosacea?
Speaker 1:And that's something the link between small intestinal bacterial overgrowth and rosacea something that had been looked at for quite a long time. And when we look at the data and look at the clinical trials, there are some studies that have shown that patients with rosacea are more likely to have that intestinal bacterial overgrowth. And there are some studies that have shown that if you can treat that with oral antibiotics, in some cases you can get the rosacea under control. And the thought is that the bacteria produce these inflammatory mediators and they permeate through the intestinal wall and get into the systemic circulation and cause increased inflammation, including in the skin, causing rosacea. Now we, you Now. It's interesting because recently we haven't talked about that so much at all. We don't talk about it in terms of our rosacea management and our guidelines, but it has been something that's out there. It's been out there for a long time and there are some nice studies that have actually looked at trying to treat this.
Speaker 1:I don't normally recommend checking for it today, but you know it's certainly something that people could think about and we do know. You know we learned with psoriasis that inflammatory skin diseases are more than just skin deep and with psoriasis we learned that you're more likely to have cardiovascular disease and mental health issues and liver disease and kidney disease, mental health issues and liver disease and kidney disease. And what's interesting is rosacea. Maybe not to the same extent, but we do know that there are some comorbidities with rosacea as well. We know neurologic disorders, parkinson's disease, alzheimer's disease. We see an increase in rosacea. There have been a number of studies that are looking at a cardiovascular disorder association with rosacea and then GI disorders and an association with rosacea, including Crohn's disease, an irritable bowel disease, ulcerative colitis. So you know, I think we have more to really understand, but you know, don't rule out that systemic inflammation and the link to other areas of inflammation.
Speaker 2:So, with all those conditions you just mentioned, if somebody's newly diagnosed with rosacea, does that necessarily mean they need to go see a cardiologist or talk to their doctor? Are there any, like you know, meaningful interventions that we really recommend, based on some of those associations, or do you feel like the jury's still out on kind of how we make you know, make sense of it all?
Speaker 1:I don't know that we're there yet. I'll tell you. If I have a patient with severe psoriasis, I will tell them you're more likely to die of a heart attack than somebody who has no psoriasis or mild disease. So I make sure that patients whether it's a psoriasis patient or somebody with significant rosacea make sure you have a primary care physician. I don't take on that challenge myself, you know, but I certainly tell my patients have a good physical done. Make sure you're up to date on all the testing that is appropriate for your age. And you know, I don't know that it's recommended to have all these patients see a cardiologist, but certainly a primary care physician should be in all of these patients' lives.
Speaker 2:And then, lastly, I like to end with this because I feel like I'm getting more questions. You may have patients, too, that are asking about this. You know we've talked to kind of the whole spectrum of rosacea, from diagnosis and clinical presentation treatment. One of the areas of treatment I think that's definitely more popular now is looking for more natural ways or potential supplements that might actually assist in treating rosacea. Are there any supplements that you recommend or think carry their weight to be a part of a rosacea regimen?
Speaker 1:I don't recommend any oral supplements, necessarily for rosacea, and when we were doing the acne guidelines in 2016, I was responsible for that alternative medicine supplement kind of category and we couldn't make any real recommendations for acne at that point either. I'll tell you something kind of interesting, though, when we were talking about natural we have a drug that was actually developed from a sponge a sponge and it was ground down and made into actually a mask. It was applied once a week, and we studied this for both acne and rosacea and it was found to be quite effective. So it's kind of interesting. It's certainly a different mechanism of action. It's not to be anti-inflammatory. Can you imagine putting a mask on once a week that comes from a sponge? But you know, there are some alternative treatments that are out there, and I think it's still exciting and our minds are open to new mechanisms of action, new treatments, so hopefully we'll get even more and better treatments in the near future.
Speaker 2:Yeah, I think that's where we're headed. For Rosacea, like I said earlier, it's finally getting you know some respect. You know, on the front of you know patients understanding it I think providers as well and treating it and bringing it up because, you're right, people like you mentioned before like that's just my skin, right, this is my norm and may not even recognize that it's truly a skin condition that warrants treatment. So I appreciate really bringing attention to that and I hope this podcast will really, you know, get people thinking twice about it. You know, on both fronts, and get patients seeking treatment, getting clinicians to go after it maybe a bit more aggressively, to help those patients not underestimate the toll it can take on them, especially, as you mentioned, their emotional and mental wellbeing. There definitely is a role there to improve this as well.
Speaker 2:Well, thank you so much, dr Steingold, for coming on today. This was fantastic. I really appreciate your time and expertise because you definitely are going to help somebody out there that's been listening to our podcast. Well, thank you, and I really appreciate the very insightful discussion.
Speaker 1:So thanks so much.
Speaker 2:Of course, happy to have you on again sometime in the future. And, of course, happy to have you on again sometime in the future and for those of you listening, if you like the podcast, please click like and don't forget to subscribe and thank you so much for joining us today and stay tuned for the next episode of Dermot Trotter dot com.
Speaker 3:Don't forget to subscribe, leave a review and share this podcast with anyone who needs a little skin care sanity. Until next time, stay skin smart.
