Do you have dry sensitive skin? Do you suffer from a red face, red nose, red eyes… Does your cheeks flush into a flaming red colour when you are stressed? No we are not talking about Rudolf here. And no, we are not talking about allergies here. And we are certainly not talking about Chinese New Year. Neither are we talking about National Day lol! We are talking about ROSACEA.

Commonly known as the English Rose in the West, this condition is known to affect Caucasians.I have seen quite a number of Singaporeans with this condition, hence I wish to share some information about this, in the hope that you can learn to identify, and manage it.

So what is Rosacea?

Rosacea consists of a set of primary and secondary features. If you have any of the primary features, you may very well have rosacea. Speak to your Dermatologist for further information.

Primary features

1. Easy Flushing
   Intermittent and easy blushing and flushing is often an early sign of rosacea.
2. Persistent Redness
   Persistent facial redness is a strong indicator.
3. Papules, bumps, pimples
   These bumps on the face resemble acne, but the distinguishing feature is the absence of blackheads and whiteheads,
4. Telangiectasia – Visible Blood Vessels
   In many people with rosacea, visible capillaries are seen, on the nose, cheeks, etc.

Secondary features

1. Eye Irritation
   Commonly, watery eyes, bloodshot eyes, can be indicative of ocular rosacea.
2. Stinging, burning or Itch
   When you notice your skin reacts quite easily to sunlight, and various cosmetic products.
3. Dry Appearance
   A dehydrated skin is common.

So what are the subtypes of Rosacea?

(from rosacea.org)

So what are the usual triggers for rosacea?

I would like to divide the triggers into

1) Exercise and stress

2) Food, alcohol

3) Sunlight, the elements

How can we manage Rosacea on a day to day basis?

Most importantly, stay away from triggers. Cleanse your skin gently with soap free cleansers. Minimise overuse of skincare products.

So how can we treat rosacea?

Here I shall outline the measures taken for erythema, telangiectasia, papulo-pustular and phymatous subtypes. For the common garden condition of erythema and telangiectasia, there are some simple measures to utilise.

1. Double agent | Ivermectin + Brimonidine

A 2017 study reported enhanced results when combination treatment of ivermectin 1% topical cream (Soolantra) and brimonidine 0.33% topical gel (Mirvaso) was used for patients with rosacea with moderate to severe persistent erythema and inflammatory lesions.

Ivermectin is indicated for inflammatory lesions, while brimonidine treats persistent erythema. Used for 3 months, majority of patients achieve good clearance of rosacea. Brimodinine topical gel ( an alpha agonist which induces vasoconstriction. They work within 30 min, and effects last for up to 12 hours. Clinical studies have shown that a once daily usage of this product can help with rosacea, and it has been safe to use it.) For patients with NO RESPONSE to double agent cream, the following steps are helpful.

2. Microbotox

A 2012 and 2015 reported the use of botulinum toxin  in cases of refractory flushing and erythema. The exact mechanism is not known however.

3. Oral Antibiotics:

Keep antibiotics at the back of your mind. In my clinical experience, for patients who recur, it is wise to add an oral agent. I find that those who recur within 3-6 months would benefit from long term doxycycline to reduce the inflammatory component of rosacea.

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4. Advanced treatment for rosacea

Erythema control can also be achieved with the following.

1) Radiofrequency devices

SYLFIRM is ideal for those who have melasma, extreme blushing and rosacea, and skin dyschromia. It is a radiofrequency microneedling device. Prices start from $399 per session.

2) IPL ( Intense Pulse light therapy, which under a doctor’s supervision, can achieve quite beautiful results). Prices start from $99.

Telangiectasia control can be achieved with the following.

1) Pulse Dye Laser

2) IPL ( Intense Pulse Light)

3) Long pulse ND Yag Laser ( This works for the deeper vessels)

Papulo-pustular variants (bumps)

These respond to oral antibiotics, tetracycline, well.

Skin thickening variants (commonly on the nose) will require a course of isotretinoin.

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So what happens if we dont treat Rosacea? 

So if you have rosacea, or think you have it, please contact your dermatologist for a consult. For those of you who are interested, here is the study on brimodinine.

Improvement in Facial Erythema Within 30 Minutes of Initial Application of Brimonidine Tartrate in Patients With RosaceaMark Jackson MD,^aJoseph Fowler MD,^aAngela Moore MD,^b Michael Jarratt MD,^c Terry Jones MD,^dKappa Meadows MD,^e Martin Steinhoff MD,^f Diane Rudisill BSc,^g and Matthew Leoni MD^gon behalf of the Brimonidine Phase III Study Group

BACKGROUND: Brimonidine tartrate (BT) 0.5% gel demonstrated significantly greater efficacy versus vehicle gel once-daily for the treatment of moderate to severe erythema of rosacea.
OBJECTIVES: To assess the 30-minute speed of onset of topical BT 0.5% gel in reducing facial erythema in Phase III studies as measured by subject and clinician assessments of erythema.
CONCLUSIONS: Once-daily topical BT gel 0.5% is not only efficacious at reducing facial erythema but also exhibits response within 30 minutes of application in a significant number of patients throughout both Phase III studies.

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