All about Rosacea … and what you didn’t know about Neurogenic Rosacea

A large proportion of the patients I see have rosacea. This is a chronic condition with a large psychological impact. The relatively less well understood subtype (‘neurogenic rosacea’) is also a focus of this post as so many people have these symptoms without receiving a formal diagnosis.

What is Rosacea?

Rosacea is most commonly characterised by background redness (affecting the forehead, nose, cheeks, chin), some patients also experience spots/bumps in the centre portion of the face. Ongoing inflammation can lead to facial swelling and a feeling of dryness. Burning, stinging and flushing are also reported by people with rosacea. It’s important to note that there are actually different types of rosacea, and, when assessing patients, I will always look to determine which type or category that patient’s symptoms best fit into – this ensures that any further treatment is most effective and tailored specifically to that person’s needs.It usually subdivided into the following categories: Erythematotelangectatic, Papulopustular, Ocular, Phymatous and Neurogenic rosacea.

The root causes of rosacea are not fully understood and it is likely a combination of factors that cause the condition, some of these factors can be treated (such as hormones, immune dysregulation, microbial imbalance, neurovascular changes) and some (such as genetics) cannot be changed, however working with an experienced dermatologist can ensure you find the best way to manage the condition. In addition to understanding what could be causing your rosacea it’s important to also be mindful of other external triggers, such as extremes of temperatures, stress, UV radiation etc., which could be exacerbating symptoms. Further research is required in this area so that management of rosacea can be more precise.

Is it common?

Yes! Rosacea is a common skin condition affecting about 10% of the population, and is particularly common in people with fair skin types, so if you are experiencing symptoms or have already been diagnosed with rosacea you are definitely not alone. In fact evidence shows that due to rosacea having some similar symptoms as other skin conditions, it can sometimes be misdiagnosed, therefore the actual percentage of people affected may well be higher.

Did you know…

Prevalence of rosacea has been reported from 2% up to 22% in fair skinned populations.

The global prevalence of rosacea has recently been estimated at 5.46%.

Incidence of rosacea may be variably reported, as people may be misdiagnosed with other conditions (e.g. seborrhoiec dermatitis, perioral dermatitis, acne) instead

Rosacea is likely under-diagnosed in skin of colour.

Rosacea seems to more commonly affect women after the age of 30 years old. Cases in males however, may be under-reported and a recent systematic review did not find a significant difference between the prevalence of rosacea in males and females.

Fair skin types of northern European or Celtic descent are at more risk of developing rosacea

Can stress trigger Rosacea?

Stress is a well-known trigger of the signs and symptoms of rosacea, and often reported as an exacerbating factor by patients.

Stress is a normal part of everyday life, however excessive stress can put the body into a natural “fight or flight” state, typical physical responses to this include, pupil dilation, sweating, increased heart rate and blood pressure which can then cause facial flushing. For those with rosacea, facial flushing is already common even without stress, therefore when stress is added to the mix, this can then trigger or make symptoms of rosacea worse or flare up. The exact mechanism of the association between stress and rosacea requires more research.

How does Rosacea affect people?

Rosacea can be a psychologically devastating condition; patients report issues with low self-esteem, embarrassment, emotional distress, social isolation, and reduced quality of life. Also, social anxiety and depression can ensue, which may require medical treatment (as well as psychological support). These psychological symptoms/feelings cause stress, often exacerbating the physical symptoms of rosacea, which then turns into a vicious cycle that can be hard to break without the right professional help. This is why the practice of psychodermatology is so important for conditions like rosacea, where both physical and psychological symptoms require addressing and support.

How do I manage Rosacea in Psychodermatology?

Management of Rosacea is complex, it is usually a combination of medical, skincare, lifestyle and psychological management:

Medical

1. Antibiotic creams – reduce inflammation
2. Antiparasitic creams – act against the demodex mite and reduce inflammation
3. Azelaic acid – reduces redness and inflammation
4. Oral antibiotics – used at low doses as an anti-inflammatory
5. Consider using short-term treatments like Mirvaso gel (prescribed by your GP or dermatologist) to control redness and flushing (e.g. before a social occasion or in pressurised situations)

If these do not lead to improvement, low dose oral retinoids are a long-term option. If skin is not improving despite your using a skincare regime and medical treatment, or if you are having frequent flares, consider reviewing treatment with your dermatologist. Importantly, don’t be despondent. It will take time to find a treatment plan that works for you.

Skincare

It is also important to incorporate good skin care. This typically includes gentle cleansers to wash the face, UV protection and light moisturisers. Having rosacea can make skin feel dry, which leads some people to over moisturise and aggravate inflammation. Avoid greasy moisturisers!

As part of the consultation I always discuss the patient’s skincare routine and then make personalised recommendations based on their lifestyle, specific symptoms, and my knowledge of the best products currently on the market.

Psychological

Try not to under-estimate the effect your skin has on your quality of life. If you feel your skin is holding you back from doing things you enjoy or causing feelings of embarrassment or anxiety do talk to your healthcare practitioner about addressing these problems (and ask to be referred to a dermatologist or psychodermatologist). If stress or anxiety is an identified trigger consider stress management techniques, such as relaxation (e.g. breathing exercises), mindfulness, or talking therapies (accessible via your general practitioner). For symptoms of low mood or anxiety that are not improving with the treatment options mentioned, occasionally tablet treatment may be required. A psychodermatologist is well placed to be able to manage the psychological distress commonly associated with rosacea.

Lifestyle

Avoid known triggers

Address lifestyle issues like hydration, sleep, diet and exercise – aim to drink at least 2 L of fluid a day, sleep at least 8 hours every night and practice good sleep hygiene (e.g. do not use phone/tablet/pc/laptop 1 hour before bed, have a night-time regime to get your mind ready for sleep, use calming scents like lavender in your surroundings), consider adding antioxidant-rich foods, omega 3 supplements and probiotics to your diet, try to spend 30mins at least 3 times a week engaging in a form of exercise that you enjoy.

You mentioned ‘Neurogenic Rosacea’ I haven’t heard of that before, what is it and why does it happen?

Neurogenic Rosacea is associated with redness and marked stinging or burning pain in the facial skin. These symptoms may be triggered by the application of products (e.g. makeup). The neurogenic subtype is also quite resistant to standard treatment for Rosacea, so patients have often tried several medications with little positive change. Cooling the skin, for example with fans, cold compresses or ice, can be helpful in controlling symptoms. Patients with neurogenic Rosacea also report other neurological and psychiatric co-morbid conditions like complex regional pain syndrome, essential tremor, depression and obsessive-compulsive disorder. Other associated reported problems include headaches (71%) and rheumatological problems.

It is suggested that skin affected by rosacea has a lower heat/pain threshold than ‘normal’ skin, therefore more likely to react to these triggers. The nerves responsible for detecting and modulating these reactions are present in higher numbers over smaller areas (such as the face) in rosacea patients.

The receptors responsible for detecting pain, temperature and taste are known as Transient receptor potential channels (TRP). People with Rosacea have an increased number of some of these TRPs in their body. This results in hyper-reactivity or sensitivity to temperature change and flavour (e.g. spice) that may trigger symptoms of Rosacea, as well as an increased likelihood to experience the itching/burning pain that is commonly reported by patients with Neurogenic Rosacea. Once activated, these channels release chemicals in the body that aggravate inflammation, as well as causing blood vessels to swell and become more open. This manifests as redness, swelling and flushing seen in Rosacea, which can become a vicious cycle and cause persistent symptoms.
The immune systems of people with Rosacea may also play a role in the symptoms. It is suggested that the immune systems of such patients are more likely to react to stimuli that other people’s bodies could ignore. For example, an enhanced reactivity to the demodex mite (which we all have!), that is implicated in the pathogenesis of Rosacea.’

Stress is also thought to play a role in causing or worsening facial flushing through the sympathetic nervous system response (i.e. preparing the body for ‘fight or flight’).

As there are so many complex interplaying factors causing or driving the mechanisms that lead to the symptoms of Rosacea it makes sense that people will vary in the number and intensity of symptoms. Neurogenic Rosacea seems to be one of the subtypes, in my experience, that is affected by this as people have very differing presentations. They do respond to treatment but often require more of an individualized approach. This is definitely not a ‘one hat fits all’ treatment plan. It is also very possible that it will take some time before large improvements can be seen, but they certainly are possible.

I think I have Neurogenic Rosacea, what should I do?

I would suggest that initially the patient should see their GP, they should make them aware of the fact that they think they may have this rare subtype of Rosacea, which might act as a trigger for referral to Dermatology. Psychodermatology services are not always local to patients, they can ask their GP if they are aware of any, or if they are willing to travel, patients can be referred to the service closest to them. If a patient is already under a dermatologist and not experiencing much improvement, they should do the same, make the treating dermatologist aware of the neurogenic subtype and ask for a specialist referral to Psychodermatology. It is always worth discussing with your healthcare practitioner the way your skin condition is making you feel and the impact it has on your life, this is a further indication for specialist referral. If you are able to, then you may seek treatment in the private sector.

Websites for more information:

1. Skin Support
2. Changing Faces
3. TalontedLex
4. National Rosacea Society

References

1. Sampogna F et al. Living with psoriasis: prevalence of shame, anger, worry and problems in daily activities and social life. Acta Derm Venereol 2012; 92(3):299-303.

2. Working Party Report on Minimum Standards for Psycho-Dermatology Services 2012. www. bad.org.uk/Portals/_Bad/Clinical%20Services/ Psychoderm%20Working%20Party%20
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3. Haber R, El Gemayel M: Comorbidities in rosacea: A systematic review and update. J Am Acad Dermatol. 2018; 78(4): 786–792.e8.

4. Heisig M, Reich A. Psychosocial aspects of rosacea with a focus on anxiety and depression. Clinical, Cosmetic and Investigational Dermatology 2018. 11:103—107.

5. Scharschmidt TC, Yost JM, Truong SV et al. Neurogenic rosacea: a distinct clinical subtype requiring a modified approach to treatment. Arch Dermatol 2011; 147: 123–6.

6. Buddenkotte J , Steinhoff M. Recent advances in understanding and managing rosacea 2018, (F1000 Faculty Rev):1885.

7. Parkins, A. et al. Neurogenic rosacea: an uncommon and poorly recognized entity? Clinical and Experimental Dermatology (2015) 40, pp920–934.

8. Schram AM, James WD. Neurogenic rosacea treated with endoscopic thoracic sympathectomy. Arch Dermatol 2012; 148: 270–1.

9. Wollina U. Recent advances in the understanding and management of rosacea. F1000Prime Reports 2014, 6:50.

10. Sulk M. et al. Distribution and expression of non-neuronal transient receptor potential (TRPV) ion channels in rosacea. J Invest Dermatol 2012, 132:1253-62.

11. Schwab VD. Et al. Neurovascular and Neuroimmune Aspects in the Pathophysiology of Rosacea. J Investig Dermatol Symp Proc . 2011 December ; 15(1): 53–62.

12. Choi JE, Di Nardo A. Skin Neurogenic inflammation. Semin Immunopathol . 2018 May; 40(3): 249–259.

13. Steinhoff M. et al.: Clinical, cellular, and molecular aspects in the pathophysiology of rosacea. J Investig Dermatol Symp Proc. 2011; 15(1): 2–11.

14. Steinhoff M. et al. Agonists of proteinaseactivated receptor 2 induce inflammation by a neurogenic mechanism. Nat Med. 2000; 6:151–8.

15. Steinhoff M et al. Facial Erythema of Rosacea – Aetiology, Different Pathophysiologies and Treatment Options. Acta Derm Venereol. 2016; 96(5): 579–86.

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