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Clear Approaches to Skin Care Health & Wellness Volume 1 Number 2 Reducing Your Rosacea Strategies That Work Eat Your Blueberries Married vs. Single Who s Happier Simple Stress Busters Candle Power Soothing the Mind Clear Dear Reader Approaches to Skin Care Health & Wellness Are you concerned about facial redness and pimples You re not alone These are concerns that I hear voiced everyday in my dermatology practice. Patients are frustrated by facial redness that develops and lingers and may even worsen with a simple walk on a sunny day daily frustrations and emotional stress a hot cup of coffee a spicy meal or even well-meaning friends and family who constantly ask Why is your face so red These same patients bring in photo albums that document the development and progression of facial redness over time. Early photographs show clear healthy skin while later photos reveal marked redness on the nose and cheeks. By the time the patient makes it to my office the redness is often difficult to conceal and the accompanying heat burning and stinging is quite uncomfortable. There s a great sigh of relief in the exam room when I explain that help is on the way. The condition described above is called rosacea and help certainly is available. In fact helping those with rosacea is the primary goal of this edition of CLEAR magazine. When I see a patient with rosacea for the first time I explain what rosacea is what causes or worsens it and basically how dermatologists treat it. I discuss the natural course of rosacea and what to expect from treatment. I talk about lifestyle changes skin care and medical and cosmetic approaches that are useful in managing rosacea. A well-informed patient is the key to long-term successful management of rosacea. This edition of CLEAR is dedicated to providing just this type of information about rosacea. In these pages you ll find An article designed to give you a basic understanding of rosacea offer guidelines for skin care and discuss treatment options--much like an initial office visit. A Q&A section addressing common questions regarding rosacea--no office visit is complete without the opportunity for the patient to ask questions A Lifestyle section on other topics of interest to you--nutrition stress relief fitness beauty tips and more. Although nothing can replace a face-to-face encounter with your dermatologist I hope this edition of CLEAR will be a helpful supplement and a comprehensive resource as you begin managing your rosacea. Warmest regards Julie C. Harper MD Editor-in-Chief 2 Clear Clear Approaches to Skin Care Health & Wellness 4 Volume 1 Number 2 Editor-in-Chief Julie C. Harper MD Editor Annette Lenzi Martin Creative Director David Zwierz Account Executive Howard Good Publisher Frank Rybinski Provided as a service by Stiefel Laboratories Inc. Copyright 2012 FMR Communications 1 Office Park West Pennington-Washington Crossing Road Pennington NJ 08534. All rights reserved. The publisher reserves the copyright and renewal on all published material and such material may not be reproduced in any form without the written permission of the publisher. The opinions expressed in the articles are those of the authors and are not to be construed as the opinions or recommendations of the advertiser or publisher. Contents 8 1 0 4 Rosacea Revealed A Guide to Causes Good news You don t have to put up with the troubling symptoms of rosacea because effective treatment is available. Find out what your and your dermatologist can do to keep this common skin disorder under control. Treatment and Sensitive Skin Care 8 Lifestyle Jump on the Blueberry Bandwagon For Better Health Try These Stress Busters Caution Nail Salons Can Spread Nasty Infections Are Married People Happier Than Unmarried People Burning Calories What 15 Minutes of Fitness Can Do Massage Acupuncture Chiropractor What s Best for an Achy Back 10 CLEAR Answers A dermatologist answers the most common questions her patients ask about their rosacea. Clear 3 Rosacea by Julie C. Harper MD Revealed Rosacea--it s a common problem that can be helped with treatment. If you re tired of remarks about your red cheeks or if you re bothered by facial burning and stinging it s time to take action. 4 Clear A Guide to Causes Treatment and Sensitive Skin Care Rosacea in its most severe forms is easily recognized. W.C. Fields bulbous red nose immediately comes to mind. Certainly though the majority of rosacea sufferers have more subtle signs of the disorder. Who gets rosacea The list is diverse. Rosacea patients are working moms and dads young single executives students homemakers and soccer moms. They may even be public figures like Fields or President Clinton who is said to suffer from rosacea. Rosacea befalls the Caucasian African American Hispanic and Asian alike. What these individuals do have in common is facial redness burning and stinging that occurs in episodes in its earliest stages. The redness may be coupled with pimples and thickening and coarsening of the skin surface. Over time these skin changes may become persistent and probably won t go away on their own. For rosacea sufferers it s important to know this Help is available and it s never too early to intervene. Here s some information on what causes rosacea how you should care for your skin and commonly prescribed medications for rosacea. and 50 years of age. Rosacea is not uncommon in seniors but it seldom affects children. Rosacea (also called acne rosacea) has three key components The most prominent component is facial redness (called erythema [ear-ah-THEE-muh]) usually on the nose chin central forehead and cheeks. The redness is temporary during the earliest stages but soon becomes more persistent. It is often accompanied by burning and stinging. In many cases a precipitating event or trigger factor can be identified. The most common triggers are emotional stress hot beverages or foods spicy foods alcohol and sunlight. What Is Rosacea Although rosacea is most often seen in persons with fair complexions it also occurs in dark-skinned people. Women are affected slightly more often than men and the typical age range is between 20 The second key component is the presence of red papules and or pustules. A papule is any bump on the skin smaller than 5mm (about the size of a pencil eraser). A papule filled with pus is a pustule. Papules and pustules are most commonly seen on the central portion of the face forehead and chin. They overlie the facial redness of rosacea. The same triggers for redness may also stimulate the development of these lesions. These rosacea papules and pustules may look like acne to the untrained eye but they are actually quite different. True acne is characterized by small blackheads and whiteheads intermixed with red pus-filled bumps. In rosacea there are few or no blackheads present and more prominent blushing on the nose cheeks forehead and chin. Clear 5 The third key component is the presence of telangiectases (te-lan-gee-EK-tuh-sis) which are dilated blood vessels that have become apparent on the skin surface. Telangiectases are small twisting purple-to-red lines that start around the nose but may become widespread on the nose cheeks and forehead. Unlike the facial redness and the papules of rosacea telangiectases are permanent once they develop. Telangiectases may also be seen in sundamaged aged skin in people who do not have rosacea. It is when they occur with facial redness and or papules and pustules that a diagnosis of rosacea can be made. do breakouts of papules and pustules. In some people the oil glands on the nose gradually enlarge and result in a bulbous red nose with overlying thickened bumpy skin. This bulbous red nose is referred to as rhinophyma (rye-know-FY-muh). Rhinophyma affects more men than women with rosacea. Aside from the skin rosacea may also affect the eyes. This type of rosacea is called ocular rosacea. It is estimated that 50% of individuals with rosacea may also have ocular rosacea. Symptoms of eye involvement include a sandy or gritty feeling in the eyes dryness tearing and frequent styes (the inflamed swelling of a sebaceous gland at the margin of an eyelid). What Causes Rosacea Rosacea Sun exposure Extreme heat or cold Hard exercise Spicy foods Alcohol Hot beverages Certain medications Menopause Common Triggers of The primary cause of rosacea is still unknown. We do know that the blood vessels near the surface of the face dilate more easily in people who have rosacea. What causes this blood vessel dilation (vasodilation) is not known. Rosacea frequently strikes fair-complected individuals in the early adult years. The combination of light skin and chronologic aging can add up to sun-damaged skin. It has been suggested that sun damage may contribute to this hyperreactivity of facial blood vessels and to the development of rosacea. There are also substances in the skin called neurotransmitters that stimulate vasodilation when they re released in the skin. Increased amounts of these substances or a heightened sensitivity to their action are also theorized to play a role in the development of rosacea. Although the cause of the vasodilation is unknown we do know that vasodilation is an early and important factor in the emergence and progression of rosacea. Dilated blood vessels can become leaky spilling material into the surrounding skin that may cause an inflammatory reaction. Inflammation is characterized by redness warmth pain and swelling. These symptoms are often present in rosacea particularly once papules and pustules have formed. If this blood vessel leaking and inflammation continue unchecked the skin may thicken in response and maintain a dark red hue permanently. Rosacea is a progressive process. It begins with vasodilation and eventually evolves to inflammation persistent redness and thickening of the skin. Because of this progressive nature it is never too early to intervene with both at-home strategies and physician-prescribed interventions. How Rosacea Progresses All three components of rosacea need not be present at the same time to make the diagnosis of rosacea. These skin changes evolve and worsen over time. Rosacea typically begins with mild flushing and blushing that comes and goes for several years. Episodes of papule and pustule formation occur sporadically. Telangiectases begin to appear on the central portion of the face and then become more evident on the cheeks and chin. With time facial redness gradually becomes more constant as 6 Clear At-Home Strategies for Managing Rosacea Less is more when it comes to caring for rosacea skin. Here are some skincare guidelines Gently cleanse with a nonabrasive cleanser and lukewarm or cool water. Avoid harsh cleansers or scrubbing with a washcloth. entire affected area once or twice a day depending on the formulation and on your doctor s instructions. As with most rosacea medications visible results don t occur overnight. It may take 4-8 weeks to see significant improvement and the medication should be continued long-term to maintain facial clearing. Azelaic acid is a mild topical cream or gel that is applied to the entire affected area once or twice a day according to your doctor s directions. Again rosacea gradually responds and clears over 1-2 months and azelaic acid should be continued long-term as a maintenance therapy. Don t use toners or astringents. These products are unnecessary and may aggravate redness. Avoid facial masks and exfoliants. Use a mild facial moisturizer with a sunscreen daily. At night a more emollient moisturizing cream can be used. Avoid products containing alpha hydroxy acids salicylic acids or retinols. In general these agents are excellent but may be irritating and worsen redness in those with rosacea. With your doctor s help you may be able to gradually introduce these products without difficulty once your rosacea is under control. Once you ve identified what activates or aggravates your rosacea try to eliminate it or protect against it. Keep a journal or log of your rosacea activity and try to detect your own triggers for rosacea. The most common triggers--emotional stress hot beverages or foods spicy foods alcohol and sun exposure--are not a problem for everyone with rosacea. Your personal triggers may not be on this list. Once you ve identified what activates or aggravates your rosacea try to eliminate it. Physician-Prescribed Interventions It s never too early to intervene in the development and progression of rosacea. Whether you re concerned about occasional blushing or the emergence of pimple-like bumps help is available from your dermatologist. Prescription medications for rosacea include topical agents (applied to the skin) as well as oral medicines. Topical medications. The most commonly prescribed topical medicines for rosacea include metronidazole azelaic acid and the combination of sodium sulfacetamide and sulfur. Benzoyl peroxides are also used but can be irritating in some individuals. Metronidazole is a topical antibiotic with anti-inflammatory effects. It comes in a lotion cream or gel and is used alone or in combination with other medications to control the redness and papules pustules of rosacea. Metronidazole is welltolerated and easy to use. A small amount is applied over the The combination of sodium sulfacetamide and sulfur provides antibacterial and anti-inflammatory effects. This combination of medications is available in cleansers topical suspensions lotions and creams. Recently a combination product with sodium sulfacetamide sulfur and sunscreens has also become available. Rosac Cream with Sunscreens (10% sodium sulfacetamide 5% sulfur) is the only rosacea therapy that in addition to the benefits of the active medication ingredients provides patients with sunscreen protection against damaging UVA and UVB sunlight. This is particularly important because sun exposure is a common cause of rosacea flare-ups and can contribute to the accelerated progression of the disease. Treatment with sodium sulfacetamide and sulfur products involves applying a small amount of the medication to the entire affected area as instructed by your physician. Improvement may be seen after a few weeks of treatment but continued on page11 Clear 7 Clear Lifestyle Jump on the Blueberry Bandwagon We re hearing a lot lately about the virtues of blueberries. For starters they re loaded with cancer-fighting antioxidants just 1 2 cup packs the same antioxidant power as 2 1 2 cups of spinach And researchers are finding other possible benefits too Blueberries might slow down agerelated memory loss help prevent urinary tract infections and improve night vision. Here are some easy ways to slip blueberries into your diet Sprinkle blueberries on mixed greens with feta cheese. Toss a few in frozen yogurt or on your morning cereal. Pour low-fat milk over blueberries with a little sugar or honey. For kids throw a small handful in their burgers before cooking they ll never know they re there The Magic of Candles are often touted as a woman s best friend. In aromatherapy scented candles use the power hidden in oils extracted from flowers herbs and other plants. There s no research to back up aromatherapy yet but here are some claims made Lavender a soothing and relaxing fragrance is purported to help reduce stress depression and anxiety. Geranium considered both relaxing and mentally stimulating at the same time is said to relieve nervous tension and PMS. Eucalyptus a decongestant may help alleviate colds and may have a helpful use as an air purifier. Unscented candles can be powerful allies too reports Prevention s Ultimate Guide to Women s Health and Wellness. Use a candle to rid your mind of negative feedback. Stare into a flame for 5 minutes and let your thoughts float but don t dwell on them. Do this regularly and you ll be able to disregard self-destructive emotions and self-critical thoughts says Lucy Papillon PhD clinical psychologist. Candles Burning Calories What 15 Minutes of Fitness Can Do There are plenty of activities that provide fitness benefits. If you re wondering how many calories they burn here s what Prevention magazine says a 140-pound woman can work off in 15 minutes About 50 calories Tai chi raking leaves badminton walking the dog playing catch or Frisbee golf (using a cart) About 80 calories Step aerobics gardening calisthenics walking briskly washing the car playing tag golf (carrying your clubs) 8 Clear Caution Nail Salons Can Spread Nasty Infections Next time you get a manicure or pedicure think hygiene Surveys show that salons can pass along a variety of nasty infections to their customers such as herpes hepatitis bacterial infections tuberculosis and even HIV. Among other hygienic practices here s what you want to see manicurists do Use only sterilized instruments discard supplies that can t be disinfected (sponges orange sticks etc.) wash their hands between customers use a clean towel over their stations for every new client and disinfect whirlpools after each use. If you ve got concerns about their procedures and materials don t hesitate to speak up. For Better Health Try These Unrelenting stress at home or at work can wreak havoc on your health and peace of mind. That s why it s important to have stopgaps when the stress in your life dials up. Some suggestions Take five-minute breaks. Find a quiet place close your eyes and imagine you re in Maui or some other peaceful place. Breathe slowly and deeply. If you do yoga you know how deep breathing works wonders on easing tension. Go for a walk around the block. Turn to Fido or Tigger. Research shows that the mere presence of a beloved pet soothes our ruffled feathers. Stroke them and you ll get even more stress-reducing benefits. Stress Busters What s Best for an Millions of Americans suffer from backache but it s hard to find agreement on what works best. Now a team of doctors after researching all kinds of treatments (alternative and traditional) for backache reports that no single therapy stands out as best. The researchers found that spinal manipulation (a common chiropractic technique) is no better or worse for treating low back pain than conventional treatments (exercises pain killers physical therapy etc.) Massage therapy appears to be effective for persistent back pain but it remains unclear whether acupuncture works. All of the methods seem to be relatively safe the doctors say. Achy Back Massage Acupuncture Chiropractor Are Married People Happier Than Unmarried People New evidence indicates there may not be much difference between married and unmarried people after all. One recent study found that people get only a tiny boost in life satisfaction from marriage. That slight increase is likely due to initial reactions to marriage after which spouses usually return to their prior level of happiness. Another recent study found that marriage doesn t improve one s social life. These findings contradict previous research. No doubt the virtues of married versus single life will continue to be a subject of debate. Clear 9 Clear Questions Some common questions about rosacea are answered below by CLEAR S editor-in-chief Dr. Julie C. Harper Q My skin is beginning to show signs of aging and I d like to do something about it. Many anti-aging products seem harsh and cause my skin to look even more red and rough. I need a comprehensive skin care regimen. What can I do A Cleanse the skin twice a day with a mild facial cleanser. Avoid using hot water and scrubbing. Avoid toners masks and exfoliants. Apply any topical medications after cleansing as directed by your physician. The best defense against aging is sun avoidance and regular use of sunscreen. Apply a broad-spectrum sunscreen every morning. If the skin feels dry a moisturizing cream can be used at bedtime as well. Anti-aging creams frequently contain retinols alpha-hydroxy acids or salicylic acids. These products are best avoided until your rosacea is under good control. Once your rosacea is well-controlled try introducing one new anti-aging product at a time. You may need to use the new product less often than recommended. Try applying the product just three times a week for example. If redness begins to worsen stop using the product. continued. A topical medication should be continued long-term to maintain clear skin. Q I don t know if I have ocular rosacea or just allergies. How can I tell the difference A Frequent eye watering and itching can be symptoms of both ocular rosacea and allergies. People with rosacea often complain of a gritty sandy feeling in their eyes and frequently develop styes. Ocular rosacea can occur with or without the classic facial changes of rosacea. Fortunately the tetracycline antibiotics prescribed by your dermatologist for facial rosacea also help eye rosacea. If eye symptoms are not adequately controlled with these medications consult an ophthalmologist. Q What can a laser do for rosacea A The pulsed-dye laser is the type used most often in rosacea. It targets the telangiectases or surface blood vessels that do not respond to topical or oral medication. No anesthesia is required and the procedure can easily be performed in an outpatient clinic. One treatment takes only a few minutes but the purple discoloration that may develop during treatment can persist and be very difficult to conceal for seven to ten days. These laser treatments are considered cosmetic and are not covered by medical insurance. For maximum effectiveness more than one treatment session may be needed. Q Does treatment in the early stages of rosacea prevent development of rhinophyma and skin thickening later A Rosacea does appear to be progressive. Most often it starts out mild and waxes and wanes before becoming a more constant problem. Theoretically early interQ How important are sunscreens in a daily vention is a very good idea and will likely hinder the treatment regimen Won t they affect the development of some of the most troublesome longstrength of my medication term skin changes seen in rosacea. A The use of a sunscreen is a critical part of any rosaQ Will I ever be able to stop treating my cea therapy. Sun exposure has been ranked as a 1 trigrosacea ger in several studies of rosacea patients. Therefore A Most individuals can effectively control their rosa- while a medication may help control rosacea a suncea by eliminating those factors in their diets or enviscreen is necessary to help prevent it from worsening ronments that activate or worsen the problem and by due to flare-ups caused by sun exposure. Sunscreens using topical medications. Those with more severe should not have any impact on the strength or effecrosacea or those who do not respond to topical treattiveness of medication as long as the topical medicaments may require oral medication. Oral antibiotics are tion is applied first to a clean dry face and is allowed usually only needed for a few months and are then dis- to absorb completely before applying the sunscreen. 10 Clear Rosacea continued from page 7 significant clearing usually takes 4-8 weeks. It is important to continue the medication after clearing is achieved to maintain improvement and to prevent further progression of rosacea. Oral Medications. Your dermatologist may prescribe a medicine to be taken orally to help control your rosacea. The most commonly prescribed oral medications fall within the tetracycline family of antibiotics. Tetracycline doxycycline or minocycline are antibiotics with anti-inflammatory effects. They target the facial redness and inflamed papules and pustules of rosacea. These antibiotics are usually taken twice a day and lead to improvement and gradual clearing of rosacea over weeks to months. The tetracycline class of antibiotics may cause gastrointestinal upset and sun sensitivity. They should not be used during pregnancy. Always take the medicines with a full glass of water and wear sunscreen on a daily basis. Tetracycline should be taken without food to maximize its effectiveness while doxycycline and minocycline may be taken with or without food. A Combination Approach to Managing Rosacea A common approach to managing rosacea is the combination of avoiding triggers protecting the skin from sun damage with daily sunscreen and using a combination of oral antibiotics and topical medications prescribed by your dermatologist. Facial redness and papules and pustules will gradually resolve in most individuals. Once the rosacea is under control the oral medications can be discontinued and the topical medications continued long-term for maintenance therapy. The papules and pustules are the easiest part of rosacea to control. The facial redness is occasionally a more difficult problem. Some of the persistent redness may be the result of telangiectses which are permanent once formed. Neither oral or topical medications will erase telangiectses. Green-tinted camouflaging make-up may be helpful to neutralize their appearance. Also some laser treatments are very effective at eradicating telangiectases. Laser treatments and in-office procedures can also dramatically improve the appearance of rhinophyma. Talk to your dermatologist for more information. Take Action Today Rosacea doesn t discriminate. Rather it affects all sorts of people from different walks of life. If you have rosacea the good news is that rosacea can be effectively treated. Interventions are available for mild moderate and severe cases. Rosacea probably won t go away on its own so make an appointment with your dermatologist and start managing your rosacea today. The author Julie C. Harper MD is a practicing dermatologist and Assistant Professor of Dermatology at the University of Alabama-Birmingham.