Rosacea and menopause: what’s the link?

Consultant Dermatologist Dr Sajjad Rajpar makes a welcome return to the podcast this week to talk about the chronic skin condition rosacea, and how it can be impacted by the perimenopause and menopause.

In a special episode to mark Rosacea Awareness Month, Dr Louise and Dr Sajjad discuss the physical and psychological effects of rosacea, as well as offering practical advice on avoiding triggers, and treatment strategies.

Dr Sajjad’s top three tops if you have or suspect you have rosacea:

1. Really look at your skincare routine and strip it right back to a gentle non-foaming cleanser and a light moisturiser containing ceramides.

2. Sunlight can be a trigger for rosacea, so block out the sun as much as you can.

3. Consider talking to your GP about trying active topical ingredients such as azelaic acid, metronidazole and ivermectin, because they can be a real game changer.

For more information about Dr Sajjad, visit www.midlandskin.co.uk

Transcript

Dr Louise Newson [00:00:09] Hello, I’m Dr Louise Newson and welcome to my podcast. I’m a GP and menopause specialist and I run the Newson Health Menopause and Wellbeing Centre here in Stratford upon Avon. I’m also the founder of the Menopause Charity and the menopause support app called balance. On the podcast, I will be joined each week by an exciting guest to help provide evidence-based information and advice about both the perimenopause and the menopause. So today in the studio, I’ve got with me Dr Saj Rajpar, who is an amazing dermatologist and also a very good friend, someone I admire from afar because his knowledge is encyclopaedic about the skin, which some people might think, oh, well, it’s only the skin, but actually as you’ll hear the skin is incredibly important. So thanks Saj for giving up some more of your time to talk to me today.

Dr Sajjad Rajpar [00:01:08] It’s a pleasure to be here, Louise, and thanks for the invitation.

Dr Louise Newson [00:01:12] So we’re going to talk today about something called rosacea. And actually, you don’t know this because I’ve haven’t told you before but my grandfather had really bad rosacea and he had rhinophyma. He had very red skin and, you know, I only knew him like that. So that was him. I used to call him Pappy, my grandfather, and I was really close to him. He helped looked after me after my dad died and that was just the way he was. I didn’t think anything different until I actually saw a photo when he was married and his nose was different, his features were different, and I was too embarrassed because I was young to say anything. And retrospectively, like most things, you learn don’t you and I thought, oh, what a shame. I bet he never had any treatment. And I bet it affected his self-confidence and everything else. He was a real gentle man, actually, a lovely, lovely man, very respectful, but it must have affected him. But when I knew him, we didn’t talk about anything embarrassing at all and let alone any skin condition. So what is rosacea, Saj, because it’s common, isn’t it?

Dr Sajjad Rajpar [00:02:11] Yeah, it is really common, and I’m not surprised you’ve got a family member that has had rosacea because rosacea probably affects 5 to 10% of the population. So it’s really common. It’s said to affect women more than men. But it may be the case that women bring up their symptoms more often to healthcare practitioners, and instances such as your grandfather might just have not brought that to the attention of healthcare practitioners. And rosacea is an inflammatory skin condition. So it’s a condition in which there is inflammation in the skin, and patients suffer from redness, flushing, spots that look like acne and burning and irritation of their skin. So it’s not just the way it looks, it’s the way it feels as well. And then a small number of people can go on to develop a permanent thickening of their skin called rhinophyma, which is what your grandfather had as well. And that can be quite disfiguring.

Dr Louise Newson [00:03:11] So there’s different sort of grades if you like, of rosacea aren’t there? I mean some people it just can affect them maybe certain times or certainly for women certain times of the month actually it can flare up. And then other people, you know, it really affects them doesn’t it? So how do you diagnose it, is it something that we can diagnose ourselves?

Dr Sajjad Rajpar [00:03:30] You’re quite right, it can vary. Sometimes it’s very mild and the same person can have severe episodes that then go into remission and become much less active. And yeah, it is possible to a degree to diagnose it. You may recognise the symptoms yourself and the most common symptom is redness with flushing. So the redness can be intermittent at first, but then as time goes by it’s permanently present and it usually affects the nose and the central cheeks, but it can also move on to the central forehead and the chin.  And flushing is when the face goes very red suddenly and there’s often an intense sensation of heat and burning with it. And sometimes that happens spontaneously, but sometimes there are triggers such as a hot drink, a spicy meal, alcohol, or just going from a cold room to a warm room. And those features can be quite debilitating. And often they’re associated with really irritating and sensitive skin that burns and it’s dry and it’s flaky. And that’s because in rosacea, the skin barrier doesn’t function normally. So that’s one type of rosacea. And dermatologists might call that erythematotelangiectatic rosacea. That just means red with thread veins. So there’s a big vascular component. And then there’s the other type of rosacea that’s what’s called inflammatory rosacea, and that’s where you get inflammation and papules and pustules. So whiteheads and red spots, they often look like acne. So sometimes that form of rosacea is called acne rosacea, but it’s actually not like teenage acne that we get or even adult acne. There aren’t any comedones for example, there aren’t any blocked pores. It’s got nothing to do with the sebaceous glands or grease production. It’s inflammation in and around the hair follicle for other reasons.

Dr Louise Newson [00:05:30] Interesting. And why is it more common in women than men? Do we know?

Dr Sajjad Rajpar [00:05:35] Well we don’t really know, and we haven’t established why women are more prone to it. Now it may be that skincare products can aggravate people with rosacea. And if you’ve got very mild rosacea, you may be under the radar. But if you’re more likely to use more skincare products and we know women are much more likely to use more skincare products and have multiple steps in their skincare regimes, it may be that the irritant effect of those products can reveal the tendency for those people to develop rosacea. So it may just be something as simple as that. We haven’t been fully able to establish the fact that the hormones are necessarily involved, but as you say, there are certain women out there for whom there is a cyclical variation in their rosacea, and that’s fair to say, that they get more skin inflammation, more redness, more dilation of the blood vessels in relation to their menstrual cycles. So there is, for some women, a hormonal component as well.

Dr Louise Newson [00:06:32] Which is interesting because there’s quite a few women I see in my clinic who have flare up of their rosacea during the perimenopause and menopause. And what I don’t know is, is it worse in the perimenopause when the hormone levels are fluctuating or is it worse in the menopause when the hormone levels are low? And then, of course, which hormone is it? Is it estrogen, progesterone or testosterone, or a combination of them all? And I don’t think any studies have been done looking at that, have they?

Speaker 2 [00:06:57] No, you’re absolutely right. There is no data about the exact relationship between hormonal changes and rosacea. But we do know that the peak incidence, so the time at which rosacea is most often first diagnosed, is around the age of 35 to 50. So that would fit very much with the period of the perimenopause and the menopause. Now, whether that is coincidental and was going to happen anyway, or there is a relationship with hormones, we’re not sure. And of course, they can be symptoms that can overlap between rosacea and the menopause as well. So the symptom of flushing, for example. The rosacea flushes are different because they are restricted to the facial skin, but there can be overlap can’t they?

Dr Louise Newson [00:07:48] Absolutely. And it is difficult because things that trigger flushes can be the same triggers for rosacea like alcohol, for example, can trigger both. So it is difficult for people to know. But a lot of women, I see they know they’ve got rosacea and they’ve enjoyed because it’s calmed down for the last 20 years or so and then it’s come back, so it’s that pattern recognition. Their skin feels the same, it has the same triggers, and sometimes it can actually be worse than it was when they were younger, which is very disheartening.

Dr Sajjad Rajpar [00:08:16] And it’s really important to try and sort of focus on any triggers that you can address. And the most common trigger we know of is sun exposure. And ultraviolet light specifically can cause the release of certain chemicals, including something called Substance P in the skin that actually irritates the nerve endings and it causes pain and burning and it dilates the blood vessels and it causes redness and flushing and then brings all these inflammatory cells into the skin causing inflammation.

Dr Louise Newson [00:08:48] So just before we talk about treatments, let’s just talk a little bit about the skin, because I said at the beginning how important skin is. And actually when we talk about the skin, often people just think about the face because skin products is usually face products. And certainly now, as you know, for the menopause, there’s all sorts of menopause skin products. And, you know, it’s only concentrating on the face and okay, rosacea affects the face. But just take it back to the skin is a massive organ in our body, isn’t it?

Dr Sajjad Rajpar [00:09:18] So the skin is the biggest organ in the body and the face only accounts for 1% or 2% of the whole surface area of the skin. And the skin is really important in protecting your body. It’s an immunologic organ. It fights bacteria, viruses and fungi. It’s your first line of defence. It keeps the outside out and it keeps the inside in. It regulates your temperature. It allows you to feel touch. It’s really rich in nerve endings. So it’s a really complex structure and actually I think one that’s been under researched for its level of complexity and that’s why there are so many unknowns with what are really common skin disorders like rosacea.

Dr Louise Newson [00:10:01] Yeah, and I think what’s really interesting with skin is that it’s giving people a window for what’s going on in their bodies. I think because we put things on our skin, you know, in the morning, I’ll, you know, obviously wash myself in the shower, I’ll puts some moisturiser on, I might put some perfume on, I put some face cream on. It’s all about external but actually, that’s very super superficial, obviously it’s superficial, but actually how healthy your skin is is often a reflection for other things going on inside the body. And I think to be an excellent rather than a good dermatologist, which indeed you are, is looking beyond the skin and seeing the skin often, not always, as a window into other conditions, isn’t it?

Dr Sajjad Rajpar [00:10:42] I think that is so, so very spot on. The skin is an insight into the wellbeing of the whole organism, and the skin will reflect illnesses elsewhere. So you can see things like anaemia on the skin or thyroid problems on the skin or menopause or estrogen deficiency presents on the skin as well. So it is a really good way of assessing the health status of somebody. And people who have healthy looking skin are much more likely to be fitter and in a good physiological condition. And that’s actually been shown in studies as well that are coming out.

Dr Louise Newson [00:11:24] And that makes sense actually, if you think the blood supply to the skin is huge, if it’s the largest organ in the body, it must have a huge amount of blood flowing through it. And our blood, as people I’m sure know, feeds every cell with all the good nutrients, but it also drains the bad stuff. Okay, so it gets filtered by the liver, if you like, and excreted or metabolised, depending on what it is. Whereas if we don’t have good blood flowing through our skin, it’s not going to be the same, is it?

Dr Sajjad Rajpar [00:11:54] No, absolutely. I think you’re absolutely right that we’ve got to have a rich blood supply going into the skin, the skin being able to use all those nutrients and then all the by-products of metabolism being carried away. And that’s really important. And your comments on the skin reflecting your health status is really important. I think it’s actually really important in the context of rosacea because sometimes there is a social construct around the way people look and their lifestyle that they must lead that affects rosacea patients quite a lot. So one common misconception about people with redness on their face or flushing or rhinophyma, which is that thickening of the nose that you mentioned your grandfather had, is that they must take a lot of alcohol, they must abuse alcohol, they must be excessive drinkers. And this is one of the things that can affect a lot of patients with rosacea, which is that they are incorrectly labelled in society as having alcohol issues. So this is where sometimes a primary skin disorder can actually give an incorrect impression on somebody’s health status.

Dr Louise Newson [00:13:06] Is It is. I mean, lots of people used to think my grandfather drank and he probably had a glass of wine at Christmas and maybe one on his birthday, he just didn’t drink at all. And not even to the extent that he knew whether that would flare up his rosacea or not. But it is that… and you know, the skin really affects your confidence as well, doesn’t it? Now, I don’t need to tell you, but most people listening will know if you don’t feel great or you’ve got something on your skin, especially your face, of course it’s going to affect the way you are. And I know people aren’t judgmental and shouldn’t be judgmental, but it’s part of you that you’re presenting and you know, especially more and more we do things on screen. You can’t even dress yourself in a different way. It is so visual, isn’t it?

Dr Sajjad Rajpar [00:13:49] And unfortunately society is more and more critical about that. And the number of patients that I see with skin conditions, for example, like rosacea, who will avoid social situations because of it. You know, I had a patient the other day who actually had successful treatment for their rosacea and said, thank you so much. I was able to go for a curry with my friends without fearing that I would go bright red through that meal. And I thought, actually, gosh, I can only imagine what that must be like. You know, you take these things for granted on a day-to-day basis. You know, you don’t even think about it. But there are people out there who are planning their day around their skin. You know, it can really restrict their lifestyle. And we say, you know, avoid the triggers, avoid the sun, avoid hot drinks, avoid exercise, avoid caffeine, avoid alcohol. If you take all that out of your life, what on earth do you have left? You know, what are you supposed to do in your life? So it is really hard. And then, you know, sometimes you’re met with frustration when you try and get medical help, because not every medical professional may be fully versed with all the possible treatment options out there. And sometimes rosacea and other skin conditions can be complicated. They can need multiple modalities of care. The guidelines are just a starting point. As you know, in menopause, guidelines are just guidance documents. They are not really practically how you can help each single individual. If all you did was follow a guideline, I think you’d have about 70% of your patients back saying, now what do I do? You know, we follow that and you have to think outside the box every single time. That’s the challenge me and you have as practitioners, which is, yes, we’ve got some guidance there, but actually practically patients need treatments that haven’t been evidence based, haven’t had all those rigorous studies, and we have to find a way to actually improve their lives.

Dr Louise Newson [00:15:44] Absolutely. And I think it’s so important that we remember actually that medicine is an art form as well as a science, and everybody’s different. And so certainly when I was a GP and saw women and men with rosacea, there’s a stepwise approach. There is for everything, isn’t there? But obviously if someone’s saying every time I drink a bottle of red wine, my skin flares up, well, the first thing that you would probably politely suggest is perhaps it’s not the best thing, but some people really want to drink that bottle of wine and then if they know there’s a cause and effect and it can trigger, that’s actually up to them, isn’t it, to decide. But giving them the tools and the education, I think for me as a practitioner, healthcare practitioner, is the most important thing for them to decide once they are empowered with information. So you’re right. So certain spicy foods, hot foods, hot drinks, alcohol, sun can, but not always. There’s not always triggers there for rosacea.

Dr Sajjad Rajpar [00:16:39] No, no. And as we’re talking about triggers, there are some less commonly known triggers that you come across. Sometimes some people can be aggravated by things like cinnamon and vanilla. Some people are actually activated by cold rather than the hot. So cold drinks can actually aggravate some people. And actually there is now science behind that, and an understanding that there are different receptors and channels in the cells that are aggravated by the cold. Some people are activated by formaldehyde containing foods like tofu and wet noodles, and some people are even aggravated by niacin containing foods like turkey, chicken breast, peanuts, tuna and liver. So there’s all sorts of things out there. So as we are understanding more about these conditions and the chemical pathways that are involved, people can make the choice and say, right, you know what, if I’ve done a food diary and I can actually see a relationship between this and my problem. If it’s practical, then yeah, it’s worth avoiding the trigger in the first place.

Dr Louise Newson [00:17:39] So taking a really careful history. We were taught at medical school, weren’t we? 90% of the diagnosis is in the history, but you have to give people time and the tools to enable them. So working out whether there are triggers, really, really crucial before thinking about any treatment, because some people are actually, you know, I don’t drink alcohol at all, but if I did drink red wine, my skin would probably would flare up and it would cause a migraine. So actually, that’s fine. I’m never going to drink it. So if you can avoid practically and it improves, that’s fine. You don’t need treatment do you? But for a lot of people, it’s not enough. So there are topical treatments that can be used, aren’t there? And systemic treatments. So treatments that we put on our skin or treatments that we take internally. So can you talk us through in a stepwise sort of way that you would manage someone who has got rosacea?

Dr Sajjad Rajpar [00:18:28] Yeah, absolutely. And I actually I move into that, I just want to make a point about rosacea and skin of colour. You often don’t see redness in those with skin of colour and therefore the redness and the flushing component are not that obvious, but often they will have very sensitive and irritated skin and the burning sensation that goes along with the flushing. And sometimes that’s the clue in the history. And often the history will also show that these patients just cannot tolerate skincare products. And that’s probably the first step, is to strip back your skincare regime. Just three days ago, I saw a lovely young lady who had started about half a dozen things on her skin for her skincare. She had fantastic skin to start with and she had gone online and she had decided she was going to start several different anti-ageing skincare products and she was going to do a weekly peel. And that triggered an acute flare up of rosacea. So if we’re going to damage our skin barrier with skincare products, we may get a flare in rosacea. So the first step is to have a very simple skincare regime. Use a simple, light moisturiser that contains ceramides and use a non-foaming cleanser. And that’s absolutely all you need. Once you’ve done that, there are three active ingredients that are really good for rosacea to consider. And these are azelaic acid, which you can buy over the counter, metronidazole, which is a prescription product and ivermectin, which is another prescription product. And in my practice, I will always select one active ingredient at a time and give that person eight to 12 weeks to just get used to that product, build it in slowly to their regime and see if it’s controlling their problem. If it’s not controlling their problem on its own, you can then add a second active agent. The wrong thing to do is to start half a dozen active agents all in one go, hoping one will hit, one would probably hit, but the irritation of the lot would undo all the good benefit that you’re going to do with your products.

Dr Louise Newson [00:20:48] So having patience, say, three months for each treatment, really, because it can take a long time, can’t it?

Dr Sajjad Rajpar [00:20:54] It can take a long time. And sometimes we may need to use oral medication. Sometimes the skin is so inflammed, so dry, so flaky, so irritated that you simply cannot start a topical treatment because anything on the skin can just cause irritation and aggravation. So in those instances, it’s actually better to calm the skin down, either with oral medication or even with lasers now. And once the skin is calm, introduce a topical treatment which can then be used for ongoing maintenance. And the oral treatments that we use include antibiotics at low doses, and a medication called isotretinoin for very difficult or very resistant rosacea. We also use a lot of vascular laser and broadband light and laser genesis. These are all different wavelengths of light that just reduce redness and reduce inflammation in the skin. And sometimes some patients need all three types of treatment, so laser, antibiotics and creams to control their skin.

Dr Louise Newson [00:21:56] So tell me about laser, because that sounds a bit scary. So there’s lots and lots of different types of lasers and they use more and more aren’t they? But talk me through, what does it mean?

Dr Sajjad Rajpar [00:22:05] I think our understanding of how lasers and the skin interacts is increasing. And what lasers are, are machines that produce light. Lights of a very high energy level and different things in the skin absorb different wavelengths of light. So if you’ve got blood vessels which are red, then those blood vessels are going to reflect red light. So red doesn’t go to red, but they are going to absorb other colours like green. So what we do is we use lasers that produce green light because we know that green light will go into those blood vessels. And what that laser does is it shuts down the blood vessel. And if you shut down the blood vessel, you’ve got less blood flow to the skin. So you’ve got less redness, you’ve got less thread veins and you’ve got reduced levels of flushing. But what you also find is just by reducing those blood vessels, you get less inflammation as well. So time and time again we see people coming back who are using lasers purely through redness control and actually say, you know what? My inflammation has gone down. I’m not getting as many spots or I haven’t had a breakout since our last treatment last month. So there is this thing called photo modulation that’s using light for anti-inflammatory properties. And I think we’re getting more and more knowledgeable about that, especially with the trend for individuals not wanting to be on long term antibiotics, for example, or long term medications. I think lasers offer an alternative which we didn’t used to have before.

Dr Louise Newson [00:23:45] Which is a great choice, especially when you’ve got a localised skin condition. It’s very different when there’s a systemic skin condition like eczema, when people, you know, it’s affecting their arms and their legs and their back and their face or whatever, then it’s a lot harder giving a localised treatment. But when it is affecting areas, then actually as a patient I would much prefer to have something that targets just that area because you know, most things systemically do have the potential to have side effects or interactions and we don’t know enough about long term low dose antibiotics. I was always taught that they wouldn’t affect the gut flora because you give them all the time.

Dr Sajjad Rajpar [00:24:26] It’s hard to believe isn’t it?

Dr Louise Newson [00:24:26] I think, you know, the more we know about our gut flora, the more we know how important our gut flora is for improving our general health, reducing inflammation and improving our mental health as well. It’s very difficult to see that low dose antibiotics aren’t going to cause a problem. They probably wouldn’t cause antibiotic resistance, which is obviously another problem, but I think it probably would affect our gut flora. So if we can avoid systemic treatments, obviously that you say some people need them, but actually they might find with a laser treatment, they don’t need to use a systemic treatments as long maybe.

Dr Sajjad Rajpar [00:25:02] Yeah, absolutely. And it just gives that extra alternative route. And I will see many patients who don’t feel comfortable for the reasons that you’ve said to start low dose antibiotics. And it’s interesting that that sort of component of oral rosacea treatment has not changed over the last 40 years. So we’ve got to move in the direction of protecting our gut flora and not being dependent on systemic treatments. And, you know, it’s not just that a lot of people can get some tummy side effects. Diarrhoea,

nausea is a common one, esophagitis. And thrush. Unless a doctor asks often patients won’t tell you, but when you actually investigate, you say, well, what happened? Did you experience anything else? Actually, a large number of women will experience thrush from even low dose antibiotics. So it is disturbing the microbiome in various areas. Definitely.

Dr Louise Newson [00:25:57] Yeah, absolutely. We do see it a lot. Just bringing it back, before we end, obviously, hormones, because that’s all I think about Saj, as you know, that there are people, like I say, who once they take the right dose and type of HRT, their skin does improve in all sorts of ways, but rosacea as well can really improve. So all the treatments you talk about, you can still take alongside hormonal treatment, can’t you?

Dr Sajjad Rajpar [00:26:22] Oh, absolutely. And I think, you know, for a number of women, balancing their hormones will sort their skin out completely. And that’s great. And perhaps, you know, adding a little bit of sun protection and that’s all they need. But if they need anything else, absolutely, all those treatments would be safe alongside it.

Dr Louise Newson [00:26:40] That’s quite safe. And I spoke to someone the other day, she was very concerned about using testosterone because she thought that would flare up her rosacea. And actually, there’s no evidence, and testosterone can be very beneficial for the skin as well. And again, we haven’t got good quality research because no one’s done the studies, but there’s no reason why people can’t have, you know, we just give physiological doses, as you know, but they can’t have that conjunction. So for many people might know, we work very closely together with our patients and a lot of our patients really benefit actually for having their hormones balance and their skin sorted as well, especially for rosacea. So we’ve seen some great results, which is brilliant.

Dr Sajjad Rajpar [00:27:19] Absolutely.

Dr Louise Newson [00:27:20] So before we finish, Saj, I’m going to ask you for three take home ticks because that’s what I always do. So three things that if someone’s listening who might have rosacea or might realise now they’ve got rosacea or maybe someone that they know or a family member has it. What are the three simple things that you think they should do?

Dr Sajjad Rajpar [00:27:39] Okay, so number one would be really look at your skincare regime and strip it right down. I think that’s so important. Number two is the sun and sun protection. Block the sun as much as you can, as we know now, the molecular mechanisms involved with sun-induced rosacea flares. And then number three, think about talking to your GP about one of those active topical ingredients, because they can be a real game changer and can help, you know, 60 to 70% of people with just one product.

Dr Louise Newson [00:28:15] So really good advice. But I would also add, if you don’t get the right help or advice or something isn’t helping, then there’s always other people to see and get some expert advice and opinion because it is a long term condition usually. So I’m very grateful for your time today, Saj, and I hope that’s been very interesting for a lot of you that are listening. So thanks again.

Dr Sajjad Rajpar [00:28:38] Thanks Louise.

Dr Louise Newson [00:28:41] For more information about the perimenopause and menopause, please visit my website, www.balance-menopause.com. Or you can download the free balance app, which is available to download from the App Store or from Google Play.

END.