Diet and triggers

[Guest guest]

A few days ago I wrote a very long reply to Deryk's Diet post, but I

got interrupted then couldn't relocate it on my hard drive until

tonight.

Like many rosaceans, I find diet, and triggers in general with

rosacea, a very confusing topic. I hope my perspective helps with

some of Deryk and other people's questions. But these are my own

ideas -- no medical references, it's based on what I read and

considered from many sources, and is what I personally believe to be

true at this point in my understanding of rosacea. My apologies for

its length.

[For background, rosaceans suffer one or both of two basic sets of

symptoms -- vascular (flushing, and its later stages) and

inflammatory (papules and associated redness, itching and burning,

and its later stages). So, we have potentially controllable triggers

that cause flushing, and those that cause inflammatory skin symptoms.

(These are the first two in the new NRS classification.) There are

lots of theories but no one knows the precise relationship between

these two manifestations of rosacea, or for other manifestations and

subclassifications of rosacea. One point that I often see overlooked:

it would seem nearly impossible for a single trigger to cause both

flushing and inflammation at the exact same time. That sounds to me

like an exacerbation of the underlying rosacea, rather than a

trigger. Controlling triggers is a part of managing rosacea, but it's

obviously far from the whole story.

Regarding flushing -- most rosaceans seek to avoid flushing whenever

possible, although if you think about it, the reason isn't clear.

There's nothing wrong with flushing per se -- most humans flush, it's

a normal physiologic response. But we rosaceans tend to flush more

easily, deeper, and for longer periods of time than non-rosaceans,

and there is also the theory (I don't believe it's been proven) that

repeated flushing exacerbates rosacea's underlying pathophysiology,

thereby making rosacea worse in general.

In contrast, the reasons for avoiding inflammation are well

documented: inflammed skin interferes with many of the skin's normal

functions, including the epidermal protective barrier, which affects

skin's ability to maintain moisture and ward off irritants and

environmental stresses.]

OK, so regarding food triggers that cause flushing: first, everyone

agrees that there are foods/drinks like alcohol and spicy foods that

cause immediate flushing in many people, rosaceans and non-rosaceans.

Statistically, they are likely culprits -- although it's important

that not all rosaceans will flush to even these common triggers.

Also, some may flush only with certain amounts or with combined

triggers such as beer under a hot sun, red wine when under emotional

stress, etc.

Much less commonly, there are people on this list and elsewhere who

attribute immediate flushing to foods that contain or release small

peptides such as histamine; whether this is related to a deficiency

in an enzyme as some hypothesize or some kind of vascular reaction, I

don't know. The list of foods varies from Web site and references,

and I don't know what to believe so I'm listing all I found (in no

particular order): cheese, sour cream, spinach, eggplant, red wine,

mackerel, anchovies, herring, sardines, yeast, sausage, sauerkraut,

canned tuna, preserves, spinach, tomatoes, strawberry, chocolate,

protease-containing fruits like bananas and papayas, alcohol, citrus

fruits, avocado, raisins, and vinegar. Obviously most rosaceans don't

flush to any of these.

Third, a number of people on this list and in the lay press attribute

rosacean triggers to to food allergies/intolerances. Unlike the

above, food allergies/intolerances usually manifest as a skin

inflammation (itchy, red, hives or small papules on the epidermis or

as angioedema (painless swelling of the dermis).

(If a food allergy manifests by flushing, it should be accompanied by

low blood pressure and with a major allergic reaction. (This is in

distinction to the rosacea triggers and histamine-containing foods

discussed above, where flushing may be accompanied with minor

lightheadedness, but not the systemic systems that are part of an

allergic reaction.))

Intolerances also involve the immune system, but not the stereotypic

pathways involved in an allergic reaction. Intolerances also tend to

be delayed by hours or even days. Most commonly, food intolerances

are accompanied by GI symptoms, but not uniformly so. They can just

involve only skin inflammation, although the face is not the most

common place they manifest.

Statistically, the most common foods to induce food intolerances in

the general public are wheat products, gluten products (Celiac

disease is one form of gluten intolerance, and for a number of

reasons it's tempting to see a relationship between rosacea and

Celiac disease, but Celiac's dermatologic feature looks nothing like

rosacea and is rarely just on the face), cow dairy products, and soy

products. I've not found evidence that explains whether rosaceans are

more suspectable to food intolerances, or more suspectible to

manifest food intolerances as facial rashes.

So here's how I would put it together, considering dietary and non-

dietary triggers:

With a flush alone, the most common triggers are environmental and

individual (physical or emotional stress), but some foods like

alcohol or spicy foods are also common culprits. Over the months, it

should be clear whether any of these triggers affect a particular

person, alone or in combination, and how much exposure can be

tolerated, if any. If flushing presents at times when none of the

most common triggers apply, it's reasonable to consider side effects

of one's medications and hormonal states such as menopause, and then

subtle environmental factors or histamine-associated foods.

Identification is made easy because the trigger causes an immediate

flush reaction; the flush will be while still in the pizzeria, not

two hours later. Also, rest assured that if you aren't being rushed

to the hospital then the flush isn't the result of any kind of

allergy. (As explained above, a flush is a serious manifestation of

an allergy usually accompanied by hypotension and other systemic

symptoms.)

In contrast to flushing, what triggers the irritative/inflammatory

symptoms of rosacea can be much harder to identify, largely because

the trigger can be hours if not days away. Far and away the most

common triggers of irritative/inflammatory rosacean symptoms are from

topicals -- something applied directly the skin. Topicals can cause

an immediate sensitivity such as burning or itching and/or delayed

symptoms, by hours or days (rarely, weeks). So the new soap today may

result in a worsening of papules and redness (not flushing redness,

but inflammatory redness) two days from now, after we've already

tried the new moisturizer. Or the reaction may occur a week later,

after the ingredients have built up in the skin or sensitization has

occurred. The most classic type of reaction here is an irritative

contact dermatitis, but consider other types of contact dermatitis as

well, such as nickel from eyeglasses or new face or hand jewelry, or

even nail polish.

What challenges most rosaceans is differentiating between the normal

exacerbation and remissions that characterize vascular and

inflammatory rosacea, with more subtle triggers that could be from

many sources, including histamine-related foods and food

intolerances, respectively.

I respect that many in this group give a higher priority to diet and

rosacea. In my opinion, the kind of elimination and other restrictive

diets aren't likely to impact the health of most rosaceans -- in

contrast to things that are likely to benefit most everyone, like

drinking 6-8 glasses of water/day, taking a good multivitamin with

healthy doses of B vitamins, getting a good nite's sleep each night,

and using the smallest amounts of basic cleansers and moisturizers

without frequent changes that risk sensitizing sensitive skin

further.

After a month of just doing these basic things, with attention to

reactions from common triggers, I would think a rosacean is in a

better position to assess whether any trigger needs to be avoided and

if so, under what conditions. I would think it's also a good place to

re-consider medications such as oral and/or topical antibiotics,

advancing as necessary under a competent dermatologist's care to

medications helpful in controlling flushing, and topicals helpful in

controlling inflammation. Setting forth a skin maintenance regimen

and getting familiar with one's exacerbations and remissions over a

course of many months would help determine if rosacea is being well

managed -- never cured or controlled, but managed. If not, that would

be the point to consider rarer causes of rosacea or rosacean-like

conditions, such as co-existing conditions that complicate diagnosis

and care, including the presence of histamine-related food and food

intolerances.

Marjorie

Marjorie Lazoff, MD