Guest guest Posted June 11, 2002 Report Share Posted June 11, 2002 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 Quote Link to comment Share on other sites More sharing options...
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