coherence in tripwires

[Guest guest]

Dr. Lazoff,

Let me congratulate you on this comment and thank you for your kind

remarks about me. Since you have entered into this group I have noticed

your compassion and interest in helping which to me is unusual

qualities. You take a sincere interest in so many individuals with

their questions and go into great detail to help even to those who are

thankless.

One of my jobs is caring for a male who has MS about 24 hours a week as

a caregiver, so I am very familiar with the disease's signs and symptoms

and the result of exposure to heat. cea pales into

insignificance when one compares it to the horror of MS.

I don't think you could have been stated it better about the confusion

on the tripwire terminology, not to mention the distraction and quandary

over flushing. My past medical training tells me that flushing is a

sign, not a disease, and the attention that flushing receives from this

group, the NRS and Dr. Nase is part of the perplexity in discussing

tripwires.

I agree with you that tripwires or triggers are not constant for all

rosaeans and there has not been one trigger yet proposed that can be

clinically proven to effect all rosaceans. Can you think of one?

As to the chocolate allergy flush, I don't see how your comments on my

'belief system' would be an attack. Your faith in the 'belief system'

of medicine has always been under attack and manages. The history of of

medicine has had some attacks and challenges in viewpoint from the

courageous efforts of unconventional physicians.

My view that sugar is a factor in rosacea flare-ups and how the NRS and

the AMA refuse to list sugar as a possible tripwire is possibly one

thing I can think of that you may have issue with? What else? Dr. Nase

lists sugar as a tripwire. There are physicians who point out the

harmful effects of sugar but admittedly a minority. Why is there a

reluctance to dismiss this factor in rosacea flare-ups?

I admit I know very little about food allergies, but my past EMT

training (that I recall) said to look for rashes, flushes, shortness of

breath, choking, sweating, shock, etc. in a victim. If a rosacean shows

signs of an allergy to cocoa, [unsweetened chocolate] and flushes,

wouldn't this exacerbate the rosacea? Personally I do not think that

unsweetened chocolate is a tripwire. I don't discuss this at all in my

book since I don't claim to have a knowledge of rosacea's connection

with a food allergy. I am only guessing at what you have an issue with

and I welcome your comment.

Brady Barrows

Message: 25

Date: Fri, 14 Jun 2002 18:32:27 -0000

Subject: Re: Tripwires in terminology

Brady, I'm trying to understand how the word trigger applies to

rosacea. I don't have the answers. I brought up the confusion before

you entered the discussion, and saw that you too were confused in how

the term should be used. Maybe I'm missing something, but the NRS

list doesn't help me understand any of this, and your discussion

regarding rosaceans and chocolate doesn't either.

Let me go into a little more background regarding why the use of

trigger in rosacea is so confusing to me.

Consider triggers in comparable confusing conditions such as multiple

sclerosis (MS). For example, a hot bath is an MS trigger, meaning

that it is common for an MS patient's neurologic condition to

deteriorate from an increase in body temperature such as occurs

during a hot bath. It may not be a full-blown exacerbation, it may

just be a few hours of weakness, and it may not happen to every

person with MS or with every hot bath. But a list of triggers for MS

patients includes hot baths.

If you or I take a hot bath, we will not develop any neurologic

weakness; hot baths are relaxing and we may feel lazy and soft and

wrinkly afterwards , but a neurologic exam would reveal normal

muscle strength. In fact, an objective neurologic response to

increased body temperature (as in a hot bath) can help diagnose a

neurologic problem.

So a trigger response is unique to MS (and other neurologically

impaired) patients. It's presence, intensity, and duration varies

among these patients and that's the changing variable; the point is,

it doesn't happen to neurologically intact people.

But in rosacea, we talk about triggers that affect not just rosaceans

but also non-rosaceans; the 'niacin flush' occurs in so many people

there are whole Web sites dedicated to it. We expect people to have

red faces when they come off the ski slopes or after shoveling snow

off their driveways. A blush to red wine is part of the candle light

romance of dating. People with normal skin, not to mention non-

rosaceans who happen to have sensitive skin, often react to topical

alcohol with redness and burning.

Now, not every non-rosacean flushes to niacin or blushes to red wine

or burns to topical alcohol, but at present we consider those who do

to be responding normally. (Compare that again to those who develop

objective muscle weakness after a hot bath -- no one regards that as

a normal response).

So what's the story with rosaceans -- are we also responding normally

to these triggers, is it that a higher percentage of us will respond

than the general population, is it that some of us are more likely to

respond abnormally, is it that we respond normally but have an

underlying pathophysiology that is touched off by flushing or skin

sensitivity? What *exactly* is the relationship between the

vasodilatory blush to red wine and rosacea? The manifestations of

rosacea may vary, the reaction to a trigger may vary, but the

definition and relationship between a trigger and rosacea should be a

constant.

Well, we say that rosaceans tend to blush more easily and longer to

these vasodilating triggers -- but what does that mean? Is rosacea

analogous to being clumsy, which makes one more likely to trip and

fall, and more likely to hurt ourselves when we do fall? How is an

exaggerated response to a normal physiologic event related to a

condition -- if it defines the condition (in other words, if being

clumsy IS rosacea), then what of those rosaceans who don't have an

exaggerated response to a vasodilator? Indeed, there are rosaceans

who never have a problem with flushing, there are rosaceans with rock-

solid skin that never experience irritation to any topical. What is

their rosacea (clumsiness) about?

Alternatively, are all the non-rosaceans who respond to oral and

topical alcohol actually pre-rosaceans, and a portion of those will

go on to develop actual rosacea? In other words, when the Iceman

Cometh, is his red face just a manifestation of pre-rosacea? Or a

third option: do humans flush and experience skin sensitivity across

a spectrum, and there's some arbitrary point beyond which one person

has rosacea, and further along the spectrum they have more severe

rosacea, and people move back and forth along the spectrum throughout

their lives?

That's different than not knowing what causes rosacea. We don't know

what causes MS, and inarguably few conditions are more challenging or

important to diagnose, treat or study as MS. But we can talk

unambiguously about MS triggers because, when present, they are

things that only affect those with MS (or other neurologic

conditions). That's not the case with rosacea.

Brady, I don't recall ever " pointing out " that you were slow, quite

the contrary, I gave you credit for being confused about what I also

see as a confusing issue, by which I meant that you aren't just

accepting things as a given, you're looking below the surface for

answers. I experience you online as intelligent and creative. The

answer to your question is no, you are not correct, but

unfortunately, I don't know how to discuss your diet ideas without

rattling your belief system. It's my shortcoming.

It's good to hear that you're so interested and patient in learning,

those are good qualities. Information on allergies and intolerances

and how they relate to food and to flushing are available in any

introductory immunology textbook. Immunology is tough material so be

very patient with yourself. You might also look into classes at a

local medical or allied health program on nutrition; even if you

don't fulfill or aren't interested in eligibility requirements, they

may let you audit for no credit.

Marjorie

Marjorie Lazoff, MD