Hello Group,

Recently there has been considerable discussion on various
rosacea/flushing boards about depression, anxiety and quality of
life. I think it is very good to talk about these subjects openly
and understand that many rosaceans experience depression, anxiety
and a decrease in their quality of life. It is good to know that
you are not alone......it is also good to understand the reasons for
these feelings. It also helps to realize that a person is not weak
if he or she is depressed or anxious concerning rosacea. I hope the
below excerpt can help in some way.

Geoffrey

----------------------------------------
Dr. Geoffrey Nase
Ph.D. Microvascular Physiologist
www.drnase.com
-----------------------------------------



INTRODUCTION

It is common for people with chronic inflammatory skin disorders to
experience periods of depression and anxiety. (1) Depression and
anxiety can be caused by any number of reasons, including cosmetic
disfigurement, painful skin sensations, decreased quality of life,
and avoidance of triggers. It must be stressed that depression and
anxiety under these conditions is quite normal, and can occur in the
healthiest, strongest-willed people. It does not mean that a person
is "weak", "mentally unfit", or "emotionally unsound". It must also
be emphasized that depression and anxiety are usually caused by the
chronic skin disorder, and not vice versa. (2) In most cases, if
the skin disorder is successfully treated or cured, the depression
and anxiety disappear!


ROSACEA AND DEPRESSION

Rosacea sufferers often report periods of depression stemming from
cosmetic disfigurement, painful burning sensations, and decreases in
quality of life. (2-4) In the moderate to severe stages, medical
experts emphasize, "Rosacea's psychological impact can be
devastating". (5) Other physicians stress, "Rosacea can be
mutilating and devastating..... resulting in grotesque
disfigurement". (6) Medical experts also indicate that rosacea
can, "Ruin lives", (7) and "Can inflict substantial damage to the
quality of life". (8) One rosacea specialist sadly states, "Many
of them never go out of doors, but conceal themselves in their
homes." (9) So, it should not be surprising that rosacea sufferers
experience bouts of depression.


Two other reports on this subject are detailed below:

• In a psychological study of 70 rosacea sufferers and 70 control
subjects, Dr. Marks found that rosacea patients did not differ from
control patients. (10) Rosacea sufferers were all found to be
psychologically stable with no discernible psychiatric disorder or
emotional trauma. However, he did find that the rosacea subjects
were significantly more depressed than controls. Dr. Marks
concluded, "This depression was a reaction to an often severe
cosmetic disability".

• Physicians who specialize in the treatment of rosacea explain, "If
an individual has had rosacea for a long period of time with
recurrent flushing, a depressive state may develop. During these
periods of depressed mood, the following symptoms may be present:
poor appetite or overeating, insomnia, low energy or fatigue, low
self-esteem, poor concentration, and feelings of hopelessness."
(11)


The key symptoms of depression are:

• A sad, anxious, or empty mood that lasts for 2 weeks or more.
• A loss of interest or pleasure in most activities you once
enjoyed.


Additional symptoms may include:

• Feelings of worthlessness, hopelessness, guilt.
• Difficulties in concentrating or making decisions.
• Changes in sleeping habits (such as insomnia or oversleeping).
• Significant change in weight or appetite.
• Fatigue, loss of energy, feeling "slowed down"
• Agitation, restlessness, and irritability.
• Frequent thoughts of death or suicide, or suicide attempts.




1. Rosacea can Cause Depression
Due to Significant Cosmetic Disfigurement

• Experts in the field of rosacea state, "Rosacea can be mutilating
and devastating", and can, "Result in grotesque disfigurement". (6)

• Others describe rosacea as a disorder that can cause, "Severe
cosmetic disability". (10)

• Drs. Garver and Wilkin emphasize, "Rosacea may cause permanent
damage to the facial skin and eyes." (12)

• Several other experts indicate that rosacea can lead
to, "Disfigurement", (4, 13) and, "Permanent damage to the face."
(14)



2. Rosacea can Cause Depression
Due to Intense or Chronic Burning
Sensations of the Face

• Facial burning sensations are reported in many rosacea sufferers
in the moderate or severe stages. (15-17)

• Facial burning sensations can become disabling in some sufferers.
(18)

• Facial burning sensations can be quite intense. (19, 20)

• Facial burning sensations can become chronic or permanent in some
cases. (21, 22)

• Facial burning sensations frequently occur during flushing
episodes, especially those induced by heat, environmental insults,
and skin irritation. (15-17)

• A case report on a rosacea sufferer documents that the face can
burn so much that, "Any gesture, even a laugh, is very painful."
(23) Now, that's depressing!




3. Rosacea can Cause Depression
Due to Substantial Decreases in the
Sufferer's Quality of Life

• Dr. Jonathan Wilkin, one of the premiere experts in the field
emphasizes, "Rosacea will never end lives, but it can ruin lives."
(7)

• Experts who have spent quality time with their rosacea patients
warn that this disease, "Can inflict substantial damage to the
quality of life." (8)

• In agreement with the above reports, other physicians
state, "Rosacea patients do suffer a negative impact on their
quality-of-life." (24) In fact, a different expert sadly notes that
while on the traditional therapies, "Many of them never go out of
doors, but conceal themselves in their homes." (9)

• Physicians who have extensive experience with rosacea sufferers
indicate that the effects of rosacea can be devastating and
that, "Even the most outgoing individual may find he wants to hide
in a closet during an outbreak of rosacea." (25)

• In a recent interview of 400 rosacea sufferers, the National
Rosacea Society found that nearly 75% indicated that rosacea
significantly lowered their self-esteem and self-confidence.
Furthermore, 60% said that rosacea negatively affected their jobs.
(26) Lastly, 60% reported that they avoided face-to-face contact
because of their condition, and 56% said the disease had robbed them
of pleasure and happiness!


• Medical physicians have published descriptions on the effect of
rosacea on their patients' quality of lives. Below are a few
examples: (27-32)

1. One rosacea sufferer reports that it is, "A devastating
condition.... I was so embarrassed that I retired as early as
possible to avoid social contact."

2. Another sufferer states, "I quit my job because of how my face
looked. One day I was helping handicapped kids board a bus headed
for summer camp. After just an hour in the sun I came inside and my
face was neon pink. My co-workers were so concerned they thought I
was going to have a heart attack."

3. A different rosacea sufferer reports, "For me, rosacea is the
most socially destroying disease I have ever experienced."

4. Other rosacea sufferers have reported, "There was such swelling
and redness it actually changed the way I look."

5. A different sufferer states, "Rosacea is a heartache for people.
This disease took over my life for two years."

6. Another sufferer emphasizes, "I take my rosacea into
consideration when planning daily events."

7. A different rosacea victim reports, "I started to resemble
Rudolph."

8. One sufferer states, "My face was burnt-looking.... I was tired
of facing people who kept asking me what was wrong."

9. Others mention, "I was totally distraught, I had never had a
complexion problem before. I was so depressed, I didn't want to
leave the house."

10. There are numerous descriptions in the medical literature of
rosacea sufferers postponing business meetings due to rosacea flare-
ups.

11. There are also numerous reports in the medical literature of
sufferers quitting jobs due to rosacea.

12. A model who was dependent on her appearance, reported that
rosacea frequently interfered with her career, and may have resulted
in a loss of income.

13. There are several medical reports detailing that rosacea
sufferers will often do anything to avoid social activities and
professional appointments if they know that a flare will result.


A special note on the overall importance of quality of life: In a
1999 medical report in the Journal of the American Academy of
Dermatology, Dr. Rapp boldly challenges physicians and
pharmaceutical companies to strive for better treatment of patients
with inflammatory skin disorders. (33) He indicates that these
disorders can cause reductions in physical and mental functioning
comparable to that seen in cancer, arthritis, hypertension, and
heart disease. (33) He stresses that physicians must take into
account the `quality of life' of their patient (i.e., the patient's
ability to achieve a level of overall functioning that allows the
individual to pursue valued life goals, and that is reflected in
general well being). Dr. Rapp states, "The historically narrow view
of health care as efforts to reduce symptom severity or reverse the
disease progression has given way to a more comprehensive view that
effective treatment should also improve the patient's functional
level and overall well being." (33) Furthermore, he
states, "Measuring the impact of a disease on a person's life
quality requires measuring its impact on disease-specific parameters
(symptoms), as well as such global parameters of well-being as
physical, psychological, and social functioning." (33) With the
above said, traditional rosacea therapy falls far short of
satisfying the above criteria because this therapy only decreases
some of the superficial symptoms (i.e., it does not treat the
underlying disorder and certainly does not allow most patients to
get their quality of life back). Rosacea
interferes with daily functioning, generates psychological distress,
disrupts family and social relationships, and causes physical pain
sensations.


A special note on facial blushing and its impact on the sufferer's
quality of life: Almost everyone has blushed from embarrassment at
one time or another. Blushing normally occurs during periods of
embarrassment, perhaps from saying something incorrectly, spilling a
drink, or leaving a zipper unzipped. In some individuals blushing
can be unusually frequent or intense, (21) occurring several times a
day. Medical experts point out that blushing (which is a form of
pre-rosacea flushing), can be a potentially debilitating disorder.
(4, 34) Dr. Drott, a medical expert who specializes in the treatment
of facial blushing, stresses, "Many doctors are unaware of the
impact of severe facial blushing on the quality of life, and
trivialization is common. Most patients have been addressed with
expressions like `it is cute to blush', `you will get used to it',
or `do not bother about it', by the medical profession. (35)
However, the impact of facial blushing on the patient's quality of
life can be devastating." (35) In a recent medical article, Dr.
Drott and colleagues published a questionnaire to help the patient
and physician determine the effect of facial blushing on the
sufferer's quality of life. (35) Below is the adapted questionnaire:


Because of facial blushing do you:

• Avoid meetings at work

• Avoid parties

• Avoid meeting someone you know on the street

• Not dare go out in daylight

• Have difficulties shopping

• Have difficulties in keeping a clear mind

• Fear being at the center of attention

• Have contact difficulties with the opposite sex

• Avoid studies

• Take periodic sick leave

• Use medication for facial blushing

• Have suicidal thoughts



I have received several dozen reports from rosacea sufferers who
experience daily blushing episodes. Many of these sufferers
describe these blushing episodes as debilitating, and all sufferers
indicate that blushing has negatively impacted their lives. Some
examples include:

1. Several lawyers report quitting their profession because they
could not speak in front of judges or jurors without intense facial
blushing.

2. Numerous salesmen/saleswomen have reported daily (and sometimes
hourly) blushing attacks in front of customers.

3. Two executives have reported daily blushing attacks that
interfere with meetings and routine interpersonal communication.
One has retired early, and the other now does all of his work from
home via the computer.

4. Three reporters have quit their jobs because they could not
conduct interviews anymore because of their blushing attacks.

5. Dozens of college students have reported dropping out of classes
(and sometimes their majors), because of class presentations and
seminars that were required of them.

6. Dozens of sufferers have reported that they do not date anymore
because of their blushing attacks.




ROSACEA AND ANXIETY

Sufferers with moderate to severe rosacea often report feelings of
anxiety. (11, 36, 37)


The key symptoms of anxiety include:

• Nervousness or tension
• Dizziness or faintness
• Trembling or shaking
• Sweating
• Chest pain or tightness
• Rapid heart beat
• Choking or lump in the throat
• Nausea or abdominal discomfort
• Panic
• Irritable bowel or indigestion
• Difficulty sleeping or insomnia
• Preoccupation with illness
• Fear of growing crazy



Important notes:

• Worry is the most common form that anxiety takes.

• Anxiety can include feelings of tension and agitation, or
inability to relax. When patients talk of stress, they are usually
referring to the underlying sense of anxiety and increased tension.
(38)

• Generalized anxiety disorder is a persistent anxiety and worry
that lasts for at least six months.



Anxiety is Caused by Facial Flushing and
Trigger Avoidance

As rosacea progresses, most sufferers realize that any trigger that
makes them flush, causes their faces to physically worsen and hurt
(i.e. increased redness, inflammation, swelling, papules, pustules,
and burning sensations). This can result in acute anxiety (short-
term), and chronic anxiety (long-term).


Acute Anxiety: During flushing episodes rosacea sufferers can
physically feel the blood rushing through their sensitive facial
skin. This is often accompanied by uncomfortable sensations of
warmth, burning, and/or stinging. Each of these sensations can
trigger feelings of anxiety. This form of anxiety is usually short-
lived, and dissipates after the flush subsides.


Chronic Anxiety: Sadly, chronic anxiety is primarily caused by the
main treatment for this disorder -- total avoidance of anything that
makes a rosacea sufferer's face flush. Most general physicians
emphasize to their patients that they must avoid all triggers for
flushing. However, what the general physician does not realize is
that most rosacea sufferers have dozens of daily triggers for facial
flushing; from skincare products, to food and drink, warmth and
heat, exercise, mental concentration, embarrassment, emotions
(feelings of excitement, happiness, or sadness), physical exertion,
sun, wind, cold, and spontaneous flushing. Very few diseases,
whether inflammatory, cardiovascular, or hormonal, have as many
triggers for disease progression. Rosacea experts stress, "People
don't realize the variety of minor things that can increase blood
flow in the face, causing aggravation of rosacea." (39) So, in
order for rosacea sufferers to avoid getting worse, they must stop
performing activities that trigger flushing, and continuously think
ahead in order to side-step potential triggers that may come up
throughout the day. This can cause chronic anxiety in the most
emotionally balanced person!



Anxiety Can Progress to Erythrophobia
and Social Phobia

Erythrophobia: Erythrophobia is the fear of getting red. Some
sufferers simply have a morbid fear of facial flushing (i.e., they
fear getting red in front of friends or strangers). However, in many
cases, erythrophobia may develop in rosacea sufferers after they
realize that flushing causes physical changes to the facial skin and
burning sensations (i.e., they fear the repercussions of facial
flushing).


Social Phobia: Over time, rosacea sufferers may develop social
phobia. The essential feature of social phobia is a persistent fear
and avoidance of social situations in which flushing may occur such
as speaking with others, dating, shopping, eating out, spending time
with others in warm rooms or environments, etc. A vicious cycle is
then created where the fear of flushing  generates anxiety =

triggering even more flushing  causing the sufferer to regress even=

further.



DEPRESSION AND ANXIETY:
THEIR EFFECT ON ROSACEA

Although depression and anxiety do not cause rosacea, they both can
worsen rosacea symptoms through alterations that take place in the
subconscious mind. The subconscious mind (an area of the brain that
we do not have control over), has a powerful influence over nerve
activity and hormone production. Depression and anxiety can cause
alterations in brain activity and neurotransmitter production 
resulting in increased sympathetic nerve activity and hormone
release (40, 41)  which can worsen facial flushing and rosacea
symptoms.


Depression and anxiety can alter nerve and hormonal activity in two
ways:

Acute alterations in sympathetic nerve and hormonal activity:
Depression and anxiety can change the subconscious brain activity  =

lowering the threshold for activation of sympathetic nerves, and
release of dilator hormones. In effect, this would make the rosacea
sufferer much more sensitive to certain flush stimuli (i.e., heat,
exertion, stress, mental activity, exercise, emotions, etc.).


Chronic alterations in sympathetic nerve and hormonal activity:
Depression and anxiety can change the subconscious brain activity  =

triggering the continual activation of sympathetic nerves, and
release of dilator hormones. In effect, this would cause a
constant, low-grade facial flush due to continuous activation of
sympathetic nerves or increased hormone production. (40)


In those rosacea sufferers who experience moderate depression or
anxiety, it is highly recommended that they seek treatment. In some
cases, treating the depression or anxiety may help break the vicious
cycle, and give the rosacea sufferer a better chance for full
recovery.



REFERENCES


1. Olff, M. Stress, depression and immunity: the role of
defense and coping styles. Psychiatry Res 85: 7-15, 1999.
2. Koo, J.Y. and C.T. Pham. Psychodermatology. Practical
guidelines on pharmacotherapy. Arch Dermatol 128: 381-388, 1992.
3. National Rosacea Society. "Rosacea Review". Summer. 1998.
Drake,L.
4. Panconesi, E. Psychosomatic dermatology. Clin Dermatol 2:
94-179, 1984.
5. Gifford-Jones. "That rosy blush may be bad". Inside Health
Column, 1998.
6. Plewig, G. and A.M. Klingman. Rosacea. In: Acne and Rosacea,
edited by G. Plewig and A.M. Klingman. Berlin: Springer-Verlag,
1993, p. 433-475.
7. Yoffe, E. "Leading with his nose".
http://www.usnews.com/usnews/issue/970331/31nose.htm . 2000. U.S.
News Online: Health and Fitness.
8. National Rosacea Society. Drake, L. Rosacea Review. 2000.
Spring.
9. Sobye, P. "Aetiology and pathogenesis of rosacea". Acta
Derm Venereol 30: 137-157, 1950.
10. Marks, R. "Concepts in the pathogenesis of rosacea". Br J
Dermatol 80: 170-177, 1968.
11. Garnis-Jones, S. Psychological aspects of rosacea. J Cutan
Med Surg 2 Suppl 4: S4-S91998.
12. Garver, J.H. and J.K. Wilkin. Flushing and rosacea:
overview and nursing interventions. Dermatol Nurs 4: 271-277, 1992.
13. Millikan, L. Recognizing rosacea. Postgrad Med 105: 149-8,
1999.
14. Anonymous. Rosacea: a chronic disease of the skin which, if
not treated, can cause permanent damage. Sante Que 3: 17-18, 1992.
15. Marks, R. and D.S. Wilkinson. "Rosacea and perioral
dermatitis". In: Textbook of Dermatology, edited by R. Marks and
D.S. Wilkinson. Blackwell Scientific Publication, 1986, p. 1433-1438.
16. Neumann, E. and A. Frithz. Capillaropathy and
capillaroneogenesis in the pathogenesis of rosacea. Int J Dermatol
37: 263-266, 1998.
17. Marks, R. and J.N. Harcourt-Webster. Histopathology of
rosacea. Arch Dermatol 100: 683-691, 1969.
18. Kikuchi, I., B. Saita, and S. Inoue. Haber's syndrome.
Report of a new family. Arch Dermatol 117: 321-324, 1981.
19. Erdogan, F.G., P. Yurtsever, D. Aksoy, and F. Eskioglu.
Efficacy of low-dose isotretinoin in patients with treatment-
resistant rosacea. Arch Dermatol 134: 884-885, 1998.
20. Holger, B. "Mepacrine and chloroquine in the treatment of
rosacea". Br J Dermatol 67: 421-425, 1955.
21. Greaves, M.W. "Flushing, flushing syndromes, rosacea and
perioral dermatitis". In: Textbook of Dermatology, edited by R.H.
Champion, J.L. Burton, and et al. Malden: Blackwell Science, 1998,
p. 2099-2112.
22. Macsai, M.S., M.J. Mannis, and A.C. Huntley. "Acne Rosacea".
In: Eye and Skin Disease, edited by M.S. Macsai, M.J. Mannis, and
A.C. Huntley. Philadelphia: Lippincott-Raven, 1996, p. 335-341.
23. National Rosacea Society. "Rosacea Review". Spring. 1998.
Drake,L.
24. Shear, N.H. and C. Levine. Needs survey of Canadian rosacea
patients. J Cutan Med Surg 3: 178-181, 1999.
25. National Rosacea Society. "Rosacea Review". Spring/Summer.
1992. Wilkin,J.K.
26. Erhard, M. "Rosacea: More americans now enter danger years
for rosacea". 1999.
http://medicalreporter.health.org/tmr0596/rosacea.html, National
Rosacea Society.
27. National Rosacea Society. "Rosacea Review". Winter. 1994.
Wilkin,J.K.
28. National Rosacea Society. "Rosacea Review". In: edited by
J.K. Wilkin. 1994.
29. National Rosacea Society. "Rosacea Review". Summer. 1994.
Wilkin,J.K.
30. National Rosacea Society. "Rosacea Review". (Winter). 1995.
Drake,L.
31. National Rosacea Society. "Rosacea Review". Spring. 1997.
Drake,L.
32. National Rosacea Society. "Rosacea Review". Spring. 1999.
Drake,L.
33. Rapp, S.R., S.R. Feldman, L. Exum, A.B. Fleishcer, and D.M.
Reboussin. "Psoriasis causes as much disability as other major
diseases". J Am Acad Dermatol 41: 401-407, 1999.
34. Stein, D.J. and C. Bouwer. Blushing and social phobia: a
neuroethological speculation. Med Hypotheses 49: 101-108, 1997.
35. Drott, C., G. Claes, L. Olsson-Rex, P. Dalman, T. Fahlen,
and G. Gothberg. Successful treatment of facial blushing by
endoscopic transthoracic sympathicotomy. Br J Dermatol 138: 639-
643, 1998.
36. Klaber, R. and E. Wittkower. "The pathogenesis of rosacea: a
review with special reference to emotional factors". Br J Dermatol
Syp 51: 501, 1939.
37. Puchalski, Z. and L. Szlendak. Anxiety as a state and
anxiety as a personality trait in patients with alopecia areata,
rosacea and lichen ruber planus. Z Hautkr 58: 1038-1048, 1983.
38. Koo, J. and C. Gambla. Psychopharmacology for dermatologic
patients. Dermatol Clin 14: 509-523, 1996.
39. National Rosacea Society. "Rosacea Review". Fall. 1996.
Drake,L.
40. Rozanski, A., J.A. Blumenthal, and J. Kaplan. Impact of
psychological factors on the pathogenesis of cardiovascular disease
and implications for therapy. Circulation 99: 2192-2217, 1999.
41. Piccirillo, G. and et al. "Autonomic modulation of heart
rate and blood pressure in hypertensive subjects with symptoms of
anxiety". Clin Sci 95(1): 43-52, 1998.