Andrew and Matija,

Thank you for your patience. You asked some specific questions
about my personal treatment of rosacea – (1) What were my specific
treatments, (2) How successful were they, and (3) Why have I
remained in remission. First, let me reiterate that in my book I
devoted most of my discussion to treatments aimed at specific
rosacea symptoms, severity, triggers and dual treatment of
coexisting skin disorders. I did discuss my personal treatment, but
underscored that everyone is unique and should follow treatments
based on their own specific symptoms (especially due to the fact
that I had rhinophyma, severe centrofacial swelling, and severe
flushing along with primary rosacea).

I will try my best to highlight my treatments and clearance as a
result of the treatment:

1. One pulsed dye laser treatment and a series of 5 photoderm
treatments – laser/IPL treatments were the best form of treatment
for my facial redness, flushing and skin sensitivity (approximately
85% to 90% clearance of those specific symptoms). Pre-flushing
before treatment with hot coffee, oral niacin, topical niacin and
topical L-arginine had a lot to do with my overall success and long
standing results. The entire microvascular bed must be filled with
blood for proper treatment. This has been emphasized at several
recent Laser conferences that I attended and journal articles in the
publication process because some patients' skin turns white
(blanches) when treatment starts due to sympathetic constrictor
fibers (or local nerve reflexes) from the stress or pain of
treatment. When blanching occurs, treatment will fail. In fact, if
you leave the office with a white face and no signs of blood vessel
coagulation, then treatment results will be minimal.

2. Long term low dose isotretinoin – 10 mgs per day for 6 months
and 5 mgs per day for 9 months. This was the best form of treatment
for my rhinophyma, centrofacial swelling, chronic dermal
inflammation, neutrophil deposition, sebaceous gland hyperactivity,
sebaceous gland hyperplasia, papules and pustules. Of those
specific symptoms, this treatment regimen resulted in a 95% to 100%
clearance and seems to be permanent due to the long term total dose
taken. Is this part of the x-factor….maybe a part. The experts
agree that this form of treatment can sometimes permanently alter
the entire disease process. In most cases, any dose over 10 mgs per
day will thin the epidermis (reversibly) and increase facial
redness. At 5 mgs per day there is no better oral anti-inflammatory
medication (except possibly oral metronidazole). The Internet
horror stories are mostly based on cystic acne patients taking 120
mgs to 180 mgs per day (not 10 mgs or 5 mgs per day).

3. Pulse dosing with macrolide antibiotics Clarithromycin and
Azithromycin – there is enough scientific, medical and anecdotal
evidence that these two macrolides inhibit angiogenesis, especially
during wound healing and post laser treatment. I was pulse dosing
after laser treatments – did this help to decrease vessel regrowth
during the all important 14 to 21 days post treatment? These are
the best antibiotics for rosacea, hands down. But, not all
insurance companies cover these antibiotics and very few doctors yet
recognize these for rosacea. Is this part of the x-factor….
possibly.

4. Moxonodine – for specific neural triggers, this was superior to
clonidine or beta blockers in my particular case. For strong neural
and hormonal triggers as a result of neural activation this
decreased the intensity and duration of flushing by 40% to 50%.
This was taken prior to laser treatments. After laser treatments
and isotretinoin, I was basically back to pre-rosacea with no signs
of rosacea, most of my triggers were gone…..but, I still had mild
bouts of flushing during seminars, national meetings, medical school
teaching, etc. It is natural to experience sympathetic drive and
dilator hormone release (e.g. cortisol and its cascade) during hour
long speeches, meetings, etc. In fact, you would not be normal if
you did not. Due to my career, my extremely stressful speeches,
class loads and seminars, I opted for ETS. I was a perfect
candidate for this based on symptomology. This did reduce the
remaining trigger down to nill. I do not recommend ETS to rosacea
sufferers (I think in all these years I only recommended it to 3
rosacea sufferers….. out of hundreds). It is the very last form of
treatment for a specific cause of flushing that should not be
considered until the patient has tried every single form of
treatment, endured several years of specific symptoms, etc. In
fact, I am quite concerned that some ETS surgeons are now on the
Internet recommending ETS for rosacea. That is appalling.

5. Finding the right topical cleansers, moisturizers and sunscreens
(and staying away from irritating dermatologist recommended
products) was also instrumental in my normalization process and at
remaining in remission. I cannot put a percentage on this or a
clearance value.

6. I also believe strongly in oral antioxidants (not so much
topical antioxidants). I believe in ester C, grape seed extract,
pycnogenol, and alpha lipoic acid (R) based on their proven
protective and strengthening actions on blood vessel walls. I
cannot put a percentage on these antioxidants or a clearance value.
It is more for prevention and their anti-inflammatory qualities.

As you both know there are dozens of other treatments – oral
medications, topical medications, skincare therapies and
naturopathic approaches that will help the majority of mild to
moderate rosacea sufferers. The above treatments are just the
highlights of treatments that I used for MY specific case.

Take care,

Geoffrey

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