ASK THE DOCTOR: My daughter's flushed face is ruining her life 

By Martin Scurr for the Daily Mail

Published: 17:11 EST, 7 September 2015 | Updated: 17:11 EST, 7 September 2015

My daughter, who is 46 and has two children aged eight and 12, has rosacea. Apparently, the only treatment is antibiotics, which she refuses to take. Her dermatologist has suggested blood tests to see if the problem is linked to hormones. The rosacea is having a detrimental effect on her everyday life, causing great stress. I would appreciate any advice.

Mrs P. Morgan, Swansea.

Dermatologists and GPs can usually diagnose rosacea just by looking at the face [file photo]

Rosacea is a common chronic skin disease, usually affecting the face. We don't really know what causes it, but it may be a disorder of the immune system, or an abnormal response to sunlight or to microscopic mites or bacteria on the skin, or a combination of these factors.

There are four patterns of rosacea. One is persistent redness or temporary flushing in the face; another is papules (red bumps) or pustules (pus-filled spots) that can be mistaken for acne. The third type involves thickening and distortion of the skin. Finally, there is ocular rosacea, which leads to red, irritated eyes and recurrent styes.

Dermatologists and GPs can usually diagnose rosacea just by looking at the face; a skin biopsy is rarely necessary.

Brimonidine is the first medicinal product approved to treat the facial redness of rosacea [file photo]

Nor have I heard of anything to be gained from testing hormone levels, as there's no evidence that rosacea is caused by hormone problems (although patients with other symptoms - such as joint pains - may require blood tests to check for the auto-immune condition lupus, which can also cause facial rash).

Good skin care is essential for all types of rosacea. Emollients (plain moisturising creams) help repair the skin's normal barrier function and can reduce dryness and discomfort. Only lukewarm water should be used to clean the skin - harsh scrubbing, toners and astringents can make it redder.

For inflammatory papules, topical treatments such as metronidazole (brand names Metrogel or Rozex) or azelaic acid (Finacea) can help. It's thought they have an anti-microbial, anti-inflammatory or antioxidant effect.

Alleviating the facial flushing involves reducing the triggers - it's caused when blood vessels expand excessively in response to factors such as extremes of temperature, sun exposure, hot drinks, spicy foods, alcohol, exercise and changes of mood. Laser treatments can also improve flushing, redness and visible blood vessels. They shrink dilated blood vessels but are not a cure and can cause abnormal pigmentation, blistering and even scarring.

Oral antibiotics (to reduce the inflammation) and the potent drug isotretinoin, also known as Roaccutane (which acts on skin secretions) are usually used for the most severe cases and are prescribed by a consultant dermatologist.

I am sympathetic to your daughter's reluctance to take antibiotics long-term, and I am glad to report the arrival of a new treatment, brimonidine, which was originally developed for the eye condition glaucoma.

There is strong evidence for its use in rosacea and it's now available on prescription.

Applied as a gel (brand name Mirvaso), it acts on receptors in blood vessels in the skin, restricting their dilation. It can be used long-term, though care must be taken in patients with heart disease and other vascular problems as trace amounts of the drug will be absorbed into the system, which could cause a catastrophic drop in blood pressure in some.

Brimonidine is the first medicinal product approved to treat the facial redness of rosacea, but your daughter may not have been offered it. It's expensive, costing the NHS £33.69 for a 30g tube. But because it's so effective, some specialists suggest only using it for days when the patient is particularly concerned about their appearance.

I hope your daughter's GP will allow her to try it.

For the past 12 months, I have suffered stress and anxiety. This has led to the return of various ailments I have experienced in the past, ie migraines, irritable bowel syndrome and acid reflux. I now also get tension headaches that cover the whole of my head and last for hours, sometimes days. Nothing seems to relieve them. Also, recently, I have experienced a sharp shooting pain in a localised area of my head, usually the top front, right-hand side. This only lasts for seconds but the area remains sore, especially to the touch, for hours. My GP thought it was probably caused by stress. I am 72 and take nortriptyline for the anxiety.

Name and address withheld.

There is a strong correlation between migraine and depression - 60 per cent of people with chronic migraine require treatment for depression at some stage [file photo]

It's a long-standing principle in medicine that the most important part of the history is either the last thing that a patient says as they leave the room, or the very thing that perhaps they do not tell you. After reading your detailed letter, I am concerned about the events that led up to the 12-month history of stress and anxiety you describe, but about which you don't go into detail.

A feeling of being stressed, with a sense of being unaccountably anxious, is an important symptom. It can be the consequence of life events, of persistent adversity, but also it can be a symptom of depression.

Your description of a recurrence of past ailments, in particular the description of long-lasting headaches not eased by pain-killers commands my attention. My view is that these headaches are almost certainly a variant of migraine.

There is a strong correlation between migraine and depression - 60 per cent of people with chronic migraine require treatment for depression at some stage.

Just as migraine is a disorder of brain function, each episode being set off by certain trigger factors in genetically susceptible people, so depression is a disorder of brain function, ignited in people who are prone, genetically, by a range of factors ranging from bereavement to chronic illness to hormonal changes, to viral illnesses such as shingles or flu.

This is why I am interested in the details of your history prior to the time you started to experience stress and anxiety symptoms.

Do bear in mind that depression is not the same as sadness. Depression is a whole-body illness with many different, very physical symptoms, as well as with an emotional aspect which may tie in with your history of IBS, acid reflux and headaches, all reawakened by your recent experience of sensations of stress and anxiety.

I am heartened that your GP is treating you with nortriptyline, an effective antidepressant medicine.

This may take some weeks, if not months, to achieve its best effect, and an increase in dosage may be required with 25mg three times daily being adjusted up to a maximum of 150 mg daily.

I hope you make good progress.

By the way... Let doctors take the lead on 7-day NHS

Regular readers will know I like to bang on about how little we learn from history. This time, my focus is the attempt to reorganise NHS hospital doctors - specifically the most senior and experienced, the consultants - into a seven-day working regimen.

This has been driven by research showing people admitted to hospital at weekends are more likely to die than if admitted on a weekday.

As a GP who has spent four decades observing, and being part of, the lurching progress of the political football we call the NHS, I remember an oft-repeated quote: 'We trained hard, but it seems that every time we were beginning to form into a team, we would be reorganised. I was to learn later in life that we tended to meet any new situation by reorganising - and a wonderful method it can be for creating the illusion of progress while producing confusion, inefficiency and demoralisation.'

A key feature of the downhill slide within the NHS has been the removal of power and leadership from the hospital consultants.

When we had an apprenticeship system, where the consultant was in charge of a team and provided inspiration, teaching and discipline, seven-day working was the norm.

Sure, support services, such as radiology, were reduced at weekends, but experienced clinical care was provided day in, day out.

But endless hospital reorganisations (often politically motivated to disempower those troublesome senior doctors who insisted on certain critical standards), plus imposed changes such as the European Working Time Directive, have left in their wake confusion, inefficiency and demoralised staff.

The only way seven-day working will work, at least in some areas, is with staff goodwill - but that is not an endless resource.

The solution: return the power, status and ownership to senior doctors by cutting wasteful management and listening to the experts of the Royal Colleges.

I do not know of any consultant specialists who, once back in charge, would not give their support and make their teams available for a seven-day culture.

It's what we signed up for when we became doctors.

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