Season 5 | Episode 7

 

 

Joe McIntyre (Host): Welcome to another episode of the Merck Manuals Medical Myths Podcast. On this show, we set the record straight on today's most talked about medical topics and questions. I'm your host, Joe McIntyre, and I'm joined by someone our listeners just might remember. Dr. Jonette Keri, Professor of Dermatology and Cutaneous Surgery at the University of Miami, Miller School of Medicine. She's also Chief, Dermatology Service at Miami VA Hospital. Dr. Keri joined us back in season three to talk about anti-aging and skincare myths. She also helped us dispel some myths about sun protection. We'll link to those episodes in the description of this one. But enough from me, Dr. Keri, welcome back to the podcast.

 

Dr. Jonette Keri: Thank you, Joe. Happy to be here.

 

Host: Great to have you. So today we're going to explore a couple of different topics, one of which is rosacea, and the other is dandruff. We'll also talk about some of the myths and misconceptions surrounding these conditions. So, Dr. Keri, for our listeners who may not be familiar, can you explain exactly what rosacea is?

 

Dr. Keri: Sure, rosacea is a chronic inflammatory condition of the skin that presents with pustules on the face in some, a red face in some, and in others what we call phymatous, or enlargement of the nose or cheeks or chin. And then last but not least, rosacea can affect the eyes and we call that ocular rosacea. It's generally seen between the ages of 35 and 65, but we see younger people and older people also with rosacea. It is not the same as acne, Joe. And I know this is something that comes up, but people can have both. I have acne and I have rosacea. So, people can have both conditions. But rosacea within itself is a different diagnosis than acne.

 

Host: Got it. And I'm sure people with rosacea know the answer to this. But for those who don't, is rosacea painful?

 

Dr. Keri: It can be. It can be itchy as well.

 

Host: And I guess when it comes to acne versus rosacea, are they in the same family? What are the differences there? How are they related, or not?

 

Dr. Keri: So, they're related in the sense that they affect our face. They can also affect our scalp. Believe it or not, we can see rosacea, even on the arms. And acne goes on the chest and on the back. But they're related in that sense, and they're related somewhat in their presentation. A rosacea patient can have pustules on the face, and so can an acne patient. The differences bear out when we look for things like blackheads or comedones, where we look for involvement on other sites of the body, or on the chest and the back, and also age distribution. In general, acne affects younger patients, but we know we see it into middle age and rosacea affects more midlife patients.

 

Host: Does rosacea affect those with lighter-pigmented skin versus those with dark, or does that not matter?

 

Dr. Keri: Yes, more people with lighter skin types get rosacea, but I have seen it in darker skin types, even fairly dark, what we call type five skin, which is the darker black skin. The patient that I'm thinking of off the top of my head was a Caribbean American who had darker skin but also had rosacea. But in general, lighter skin types.

 

Host: Okay. Are there certain foods or drinks that can cause rosacea to flare up, or appear more often, or more severe than at other times?

 

Dr. Keri: Sure. So the bad boy in rosacea, outside of food, is the sun. So, I want people to know the number one trigger, and triggers are important in rosacea, is the sun and along with that, heat. But, when we talk about foods, we know that spicy foods, hot-temperature foods, and caffeinated foods, although generally cold coffee or iced coffee, are better than hot coffee. These are things that can aggravate. Now alcohol is a big one. We know that red wine is the worst of the alcohol types for rosacea patients, and it often comes out, and this has been studied in a nice response survey for rosacea patients; what's the best for them? And actually, beer is the best, so patients will ask me: “Can I have something to drink?”. So red wine is the worst, hard liquor is in the middle, and then beer is the best. That's a common question because people want to be able to enjoy a drink with their meal. So that is something that I tell patients. Other things that can aggravate, you need to look for triggers. Some people will say chocolate, I don't believe chocolate aggravates my rosacea at all. So you look for triggers within yourself, but consistently, spicy, hot-temperature food and red wine are at the top of the list.

 

Host: You mentioned alcohol, is having rosacea the same as when people say they get flushed when they drink, or is that a different experience?

 

Dr. Keri: Let's talk about the one that isn't rosacea so much, flushing with alcohol can occur in certain ethnic groups. Certain Asian Americans will flush when they drink alcohol and that's really different than rosacea. But there are people who might flush with alcohol in their 20s and then develop into rosacea in their 30s or 40s. So it's not always the same thing. But it may be a sort of a harbinger of, or a canary in the coal mine, if you want to say it that way, of someone who may get rosacea later on.

 

Host: Now, is rosacea caused by poor hygiene or a lack of consistent skincare routine? Maybe not cleaning your face enough or cleaning it too much. Is there anything related there?

 

Dr. Keri: I wouldn't really say it's caused by these things, but I can say that such types of care, or lack of care can exacerbate rosacea. For example, if a rosacea patient over washes their face or scrub too hard, it is going to get worse. Also, as far as having a consistent routine, if you use a mild wash, and use a sunscreen. For rosacea patients, we like the physical sunscreens of zinc and titanium; we do not like the chemical sunscreens for rosacea patients because they can irritate. So, if you had a routine with a mild wash, and a physical sunscreen, that can definitely help your condition.

 

Host: Are there any other common questions or myths that you hear in your practice or have heard in your career about rosacea that you want to bust while we're here?

 

Dr. Keri: I think probably the one myth that I have heard is that people who are alcoholics get rosacea, that's not true. There are people who are alcoholics who never get rosacea. But we do know that alcohol is an exacerbator for people who might have a tendency towards it. And that would be one myth that I would say. And not everybody who has rosacea is an alcoholic if I can say that back the opposite way. So, if you see somebody with rosacea, they may be, for example, I had a patient years ago who was a baker; that was her job. So, she was in the oven all day baking from like 3 am in the morning. And the heat caused it, and she didn't drink a drop of alcohol. So, we want to make sure that that myth isn't perpetuated.

 

Host: That’s good. Yeah, being in the oven all day, from what you said, I get that, totally makes sense to cause rosacea outbreaks. So, you mentioned the heat, obviously, as you just said, and then also the sun. So, I imagine, as we know, sunscreen and sunblock is important for everybody. But for those with rosacea, is there anything else different other than using those more natural zinc-based sunblocks that they should keep in mind?

 

Dr. Keri: I think probably when you pick a sunscreen, you want to pick one, even if it says zinc, if it irritates you, you don't want that one. You want one that is zinc or titanium, and that doesn't irritate your skin. So, I always look for ones that say sensitive skin or, might say, for skin that has redness. How do they say it? Redness-prone skin or there's a word that they use. I apologize, I'm blanking on it. But you know skin that is sensitive in nature. So, if it burns, even if it has zinc or titanium, don't use that one, use one that's milder.

 

Host: Makes sense. Let's pivot a little bit to some treatment for rosacea. How do you treat rosacea? What can patients think about or what sorts of treatments do they have that can be helpful in this case?

 

Dr. Keri: Sure, so the first thing is if you can identify a trigger, you want to avoid it. If you're worse after, let's say having three cups of hot coffee in the morning, then maybe you want to decrease your amount of coffee or make it an iced coffee. So first, avoid your triggers. Second, have a nice bland skincare regimen, a nice bland moisturizing wash and a sunscreen with zinc or titanium or both. Actually, we like both together but if not, zinc. The next thing I would say is topical medicines that you could get from your dermatologist. The next step beyond that, we often use antibiotics because it is an inflammatory disease, not using the antibiotic as an infection. And I want to make sure that people understand that. Antibiotics have other properties besides being antibacterial, they can be anti-inflammatory, and that's why we use medications in the tetracycline class of medicine. And specifically, doxycycline is a nice one to use for rosacea. That being said, people don't want long-term antibiotics, there are low-dose formulations that act as anti-inflammatory agents, and those are good long-term. So you could do that.

 

Other things that we use, sometimes if somebody has severe rosacea we will use isotretinoin, which is a medicine for about six to eight months, sometimes we will use that. You may know that, as formerly available in the United States, branded Accutane, isotretinoin is a good way to treat severe rosacea. And then last but not least, we are getting more into the physical sort of modalities, which in our world, in dermatology, means lasers and lights. People use those to treat more the redness part of rosacea, but they can also treat the phymatous changes, the thickening of the nose, they can treat the pustular changes. In general, those are something that patients have to pay for out of pocket and aren’t covered by insurance. And I, not being a cosmetic doctor, usually go to the traditional treatments first.

 

Host: Makes sense. Now, when you're taking these medications, or you're just starting, maybe a patient is just seeing you for the first time, how long can they expect this treatment, or these treatments to take before they start seeing results?

 

Dr. Keri: So I generally tell patients, if you have a rosacea flare, the flare can last up to three months. And a lot of people get worried - they think it's going to be better in a week or two. So, a flare can last up to about three months. We hope it doesn't last so long. And the goal is always to calm the flare and then get the patient on a nice maintenance routine.

 

Host: I have a guess, but you tell me obviously. Is there a known cure for rosacea?

 

Dr. Keri: No, but we can definitely get it under control.

 

Host: That's a relief, I'm sure, for a lot of people, so that's great to hear. So, Dr. Keri, if our listeners are looking for more information about rosacea, how to treat it, or any questions they have about it, where should they go?

 

Dr. Keri: I would go to this podcast or the consumer version of the Merck Manual. I think it's a great resource for many medical conditions. So that would be my go-to. Another reference for the rosacea is that there is a group that I'm a part of called The American Acne and Rosacea Society, and they are a good resource. In addition, the National Rosacea Society, so there are two physician-run groups that want to provide patient education. So, the American Acne and Rosacea Society, and the National Rosacea Society.

 

Host: Thanks for that, Dr. Keri. Let’s pause there for a second, but when we come back, we’ll dive into another skin-related issue, with plenty of myths and misconceptions to bust.

 

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Host: So we're back with Dr. Keri here. When we first started this podcast, you mentioned two separate topics. One is rosacea, and the second, which we're going to talk about now, is dandruff. I think a lot of our listeners, Dr. Keri, know what dandruff is, or they think they know what it is when they see it. But can you explain what exactly dandruff is?

 

Dr. Keri: Sure. So, almost everybody has a little bit of dandruff at one point or another in their lifetime. As a child we know it as cradle cap. So, with respect to dandruff, dandruff is a condition where we all have yeast on our skin, and it's called Malassezia. And Malassezia overgrows on some people on their scalp, sometimes in their eyebrows, in their beard, sometimes even on their chest and their back. So why does it overgrow? Well, mainly, it's because of oil. And people think it's a dry scalp, or you might call it oil, but I might call it sebum. So this overgrowth of this bacteria that we have on all of us then causes the skin to say, “Why is it there?” and “This isn't right,” and it becomes an inflammatory response. And the skin says, “I want to get rid of this,” and you get an itchy scalp if that makes sense. So, in general, and this may be one of your future questions, we like patients to wash away the oil and wash away the Malassezia.

 

Host: Yeah, I think that was the next question I was going to get into because I think there's a lot of confusion about whether dandruff is related to dry scalp or oily scalp and how they're different. Are those two separate conditions and maybe you can explain how dandruff works versus other similar conditions that people may be confused about.

 

Dr. Keri: Sure, so in general, when you see what people are calling dry scalp, in general, more times it's going to be seborrheic dermatitis which is aggravated by the sebum or oil. There are other conditions that can mimic seborrheic dermatitis on the scalp, and they are less common on the scalp. So, the most common thing is what would dermatologists say is Seb DERM or seborrheic dermatitis -  what are the conditions that mimic psoriasis. Now psoriasis is more of a thicker adherent, white scaling plaques on the scalp. You may also see it elsewhere on the body. You might see it in the elbows, you might see it on the knees, you might see it on the hands. So, psoriasis makes more of these thick confluent plaques. That's one thing that can mimic it.

 

Also, atopic dermatitis, which listeners may know as eczema, and eczema can also affect the scalp sometimes, but then again, you might not see that, you might see it on the face, you might see it in the crux of the elbow where we bend rather than on the elbow itself on the inside part of the elbow. Or you might see it behind the knees rather than on the knees, and this is atopic dermatitis or eczema.

 

So, in reference to dry scalp, I think in general—and I actually did a PubMed search before I got on just to see—dermatologists hardly ever call anything a dry scalp; we call it by the condition. So, we say seborrheic dermatitis. Dry scalp can occur, and there are people who just have dry scalps. But in general, washing the scalp does not make things worse; it actually can make things better.

 

Host: I'm sure that's helpful for a lot of people. I was going to ask. I think there's a lot of folks and a lot of conversation about how often you should wash your hair, how often you shouldn't wash it, whether every day is too much, and whether it should be every three days. I'm sure it depends on each individual person. But you tell me, what is the recommendation when it comes to shampooing?

 

Dr. Keri: So different ethnic groups and different hair types wash hair differently. If you're African American, you may wash your hair once a week, and that's fine. And if your dandruff flares up or your seborrheic dermatitis flares up, then you might want to use a medicated shampoo once a week, and then in between, you might want to use, for example, a scalp oil, a prescription topical steroid oil.

 

I'm Caucasian, of Hungarian descent, and I wash my hair every day and I also have seborrheic dermatitis, to keep my seborrheic dermatitis away. So, it depends on the hair type. Generally, what I tell patients when they come in, I ask them, “how often are you washing your hair?” And if they have a skin type like me, and they're washing their hair once a week, I suggest to them that they should wash their hair maybe every other day and maybe even every day. So, you look at the hair type, you look at the scalp itself. And then what you want to do is you want to generally increase the frequency, whatever the frequency may be, you want to increase the frequency. So I think it's a myth to say that if you have a dry scalp, you shouldn't wash your hair. That gets a lot of patients into my office, and I'm telling them the opposite of what people have told them forever. So, I tell them to wash more frequently.

 

Host: Very, very helpful. Are there certain times of year that these conditions, dandruff, are more common, that you see more often? Cold weather, hot weather, more prone to be sweaty, dry air, what is the commonality there?

 

Dr. Keri: So, dry temperature usually doesn't aggravate it. It's usually moisture, humidity, sweating, people who maybe work out but then don't wash their hair afterward, and things like that.

 

Host: That makes sense. Are there certain shampoos that you recommend? Again, like you mentioned, certain people may need certain types of shampoos, but I'm sure everybody's heard of the name-brand dandruff relief shampoos. Are they effective? What is the recommendation there?

 

Dr. Keri: They can be very effective. Many people can control their seborrheic dermatitis and their dandruff with over-the-counter shampoo, Parathion C, and Ketoconazole.  There are some coal tar shampoos. There are some salicylic acid-based shampoos. So many people do just fine with those. However, if you're not getting better, you may want to see the dermatologist for a prescription shampoo, and we have higher-strength ketoconazole shampoo. We have something called Ciclopirox. We have some higher-concentration selenium sulfides that we can use. In addition to that anti-yeast component, which we've just talked about. You can also use topical steroids on the scalp that calm down the inflammation and the itching.

 

Host: Are there certain types of hair products, such as conditioner, hairspray, hair gels, and other hair products, that cause these oils to build up more?

 

Dr. Keri: You know, I haven't seen hairspray be that bad of an aggravator. And I haven't seen hair gels because the hair gel residue usually is on top of the hair and you'll see it on patients. And you look at their scalp and their scalp is clear. I think it, in general, goes back to washing; wash away whatever product you put on.

 

Host: Makes sense. Is dandruff a contagious condition?

 

Dr. Keri: No, it's not contagious. So, you're good. We all have it on us but then some people just have that environment where Malassezia overgrows.

 

Host: Yeah, I think there is, and I'm sure you see this, a stigma around dandruff and people seeing flakes on their shirts or dark clothing or whatever it may be. But from what you've said today, it seems like there are plenty of treatments. People just may need to seek out someone like you, a doctor like you to help them out with it.

 

Dr. Keri: Exactly. And that was going to be my final wrap-up point: If you're not getting better with over-the-counter treatments for either condition, rosacea or seborrheic dermatitis, seek out a provider, a dermatologist. If you can't get to the dermatologist, or the primary care doctors, they're also very good with treating these conditions.

 

Host: Yeah, one final question from me on screening and treatment. Should patients, or should folks who maybe are struggling with dandruff, do a bit of a guess and check with trying different shampoos and see what works? Or should they go right to the source and go right to their physician to see what they think before starting any sort of dandruff shampoo?

 

Dr. Keri: I think they should try themselves first. I'm going to be quite honest with you. Going to a doctor takes time out of workdays, it costs money with copays. If they can get by with an over-the-counter treatment that works for them first, I would say go for it before you take the time to go to the physician.

 

Host: Dr. Keri, if our listeners have questions specifically about dandruff or any other conditions along that vein, where should they go for that?

 

Dr. Keri: I would say for dandruff, you can find a lot of very good information from this podcast of course, but also from the Merck Manual Consumer Edition.

 

Host: Dr. Keri, thank you so much for joining us on this podcast; really great conversation busting some of the myths surrounding rosacea and also around dandruff. As we close out. I'll let you leave our listeners with the final word.

 

Dr. Keri: If something bothers you on your skin or your scalp, seek out help if you need it. We want you to put your best self forward and we want to help you get there. In addition, medical knowledge is power, pass it on!