Ananda Mahony - A Naturopathic Approach To Rosacea_en (auto-generated)
hello my name is Ananda mani and today my topic is a naturopathic approach to rosacea the why for this talk is that I see a lot of patients in clinic with rosacea but also it's personal through my 20s and early 30s I suffered from a rosacea um type one rosacea and it took a while to find the strategies to work my way through and out of that condition so today I'll talk to you about some of those strategies where the research is at which is pretty Grim when it comes to rosacea but I look also some translational ideas around what are some of the mechanisms that are driving rosacea and how can we apply nutrients or herbal um to those mechanisms to get good outcomes for the patients we see in our Clinic okay so let's talk a little bit about rosacea itself it's a chronic inflammatory condition it impacts between 2 to 5% of the population it's more predominant in women and women over condition that probably burbles along below the surface we say some flushing blushing propensities but it takes a while to see the fixed changes in the vasculature of the skin and so we see the condition itself emerging at a stage where it could be diagnosed in those third or fourth decade of Life the diagnosis is clinical there's no histological or serological markers that indicate the presence of the condition So it's b done based Bas on what's happening with uh the patient presentation and their medical history and the presence of one or more primary features necessary for a diagnosis such as flushing or non-transient aemma papules or pules um abnormal dilations of venules or capillaries and fattis changes in ocular symptoms acne I'm sorry it can be infused with other sorry it can be confused with other conditions such as acne or perioral dermatitis or soric dermatitis but usually you'll see other features that aren't commonly seen in those conditions for example with acne you'll see the pap Papio and pasture but you'll also see that flushing blushing tendency which you don't see with acne okay and there's also secondary features that may be present such as those ocular symptoms burning or stinging Sensations dry rough appearance of the skin and you can see them there on the slide so rotation classified into four subtypes and the first subtype is that facial redness and flushing and that's uh characterized by persistent skin redness then there's papulo pular racea which is subtype 2 and you see still the flushing blushing but also seen with bumps and pimples third subtype is fadus rosacea which is characterized by thicken skin and scars making it look bumpy or swollen and this type is most common in men we we also see Rhino so there's changes associated with that characteristic bumpy red bulbous nose and then ocular rosacea and you can see that diagram there the eyes appear watery red bloodshot and they might feel burning irritated or dry so the pathogenesis of rosacea is complex and it involves a variety of factors which can trigger both the vascular and the inflammatory factors seen in rosacea the genetic factors well they they haven't been pinned down completely but we do see genetics that are associated with greater levels of Rea oxitive greater levels of reactive oxygen species in the Skin So then that driving some of those skin changes potentially we also see some vitamin D Snips and even some HLA Snips that are associated with other autoimmune conditions and even though rosacea itself is not an autoimmune condition we may see that common um genetic pattern there the other things that are associated with the um pathogenesis is neurogenic disregulation there's immune system disregulation there's um disbiosis of both gut microorganisms and skin microorganisms are common um with the skin there's barrier function impairment and sebaceous gland dysfunction and of course there's the inflammatory response which plays a major role in the development of rosacea so the triggers and there quite a few known triggers which result in that flushing blushing propensity and that flushing blushing plays a vital role in the development of rosacea and as I said it's often present a long time even decades before a diagnosis of a rosacea is um confirmed um most significantly we see sun exposure um and that is common to 81% of people with rosacea but then also emotional stress along with those others on the slide we see humidity hot weather um spicy foods Etc but that emotional stress is the one that is most um commonly associated with the blushing rather than the flushing and that can affect or amplify rosace by modulating the hypothermic pituitary adrenal axis and releasing neuropeptides or neurotropins or lymoc kindes from nerve endings and dermal cells which then go on to of course further that Ros picture with the immune system there is significant immune disregulation and um I'm going to basically talk to this slide a little bit um first of all the innate immune system there is an augmented innate immune response and this leads to the upregulation of a pathway called the catholicon pathway that pathway then has Downstream inflammatory and physiochemical Cascades so in the skin of people with rosace there's higher levels of tollite to receptors and that's a danger recognition pathway it leads to an augmented danger recognition in the skin in response to a trigger such as UV light or spices and its signaling is involved in inflammatory Pathways and so once those inflammatory pathways are triggered by The tolik receptors there's upregulation and release of protolytic enzymes and we can see there on the slide mmk sorry MMP which is metalo Matrix metaloproteinases k5k um and that is calic related pepti a Cathy lidin pathway and its related peptide ll37 so ll37 and Cathy lidin act as inflammatory signals and they drive angiogenesis and stimulate the vef pathway which promotes the vascular changes that are seen in rosacea the role of mass cells is also key to rosacea mass cells are one of the major sources of Cathy lidin and klk5 in the skin and they are highly active in rosacea patients and in turn uh the release of ll37 exerts a powerful stimulus of the mass cells so we see M cells um stimulating the release of ll37 or stimulating the Cathy liin pathway and as such ll37 and ll37 in turn activating those mass cells so it's a kind of downward NE negative spiral once that pattern gets set off and this drives this inflammatory soup in the skin of rosacea patients and from there we see the changes in the skin vascular to responsiveness and then fixed physical changes in skin vasculature which is characteristic of rosacea the Adaptive immune system is also disregulated but the involvement of the Adaptive immune system is less well understood than the relevance of the innate immune system but what we do know is that this te- cell response is dominated by T helper 17 cells and there is an increase in interlan 17 as a result um we also see B cell mediated responses and we see an accumulation and activation of dendritic cells with over expression again that drives more il7 cyto kindes and it's these il7 cyto kindes and the elevated elevated levels of them in rosacea patients that have been linked to the formation of new blood vessels and then of course the induction of ll37 and again we see this link into driving more inflammation so with rosace PA with rosacea patients there's multiple Pathways in the skin that all Drive inflammatory responses that then go on and drive those changes in the vasculature of the Skin So looking at the neurovascular dysfunction and first of all the trigger and that trigger as we looked at there were some environmental triggers or also we could consider microbial triggers which I haven't discussed but I'll go on and discuss more but one of those that's well known is dermedex and so those triggers lead to increased skin blood flow angiogenesis and vasodilation and there essential to the process that drives rosacea and they are demonstrated in those typical clinical features such as facial athema and flushing and a key driver of this process is the activation of transient receptor Pro potential channels and there's two that are key to um rosacea and that's the trip V1 and the trip A1 and these channels activate sensory nerving endings in response to for example spices or alcohol or temperature changes and it leads to to the release of vasoactive neuropeptides such as amongst others substance P or calcitonin Gene related peptide these then in turn Drive inflammatory responses in the skin and vessels by activating mass cells macrofagos n nutrifil and tea cells and so you can see they feed into that innate and adaptive immune responses in the skin and an increased and prolonged expression of these trip V1 or trip VA um potential channels in rosacea results in facial flushing we also see then the disregulation of vascularity and neurog neurogenic inflammation and this is a part of the development of the fixed changes in vasculature which leads again to that persistent aemma or larged vessels or dilated vessels in the skin looking at the role of the gut skin axis in rosacea there is a high prevalence of um helicobactor pylori biosis small intestinal bacterial overgrowth inflammatory Bell disease and Celiac in patients with rosacea and if we just look at a dis biotic State such as sibo it's associated with intestinal permeability or leaky gut and that allows for movement or translocation of bacteria that should stay in the gut and or harmful components of bacterial origin such as lipop polysaccharides or lbs to move from the gut and out into the bloodstream so those components on they're in the once they're in the bloodstream can actually stimulate the immune system leading to say hyperresponsiveness of B cells or impair differentiation of tea cells but they can also directly reach the skin and impact skin physiology pathology and immune responses within the skin and in for example sibo in patients with rosacea has been linked to higher levels of inflammatory pyocin including tnf Alpha in addition I with uh to a dis biotic State and kind of that bacterial translocational leakiness there tends to be less production of um compounds such as butyrate in the gut and butyrate has that powerful anti-inflammatory effect as it suppresses immune responses and it does that by reducing cyto kind production of inflammatory cells and so we see more proinflammatory and less anti-inflammatory capacity of someone who has that gut skin acid access issues when they have rosacea as well we look at the pathophysiology of rosacea it involves the activation of skin immune and nervous systems in response to physical chemical or biological triggers such as um UV um sun exposure or spices and so these gut disbiosis driven changes could actually be one of those triggers and could lead to disease progression increased severity flare ups and even sustain symptomology and there is a little bit of research in this space there's some big correlational research showing that helicobactor pylori is seen in patients with rosacea and sibo is seening patients with rosacea but from a causitive perspective we need to look a little bit deeper but one of the research papers that came out was a three-year follow-up study and it it was in 2016 and it evaluated the role of sibo in the path of physiology of R and it showed that CBO treatment with refaim LED to clinical remission of rosacea in all participants in the trial and that persisted for the majority throughout the follow uh threeyear follow-up period and interestingly this study showed that the risk of sio is significantly higher in papular pular rosacea than the other subtypes and so that's subtype 2 so when you've got a patient presenting with subtype 2 rosacea you may um choose to investigate a little bit more deeply whether any of these gut skin issues may be part of the problem however I would generally state it is worth investigating the role of the gut in any presentation of rosacea helicobactor helicobactor pylori may also be a concern for rosacea and it's sought to uh progress rizia by increasing reactive oxygen species both in the gut but also in the skin and that can alter physiological processes in the skin including vasodilation inflammation and immunomodulation and we've seen that those changes can lead to the characteristic um flushing blushing and changes in the vasculature of patients in rosacea so certainly an area to focus on is that gut skin axis looking at sebaceous and Skin Barrier dysfunction we see sebaceous gland hyperplasia in fattis rosacea and this can lead to that thickening of the skin that's seen in this subtype and in patients generally with rosacea we see a shift in the fatty acid profile um of the spaceous secretion and we see a decrease in longchain saturated fatty acids that leads to skin dryness because there's less of that protective layer and more epidermal water loss and increased hyp sensitivity due to that lack of protection and more things getting directly into the skin and having the potential to impact them we also see micro Rial skin imbalance and this is likely because of Skin Barrier Integrity issues so we see either growth not just of dermedex but also of cutie bacterium acnes stap coccus epidermis and basilis alonis those are all hard to say fast these pathi likely play a role in the pathogenesis of racea by driving inflammation directly and indirectly by altering seum levels then to Skin Barrier integrity and that skin integrity acts as a barrier to microbes on the skin to toxins or even ingredients such as essential oils that might be in you know skin care products and to physical stress or such as UV radiation and it's also associated with this greater Skin Barrier leakiness so we have the potential for gut barrier leakiness and we also see Skin Barrier leak and this leak leakiness as I said it leads to loss of water and dryness and then hypers sensitivity which is commonly seen in rosacea skin there is an association with metabolic dysfunction and rosacea and it has been associated with dysliidemia obesity thyroid disorders and diabetes and there is potentially common mechanisms and so whether that's correlation or causation we don't know but there are common drivers or mechanisms that we see both in metabolic dysfunction and rosacea and they are increased levels of Cathy lidin and inflammatory cyto kindes so we see them driving both conditions which may mean that they independently develop but those mechanisms drive them both or that there is some crossover um with metabolic dysfunction furthering um worse outcomes for rosacea and I guess part of that story is um when we look at the research that there's a higher potential for insulin resistance in metabolic uh syndrome generally in patients with rosacea so lean in and again look for that in your patients particularly as they we see a rise in metabolic dysfunction in the third and fourth decade of life and that's when we also see rosacea being more likely to emerge of course inflammation is a big factor but I think stress induced chronic low grade inflammation might be the common soil of skin conditions like many other inflammatory skin conditions rosacea begins with the perception of external physical chemical or biological stimula by the Skin's nervous and immune systems and part of that picture is corticotropin releasing hormone and it's a central coordinator of the neuroimmune responses in the skin and it also participates of course in HPA AIS hypothermic pituitary adrenal axis activity and can has a potential if you like to promote Mass cell degranulation and increased vascular permeability so we see it potentially higher levels of CRP in the skin um pushing that inflammatory soup that is commonly seen mosaa so I guess generally what I would say is when we see a stressed person with rosacea we also consider stressed skin and I will I don't know that I've got this in the notes but one of the key ingredients that can or key herbs that can lower levels of cortico tropen releasing hormone in the skin is eonia so it's great for supporting the immune system but it will also reduce that stress skin picture looking at some holistic treatment strategies one is uh the first one I think can um primarily support vascular Integrity we need to stabilize and support the blood vessels in the skin to slow or reduce progression uh of course avoiding known triggers um reduce inflammation and immune dis disregulation address skin and gut microbial imbalance reduce sebaceous and Skin Barrier dysfunction I think put here support stress responses but also emotional health because having a skin condition that is inflamed and red and obvious to the whole world also has impacts on quality of life and we see this in research about all chronic skin conditions that it significantly impairs quality of life of the PE people who are affected by it support High Health to reduce progression and that's from type three to type four quite often we'll see that progression um and so we can actually slow that whole process down but also a generally support Eye Health and address metabolic issues if they're identified so some ways to do that first reduce flushing and we can do this by supporting vascular integrity and uh there's only a little bit of research as I said in the space about rosacea and oral um dosing of herbs or nutrients but one of them and this is commercial research looked at this product that's listed there on the page on the slide and it was a turmeric poly herbal combination and it was shown that supplementation over a 4we period improved facial redness the interesting thing was they had the turmeric poly herbal combination they had a placebo but they also had a straight turmeric arm and the turmeric arm and the placebo arm showed no r reduction in facial redness after 4 weeks it was only the poly herbal combination and so I looked at that poly herbal combination and what I pulled out of that is that IT addresses many of the mechanisms that we see um that are underlying drivers in rosacea so herbs like hemidesmus might have an immune modulating effect things like goaa will work on that vascular support and microcirculation and then we've got turmeric and licorice who for anti-inflammatories and then and things like Al and philanthus which provide that digestive support so we could see that and I'm certainly not recommending that you go out and find this tablet for your um uh for your rosacea patients mainly because it's not an Australian product but we could easily replicate something similar that addresses the mechanisms that underly um or that drive rosacea by looking at immun modulating herbs supporting vascular Integrity supporting the gut health and reducing say sibo or helicobactor and having an anti-inflammatory effect the next level of research or the next um dot point there is about um Goa Cola and uh it is a useful herb that has uh microvascular support but also reduces the inflammatory response and it's shown to do that in a small study in patients with rosacea often the research is done on topical um approaches and if we have a look at here there's a couple of topical options all which have a little bit of research behind them so this one was a um 2.5% of egcg which is a cakin of green tea over a 6E period and that reduced athema and those changes to the microvascular that was antioxidant imuno immunomodulatory photoprotective and antien it also reduced inflam and suppress vef expression and that was a double blind Placebo control trial in and that showed benefit there another study that has shown benefit was the combination topical combination of Sly Marin and MSM or methanol sulur methane and that was used over a one month period and we saw more symptom control there they didn't talk about mechanism but it reduced itching redness and papules and I think only four weeks of application and I also think this about the topical um sorry about the oral poly herbal combination four weeks is a relatively short amount of time to see some good outcomes other and I'll just go to the next slide for this other combinations that have been studied are grape seed extract and these are all topical vitamin C and aoic acid and as isic acid is one of the standard medical treatments for rosace now but tropical vitamin C and grape seed extract in combination with bre veratrol green tea and polyphenols and caffeine have also shown to be beneficial what I'd say about any of these topical approaches is often rosacea skin is very sensitive um uh to any topical application so test first patch test for 48 hours before you get your patient to use anything in an ongoing way just to make sure that there's not flares other ways to reduce flushing is to avoid dietry triggers as discussed heat causes direct vasid dilation and stimulates the trip V1 channels which are implicated in Flushing stinging Sensations and sensitive skin so if your patient finds at hot foods or beverages are part of the problem they best avoid them and usually your patients will know what triggers there are but if they don't are a food trigger diary can be helpful other food categories include cinnamon alahh rich foods or capin rich foods alcohol is a classic one caffeine is interesting because it may have protective effect as a vasoconstrictive agent but as a hot drink it may trigger those trip V1 receptors so iced coffee may be beneficial in that case looking at histamine it causes cutaneous vessel dilation and the histamine receptor hs2 sorry H2 and H3 have been found to be upregulated in Rosia skin and they contribute to that hypers sensitivity and as always facial flushing now I consider histamine may be local it may be more local than systemic and so you may be dealing with local histamine issues rather than Global histamine issues in a patient so before putting them on a whole low histamine diet it's assess whether it's actually a factor or whether it is more Mass cell um strategies that you work with rather than cutting a large proportion of their diet out I'm very much against restrictive diets and so I prefer to excuse me only avoid the foods that the patients have to avoid and in meanwhile have a diverse and Rich diet that will feed that good healthy um gut microbiome high fat diets may be a problem which is associated with type one and type two so have a look at that it may also be a factor in metabolic indices or um for patients where metabolic um issues are contributing to their rosacea and as we saw the types of fats that um patients are eating may be contributing to the seen production uh Dairy may be protective and I found that interesting although I will comment here that it needs to be good quality Dairy so it may be a you know a natural tubs set yogurt rather than a lowfat sugar-free typ of of yogurt because when they take out the fat and the sugar they put in a whole lot of chemicals so that's more like a chemical storm in a tub rather than natural yogurt neurovascular support I think is an area that um naturopaths Can shine because yes it's avoiding triggers such as emotional stress and I found that was a big factor for me um so it was that I had to learn to manage emotionally in say um um group environments or in social engagement but it was also through supporting my nervous system through supporting stress regulation or resilience and HPA actess disregulation and I think that we really excel in this area as naturopaths and nutritionist I have put just some ideas but it's by no means extensive I also think we need to encourage our patients not just to take herbs and supplements but also to build their own stress resilience yoga meditation ta Chi mindfulness based stress reduction are some of those factors that might um support quality of life and indeed apart from building stress resilience they also have the potential to lower inflammation and a review of 26 randomized control trials looked at the effects of Mind Body Therapy specifically yoga meditation and Tai Chi and they looked at what effect it had on circulating cellular and those genomic markers of inflammation and overall there was a decreased expression of inflammated related genes and reduced signaling through NF Kappa B in patients or participants in that in those trials that had practiced for an extended period of time and generally it's 8 to potential mechanisms for these effects that reduction of inflammation is through alterations in the ne endocrine neural and physiological processes as well as behavioral processes so I think really um looking at some of those mindfulness-based stress um approaches or yoga meditation and taii can help with reducing anxiety but also acceptance of skin appearance looking at immune disregulation and inflammation and firstly just the role of mass cells and as I said they play that role in the inflammation um uh pathogenesis of rosacea they lead to the flushing the changes in vasculature and the formation of papales and pastures so uh looking at cistin because it reduces M Cell Activation and histamine we can consider lactobacillus parasia because it reduces inflammation in the sken in the skin by decreasing inflammatory cyto kindes and activating te regulatory cells I love Ginko and I think about it in this case as a skin anti inflammatory it inhibits VF reduces inflammation and promotes a net anti-inflammatory effect in the skin and it's also really great for supporting circulation and skin microvascular turmeric uh I think the jwy is out on that one particularly as a solo but maybe as part of a combined comprehensive or comprehensive herbal approach as and as an anti-inflammatory yes it may have benefit we want to specifically go after Cathy lidin and lower cathelicidin and therefore those Downstream inflammatory drivers and so cistin again and Bal skull cap because it reduces Mass Cell Activation and Cathy lidin release and then Vitamin D it re helps regulate cathd and expression so testing your patients to see where their vitamin D is at and making sure that they have sufficient levels we want to reduce immune disregulation andrographis is a good one here echin talked about its role in low cortico TR and releasing hormone before um so reducing stressed skin and astralis are just some of the recommendations and the things that I use in clinic and then um antioxidants and there was some research in with zinc vitaminc and selenium with 30 patients with stage one rosacea 15 were given the standard treatment which was antibiotics and antihistamines and 15 were given long acting vitamin C zinc and selenium in addition to the standard treatment and the group that received the supplement experiened less redness and frequency of reoccurrence and that's a good start um and then of course I include an antioxidant Rich diet and in particular red orange and yellow foods can really support skin health and lower reactive oxygen species in the [Music] skin looking at the microbi skin and gut I am not really going to SP talk to the detail of this slide I will just say that I have focused on in my clinical practice quite often berberine containing herbs um because they also are useful for managing insulin resistance and some of those met metabolic conditions um as well as that picture of uh small intestinal bacterial overgrowth but I think you'd choose herbs based on the specific presentation if they were indicated certainly I like prebiotics and probiotics to build up the health of the gut that anti-inflammatory rate we may give digestive support and epithelial support and of course um those nutrients that support the lining of the gut and reduce gut leakiness also reduce Skin leakiness So vitamin A and zinc and vitamin C looking at Skin Barrier Improvement these are quite specific vitamin B3 and uh it's been moderate um amounts of of topical vitamin b3.
been shown benefit for Skin Barrier function and you will hear patients report back when they have oral B3 that their skin is holding moisture better so uh I will often use either topical and or oral um vitamin B3 where I think there's um Skin Barrier function issues um B3 is an anti-inflammatory when applied topically and oral use supports that topical use and oral use is also photoprotective and it reduces oxidative stress in response to UV light so if UV is one of the biggest triggers then consider B3 if you also think that Their Skin Barrier dysfunction omega3 is also useful for Skin Barrier Improvement so it reduces skin inflammation it supports the quality of sebum in fat fraia and it is particularly useful for um ocular race to reduce the risk of progression finally I look at metabolic support and I mentioned berberine coctus or hydrastis those berberine containing herbs because not only do they have potential benefit for that gut microbial picture They al support Al They also support lipid glucose and energy regulation where metabolic issues are present um it reduces Ox inflammation and oxidative stress and it has anti-angiogenic potential bya the reduction of V jef so it is one of the herbs or those berberine containing herbs I do lean on a little bit where I perceive any of those factors are present with the patient in front of me along with that have a look at homosysteine and consider measuring homosysteine levels because a recent study has shown a correlation between rosacea severity and decreased levels of B12 and Fallout and also a correlation between homosysteine levels and rosacea severity so addressing that where it is a factor for your rosacea patients so thank you for your time today I hope that you can use some of these strategies with your rosacea patients and get good outcomes for the future