136: Alternative Solutions For Rosacea w/ Dr. Peter Lio

Rosacea is a skin condition best known for causing redness and flushing. But is can also lead to pustules and comedones. My guest today will share more about rosacea, as well as possible treatment options.  


Or, listen on your favorite app: iTunes (Apple Podcasts) | Spotify | Stitcher | TuneIn | Subscribe on Android

My guest today is Dr. Peter Lio, a Clinical Assistant Professor of Dermatology & Pediatrics at Northwestern University Feinberg School of Medicine.

He received his medical degree from Harvard Medical School, completed his internship in Pediatrics at Boston Children’s Hospital, and his Dermatology training at Harvard where he served as Chief Resident in Dermatology. While at Harvard, he received formal training in acupuncture.

Dr. Lio has written a textbook on Integrative Dermatology and has published over 100 papers.

Join us as we talk about rosacea: what it is, how it is diagnosed, possible triggers, and treatment options.

Do you successfully manage your rosacea? Let me know in the comments!

In this episode:

  • What is rosacea?
  • How people are diagnosed with this condition
  • Nicotinamide for rosacea
  • Other treatments for rosacea
  • What are Demodex mites?
  • Can wild chrysanthemum help with rosacea?


“We also have to make sure we're removing the triggers because another thing that rosacea and acne are really kind of different is that with acne, yes, there are certain triggers that can bring it out, no doubt about it. But rosacea happens on a much faster timescale.” [2:56]

“So our first line treatments would be things like topical metronidazole. It's technically an antibiotic, but we're pretty convinced in this context it's more for its antiinflammatory effect. It's very safe and gentle. It's even pregnancy safe.” [11:10]


Find Dr. Lio Online

Healthy Skin Show ep. 001: How to Protect & Strengthen Your Skin Barrier w/ Dr. Peter Lio

Healthy Skin Show ep. 037: Nickel Allergy And Eczema w/ Dr. Peter Lio

Healthy Skin Show ep. 104: Topical B12 For Skin Rashes w/ Dr. Peter Lio

Follow Dr. Lio on Twitter | Facebook

136: Alternative Solutions For Rosacea w/ Dr. Peter Lio FULL TRANSCRIPT

Jennifer: Hi everyone. Welcome back. Today I've got a recurring guest, probably one of my absolute favorite guests. He is absolutely brilliant in my mind, so I'm excited to have him back. And today, we're not talking about eczema. This is the first time ever Dr. Peter Lio and I are diverging from that topic. And we're actually going to be digging into rosacea. If you don't know Dr. Peter Lio, if you have not for whatever reason listened to his other episodes, go back and do so because they are really loaded with great information. But he is a clinical assistant professor of dermatology and pediatrics at Northwestern University, Feinberg School of Medicine. And he received his medical degree from Harvard Medical School, completed his internship in pediatrics at Boston Children's Hospital and his dermatology training at Harvard where he served as chief resident in dermatology.

Jennifer: While at Harvard, he received a formal training in acupuncture too. So he's very, he's got a really wide scope of how he looks at things, which is why I love this, and he's also written a fantastic textbook on integrative dermatology and published over 100 papers. Thank you so much for coming back, Dr. Lio.

Dr. Lio: Thank you for having me back. It's a pleasure.

Jennifer: I know. So now we're going to talk about rosacea. Our first time ever talking about rosacea. So, can you share for everyone who's listening what rosacea is, in the event that they're not really sure, but they think they might have it, so we could just kind of frame the conversation first?

Dr. Lio: Absolutely. So, rosacea is interesting because it used to be called acne rosacea and it does have some familiarity and some similarities to acne. You're getting papules or pustules usually in the mid phase. So cheeks are most common, sometimes chin and forehead as well, and the nose. But what makes it different than acne is that where acne has a poor clogging effect, you're actually getting what we call the comedones, the clogging of the pores, in rosacea, it's almost exclusively inflammatory. So more of just the papules and pustules.

Dr. Lio: Now, there's another part, another dimension of rosacea, if you will, which is called the, we call it ETT type, the Erythrotele, oh my goodness, I just botched this. I'm so sorry. Erythematotelengiectatic. Thank you. I couldn't get it out. Erythematotelengiectatic rosacea or ETT. So that is the other dimension or the other kind of aspect of it. And that's the redness, the flushing and the blushing. So, that is the other piece of it. So we have the papules and inflammation and then the flushing and the blushing of ETT type, much easier to say ETT than the longer word. And many patients have both. So part of our trouble is we want to make sure we're addressing both of those things and seeing if they're more predominant in one or the other.

Dr. Lio: If they're mostly redness, if it's just that ETT type, then we can often treat it with laser. Laser does an amazing job in just closing down those blood vessels and getting things much better. So that's pretty amazing. But we also have to make sure we're removing the triggers because another thing that rosacea and acne are really kind of different is that with acne, yes, there are certain triggers that can bring it out, no doubt about it. But rosacea happens on a much faster timescale.

Dr. Lio: So there are real triggers that can, you can like, for example, hot yoga, Bikram yoga has been something that has risen in popularity, and I've seen kind of an epidemic of rosacea from people doing Bikram. Now, I don't think it necessarily caused the rosacea, de novo but I think that it brought it out, and it brings it out because they're pushing and they're straining and they're really hot. So that is sort of a recipe for disaster to get a bad rosacea flare, usually that Erythematotelengiectatic type, the redness, but sometimes papules and pustules as well.

Dr. Lio: So these two dimensions of the disease are both important. It also tends to happen to adults. So most people get rosacea are kind of in their late 20s, 30s, and 40s, and they really didn't have it as a teen, they didn't have it as a kid. It's not really related to whether or not they had true Acne vulgaris. And that makes it kind of an interesting condition. And unfortunately, it is somewhat incurable. We have a lot of treatments but many patients struggle with it. So it's a common common complaint in my office.

Jennifer: If someone was to get diagnosed with this, is it similar with eczema where you could do a biopsy or is it pretty much just a visual diagnosis?

Dr. Lio: We can do some diagnostics. It's much harder with things on the face though because everything, if we're doing a biopsy on the face, then the issue is you will leave a scar, and no one really wants a biopsy on their cheeks or on their nose. So we really try not to. There are certain situations, for example, there's a type of rosacea called granulomatous rosacea where you get kind of almost brownish deeper seated papules. And there, that doesn't respond very well to most treatments so we find ourselves saying, okay, we have to make sure there are a couple of things in the differential that can mimic it. So it's like, let's make sure this isn't a funny infection or something weird, and we'll do a biopsy. Usually it's a clinical diagnosis. Most of the people are very healthy otherwise, so we can make this, and start treating.

Jennifer: Interesting. Okay, well that is really good to know. And one of the reasons that I wanted to have this conversation today is because back in 2016 you wrote a really interesting paper kind of reviewing some of the alternative options for helping people with rosacea. And I always think that that's a fun way to look at this because everybody is open to new ideas, and especially now, there's been a few years between that paper and now. And I'm curious, you mentioned nicotinamide. Is that something that you still use in your practice?

Dr. Lio: Quite a bit actually. It is something that I'm fairly obsessed with. Nicotinamide, it's a vitamin B3 analog, so it's other name is niacinamide. So you might see it as either, nicotinamide or niacinamide. The key thing though is that it is not niacin. So, it's a cousin of niacin, it's in the B3 family, but it's not vitamin B3 which is niacin. If you take niacin, it turns out, not only will it probably not help with your acne or your rosacea, but it actually makes you flush. So, we definitely don't want niacin. I've had over the years, occasionally, a patient will call me and say, “You know, the pill gave me, it's really not helping. I think it's making things worse.” Just read me the bottle.” “Oh niacin, like you said.” I'm like, “Wait, no, not niacin. Niacinamide or nicotinamide.”

Dr. Lio: So this is fascinating because we've known about it in a couple of different contexts for a number of years. First of all, we use it for blistering diseases. So there's a group of autoimmune blistering disorders. The big one that we use it for is called bullous pemphigoid, and bullous pemphigoid is when your body is making antibodies to parts of your skin. And by doing that, by binding to it, it basically makes huge blisters form. And it can be really bad. I mean, it can look terrible and really be pretty, pretty bad for the patient. So, it turns out that niacinamide can actually cool some of that inflammation down. So that's been known for a long time. And then more recently, there've been some studies for both acne and rosacea showing that it helps both with the redness and with some of the inflammation. So I use it quite a bit in both of those conditions.

Dr. Lio: Now, by itself, it may not be enough, especially if it's anything more than moderate, but I love it as an adjunct. So especially if I'm doing other things, I add that on and it really helps strengthen it, or as a step down. Once they're better, I'm like, okay, let's keep the niacinamide going because we think that may have a bit of a preventative effect. And it's super duper safe.

Dr. Lio: The other cool thing about niacinamide it's been in the news in the last couple of years, there was a paper a few years ago that showed it actually decreases the incidence of squamous cell carcinoma, skin cancer. So it actually has an anti-aging, and anti-sun damage effect. So a lot of my patients who had skin cancer, I say, take the niacinamide, it won't hurt, it may actually help prevent it. And I will tell you, full disclosure, I personally take niacinamide myself. I only take two supplements, vitamin D and niacinamide, so those are the two I take.

Jennifer: I'm always careful about providing people with dosing, but is there any just guidelines that you could give some, because I know what's going to happen, they're going to go, oh, I should take this. And they're just going to go out and they'll probably go more is better. That's always what happens.

Dr. Lio: It's fairly standard. There's a fairly standard. So, the kind of the studies have been done, usually it's 500 milligrams of the niacinamide taken twice daily. And because it's a water soluble vitamin, it's hard to get into trouble. But I mean, I wouldn't necessarily say, I don't think you need any more. The other great thing is it's really inexpensive. Like if you order it online, I'm talking like less than $10 for a couple of months supply, which is great. So quite inexpensive, which is refreshing.

Jennifer: So with this, you found that the oral supplementation is just as beneficial as say if it's included in a salve or a cream of some sort?

Dr. Lio: Yes. To my knowledge, it's never been done head to head. And we do know that niacinamide topically has an antiinflammatory effect too, and it's in a bunch of moisturizers, which is great. But I kind of like to do the oral one at least, and it's true. I tend to try to pick a moisturizer for my acne in rosacea patients that has it built in, which is kind of nice because then they're getting it both internal and external. Double hit.

Jennifer: That is [inaudible 00:08:43]. Okay, so this is the forum number one that does not cause flushing. So if you start to flush, wrong form, number one. Number two, how long if someone was to start this, should they expect it to take about a month in order to start to see changes? Like what's the expectation there?

Dr. Lio: I think that's about right. I usually say three to four weeks before it really starts kicking in. And it is a little bit hit or miss. Some people it's quite dramatic. Other people, it's like maybe it's helping a little, but I do think it's one of those things it's worth leaving on, especially if we're having trouble getting it under control because what I love is that this may decrease or even eliminating some folks need for other medicines. So even if it helps just a little bit, I'll take it.

Jennifer: Yeah. And the last question I have on this, because a lot of people think they take it until it goes away and then they're good. Is this something that someone would basically keep as part of their regimen once they start seeing results?

Dr. Lio: More or less, yes. With rosacea, it's something, I don't want to say it's permanent. It doesn't mean you're going to be on this for 50 years. But people go through these phases and I think a lot of times young adulthood, they're kind of struggling with it. So I figure at least a few years you may be on and off of this, but you might go through a phase where things are quiet. So you can certainly test, but I really, if it means, because some of our patients [inaudible 00:10:02] need to go on antibiotics, I really try to avoid that. And I don't want them to flare up so they call me and say, no, I need to go back on the doxycycline or the minocycline. And it's like, well, if we can prevent that, let's just stay on the niacinamide if that will help us.

Jennifer: And so, for people who do have rosacea, is the pretty standard treatment you just mentioned a couple of antibiotics, is that also potentially an option for people that are struggling with this if say they are comfortable doing that or maybe it is, sometimes it's necessary to include antibiotics and medications. What's your thoughts on that?

Dr. Lio: Yes. We try to start at sort of a baseline of, is there an obvious trigger? So if they're washing their face with something harsh, drinking alcohol, tons of caffeine, spicy foods, and even with heat food. So people who drink their coffee scalding or drink scalding hot soup, all those things can actually trigger flare ups. To the extent that we can and, and there's a range on what people will want to do and what they will do, we try to decrease those things and diminish them. That's step one. Step two, good moisturizer, gentle cleanser, kind of just strengthen the skin. And then step three would be some of the treatments.

Dr. Lio: So our first line treatments would be things like topical metronidazole. It's technically an antibiotic, but we're pretty convinced in this context it's more for its antiinflammatory effect. It's very safe and gentle. It's even pregnancy safe. Topical azelaic acid, which actually is a buckwheat extract. It's very natural. It actually is a prescription, but it's very mild and natural. Again, pregnancy safe, which I like. Has both an antiinflammatory and an anti-redness effects. And then one of the newer ones on the market is this one called, it's topical ivermectin. And ivermectin actually is amazing because it has an anti-parasitic effect, and we actually can use it for scabies and stuff like that, mites and infestation. And you can put it on topically.

Dr. Lio: And for some patients, it's pretty dramatic because we think there's this other component to rosacea, there's a mite on our skin that lives actually in the follicles called Demodex. And Demodex seems to overgrow in some patients or most patients with rosacea. And there's sort of a chicken an egg. It's like, are you sure, is like the Demodex driving it or is the rosacea making more oil and stuff and changing the environment? We don't know. But it turns out the ivermectin kills the Demodex and probably is antiinflammatory.

Dr. Lio: So, any one of those things topically, we actually have in our office, a company makes a triple cream version of it. So we get all three in one, which is kind of cool. And I like that one a lot too. And then I often have people wash with a sulfur based cleanser because sulfur, natural element sulfur, sodium sulfacetamide, its kind of cousin, those both have, again, an antiinflammatory property and probably an anti-demodex property. So they're helping on both those concepts.

Dr. Lio: So that's level two. And then if they're still having trouble, because we really try to be good antibiotic stewards. You don't want to abuse antibiotics. But as you say, sometimes you're miserable. I have people would giant pustules and they're, they can't go to work. You work facing people, everyone's like, what's wrong with your face? Are you contagious? So then we would use usually one of the tetracycline antibiotics. So doxycycline or minocycline are the two most commonly used. And they're actually in the last few years, there was an approved version of doxycycline that's super low dose. It's 40 milligrams one time per day. It's so low that the FDA allows them to say that it is not an antibiotic because it doesn't upset your gut. It doesn't kill the bacteria. It's truly just the antiinflammatory effect of the doxy. And that's a great one to marry with niacinamide. Those two together, really good synergy.

Jennifer: That is super interesting. So you brought up something that I want to ask about because I've had two people email me about that mite.

Dr. Lio: Demodex.

Jennifer: Yes, Demodex. You said it's a mite, it lives in the pores, correct? How would someone know if they have that? Is it a scraping?

Dr. Lio: Exactly. So first thing, we all have it, it's on all of us. It's a normal commensal, so we could find it in anybody. But in our rosacea patients, we'll actually scrape a little bit, cheek or nose. Usually I'm looking for, the word I use is patulous. The kind of larger follicles and I could send you some neat pictures of how it looks. Or if you search online, you'll see it. And the follicles look kind of big, they often have like a little spicule, stuff coming out of it. You scrape that and you see a Demodex party, and you're like, whoa, this is not normal. You might get one or two normally and you'll see like 10 all squished together. And a lot of times they're still alive. So you see them moving and eating and pooping doing their thing, it's kind of gross.

Jennifer: Oh my goodness.

Dr. Lio: Kind of crazy. So when we see them, I'll often take a picture of my phone and bring it to the patient and say, look, this is what's going on. And they're like aghast. But I say, we're going to work on them. So that's when we might use the ivermectin and sometimes even oral ivermectin if it's really a bad case.

Jennifer: So, with that said, because this is making me think for a moment, for someone who believes that they have rosacea because I've seen pictures online and they're like, well, I don't want to go to a dermatologist, they're just going to give me like a steroid cream or something. But in actuality, if you have an overgrowth of this particular mite, it would be important to, number one, know that, and number two, deal with that, right? Because no one amount of nicotinamide is going to fix that.

Dr. Lio: Probably not. You're right. And I mean, dermatologists, we get a bad rap for putting steroids on everything, but rosacea and acne both are situations where we truly never want to put steroids on. In fact, steroids often are put on rosacea incorrectly. It'll get a little better initially, but then it will come back with a terrible vengeance. And we know that topical steroids actually can cause a rosacea, we call it steroid-induced rosacea. So it's really bad. So I promise you, they do offer it. You might say, yeah I need to see another opinion because we really shouldn't be putting any of that on there. And everything here is much more targeted towards changing the flora, changing those Demodex and potentially doing some antiinflammatory and anti-redness things just to cool things down.

Jennifer: So I have one more question kind of, we'll see where it goes. But you also mentioned in your paper about wild chrysanthemum and that that could also possibly be helpful for rosacea. And this is an herb, obviously, it's not a drug. Any thoughts on that? Have you used that in practice? Do you feel like that still could potentially be an option for people?

Dr. Lio: Yeah. Well, I'm very interested in sort of natural therapies and trying to find alternatives to drugs whenever we can. And no, I haven't tried it because one of the problems is I cannot find a good supplier of it. So this is a good example of alternative medicine literature. Somebody had some formulation, I don't know if they were thinking about marketing it or tried to or, who knows, but that paper came out, it looked promising, but you cannot get it, at least not get the one they showed. And then you take a little bit of a Russian roulette when you buy, you could just try to find something and hope that it is, but that's never good practice. So we're trying to find a way. So I'm working with someone here in Chicago to help us manufacture one that he likes and he's an herbalist and botanist and he knows a lot of stuff. So it's like, can you help us mimic what we saw in this article to give something to our patients that we know is well sourced.

Jennifer: Interesting. And it's always important with botanicals. You have to know that you're getting them from a good quality. I know too, just from experience, my sister is an herbalist and an acupuncturist like yourself and she's always like, we have to be careful to have Chinese herbs. Sometimes they're contaminated with things. So it's important that we look for good qualities, especially your skin is so porous and it absorbs things. So, it'll be interesting to see how that pans out. I'll be curious once you start to actually utilize it to hear how it goes.

Dr. Lio: I'll keep you posted.

Jennifer: Any final thoughts? For somebody who's been dealing with rosacea for a really long time and they feel super frustrated, any just thoughts that you could share with them from having worked with rosacea patients?

Dr. Lio: I think really it is one of the conditions where we almost always can help. So, I think it is worth seeing somebody to get an opinion and talk about some of the options. And there's so many different approaches. And everything we said from some lifestyle changes to the topical treatments to more powerful oral treatments. So there's really something for everybody and there are very few situations where I really feel helpless with rosacea. They come up, there are cases where I'm like, oh my gosh, I can't get this patient better. But they are really fortunately few and far between. Most patients come back and say, wow, I'm really happy, this is great. And we can get you there really safely with minimal stuff for the most part.

Jennifer: Oh, that's good to hear. And I think too that gives people hope because, like you said, it does affect the face and people see your face and, oh my goodness, it's so hard. It ruins your confidence, it makes you feel like, like you said, sometimes there can be issues or questions of like, are you infectious? And people are uncomfortable being around you. And so, I'm glad that we could have this conversation. When we found this paper, we were just like, oh, this is so cool. I have to share this. But yeah, I'll be curious to hear about the wild chrysanthemum as you start to use it and see how it works out in clinical practice.

Jennifer: And again, I so deeply appreciate you being here because you are one of the most, I don't know, I feel like you're one of the most creative, open minded and kind giving dermatologists that I've come across. And I love the things that you're doing.

Dr. Lio: You're too kind. You're too nice. Thank you though.

Jennifer: You're very welcome but it's an honest compliment because …

Jennifer: Some results. And so, I just want to make sure everybody can find you because it's so important to me. You have a clinical practice in Chicago, you're at chicagoeczema.com. And I know you're on Facebook and you're on Twitter as well. Is there anything else that anyone should know about if they did want to get in touch with you?

Dr. Lio: Yeah. Honestly, that's our best spot is the Facebook group, the Chicago Eczema Center. The full name is the Chicago Integrative Eczema Center. So, check us out. That's where I post everything I'm thinking about. If I write a paper, I usually put it up there just for those following along. Every other month, we actually have a support group for eczema. And sometimes people who don't have eczema but have other kind of related conditions come. Everybody's welcome there on a Saturday morning and we always post the next date on the website. So come and hang out and you can meet everybody and get to meet the support group and learn all about what we do.

Jennifer: Oh, that's perfect. Well, I just want to thank you so much for joining us and I look forward to having you on the show again.

Dr. Lio: I can't wait. Thanks Jen. Take care.

“We also have to make sure we're removing the triggers because another thing that rosacea and acne are really kind of different is that with acne, yes, there are certain triggers that can bring it out, no doubt about it. But rosacea happens on a much faster timescale.”

Jennifer Fugo, MS, CNS

Jennifer Fugo, MS, CNS is an integrative Clinical Nutritionist and the founder of Skinterrupt. She works with women who are fed up with chronic gut and skin rash issues discover the root causes and create a plan to get them back to a fuller, richer life.

Follow Us

Medical Disclaimer

Skinterrupt offers health, wellness, fitness and nutritional information which is designed for educational purposes only. You should not rely on this information as a substitute for, nor does it replace, professional medical advice, diagnois, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other health care professional. Do not disregard, avoid, or delay obtaining medical or health related advise from your physician or other health care professional because of something you may have seen or read on our site, or in our advertising, marketing, or promotional materials. The use of any information provided by Skinterrupt is solely at your own risk.

Nothing stated or posted on our site, or in our advertising, marketing or promotional materials, or through any of the services we offer, as intended to be, and must not be taken to be, the practice of medicine or counseling care. For purposes of this disclaimer, the practice of medicine or counseling care includes, without limitation, nutritional counseling, psychiatry, psychology, psychotherapy, or providing health care treatment, instruction, diagnosis, prognosis, or advice.