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rosacea and/or acne and/or sebderm combo: how to Dx and treat?
49-year old fair-skinned male. Lifelong rapid, deep blusher. Mild facial redness steadily more permanent starting in mid-30s, worsens with many typical rosacea tripwires (e.g. heat, cold, stress). On face, there have never been any pustules or papules, though perhaps up close a few fine lines. Tx Metrogel bid to try to limit the progression of rosacea.
Have always had seb derm in nasal folds, behind ears, itchy area at breastbone, sometimes groin. And, scalp.
The issue is the scalp. Am entirely bald on the top of head. Scalp was always oily, and became severely so as the baldness progressed. Scalp manifests two conditions:
1) nearly always, a fine flakiness, completely impervious to any anti-sebderm shampoo (tried them all). "Looks like" dry flaky skin. No falling dandruff, no oozing, and the shampoo makers might consider the treatments a complete success; if I had hair, the condition would be 100% invisible. But a bald scalp readily shows even a single flake and the condition is quite obvious, especially right after a shower. Have tried different steroid creams; tends not to help the flakiness at all.
2) occasional breakouts on the scalp. Sometimes little red spots, which have been treated UNsuccessfully with benzoyl peroxide washes & lotions of various potency. What tends to help these is 1% cortisone cream. But there are also sometimes MASSIVE pimples on the scalp that are incredibly huge and embarrassing, even freakish - never saw them on anyone else! - and take 1-2 weeks to recede, leaving a discoloration for months, and I have no idea how to successfully prevent or treat these.
To reduce the oilness of my scalp to try to prevent the giant zits, I use OTC topical salicylic acid acne pads or lotions with cotton balls. This however may make the flakiness/dryness worse and may be an irritant if the problem is rosacea!
The issues for me:
1. Are the scalp breakouts acne or rosacea? Both?
2. What is best for the scalp? Metrogel? Metrocream? BP washes? Salicylic acid? Cortisone? Some combo? Will cortisone make rosacea worse over time?
3. Nothing entirely eliminates the flakiness; I can hide it with a light moisturizer like Complex 15 or a sunscreen but run the risk of increasing breakouts. ("Non-comedogenic" seems to refer to the face, not tested on a VERY oily scalp!)
4. Sunscreens: I need to protect the scalp (have already had a few AKs up there), but EVERY sunscreen lotion causes breakouts on scalp, and every sunscreen gel increases flakiness (alcohol-based).
No dermatologist has been able to give a definitive Dx of my scalp breakouts. When treated as acne, treatment was 100% unsuccessful. One dermatologist said maybe it was a "type" of rosacea but didn't get more specific.
I live in San Francisco and have seen many dermatologists here. I would go see ANYONE who could authoritatively answer these questions. (Otherwise, I may need a referral for a skullectomy.)
Hoping you have some answers!
Thanks much.
Have always had seb derm in nasal folds, behind ears, itchy area at breastbone, sometimes groin. And, scalp.
The issue is the scalp. Am entirely bald on the top of head. Scalp was always oily, and became severely so as the baldness progressed. Scalp manifests two conditions:
1) nearly always, a fine flakiness, completely impervious to any anti-sebderm shampoo (tried them all). "Looks like" dry flaky skin. No falling dandruff, no oozing, and the shampoo makers might consider the treatments a complete success; if I had hair, the condition would be 100% invisible. But a bald scalp readily shows even a single flake and the condition is quite obvious, especially right after a shower. Have tried different steroid creams; tends not to help the flakiness at all.
2) occasional breakouts on the scalp. Sometimes little red spots, which have been treated UNsuccessfully with benzoyl peroxide washes & lotions of various potency. What tends to help these is 1% cortisone cream. But there are also sometimes MASSIVE pimples on the scalp that are incredibly huge and embarrassing, even freakish - never saw them on anyone else! - and take 1-2 weeks to recede, leaving a discoloration for months, and I have no idea how to successfully prevent or treat these.
To reduce the oilness of my scalp to try to prevent the giant zits, I use OTC topical salicylic acid acne pads or lotions with cotton balls. This however may make the flakiness/dryness worse and may be an irritant if the problem is rosacea!
The issues for me:
1. Are the scalp breakouts acne or rosacea? Both?
2. What is best for the scalp? Metrogel? Metrocream? BP washes? Salicylic acid? Cortisone? Some combo? Will cortisone make rosacea worse over time?
3. Nothing entirely eliminates the flakiness; I can hide it with a light moisturizer like Complex 15 or a sunscreen but run the risk of increasing breakouts. ("Non-comedogenic" seems to refer to the face, not tested on a VERY oily scalp!)
4. Sunscreens: I need to protect the scalp (have already had a few AKs up there), but EVERY sunscreen lotion causes breakouts on scalp, and every sunscreen gel increases flakiness (alcohol-based).
No dermatologist has been able to give a definitive Dx of my scalp breakouts. When treated as acne, treatment was 100% unsuccessful. One dermatologist said maybe it was a "type" of rosacea but didn't get more specific.
I live in San Francisco and have seen many dermatologists here. I would go see ANYONE who could authoritatively answer these questions. (Otherwise, I may need a referral for a skullectomy.)
Hoping you have some answers!
Thanks much.
I have the exact same thing you do! My mom's a hairdresser and doesn't know what that is! I'm female and have hair that's fine and thin. I get zits that you can't squeeze, dry scale-like things (not so much dandruff) that I pick off cause they drive me crazy and now, rashes on my back, neck, and bridge of my nose/cheeks/forehead. I've tried almost everything and it works for a short period of time. I am currently using tea tree oil soap and and the oil drops to regular cleansing shampoo. I also get adult acne and have combination skin! I'm a mess! LOL If you want, please email me at ***@**** and we can compare what we've tried....there has to be something out there! :)
Thanks, doctor. You've offered some new ideas, esp with regard to NSAID topicals which I've never tried. I'll bring it up at next visit with my current dermatologist.
I am curious about your point that seb treatments like tar and sal acid would make scaling worse; I thought those treatments were meant to reduce flakiness. Are flakiness and scaliness two different things?
I have noticed recent disclaimers at the bottom of Head & Shoulders TV commercials, though; they used to claim "as effective as T-Gel" but now footnote it with "visible flakes only."
Perhaps these treatments reduce visible shedding at the cost of creating a fine scaling which is normally invisible assuming a normal head of hair? Otherwise, I'm not sure what you comment implied. I do know that when I stop using anti-dandruff or anti-sebderm shampoos, the scaling gets worse.
Today I purchased a new Neutrogena product ("Combination Skin Moisture") that claims success with combination skin; claims to moisturize dry areas while controlling oily shine. What the heck, another $9 experiment :). Too bad it doesn't contain sunscreen, but if it does everything it claims, I should be able to use it on my scalp and then apply a sunscreen lotion or gel on top of it with no problems. We shall see...
Thanks again for your suggestions.
I am curious about your point that seb treatments like tar and sal acid would make scaling worse; I thought those treatments were meant to reduce flakiness. Are flakiness and scaliness two different things?
I have noticed recent disclaimers at the bottom of Head & Shoulders TV commercials, though; they used to claim "as effective as T-Gel" but now footnote it with "visible flakes only."
Perhaps these treatments reduce visible shedding at the cost of creating a fine scaling which is normally invisible assuming a normal head of hair? Otherwise, I'm not sure what you comment implied. I do know that when I stop using anti-dandruff or anti-sebderm shampoos, the scaling gets worse.
Today I purchased a new Neutrogena product ("Combination Skin Moisture") that claims success with combination skin; claims to moisturize dry areas while controlling oily shine. What the heck, another $9 experiment :). Too bad it doesn't contain sunscreen, but if it does everything it claims, I should be able to use it on my scalp and then apply a sunscreen lotion or gel on top of it with no problems. We shall see...
Thanks again for your suggestions.
MEDICAL PROFESSIONAL
I'm flattered that you think that sight unseen I can say something useful about a condition that's stumped a bunch of San Francisco dermatologists. Still, I'll try.
Rosacea affects the mid-face. It does not affect the scalp.
The cases I have seen of pimply scalp eruptions were mostly bacterial folliculitis. A culture followed by tretament with an antibiotic like erythromycin usually helped, though not always completely.
Scalp scaling is most often seborrhea, though this is usually limited to hair-bearing areas. I don't know which cortisones you used, but I would like to see the effects of a maximum-strength preparation applied twice daily for 2-3 weeks. Should that fail the new non-steroidal anti-inflammatory creams Protopic or Elidel might be worth a try. Seborrhea tretaments like tar or salicylic acid would most likely make scaling worse, as seems to have been the case with you. Because scalp scaling does not represent rosacea, there should be no problem trying a steroid. One way or another, the scaling should be able to be gotten rid of.
I hope this is at least somewhat helpful. Another live opinion may be in order.
Best.
Dr. Rockoff
Rosacea affects the mid-face. It does not affect the scalp.
The cases I have seen of pimply scalp eruptions were mostly bacterial folliculitis. A culture followed by tretament with an antibiotic like erythromycin usually helped, though not always completely.
Scalp scaling is most often seborrhea, though this is usually limited to hair-bearing areas. I don't know which cortisones you used, but I would like to see the effects of a maximum-strength preparation applied twice daily for 2-3 weeks. Should that fail the new non-steroidal anti-inflammatory creams Protopic or Elidel might be worth a try. Seborrhea tretaments like tar or salicylic acid would most likely make scaling worse, as seems to have been the case with you. Because scalp scaling does not represent rosacea, there should be no problem trying a steroid. One way or another, the scaling should be able to be gotten rid of.
I hope this is at least somewhat helpful. Another live opinion may be in order.
Best.
Dr. Rockoff
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