1. CLONIDINE (Cetapres/ Dixarit) dose varies between 0,050 mg twice a day to 0,075 mg 3 times a day. Especially severe flushers find that they need to take it every 8 hours, or they get rebound flushing. I was prescribed this drug by dermatologist and rosacea expert Dr. Tony Chu from London's Hammersmith Hospital, who found it helpful in many of his vascular rosacea patients. It helps with facial flushing in several ways, from what I have understood (although the exact way of action seems not fully understood yet): it acts as a peripheral vascular stabilizer, and flushing is partly due to vasomotor instability. But it also tends to shut down the smaller blood vessels in the extremities (hands, feet and face) to some degree, since it works officially as a blood pressure lowering drug. It widens the big arteries in the centre of your body and around your heart, so that the blood pressure in the rest of the arteries goes down. Therefore more blood is drawn away from the extremities (hands, feet and face) and the face gets less red, flushed and therefore it burns less. It gives the facial blood vessels some (well deserved) rest and that seems to turn around the severity of the rosacea for many. Clonidine also relaxes the smooth muscle of blood vessels, causing them to widen, or dilate. This reduces the pressure of blood flow through the artery. It's calming affect is also used to treat anxiety disorders, hot flashes, flushing and sleeplessness. Clonidine can make your mouth dry cause severe drowsiness. This medication shouldn’t be used every now and then, but structurally and daily, for a longer period of time preferably, as the full effects of it tend to accumulate over time and it might give rebound flushing if you stop with it suddenly. I had normal blood pressure to start with and I had a short drop of blood pressure (but within the safe range) for a few months and then my body adjusted it, as Dr Chu had predicted and I have now a steady blood pressure of 110 over 80. Clonidine can also be used to treat hot flashes. Because it is a non hormonal treatment, women with a history of breast cancer can use it without increasing the risk of further cancer cell growth (as in the case of estrogen treatment). *Possible side-effects: -cold hands and feet in the winter: in my experience these symptoms are mild ( I have been diagnosed with Raynaud´s syndrome) and for many they are non existent. -dizziness/tiredness: this happens mainly in the first weeks/months of using, when the body needs to adjust. In time it usually wears off, so you will need to give it some time in this respect as well. -Dry mouth: tends to wear off as well, but Clonidine can dry out your membranes (dry mouth, dryer eyes), so you should drink plenty when you use it.
Facial flushing
Facial blushing is an involuntary reddening of the face due to embarrassment, stress or a lot of other possible triggers. It is thought that facial blushing is caused by an overactive sympathetic nervous system. This system helps to regulate glands and organs without our conscious effort, and controls the diameter of blood vessels to the face. In some people, these nerves are unusually sensitive to emotional stress. For a person to flush is to become markedly red in the face and often other areas of the skin, from various physiological conditions. Flushing is generally distinguished, despite a close physiological relation between them, from blushing, which is milder, generally restricted to the face, cheeks or ears, and generally assumed to reflect embarrassment.
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Mirtazapine (remeron)
3. MIRTAZAPINE (Remeron/ Avanza/ Zispin) dose varies between 15 mg and 30 mg at night, before bed time. I was prescribed this drug together with Clonidine and Propranolol, but it can be taken individually. Many will find however that the two drugs seem to be more effective together than separately to cut down on the flushing (despite being antagonizing drugs, but this has only a slight influence on their ability to lower blood pressure, NOT their ability to tackle the facial flushing). Mirtazapine is a relatively new antidepressant, that also has a proven track of lowering the severity and incidence of facial (hot) flushes. Mirtazapine is a newer type of antidepressant and works on the same primary receptor (alpha2-adrenergic autoreceptor) as clonidine however paradoxically as an antagonist (the theory that there is an alpha2 dysregulation not simply an excess or deficiency). It recently has been shown to help hot flushes, just as clonidine. It also increases serotonin similar to SSRIs, Prozac, Paxil etc with significantly less risk of sexual dysfunction but can cause some more rapid weight gain in some (thought through an increase in appetite more than metabolism) & sedation so best taken around bedtime. From what I have understood from Dr. Chu is has not only potent antihistamine actions, but also seems to act somewhat as an anti-inflammatory and shuts down flushing to a degree. It also blocks 5-HT(2A) which helps combating facial flushing. My personal experience was that I went within some weeks of using it from a 24/7 flusher, at my wits ends, to a ‘part-time’ flusher. It seems to heighten the threshold for flushing. I have heard this from several other forum members, including WrinkledClue. From the 3 meds mentioned, Mirtazapine has the best scientific studies backing up it’s positive effect on facial flushing (see the link below). It is mentioned in the link that Clonidine and Mirtazapine shouldn’t be used together, but I have done this for 4,5 years now without problems, as have many others and Dr. Tony Chu has explained to me that there is no problem in this, as long as you use both meds mostly for the flushing. They antagonize each other in the way that Clonidine lowers the antidepressant actions of Mirtazapine, and Mirtazapine lowers the blood pressure lowering actions of Clonidine, but this is only partly. The pharmacists in Holland were positive that there is no prove for this as they are up to date on medication interactions they say, and never officially were informed about this. They prescribe both drugs together still without problems, as do dermatologists. For the flushing actions of both, there is no impediment. Positive note: even on these low doses Mirtazapine works strongly against anxiety and depression. This can lift your darkest rosacea-induced clouds and the better spirits and reducing of anxiety help combat flushing and inflammation even more. It also helps you sleep long and sound. *Possible side-effects: -weight gain. I gained weight, about 15 pounds, I must say this. But there are others on the forum who were able not to, taking care of a good (though strict) diet. It´s not clear to me if the weight gain comes from the increase in appetite, as antihistamines give as well, or from a change in metabolism. You will most probably get an increase in appetite though, although I know people on it who didn´t……. Same here, nobody reacts exactly the same, it seems. -Dizziness and tiredness: if you take this med before bedtime, you won’t have much trouble with it probably. But your body might need some time to adjust to it, so give it some time before evaluating. The anti-depressant actions officially will start to kick-in after 3 weeks of use, but many experienced them sooner, as with the anti-flushing actions. Objective: To evaluate the effect of mirtazapine on the severity of hot flushes and bouts of perspiration in women. Method: In two women with depression a reduction in hot flushes was noticed by serendipity during treatment with mirtazapine 15-30 mg/daily. On the basis of this observation clinical studies were extended with two non-depressed and non-anxious women with hot flushes. Both subjects were prescribed mirtazapine daily. Results: Four cases are described as case reports. All subjects reported a practically complete disappearance of hot flushes and associated perspiration, within the first week of treatment. Conclusion: Mirtazapine appears to have a substantial ameliorating effect on hot flushes and perspiration bouts. It is postulated that the 5-HT(2A) blocking properties of mirtazapine is accounted in the symptomatic relief of hot flushes. In addition it is hypothesized that the serotonergic system is crucially involved in the pathogenesis of hot flushes and perspiration bouts. Further evaluation in double-blind placebo-controlled studies is encouraged.
Propranolol
2. PROPRANOLOL (Inderal) Dose up till 40 mg 1,2 or 3 times a day. This medication can be used occasionally, although long term use tends to give the best results. Dr. Chu prescribed me this medication together with the Clonidine (and a third med, see below), as he finds the combination of the three to be significantly more effective in tackling the flushing and inflammation from rosacea. It is also possible to take them separate though (but for me as a severe flusher they work best together). Propranolol is officially a blood lowering medication as well, also called a beta-blocker. It is a beta-adrenoceptor blocking drug (beta-blocker) which is so-called because it blocks the activity of the nerves which form the sympathetic nervous system. Beta-blockers reduce the amount of blood which the heart pumps out at each stroke. This leads to a fall in blood flow through the body tissues particularly affecting the skin, the muscles and the extremities (fingers, toes, etc). As a result people often complain of feeling listless or tired and experience cold hands and feet, especially for a few weeks after starting treatment. This is entirely predictable and to some extent is an indication that your treatment is working. So just as clonidine, it helps with hypertension, but it works in a different way then Clonidine and seems to tackle a different aspect of facial flushing. Beta-blockers to a degree block the activity of the nerves from the sympathic nervous system, thereby reducing facial flushing responses and especially those that are connected to adrenaline release. When the brain sends signals to the heart to speed up, beta blockers block the uptake of adrenaline which causes the heart to race and subsequent flushing that occurs on the face and neck. It is effective because it stabilizes vascular expansion. It dampens the symptoms of an overactive sympathic nervous system, including facial flushing and hot flushes, rapid heart beat and adrenaline rushed effects of stress and anxiety, intolerance to heat and sweating. It seems to help particularly for the “fight and flight” flushes, that you might have for instance when speaking publicly, but also for more day to day flushing triggers. *Possible side-effects: -mainly the same as with Clonidine (possible cold hands and feet in the winter, initial dizziness and tiredness, dry mouth). There has been some prove that beta-blockers can make someone more prone to depression, which might be a concern for many rosaceans, but it doesn’t have to happen. In my case, I was given an antidepressant with it as well (see below), so I didn’t notice any depressive effect. Also, theoretically these medication can cause difficulty in obtaining erections in men, but this might be related to the dose you use and it is only a possible side-effect. My experience is that both Clonidine and Propranolol didn’t lower my blood pressure too much. Your body tends to adapt also, I heard from my dermatologist, so the chances of getting really low blood pressure from it when you haven’t already got this, are slim. You might want to monitor your blood pressure though during treatment. You can buy a small house device for little money usually.