Creams may provide some relief (if you are lucky), however you should undertake a test patch before full face application (like that’s not obvious). Here is how to do it.

1. Choose a small site in front of the ear (one side).
2. Apply a small amount of cream, fingertip, to cover 1-3 cm squared. 
3. If your symptoms don’t get worse, increase the application amount gradually. 

Of the creams listed above, the one that provides the most relief, with least amount of side effects is aqueous cream, available in most pharmacies. Your medical dermatologist can add 0.5 to 2% menthol to be compounded in the formulation. Keep this in the fridge & apply 1-4 times per day. Use a portable fan immediately after to relieve burning, stinging & pain. 

Botox can be considered in refractory cases of rosacea, including neurogenic rosacea. Botox is NOT the first line as tablets & medical therapy ideally should be considered prior to injections. 

Botox does not cure neurogenic rosacea, but can work by stabilizing nerve fibres & deactivate mast cells. It works in 60-70% of cases & lasts up to 4-5 months. Here is how I do it-

• A patch test is chosen. This involves treating a small area (e.g. forehead or one cheek). 
• If Botox is successful, other areas may be treated.
• Botox takes 7 to 14 days to be effective. 
• It can not be placed in all areas as Botox relaxes muscles. 

The downside of Botox is the expense & limitations of how much we inject & where we inject as well as duration of action. 

Botox can work in about 60-70% of refractory cases. Costs are prohibitive, as a guide, patch testing a small area costs $750 to $800, whilst extensive areas cost between $1200 to $1790. Not all areas can be treated as Botox also relaxes muscles. 

This is my realm of work, namely procedural, however here are the facts about lasers & neurogenic rosacea. 

1.       Lasers are much more useful at treating ‘normal rosacea’, namely redness, broken blood vessels, pimples, as well as phyma. 
2.       IPL & lasers have been reported to help relieve the signs & more so the symptoms of neurogenic rosacea as they can reduce inflammation. These are exceptional cases & not the norm. 
3.       Medical therapy (via a normal dermatologist) with the use of oral medication, provides superior results compared to lasers in most cases of neurogenic rosacea. 
4.       Lasers can, in some cases, temporarily worsen neurogenic rosacea, hence they should not be considered as first line therapy. Lasers, much like Botox, sit at the very end of the treatment line for this form of rosacea. 
5.       If lasers are to be considered, a patch test is required (often one cheek or part of the cheek- forehead). Costing for patch testing ranges between $800-$990 per session. Medicare may provide a nominal rebate of only $150. 
6.       If a laser is considered, the best ones will have dynamic cooling over contact cooling. These lasers include V Beam or Derma V. 

Disclaimer: My advice is that patients should have trailed & failed medical & psychological treatment before attempting vascular laser. If you have true redness that can be objectively measured, lasers may help. If you have very little target, chances are, lasers won’t work. 

Side effects of lasers for this type of rosacea are much higher than in normal rosacea, hence why I advocate medical over procedural intervention for neurogenic rosacea. They include-

1. Increased pain & sensitivity that may last for hours, days, or weeks. In some cases, hypersensitivity may last months to even years.
2. Swelling & paradoxical redness. 

Lasers are aimed at treating inflammation & redness. They have much less modulation on the nerves of the skin, as compared to drugs. Cases of mixed ‘normal rosacea’ & neurogenic rosacea do best with lasers, not just neurogenic subtypes. 

Ideally, a physical blocker such as zinc or titanium dioxide, as these are better tolerated compared to chemical sunscreens. Invisible Zinc is an example that you can readily purchase in Australia.

As with all topical creams, you should test patch sunscreens by applying a small amount (2-3 cm squared) on one cheek, in front of your ear to see if you react to the product. 

For neurogenic rosacea patients, you may be better served by NOT applying anything on your face & concentrate on sun avoidance, over the use of sunscreens. 

Mineral over liquid foundation. Ensure that make up is talc & paraben free. For severe cases of neurogenic rosacea, removal of make up can be problematic as it may increase symptoms. 

*Parabens can be a source of allergic reactions, which may give rise to stinging, burning & itching, symptoms of neurogenic rosacea. In the context of things, allergic contact dermatitis to parabens is rare, however your medical dermatologist may elect to patch test you to exclude allergens.

**Disclaimer: I do not practice medical dermatology, including patch testing. Patch testing can be considered if you have symptoms & history suggestive of allergies. Leave this decision to your medical dermatologist. 

Gentle cleansers without exfoliants are recommended for rosacea. The role of a cleaner is to remove dirt, oil & make up without flaring up your symptoms. They are not designed to treat your symptoms. 

La Roche Posay Rosaliac or Toleriane range are good products. 

Put bluntly, most dermatologists are hopeless at psychological counselling as we are focused on short consultations given our patient load. Additionally, we do not receive adequate training to deal with psychological counselling. 

Any condition that has a significant impairment on the quality of life will benefit from professional input from a psychologist who can spend one hour or more listening. 

The more analytical you are, the greater the chances of symptom relief, acknowledging that this form of rosacea is much harder to ‘figure out’ compared to normal rosacea. 

The less you ruminate about this problem, the better your headspace will be. Easier said than done, hence why I advocate that you seek professional counselling by a psychologist who has experience in managing chronic pain. Seeking professional help early is the key to getting your sh*t shorted as this is the most debilitating form of rosacea. 

Listen to your dermatologist: most will recognise this condition early. Most will move quickly to start you on the usual rounds of doxy, minocycline, EES, isotretinoin & lasers. Failing that, they will do a Pubmed search, however experienced ones know how to titrate you on TCA & SSRI. Do it. You have a much higher chance of symptom relief. 

OK, let us say you have consulted a medical dermatologist who has worked with a psychologist & a pain management specialist. You have trialed & failed all the usual medications for this condition, including pregabapentin, gabapentin (under neurologist), variable doses of antidepressants, including TCAs such as amitriptyline, undertook CBT & pain management strategies, your choices are now limited. Your specialist may –

1. Prescribe you Cycosporine; not under PBS for this condition. 
2. Refer you for ETS under a vascular surgeon (or at least have a consultation). They may propose a sympathectomy, especially if there is associated flushing. 
3. Trial you on topical agents that degranulate your mast cells. 
4. Refer you off for Botox. 

As previously mentioned, neurogenic rosacea is very rare. It often occurs as a standalone form of rosacea, but in some cases may co-exist with more common types of rosacea including-

1.       Papular – pustular rosacea; namely pimples & lumps.  
2.       Flushing-blushing rosacea. 
3.       Erythotelengectatic rosacea (often co-existing with above). 
4.       Ocular rosacea, with eye symptoms such as redness, stinging, sun sensitivity. 
5.       Phymatous rosacea. Swelling of the nose (common), ears, forehead. 
6.       Mid-facial swelling, controversial form of rosacea.

90% of patients with ‘normal’ rosacea will experience symptoms such as burning, stinging, itch, & ‘sensitive skin’. Neurogenic rosacea however presents as symptoms that are significantly more severe than what your skin looks like, ie. your symptoms lie to the right of the bell curve & the impact on your life is significantly more than ‘normal’ rosacea. 

Tip: Don’t get normal symptoms of rosacea confused with true neurogenic rosacea otherwise your psyche will flip to a cycle of symptom obsession, leading to greater (& often unnecessary) rumination of symptoms. This will have a tremendous negative impact on your life. Chances are, if you are reading this paragraph, it applies to you.  

Let a medical dermatologist diagnose you, don’t Google it or Reddit this condition. 

You may want to consider non-pharmacological methods to treat rosacea as medical dermatologists, as the name suggests will always prescribe medication (over fairy dust). 

The natural route has no scientific basis, however given the banal nature of fluffy medicine, you may want to try a low inflammatory, low acid diet as the first step. Adding anti-inflammatory supplements such as curcumin & turmeric may reduce inflammation, or better still function as a placebo. You can use aloe vera gel on your skin, together with a cooling fan to provide short term relief of pain, burning, & itch. 

The greatest gain of natural remedies is to see a clinical psychologist for help. 

More on fluffy ways to treat rosacea. 

Discuss options with your medical dermatologist. They will diagnose your condition, confirm the subtype of rosacea & in some cases exclude other conditions that may mimic neurogenic rosacea. Additionally they will prescribe medical therapy prior to consideration of lasers & Botox. Disclaimer: My work is entirely procedural. In the context of rosacea, my skill sets are with lasers including vascular lasers for refractory rosacea & ablative treatment of end-stage rhinophyma. For 

Neurogenic rosacea cases, I do inject Botox if medical management fails. I am not the first port of call, I am the last dermatologist you consult if all else fails.