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Affecting more than 415 million people globally, rosacea is a common skin condition, although a poorly understood one. The face and eyes are primarily affected, and the condition is often mistaken for being an 'adult acne'. According to a National Rosacea Society survey, close to 95% of patients know next to nothing about the signs just before being diagnosed. So, what are the types of rosacea and how different are they from acne? And, what's the role of your DNA in all of this?

The basics of rosacea

Dating back to the 14th century, Rosacea was first called 'goutresse’, by a French doctor because of the facial redness it caused. The condition is now known to be chronic and inflammatory. There are different types of rosacea, most often accompanied by swollen red bumps and small visible blood vessels.

Since the condition mostly affects the face, they’re often mistaken for acne, eczema, or allergy. It predominantly known to affect females, especially when they are between 30 and 50 years of age. Those of European ancestry are also at a higher risk for the condition.

Types of rosacea: Just how many are there?

Rosacea is kind of an umbrella term that covers the four different subtypes:

Erythematotelangiectatic rosacea (ETR)
Symptoms:  Facial redness, flushing, and visible blood vessels.
Papulopustular (or acne) rosacea
Symptoms: Acne-like breakouts, swelling, and redness.
Phymatous/Rhinophyma rosacea
Symptoms: Thickening and redness, mostly on the nose. Often co-exists with other types.
Ocular rosacea
Symptoms: Redness in the eye, along with irritation and swollen eyelids.

Symptoms: The giveaways of rosacea

  1. Facial redness: A persistent redness on the face, especially around the central part. Small blood vessels become visible. 
  2. Swollen, red bumps: Pimples are seen across the face, and the swollen bumps may also contain pus. 
  3. Eye problems: Mainly seen if a person has ocular rosacea. This results in swollen, often irritated and dry eyes.
  4. Swollen nose: Associated with rhinophyma rosacea, the skin under the nose thickens and starts to swell. This is more seen in men than in women.

Rosacea: What are the triggers?

Before taking up a certain course of treatment, dermatologists often look for common triggers that cause a rosacea flare-up. The common triggers are:

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Genetics and rosacea

Genetic factors have been shown to play a role in increasing the risk of the condition. Since the most apparent symptoms are redness and inflammation of the skin, rosacea could be caused by genes associated with blood vessel abnormalities and immune reactions. Rosacea is caused by mutations in two gene families:

Human leukocyte antigen (HLA) complex:

The HLA genes, primarily involved in immune function, help the body in distinguishing foreign proteins from the body’s own. Variations in these genes have also been linked to rosacea symptoms - when the immune system misdirects the response, causing inflammation of the blood vessels.

Glutathione-S-transferases:

The proteins encoded by the GSL gene family help in protecting cells from oxidative damage - for example, the ones caused by exposure to sunlight and UV rays. Mutations in this gene complex could affect its efficiency in protecting skin cells, leading to rosacea.

Effects of gene variants

A genome-wide study that analyzed over 20,000 individuals with European descent was able to set forth a genetic basis to Rosacea. In this preliminary study, volunteers who were in the ‘cases’ group having answered yes to rosacea symptoms, were tested for genetic variation. One variant was found to be associated with disease occurrence, and this is located between two genes - HLA-DRA and BTNL2. The variant was found to influence the inflammatory response associated with rosacea.

A coincidental finding of this study was that variations in the HLA gene were also related to symptoms of diabetes and celiac disease, giving a suggestive link that rosacea may act as a visual cue to another underlying disease.

Rosacea and acne: What’s their relation? 

It is easy to misdiagnose rosacea for acne, but there are several subtle differences:

TriggerOrgans affectedRisk groupTreatment
Rosacea- Stress
- Sunlight
- Exercise
- Spicy food
- Alcohol
- Eyes
- Eyelids
- Cheeks
- Nose
- Forehead
- 30+ years
- Women 
- Men (severe form)
- Topical solutions
- Retinoids
- Laser therapy
- Antibiotics
Ance- Hormonal imbalances
- Medications
- Stress
- Diet
- Face
- Chest
- Back
- Shoulders
- Teenagers
- Young adults
- Topical solution
- Retinoids
- Chemical peels
- Antibiotics

Getting the diagnosis right

There is no direct diagnosis for this condition. The main indicator of rosacea is that the redness is contained to the face or the presence of enlarged blood vessels on the face. 

I. Preliminary diagnosis:

The preliminary diagnosis occurs with a physical examination of the face. If there is scarring elsewhere (like on the scalp), or if the doctor suspects another medical condition, like lupus, blood tests would be ordered. 

II. Clinical tests:

Other clinical tests would also be performed to rule out other confounding conditions like psoriasis or eczema. If the symptoms include the eyes, consultation with an ophtlamologist may be required.

Fighting different types of rosacea with dietary changes 

What should you avoid?

Several foods could trigger flare-ups. It is preferred that these are limited or avoided:

  1. Alcohol - Even a tiny amount of alcohol (champagne, vodka, beer, gin, and bourbon) has resulted in flareups in a majority of patients.
  2. Hot beverages - Drinking hot beverages can cause the vessels on the face to dilate, causing a blushed appearance.
  3. Spicy foods - Most spicy foods contain the chemical ‘capsaicin’. Eating foods that contain this chemical, can worsen symptoms. Avoid jalapenos, chilies, or tabasco peppers.
  4. Dairy - Common culprits are milk, sour cream, yogurt, and cheese.
  5. It is also recommended to avoid foods that contain high amounts of histamine and cinnamaldehyde, like chocolate, nuts, cinnamon, and foods pickled with vinegar.

What should you add?

Foods that reduce inflammation, healthy fats, probiotics, and fiber-rich foods may be able to help or reduce the severity of some rosacea symptoms. These include:

  1. Whole foods like oatmeal and brown rice
  2. Nuts, fatty fish, rich in omega-3 fatty acids
  3. Berries, rich in antioxidants
  4. Yogurt, sauerkraut, miso are probiotic foods
  5. Fiber-rich foods like bananas, onions, leeks, garlic, and whole grains

Skincare: When too much becomes too little 

People with rosacea may develop really sensitive skin, that could be easily irritated by the wrong choice of cleansers, creams, and makeup. Some common triggers:

Treatment: How effective are they? 

Rosacea could become severe if left untreated. However, most treatment practices help in managing symptoms. The course of treatment usually differ based on the types of rosacea.

  1. Medications: Azelaic acid clears up the bumps and swellings. Antibiotics help in clearing bacteria, reducing swelling too.
  2. Gels: Brimonidine is a gel that helps in tightening blood vessels on the face, reducing the redness.
  3. Alternate treatments: Lasers and light treatment help in tightening blood vessels in extreme cases. Dermabrasion can also be done if recommended by the physician

It is important to note that rosacea is a chronic condition and so these treatments only help in reducing the intensity of the symptoms.

The power of home remedies 

There are a lot of DIY/home remedies to manage rosacea:

Summary

In all, the many types of rosacea are chronic and inflammatory that requires intensive care and a strict diet and skincare regime. The exact cause of this condition is unknown, and maybe there could be a link between rosacea and other underlying diseases, but that can only be determined through more studies. Currently, there is no treatment, however, symptoms can be managed.

References

  1. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4434179/
  2. https://www.mayoclinic.org/diseases-conditions/rosacea/diagnosis-treatment/drc-20353820

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Our affinity for alcohol is not new; in fact, we developed it ten million years ago, even before we evolved into humans! The natural source of alcohol is fruits, with usually less than 1% of ethanol in ripe fruits and up to 8% in overripe fruits. The presence of alcohol was beneficial both for our primate ancestors as well as the plants that bore the fruits. The strong smell of alcohol traveled far and wide, attracting primates. This helped primates reach food sources while they helped the plants by dispersing the seeds. Alcohol was considered highly beneficial when fruits were its major source. In the present time, where alcoholic drinks are available in large quantities and are consumed in higher concentrations, they tend to do more harm than good.

Alcohol flush reaction: What is it?

The consumption of alcohol in some individuals causes blotches of erythema on their face and neck region, and sometimes on the entire body. Such an event is called an alcohol flush reaction.

Most of the time, it happens as a result of improper digestion of alcohol.

Accumulation of acetaldehyde in the body after alcohol consumption leads to this reaction.

When you consume alcohol, it gets metabolized to its byproduct acetaldehyde.

In typical cases, acetaldehyde gets metabolized further.

An enzyme called aldehyde dehydrogenase, coded by the gene ALDH2, is responsible for this metabolism.

However, some individuals have a defective gene that prevents the further metabolism of acetaldehyde.

This causes its accumulation in the body resulting in an alcohol flush reaction.

More about the enzyme

There are two types of enzymes responsible for the breakdown of alcohol: alcohol dehydrogenase (ADH) and aldehyde dehydrogenase. Acetate is synthesized with the help of aldehyde dehydrogenases (ALDH), mostly by ALDH2, a mitochondrial enzyme, but also by ALDH1, the cytosolic enzyme. 

There are five different types of ADH enzymes based on structural similarity and kinetic properties. 

Class I enzymes: The class I enzymes are coded by the ADH1A, ADH1B, and ADH1C genes, which are associated with about 70% of the total ethanol oxidizing capacity.

II: The class II enzymes are coded by the ADH4 gene, which is associated with about 30% ethanol oxidizing capacity. 

III: The class III enzymes are coded by the ADH5 gene and is the only class of enzyme that is detected in the brain. 

IV: The class IV enzymes are coded by the ADH7 gene and are found mainly in the upper digestive tract, where it oxidizes ethanol at high concentrations. 

V: The class V enzymes coded ADH6 gene are found in a variety of substrates, including retinol but are less efficient in ethanol metabolism.

Who is more prone to alcohol flush?

People of Asian descent, especially the East Asian descent, are more susceptible to have an alcohol flush reaction.

In fact, this red face phenomenon is also called the "Asian flush or "Asian glow."

According to some studies, over 70% of East Asians have genetic polymorphisms in either ADH or ALDH2, leading to intense flushing with ethanol consumption.

What happens during an alcohol flush reaction?

Other than the primary flushing red face, the other symptoms include:

Is the reaction dangerous?

While the flushing by itself may not to be dangerous, the reaction may have other health-related implications.

A 2013 study reported that people who experience an alcohol flush reaction on drinking might have a higher chance of developing hypertension, or high blood pressure.

Another study done on East Asian men in 2017 found an association between high risk of cancer, especially esophageal cancer, and flushing reaction.

This can be due to the high levels of acetaldehyde, which can trigger the growth of cancer cells.

How's it diagnosed?

When you report with suspected alcohol flush reaction, your doctor may first perform a physical examination. Other confirmatory tests also help with the diagnosis.

Skin test 

It detects your allergy, if any, to a substance in alcoholic beverages such as grains like maize, rye, and wheat. 

A little amount of the substance is injected into your skin, and the reaction is studied. If the skin appears red and raised, you are noted positive for the test.

Blood test

A blood test is done to detect the presence of antibodies like IgE that are found in the blood when there is an allergic reaction to a substance in alcohol.

Enzyme test

Measuring the amount of alcohol metabolizing enzymes, alcohol dehydrogenase and aldehyde dehydrogenase, can predict the intensity of reaction that one may experience.

Genetic test

The gene responsible for acetaldehyde metabolism in the body is ALDH2 that produces the enzyme ALDH2 or Aldehyde Dehydrogenase 2. 

Individuals who suffer from an alcohol flush reaction may have a faulty or deficient ALDH2 gene, and this can be identified using genetic testing.

Treating alcohol flush reaction

There is no definitive treatment for the root cause of this reaction, ALDH2 deficiency.

However, there are options when it comes to managing the symptoms.

  1. Antihistamines or histamine blockers can help control facial flushing.
  2. Another treatment, brimonidine, approved by the FDA for treating rosacea (a skin condition that causes redness in your face), can be effective for managing the flushing as well.
  3. Some laser-based therapies are also helpful to control the redness in the face.

Alcohol flush prevention

The only foolproof way to prevent this reaction is to avoid or limit your alcohol intake.

A lot of people tend to use OTC antihistamines to manage the reaction, but this is strongly not advisable.

The first and foremost step is to recognize your risk for this condition by studying your ALDH2 gene variants.

Check your 23andMe raw data or your Ancestry DNA raw data to find out the variant you carry

Genotype
Phenotype
TT[Limitation] More likely to show signs of alcohol flush on alcohol consumption
TCModerate risk of alcohol flush on alcohol consumption
CC[Advantage] Less likely to show signs of alcohol flush on alcohol consumption

According to the variant you carry, you might need to limit or discontinue alcohol consumption.

Other unwanted reactions to alcohol consumption addressed

Why do I bleed after a night of drinking?

Alcohol irritates the gastric lining.

When you drink alcohol, even a small quantity of it, it causes your stomach to produce acid.

Consumption of excess alcohol leads to increased production of stomach acid, which can lead to gastritis.

In many cases, due to excess alcohol, it triggers pain in the stomach, causes diarrhea, vomiting, and even bleeding.

Why do my ears burn when I drink alcohol?

Alcohol affects almost all parts of our body.

Consumption of excess alcohol affects the part of the brain that controls hearing.

In fact, alcohol consumption affects ears and hearing in more than one way.

When we drink alcohol, it also gets absorbed in the fluid of our ears and causes a burning sensation.

Does alcohol cause hot flashes?

Alcohol causes hot flashes in women, especially those going through menopause.

Does alcohol increase body temperature?

Having even a few sips of alcohol can make you feel warmer.

This is because alcohol makes the blood vessels underneath your skin dilate and increases the blood flow in them, which can induce the 'warm feeling.'

But in reality, alcohol reduces your core temperature.

What are some steps to reduce alcohol consumption?

Reducing alcohol consumption can immensely improve your health. Here is a list of a few things you can do to help you reduce drinking:

  1. Keep track of your drinking habits, and change them if warranted
  2. Drink slowly and hydrate yourself with water between drinks
  3. Switch to low alcohol alternatives
  4. Avoid salty snacks such as peanuts, as they make you more thirsty leading you to consume more alcohol
  5. Space out your drinks along with lots of food
  6. Watch out for peer-pressure and avoid any triggers
  7. Don't be shy to reach out for support

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Updated 05 May 2020

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