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The rosy reality of coffee

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Ronnie and me enjoying our rosacea prevention tour of Madrid in 2012
By Warren R. Heymann, MD
Nov. 5, 2018

To paraphrase Justice Kavanaugh, I loved coffee. I still love coffee. I have probably been drinking coffee since my time in utero. My mother was a coffee addict; she stopped smoking when pregnant with me, but “vitamin C” kept crossing the placenta (for any pregnant readers of DI&I, please limit your caffeine intake — see below). Now you know my bias — I would not be writing about the effect of caffeine on rosacea if it were found to be detrimental — I would just say that more studies are needed!

I have never discouraged caffeine in rosacea patients, because of a brilliant study by Jonathan Wilkin that I read early in my residency (1). The following is the abstract:

The effects of caffeine and coffee, agents widely alleged to provoke flushing in patients with erythematotelangiectatic rosacea, were investigated. Neither caffeine nor coffee at 22 degrees C led to flushing reactions. Both coffee at 60 degrees C and water at 60 degrees C led to flushing reactions with similar temporal characteristics and of similar intensities. It is concluded that the active agent causing flushing in coffee at 60 degrees C is heat, not caffeine.

The pathogenesis of rosacea is unknown, but is presumably involves a complex interplay of genetic factors, immunodysregulation, neurovascular dysregulation, microorganisms, and environmental factors. Enhanced activation of the immune system may be due to increased levels of cathelicidin and kallikrein 5, Toll-like receptor 2, matrix metalloproteinases, and mast cells. (2)

Abram et al evaluated risk factors associated with rosacea by comparing 172 patients with either flushing episodes or established rosacea to 145 healthy controls. In a multivariate analysis, rosacea patients had a significantly higher chance to have photosensitive skin types, a positive family history of rosacea, or a prior history of smoking compared to skin-healthy controls. There were no statistically significant differences either in gender, Helicobacter pylori serologic status, caffeine intake, alcohol consumption, occupational environment, or education level between rosacea patients and controls. (3)

Li et al performed a prospective cohort study of 82,737 women who responded to a question regarding the diagnosis of rosacea in 2005 in Nurses’ Health Study II. During 1,120,051 person-years of follow-up, the authors identified 4945 incident cases of rosacea. After adjustment for other risk factors, they found a significant inverse association between increased caffeine intake and risk of rosacea, with a hazard ratio (HR) for the highest quintile of caffeine intake versus the lowest = 0.76. A significant inverse association with risk of rosacea was also observed for caffeinated coffee consumption (HR, 0.77) for those who consumed ≥4 servings/day versus those who consumed <1/month, but not for decaffeinated coffee. Further analyses found that increased caffeine intake from foods other than coffee (tea, soda, and chocolate) was not significantly associated with decreased risk of rosacea, presumably because of their lower caffeine content compared to coffee. (4)

In the editorial that accompanies Li et al, Wehner and Linos elaborated on the benefits of drinking coffee: offering protection against cancer (including total cancer, prostate cancer, endometrial cancer, melanoma, nonmelanoma skin cancer, and liver cancer), cardiovascular disease, type 2 diabetes, chronic liver disease, Parkinson disease, Alzheimer disease, and depression. Most importantly, coffee protects from all-cause mortality. Pregnancy is the exception whereby higher coffee consumption (usually more than 3-4 cups daily) is a risk factor for adverse outcomes, including low birth weight, preterm delivery, pregnancy loss, and childhood leukemia. Therefore, the American College of Obstetrics and Gynecologists currently recommends less than 200 mg of caffeine (1-2 cups of coffee) during pregnancy. (5)

In their conclusion, Li et al conservatively state: “Increased caffeine intake from coffee was inversely associated with the risk of incident rosacea. Our findings do not support limiting caffeine intake as a means to prevent rosacea.” The fact that coffee may actually be protective is revelatory. Like all thoughtful academicians, they suggest that further studies to replicate these findings and explore the pathomechanism(s) of the association are warranted. My head tells me they’re right. My heart says that their study should be the final word.

Point to remember: Rosacea patients may enjoy their cup of joe!

1. Wilkin JK. Oral thermal-induced flushing in erythematotelangiectatic rosacea. J Invest Dermatol 1981; 76: 15-8.
2. Alm CS, Huang WW. Rosacea pathogenesis. Dermatol Clin 2018; 36: 81-6.
3. Abram K, et al. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol 2010; 24: 565-71.
4. Li S, et al. Association of caffeine intake and caffeinated coffee consumption with risk of incident rosacea in women. JAMA Dermatol 2018. Oct 17 [Epub ahead of print].
5. Wehner MR, Linos E. One more reason to continue drinking coffee – It may be good for your skin. JAMA Dermatol 2018; Oct 17 [Epub ahead of print].

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