Rosacea is a facial skin condition which shows as redness in pimples, cheeks, nose and chin. It is chronic, comes in several forms, and is generally characterized by a strong, local tendency for increased blood flow near the skin surface, causing the localized reddening. It is generally seen on the face, though it can also affect the eye, neck, and upper trunk, and is most often diagnosed in patients 30 to 50 years old, more commonly in women than in men. Rosacea is chronic: while it can be controlled, there is no cure, though it often goes into remission before relapsing. The causes of rosacea are poorly understood.
The first symptom may be a tendency to flush or blush easily, which then may progress to persistent redness associated with small blood vessels and pimples. Facial redness is often genetic and is generally worsened by sun exposure. Sun-damaged facial blood vessels dilate easily and the increased blood flow near the skin surface permits the skin to redden and flush. Trigger factors can increase this red response, and any inflammation in the acne-like bumps appearing in the face reddens the area further.
Some exacerbating factors (those that might make things worse), particularly in regard to flushing (blushing) may be:
- sunlight, wind, humidity
- hot beverages
- spicy foods
- heavy exercise
- extremes of hot or cold temperatures
- certain medications (e.g., topical corticosteroids)
- certain foods
A common misconception that both the facial redness and the enlarged nasal features (rhinophyma) associated with rosacea are due to excessive alcohol consumption makes rosacea a socially stigmatizing condition for many people. There is no evidence of alcohol as a causative factor in the disease, though patients with rosacea may risk it becoming temporarily more pronounced with alcohol use.
There are subtypes of rosacea:
- Erythematotelangiectatic Rosacea – associated with blood vessels and redness of the face. Flushing often fluctuates not only throughout the week but often during the course of a given day. It may improve with the avoidance of provoking/triggering factors (see above). Flushing may be associated with persistent central facial redness and is probably the most common presentation of rosacea.
- Papulopustular Rosacea – associated with papules and pustules. Systemic or topical antibiotics are the mainstays of therapy. Moderate to severe papulopustular rosacea may require systemic therapy to achieve clearance whereas milder cases can often be treated with topical medications alone.
- Ocular rosacea – associated with eye irritation. It is usually mild and responsive to lid hygiene, tear replacement, and topical or systemic antibiotics, and may need to be evaluated by an ophthalmologist. [In a March 2011 study, one-third of patients with rosacea had ocular signs and symptoms.] It may precede, follow, or occur simultaneously with the skin changes typical of rosacea. There is no test that will confirm the diagnosis. Patients may complain of burning or stinging of the eyes and people usually have mild, nonspecific symptoms.
- Phymatous Rosacea – associated with skin thickening of the nose (uncommon). Also called Rhinophyma. It is a disfiguring condition of the nose resulting from increased oil glands and connective tissue of the skin. Almost all patients with Rhinophyma are men. Surgical intervention is required for treatment.
Treatment approaches vary from one patient to the next; a standard formula does not exist. Treatment involves advising patients to apply a sunscreen daily that provides protection against both UVA and UVB irradiation and to avoid using irritating topical products. Treatment may initially consist of oral antibiotics, topical azelaic acid, topical metronidazole, topical erythromycin, or a sodium sulfacetamide-sulfur preparation.
- Antibiotics: the effectiveness of antibiotics is due more to their anti-inflammatory properties than their bacteria-fighting capabilites. As in patients with acne vulgaris, oral antibiotics are often combined with topical therapy to help bring the condition under control. The most common antibiotics prescribed are tetracycline, minocycline, and doxycycline .
- Avoid triggers: rosacea patients are advised to identify and avoid lifestyle and environmental factors that may aggravate their conditions on an individual basis. Avoid astringents and exfoliating agents. It may be help to avoid alcohol, spicy food, hot drinks, etc.
- Gentle skin care and cosmetic concealers may be used to reduce the effect of rosacea on appearance. Cosmetics with a green tint can be a good source of camouflage.
- Avoid use of washcloths, loofahs, brushes or sponges on the skin.
- Apply topical medication for 5-10 minutes prior to makeup or other skin care products. Such topical medications may contain metronidazole, azeleic acid, erythromycin, sulfa suflacetamide (other medications may also be appropriate).
- Important: use sunscreens effective against the full spectrum of both UVA and UVB radiation. SPF of 30 or higher is recommended, and physical blocks containing zinc oxide or titanium dioxide are highly recommended and may cause less irritation than chemical sunscreens.
- Laser therapy, particularly a pulsed dye laser such as the VBeam can be used for the facial redness and especially for prominent telangiectatic blood vessels.
The National Rosacea Society has designated the month of April as “Rosacea Awareness Month” to heighten public awareness of this emotionally distressing disorder which affects more than 16 million Americans.
A combination of therapies, including topical and oral therapies in conjunction with laser has helped decrease the embarrassment of this disease among my patients and help them to be comfortable in their skin and in the public. It is our pleasure to discuss alternative therapies to help people with rosacea feel more comfortable with themselves and their peers.