Rosacea is a chronic condition characterized by facial erythema (redness). Pimples are sometimes included as part of the definition. Unless it affects the eyes, it is typically a harmless cosmetic condition. Treatment, if wanted, usually involves topical medications to reduce inflammation.
It is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide It primarily affects Caucasians of mainly northwestern European descent and has been nicknamed the ‘curse of the Celts’ by some in Britain and Ireland, but can also affect people of other ethnicities. Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.
Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp. In some cases, additional symptoms, such as semi-permanent redness, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.
There are four identified rosacea subtypes and patients may have more than one subtype present:
There are a number of variants of rosacea including:
Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea, but antibiotics may only work because they inhibit some SCTEs.
Rosacea has a hereditary component and those that are fair-skinned of Celtic and other European ancestries have a higher genetic predisposition to developing it. Women are more commonly affected. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.
It has also been hypothesised that rosacea is in fact a neurological disorder resulting from hypersensitization of sensory neurons by bradykinin following activation of the plasma kallikrein-kinin system due to exposure to intestinal bacteria in the digestive tract. This hypersensitivity then produces neurogenic inflammation upon dermal stimulation causing the flushing symptoms and vasodilation that are characteristic of the disorder. This hypothesis has been recently supported by the finding that rosacea patients exhibit a very significantly increased prevalence of bacterial overgrowth in the small intestine vs. controls (p<0.001) and that eradication of this overgrowth in affected patients, using a 10-day course of an antibiotic that cannot be absorbed from the digestive tract, produces complete remission of symptoms in 96% patients for at least 9 months without further treatment. In the remaining 4% of patients that experienced symptom recurrence, bacterial overgrowth was found to have reoccurred and a second course of eradication treatment again produced sustained remission.
Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include alcohol, foods and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food.
Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of isotretinoin, benzoyl peroxide and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.
Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea. When large numbers are present they may play a role along with other triggers. On other occasions Demodicidosis (Mange) is a separate condition that may have “rosacea-like” appearances.
Most people with rosacea have only mild redness and are never formally diagnosed or treated. There is no single, specific test for rosacea.
In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.
The disorder can be confused with, and co-exist with acne vulgaris and/or seborrhoeic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.
Treating rosacea varies from patient to patient depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists. Mild cases are often not treated at all, or are simply covered up with normal cosmetics.
While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually one to two years, may result in permanent control of the condition for some patients. Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission.
Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. The National Rosacea Society recommends that a diary be kept to help identify and reduce triggers.
Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims.
People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily, gentle cleansing of the eyelids with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.
A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.
Oral tetracycline antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defense prescribed by doctors to relieve papules, pustules, inflammation and some redness. Topical azelaic acid such as Finacea (15%) or Skinoren (20%) may help reduce inflammatory lesions, bumps and papules. Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed. Isotretinoin has many side effects and is normally used to treat severe acne but in low dosages is proven to be effective against papulopustular and phymatous rosacea.
The treatment of flushing and blushing has been attempted by means of the centrally acting α-2 agonist clonidine, but this is of limited benefit on just this one aspect of the disorder. The same is true of the beta-blockers nadolol and propanolol. If flushing occurs with red wine consumption, then complete avoidance helps. There is no evidence at all that antihistamines are of any benefit in rosacea.
One alternative skin treatment, fashionable in the Victorian and Edwardian eras, was sulphur. Recently sulphur has re-gained some credibility as a safe alternative to steroids and coal tar.
Dermatological vascular laser (single wavelength) or Intense Pulsed Light (broad spectrum) machines offer one of the best treatments for rosacea, in particular the erythema (redness) of the skin. They use light to penetrate the epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed by oxy-hemoglobin which heat up causing the capillary walls to heat up to 70 ºC (158 ºF) , damaging them, causing them to be absorbed by the body’s natural defense mechanism. With a sufficient number of treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly-formed capillaries.
CO2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused and used to vaporise tissue. Low level light therapies have also been used to treat rosacea. Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness associated with it.