What is rosacea?

Rosacea is a common, chronic skin disorder affecting the central face. It is an episodic and variable condition but classically presents as acne-like bumps (papules and pustules), red or pink patches and broken capillaries. The condition is common in people with fair skin and blue eyes who are of Celtic or English ancestry.

rosacea Image reproduced with permission of Dr Davin Lim
Image reproduced with permission of Dr Davin Lim

The symptom initially noticed is blushing (facial flushing) which becomes more frequent and eventually leads to persistent facial redness which fluctuates in intensity. Small blood vessels dilate and become visible as telangiectasia (broken blood vessels) and the continual or episodic blushing may promote inflammation, causing red bumps to appear which can resemble teenage acne. The cheeks, chin and nose are most commonly affected. Rosacea is more common in women and typically presents between the ages of 30 to 50.

rosacea Image reproduced with permission of Dr Davin Lim
Image reproduced with permission of Dr Davin Lim

What causes it?

The exact cause of rosacea is unknown. There could be a combination of factors involved including hereditary (genetic), environmental, vascular and inflammatory factors as well as reaction to the demodex mite (microscopic mite that lives on human skin, commonly called ‘eyelash mite’).

A number of factors can trigger or aggravate rosacea by dilating blood vessels and therefore increasing blood flow to the surface of the skin. These include:

  • Hot food or beverages
  • Spicy foods
  • Alcohol
  • Temperature extremes
  • Sunlight
  • Stress, anger or embarrassment
  • Strenuous exercise
  • Hot baths or saunas
  • Oral and topical corticosteroids
  • Drugs that dilate blood vessels such as blood pressure medications
  • Inappropriate use of skin care products such as facial creams and oils.

What does it look like?

There are a number of different types of rosacea which have their own distinctive features.

1. Erythematotelangiectatic rosacea

  • Frequent blushing and flushing
  • Temporary or persistent facial redness in the central portion of the face
  • Telangiectasias (broken blood vessels) on the nose, cheeks and chin.

2. Papulopustular rosacea

  • Papules and pustules (swollen bumps) on the face that resemble acne.
  • Sensitive skin: This is common to all forms of rosacea.  Some skincare products may cause stinging, redness and irritation. This can also occur with make-up.

3. Swollen rosacea

  • Lymphoedema (hot and swollen facial skin)
  • Thickening ‘orange peel’ skin over the nose, cheeks, forehead and chin
  • Rhinophyma (enlarged bulbous nose with dilated pores which in severe cases can result in a deformed nose). Rhinophyma is more common in men.
rosacea Image reproduced with permission of Dr Davin Lim
Image reproduced with permission of Dr Davin Lim

4. Ocular rosacea

  • Occurs in more than 50% of people with rosacea
  • 25% of people with eye disease have skin related rosacea
  • Presents with red, sore or gritty eyelid margins or eyes. This can result in inflammation of the eyelids (blepharitis), conjunctivitis and inflammation of the white part of the eye (episcleritis).

Untreated eye rosacea may result in permanent damage and impaired vision. An ophthalmologist should be seen if eye involvement is suspected.

How is it diagnosed?

In most cases, rosacea is diagnosed based on history and clinical signs such as typical red or blushed facial appearance with associated papules and pustules (bumps) and telangiectasia (broken blood vessels).

In unusual cases, a skin biopsy or blood test may be required to rule out other causes of facial flushing and facial redness such as systemic lupus and dermatomyositis.

How is it treated?

General measures:

  • Avoid the triggers of flushing, as discussed above.
  • Avoid skincare products and make-up that cause stinging, burning or irritation, eg products that include fragrances, waterproof cosmetics, toners and astringents, menthols and camphors or sodium laurel sulphate.
  • Use a gentle cleanser and moisturiser.
  • All topical products must be oil free (non-comedogenic).
  • Never apply topical steroid to rosacea as it will make the rosacea worse.
  • Protect your skin from the sun with sunscreen and by covering up with a hat.
  • Keep your face cool to reduce flushing.

Topical treatments:

  • Topical products can be used in isolation or in combination with oral treatment. Examples of topic products include: topical metronidazole cream or gel, topical azelaic acid, topical erythromycin gel, topical sulphur in cetaphil lotion, topical clindamycin, and topical tacrolimus 0.1%.
  • Topical brimonidine can be used to reduce redness.

Oral treatments:

  • Oral antibiotics

Oral tetracycline antibiotics (such as doxycycline) can reduce inflammation. Both skin and eye involvement usually responds to oral antibiotics. The duration of treatment depends on the severity of the rosacea.  Other antibiotics (such as oral erythromycin) can also be used.

Isotretinoin may be used when antibiotics are ineffective. This medication has side effects and is not suitable for everyone.

  • Other oral treatments to reduce flushing include alpha 2 receptor agonists (such as clonidine) or beta-blockers (such as carvedilol).

Procedural therapies:

Persistent telangiectasia and difficult to control rosacea can be improved with vascular laser treatment. These lasers include KTP laser, PDL-Pulsed dye laser, long pulsed ND: YAG laser. Multiple treatments are required. They do not cure rosacea and over time the rosacea will recur and future treatments may be necessary. Intense pulse light, IPL, can also be used but it is not as effective as vascular laser treatment.

Rhinophyma can be difficult to treat.  It may partially improve with medication, but a combination of surgical and laser remodelling is often required to achieve a cosmetically acceptable result.

Consult a dermatologist to discuss management and treatment options for rosacea.

What other problems can occur with it?

There are no internal associations.

What is the likely outcome of the condition?

Rosacea tends to be a chronic condition. It can be constant or it can fluctuate in severity. There can be periods of remission in some people but in others, it can progress and slowly worsen.

This information has been written by Dr Antoinette Ciconte

Last Updated 06/04/2017


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