Rosacea

Rosacea (ro-zay-sha) is a common, acne-like benign inflammatory skin disease of adults, with a worldwide distribution. Rosacea affects an estimated 16 million people in the United States alone and approximately 45 million worldwide. Most people with rosacea are Caucasian and have fair skin. The main symptoms and signs of rosacea include red or pink facial skin, small dilated blood vessels, small red bumps sometimes containing pus, cysts, and pink or irritated eyes. Many people with rosacea may assume they have susceptible skin that blushes or flushes easily.

Rosacea is considered an incurable auto-inflammatory skin condition that waxes and wanes. As opposed to traditional or teenage acne, most adult patients do not "outgrow" rosacea. Rosacea characteristically involves the central region of the face, mainly the forehead, cheeks, chin, and the lower half of the nose. It commonly appears in people with light skin and particularly in those of English, Irish, and Scottish backgrounds. Some famous people with rosacea include former U.S. President Bill Clinton and W.C. Fields. Alcohol intake does not directly cause rosacea, but it can be aggravated by it. Rosacea is not contagious or infectious.

The redness in rosacea, often aggravated by flushing, may cause small blood vessels in the face to enlarge (dilate) permanently and become more visible through the skin, appearing like tiny red lines (called telangiectasias). Continual or repeated episodes of flushing and blushing may promote inflammation, causing small red bumps, or papules, that often resemble teenage acne. Acne rosacea and adult acne are other names for rosacea. One of the most unpleasant aspects of rosacea is the overgrowth of dermal tissues producing a "phymatous" change in the skin. This appears as a thickening and permanent swelling of the facial tissues. A bulbous nose called rhinophyma is an example of this change.

Rosacea, although distinct from acne, does have some similarities. Unlike common acne, rosacea occurs most often in adults (30-50 years of age). Unlike acne vulgaris, rosacea is devoid of blackheads and characteristically does not resolve after puberty. Rosacea strikes both sexes and potentially all ages. It tends to be more frequent in women but more severe in men. It is very uncommon in children, and it is less frequent in people with dark skin.

The exact cause of rosacea is still unknown. The basic process seems to involve the dilation of the small blood vessels of the face. Currently, health researchers believe that rosacea patients have a genetically mediated reduction in the ability to dampen facial inflammation that is incited by environmental factors such as:

• Sunburn
• Demodicosis (Demodex folliculorum in the hair follicles)
• Flushing
• Certain medications

Rosacea tends to affect the "blush" areas of the face and is more common in people who flush easily. Additionally, a variety of triggers is known to cause rosacea to flare, including:

• Emotional factors (stress, fear, anxiety, embarrassment, etc.) may trigger blushing and aggravate rosacea
• Changes in the weather, like strong winds or a difference in the humidity can cause a flare-up
• Sun exposure and sun-damaged skin are associated with rosacea
• Exercise, alcohol consumption, smoking, emotional upsets, and spicy food are other well-known triggers that may aggravate rosacea
• Many patients may also notice flares around the holidays, particularly Christmas and New Year's holidays

Rosacea risk factors include:

• Fair skin, English, Irish, or Scottish heredity
• Easy blushing
• Having other family members with rosacea ("positive family history")

Additional risk factors include:

• Female gender
• Menopause
• Being 30-50 years of age

Typical signs and symptoms of rosacea include:

• Facial flushing
• Blushing
• Skin redness (erythema)
• Burning
• Red bumps and pustules
• Small cysts
• Thickening of the facial tissue, especially the nose

The symptoms and signs of rosacea tend to come and go. The skin may be clear for weeks, months, or years and then erupt again. Rosacea tends to evolve in stages and typically causes inflammation of the skin of the face, particularly the forehead, cheeks, nose, and chin.

When rosacea first develops, it may appear, then disappear, and then reappear. However, the skin may fail to return to its normal color, and the enlarged blood vessels and pimples arrive in time. Rosacea rarely resolves spontaneously.

Rosacea generally lasts for years, and if untreated, it gradually tends to worsen.

Early in the course of rosacea, facial flushing is transient, lasting for minutes to hours. Later, as the disease progresses, the flushing becomes permanent and the redness does not resolve.

The nose is typically one of the first facial areas affected by rosacea. It can become red and bumpy and develop noticeable dilated small blood vessels. Left untreated, advanced stages of rosacea can cause a disfiguring nose condition called rhinophyma (ryno-fy-ma), literally, growth of the nose, characterized by a bulbous, enlarged red nose and puffy cheeks (like the classic comedian W.C. Fields). There may also be thick bumps on the lower half of the nose and the nearby cheek areas. Rhinophyma occurs mainly in men. Severe rhinophyma can require surgical correction and repair.

Some people falsely attribute the prominent red nose to excessive alcohol intake, and this stigma can cause embarrassment to those with rosacea.

Rosacea may affect the eyes. Not everyone with rosacea has eye problems. A complication of advanced rosacea, known as ocular rosacea, affects the eyes. About half of all people with rosacea report feeling burning, dryness, and irritation of the tissue lining of the eyes (conjunctivitis). These individuals may also experience redness of the eyelids and light sensitivity. Often the eye symptoms may go completely unnoticed and not be a major concern for the individual. Many times, the physician or ophthalmologist may be the first one to notice the eye symptoms. Untreated, ocular rosacea may cause a serious complication that can damage the cornea permanently damaging vision, called rosacea keratitis. An ophthalmologist can assist in a proper eye evaluation and prescribe rosacea eyedrops. Oral antibiotics may be useful to treat skin and eye rosacea.

Although rosacea has a variable course and is not predictable in everyone, it gradually worsens with age, especially if untreated. In small studies, many rosacea sufferers have reported that without treatment their condition had advanced from early to middle stage within a year. With good therapy, it is possible to prevent the progression of rosacea.

Dermatologists are most familiar with which option might be best for each individual. Ophthalmologists treat rosacea-related eye disease.

Doctors usually diagnose rosacea based on the typical red or blushed facial skin appearance and symptoms of easy facial blushing and flushing. Rosacea is underdiagnosed, and most people with rosacea do not know they have the skin condition. Many people may not associate their intermittent flushing symptoms with a medical condition. The facial redness in rosacea may be transient and come and go very quickly.

Dermatologists are physicians who have special training in the diagnosis of rosacea. Generally, no specific tests are required for the diagnosis of rosacea.

In unusual cases, a skin biopsy may be required to help confirm the diagnosis of rosacea. Occasionally, a dermatologist may perform a noninvasive test called a skin scraping in the office to help exclude a skin mite infestation by Demodex, which can look just like rosacea (and maybe a triggering factor). A skin culture can help exclude other causes of facial skin bumps like staph infections or herpes infections. Blood tests are not generally required but may help exclude less common causes of facial blushing and flushing, including systemic lupus, other autoimmune conditions, carcinoids, and dermatomyositis.

While most cases of rosacea are straightforward, some atypical cases are not as easy to diagnose.

Other skin diseases and rosacea look-alikes include:

• Acne vulgaris
• Demodex folliculitis
• Staph infection
• Systemic lupus erythematosus
• Medication reaction (for example, niacin)
• Seborrheic dermatitis
• Allergic or contact dermatitis
• Eczema
• Seasonal allergies
• Allergic conjunctivitis
• Perioral dermatitis
• Carcinoid syndrome
• Dermatomyositis
• Impetigo
• Herpes simplex

Recently, there has been an association noted between rosacea and certain auto-inflammatory diseases, including diabetes, inflammatory bowel disease, and cardiovascular disease.

There are many treatment choices for rosacea depending on the severity and extent of symptoms. Available medical treatments include antibacterial washes, topical creams, antibiotic pills, lasers, pulsed-light therapies, photodynamic therapy, and isotretinoin.

• Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition.
• More resistant situations may require a combination approach, using several of the treatments at the same time.

A combination approach may include a prescription sulfa facial wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office lasers, intense pulsed light, or photodynamic therapies may also be used in combination with the home regimen. It is advisable to seek a physician's care for the proper evaluation and treatment of rosacea.

With the proper treatment, patients can control rosacea symptoms and signs. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole (Metrogel) applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid (Azelex cream, Finacea gel 15%) is another effective treatment for patients with rosacea. Both metronidazole and azelaic acid work to control the redness and bumps in rosacea.

Some patients elect combination therapies and notice an improvement by alternating metronidazole and azelaic acid: using one in the morning and one at night. Sodium sulfacetamide (Klaron lotion) helps reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin (Cleocin). Topical ivermectin cream (Soolantra Cream, 1%) is also available.

Recently, a new topical prescription gel has become available designed to relieve the redness so characteristic of rosacea. Brimonidine gel (Mirvaso) and oxymetazoline hydrochloride cream (RHOFADE) applied once a day can produce a prolonged period of blanching of previously red skin in rosacea patients.

Oral antibiotics

Physicians commonly prescribe oral antibiotics to patients with moderate rosacea. Tetracycline (Sumycin), doxycycline (Vibramycin, Oracea, Adoxa, Atridox), and minocycline (Dynacin, Minocin), are oral antibiotics commonly prescribed are presumed to work by reducing inflammation. A newer low-dose doxycycline preparation called Oracea (40 mg once a day) treats rosacea. The dose may be initially high and then tapered to maintenance levels. Patients should consider common side effects and potential risks before taking oral antibiotics.

Miscellaneous medications

In occasional cases, patients may use short-term topical cortisone (steroid) preparations of minimal strength to reduce local inflammation. Some mild steroids include desonide lotion or hydrocortisone 1% cream applied sparingly once or twice a day just to the irritated areas. There is a risk of causing a rosacea flare by using topical steroids. Prolonged use of topical steroids on the face can also cause irritated skin around the mouth (perioral dermatitis).

Some doctors may also suggest tretinoin (Retin-A), tazarotene (Tazorac), or adapalene (Differin), which are medications also used for acne. Rarely, do physicians prescribe permethrin (Elimite) cream for rosacea cases that are associated with skin mites. Permethrin also treats follicular Demodex mites if warranted.

Isotretinoin (Accutane)

Doctors infrequently prescribe isotretinoin for severe and resistant rosacea. Often physicians prescribe it after multiple other therapies have been tried for some time and have failed. Patients take a daily capsule of istotretinoin for four to six months. Typically, isotretinoin is most commonly used in the treatment of severe, common acne called acne vulgaris. Close physician monitoring and blood testing are necessary while on isotretinoin. Generally, at least two forms of birth control are required for females using this medication, as pregnancy is contraindicated while on isotretinoin.

Cleansers

In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Avoid harsh soaps and lotions. Simple and pure products such as Cetaphil or Purpose gentle skin cleanser may be less irritating. Patients should avoid excessive rubbing or scrubbing the face.

Other recommended cleansers include:

• sulfa-based washes (for example Rosanil)
• benzoyl peroxide washes (for example Clearasil)

Laser and intense pulsed light

Many patients are now turning to laser and intense light treatments to treat the continual redness and noticeable blood vessels on the face, neck, and chest. Often considered a safe alternative, laser, and intense pulse-light therapy may help improve the skin and complexion.

Laser treatment may cause some discomfort. While most patients can endure the procedure, ice packs and topical anesthetic cream can help alleviate the discomfort. Multiple treatments are typically necessary, and most insurance does not cover the procedure. Doctors recommend treatments in three- to six-week intervals; during this time, sun avoidance is necessary. Review risks, benefits, and alternatives with a physician before treatment. Combine laser treatments with photodynamic therapy (light-activated chemical using Levulan) for more noticeable results.

Photodynamic therapy

Photodynamic therapy (PDT) is one of the newly available treatments. PDT uses a topical photosensitizer liquid that one applies to the skin and a light to activate the sensitizer. Levulan (aminolevulinic acid) and blue light, commonly used to treat pre-cancers (actinic keratosis) and acne vulgaris, can treat some rosacea patients. The use of PDT in rosacea is off-label since it is primarily designed for regular acne. PDT works at reducing inflammation; PDT is performed in a physician's office. The treatment takes anywhere from one to one and a half hours to complete. Strict sun avoidance for approximately one to three days is required after the treatment. Mild discomfort during the treatment and a mild to moderate sunburn appearance after the treatment are common. Some patients have experienced remissions (disease-free periods) of several months to years from these types of treatments. Other patients may not notice significant improvement.

Glycolic peels

Glycolic-acid peels may additionally help improve and control rosacea in some people. Professionals can apply chemical peels to patients for approximately two to five minutes every two to four weeks. Mild stinging, itching, or burning may occur and some patients experience peeling for several days after the peel. Any peel can irritate very sensitive skin and cause flares for some people. Peels should be used with caution in rosacea as not everyone can tolerate these treatments.

Sun protection

Sun exposure is a well-known flare for many rosacea sufferers. Sun protection using a wide-brimmed hat (at least 6 inches) and physical sunscreens (like zinc or titanium) are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, physicians recommend the use of an appropriate daily SPF 50 sunscreen lotion, along with overall sun avoidance.

While not all rosacea people are the same, there are some common rosacea triggers. Avoiding these potential triggers may also help relieve symptoms and disease flares. It may be helpful to keep a personal diary of foods and other triggers that flare rosacea symptoms.

Smoking, spicy foods, hot drinks, and alcohol may cause flushing and should be avoided. Exposure to sunlight and extreme hot and cold temperatures should be limited as much as possible. Red wine and chocolate are two well-known rosacea triggers. Some listed foods may not affect one patient's rosacea but severely affect someone else. Individual reaction patterns vary greatly in rosacea. Therefore, a food diary may help to elucidate one's special triggers.

Possible rosacea dietary triggers include:

• Dairy, including yogurt, sour cream, and cheese (except cottage cheese)
• Alcohol, including red wine, beer, vodka, gin, bourbon, and champagne
• Chocolate
• Soy sauce
• Yeast extract
• Eggplants, avocados, spinach
• Some beans and pods, including lima, navy, or peas
• Citrus fruits, including tomatoes, bananas, red plums, raisins, or figs
• Spicy and temperature hot foods

Avoid potent cortisone or steroid medications on the face because they can promote the widening of the tiny blood vessels of the face (telangiectasis). Some patients experience severe rosacea flares after prolonged use of topical steroids.

Vasodilator pills can also flare rosacea. Vasodilators include certain blood pressure medications like nitrates, calcium channel blockers (such as nifedipine [Procardia]), and thiazide diuretics (such as Dyazide).

Many skin cleansers contain these potential triggers and should be avoided in rosacea, such as:

• Alcohol
• Witch hazel
• Peppermint
• Eucalyptus oil
• Clove oil
• Fragrance
• Menthol
• Salicylic acid

Foods that decrease rosacea flares include less spicy meals, nonalcoholic cool beverages, caffeine-free drinks, nondairy cheese, and thermally cooler meals.

Rosacea skin tends to be sensitive and may easily flare with self-treatment or common acne therapies. Approach any home treatment or attempts for natural remedies with some caution. As with any rosacea therapy, some people may experience sensitivity or irritation with treatment. Several possible natural remedies, including dilute vinegar cleansing and green tea applications, may be useful in rosacea.

Dilute white vinegar facial soaks or cleansing daily or weekly using approximately 1 part regular table vinegar to 6 parts water may be helpful. Vinegar helps as a natural disinfectant and can help decrease the number of yeasts and bacteria on the skin. Since vinegar may flare rosacea in some people, try a small test area before applying it to the entire face.

Green tea soaks to the face may also help decrease the redness and inflammation seen in rosacea. Green tea has anti-inflammatory properties. A few commercially available products also use green tea as the active ingredient.

Proper skin care involves using a gentle cleanser to wash the face twice a day. Overwashing may irritate. A sunscreen lotion is advisable each morning. A physician may prescribe a topical antibiotic to use once or twice a day under sunscreen.

Rubbing the face tends to irritate the reddened skin. Some cosmetics and hair sprays may also aggravate redness and swelling.

Facial skin care products such as soap, moisturizers, and sunscreens should be free of alcohol or other irritating ingredients. Apply moisturizers very gently after any topical medication has dried. When going outdoors, use sunscreens with an SPF of 50.

Telangiectasias are the small blood vessels that arise on the surface of the skin, commonly around the nose, cheeks, and chin.

Patients can use simple cover-up makeup for the telangiectasias. There are some green-based moisturizers or tinted foundations that may help conceal the redness.

Doctors can treat telangiectasias with a small electric needle, a laser, intense pulsed light, or minor surgery to close off the dilated blood vessels. Usually, multiple treatments are required for the best results, and only a portion of the blood vessels improve with each treatment. Not everyone responds the same to these types of treatments, and a physician can help someone decide which treatment is best for his or her skin type, condition, and size of blood vessels.

• Electrocautery
• Laser
• Intense pulsed light therapy

Surgery frequently treats rhinophyma of the nose. A physician uses a scalpel, laser, or electro-surgery to remove the excess tissue. Dermabrasion can help improve the look of the scar tissue. Follow-up treatments with laser or intense pulsed light may help lessen the redness. Medical maintenance therapy with oral and or topical antibiotics may be useful to decrease the chance of recurrence.

Since there is some overlap between acne and rosacea, some of the medications may be similar. Acne and rosacea have in common several possible treatments, including (but not limited to) oral antibiotics, topical antibiotics, sulfa-based face washes, isotretinoin, and many others. It is important to seek a physician's advice before using random over-the-counter acne medications since they can irritate skin that is prone to rosacea. Overall, rosacea skin tends to be more sensitive and easily irritated than that common acne.

Rosacea is an incurable chronic condition. While there is no cure for rosacea, it can be controlled with proper, regular treatment.

Some forms of rosacea may be significantly cleared for long periods using a laser, intense pulse light, photodynamic therapy, or isotretinoin (Accutane). Although still not considered a "cure," some patients experience long-lasting results and may have remissions (disease-free periods) for months to years.

Rosacea may affect someone's life minimally, moderately, or severely depending on how active the condition is and one's overall tolerance of the skin symptoms and signs.

Some individuals have absolutely no symptoms, and rosacea doesn't bother them. They may enjoy perfectly healthy normal lives without any effect from this benign skin condition. Some patients like the pink glow to their cheeks and find it gives them a pleasant color without having to use blush. They may not even know they have rosacea. They usually do not want to use any treatment.

Patients with moderate rosacea may have periodic flares that require treatment with oral antibiotics, lasers, and other therapies. They may require oral antibiotic therapy for years. Some patients complain of looking like they have been drinking alcohol when in fact they don't drink at all. Although rosacea is not a grave medical situation, severe cases may damage some patients' lives. It is important for these patients to express their concerns to their physician and to get professional help in treating their rosacea.

Overall, promptly diagnosed and properly treated, rosacea should not prevent people with the condition from enjoying long and productive lives.

It is not possible to prevent rosacea, but it is possible to limit one’s exposure to triggering factors. Once a patient receives a diagnosis of rosacea, it is wise to avoid factors like spicy foods, hot liquids, smoking, and irritating cosmetics that are known to trigger rosacea.

For more information on rosacea, contact the National Rosacea Society (NRS) at http://www.Rosacea.org or 888-no-blush. Support information and research updates may be regularly available from NRS. NRS also sponsors research grants and studies on rosacea treatment.

Additional information is available from the American Academy of Dermatology at http://www.AAD.org. Names of U.S. board-certified dermatologists are available on this website.

While online chat groups are available at http://www.Rosacea-Support.org, these should not replace the advice of a physician. Online public posts and comments may not be scientifically or medically accurate, and people with rosacea should evaluate these cautiously.