Rosacea

Rosacea is a skin condition that typically occurs in adults. It appears as a red rash, which looks like a sunburn, on the face. There is no known cause but small blood vessels at the skin's surface that enlarge can give a flushed appearance. Small pimples may also develop on the forehead, cheeks, nose and chin with a similar appearance to acne, which is why it is sometimes called acne rosacea. However, the two conditions are unrelated and unlike acne, rosacea does not result in scarring.

As well as skin redness and pimples, rosacea may also cause inflammation and irritation of the eyes or a thickening of the skin, particularly towards the end of the nose. Symptoms of rosacea may change over time and can vary from person to person.

Although rosacea can occur in anyone, it is most commonly seen in adults aged 30-60 years and in people who have fair skin, blue eyes or are of a Celtic heritage. While it is also more common in women, symptoms are often more noticeable in men. Rosacea can occur in children, but this is rare.

Signs and symptoms

Rosacea often begins with frequent flushing of the face, which may be the only symptom for months or even years. As the condition progresses, other symptoms may include:

• Redness (erythema);
• Small bumps (papules) or blisters (pustules);
• Burning or stinging skin;
• Dry, scaly skin patches (plaques);
• Visible blood vessels (telangiectasia);
• A swollen face;
• Red, sore or gritty eyes (ocular rosacea), and;
• Thickening of the skin, particularly on the nose (rhinophyma).

Symptoms are usually confined to the face, particularly the forehead, nose, cheeks and chin. Less commonly, other parts of the head and sometimes even the back and arms may be affected.

Causes

The exact cause of rosacea is unknown, but a combination of inherited and environmental factors are thought to be involved. These include:

Immune response

One theory is that an immune response in the skin contributes to the development of rosacea. This theory comes from the fact that high levels of a chemical found in immune cells are seen in the skin of people with rosacea. This chemical, called cathelicidin, promotes blood vessels in skin to enlarge and fluid to leak out, which causes the redness and swelling seen in rosacea.

Blood vessel abnormalities

Another possibility is that abnormal blood vessels in the face are particularly prone to leaking fluid in rosacea. While the cause of these proposed abnormalities is unknown, sun damage to the skin's collagen - a type of protein that gives the skin its structure and elasticity - may be a factor.

Mites

A type of hair follicle mite, called Demodex folliculorum, is often found in higher-than-usual numbers in people with rosacea. These mites are found naturally on facial skin and usually do not cause any harm. However, it is unclear whether the increase in mite numbers is a cause or result of rosacea. Also, large numbers of Demodex folliculorum mites are sometimes present in people who do not have rosacea.

Helicobacter pylori bacteria

Rosacea tends to occur more often in people who carry Helicobacter pylori bacteria in their stomach. It has been suggested that this bacteria may promote production of natural inflammatory chemicals that cause blood vessels to dilate. Again though, no specific link between Helicobacter pylori and rosacea has been established and many people who carry the bacteria do not develop rosacea.

Genetic factors

Often people with rosacea also have family members with the condition. This suggests an inherited component that is passed down from parents to their children. However, it is not known what genes are involved or how they are passed on.

Other environmental factors

A number of additional environmental factors are known to make rosacea symptoms worse, most likely by increasing blood flow to the skin. However, these factors are triggers and not direct causes of the condition. Some examples include:

• Embarrassment, stress or anger;
• Certain medications, such as topical corticosteroids;
• Exposure to sunlight;
• Strenuous exercise;
• Hot or spicy foods;
• Dairy products;
• Alcohol;
• Hot baths or saunas;
• Another medical condition, such as high blood pressure, cold or fever, and;
• Weather extremes, including hot or cold temperatures, humidity or wind.

Types

Rosacea can be classified into four different types that often overlap, including:

Vascular rosacea

Also known as erythematotelangiectatic rosacea, this type is characterized by a redness in central areas of the face, frequent flushing, visible blood vessels (telangiectasia) and a burning or stinging sensation. Affected areas may appear rough, scaly and less oily than other types of rosacea.

Inflammatory rosacea

Inflammatory rosacea is the classic subtype of rosacea, appearing as a redness in the central areas of the face, along with bumps (papules) or pimples (pustules). Without treatment, these may come and go or remain long-term. This type of rosacea most commonly affects middle-aged women. It is also sometimes known as papulopustular rosacea.

Ocular rosacea

Ocular rosacea affects the eyes and causes itching, dryness, a gritty sensation and crusting of the eyelids. These symptoms occur in about half of all people with rosacea and may appear before the skin symptoms.

Phymatous rosacea

More common in men than women, this rare type of rosacea occurs when the skin's oil glands (sebaceous glands) become enlarged, resulting in a thickened or lumpy appearance. It usually affects the nose (rhinophyma), but may also occur on the chin, forehead, ears and eyelids.

Visual appearance of the main types of rosacea. 

Methods for diagnosis

A doctor will usually diagnose rosacea by looking closely at the skin and eyes, asking about symptoms and establishing a family link. While there are no specific tests for diagnosing rosacea, a blood test may be done to rule out other conditions that also cause skin redness, such as lupus, acne or psoriasis. Occasionally, a skin sample may be taken to determine the presence of skin mites (Demodex folliculorum) or an infection.

Types of treatment

As there is no cure for rosacea, the aim of treatment is to control symptoms. A doctor will most likely recommend a combination of self-care measures and prescription medications. Sometimes treatment may not be required if symptoms are not causing distress or discomfort, but overall, options include:

Self care

Self-care measures for rosacea focus on good skincare habits and avoiding factors that trigger or aggravate symptoms. Some examples could include:

• Wearing an oil-free sunscreen with a high sun-protection factor (SPF 15 or higher);
• Choosing products that will not clog the pores;
• Protecting the face during winter months;
• Using a cold pack to reduce inflammation and swelling, and;
• Avoiding known triggers, which could include alcohol, sunlight or spicy foods.

Oral antibiotic medications

Oral antibiotic medications, such as minocycline, doxycycline and metronidazole, are the usual treatment for bumps and pimples associated with rosacea. However, it is unclear exactly why these medications are effective, as bacteria are not thought to be a primary cause of rosacea. Instead, antibiotics probably work by reducing inflammation, rather than by killing the bacteria.

While some improvements may occur after 2-3 weeks of treatment, oral antibiotics are generally prescribed for 8-10 weeks to clear the symptoms. After a course of antibiotics has finished, bumps and blisters may return. When this occurs, a doctor may prescribe another course of oral antibiotics, either on a short-term or ongoing basis.

Topical medications

For mild skin redness and inflammation, a doctor may prescribe an antibiotic or other type of medication to be applied directly onto the skin. Some examples of topical antibiotics include metronidazole, erythromycin and clindamycin. Other topical medications prescribed for the treatment of rosacea include azelaic acid, sulphur creams or brimonidine. Care should be taken with topical antibiotics as they may cause sensitivity or allergy.

While corticosteroids, such as hydrocortisone, may be effective for treating rosacea, they are avoided as they can make symptoms worse in the long-term. Similarly, over-the-counter medications are not suitable for the treatment of rosacea.

Eye medications

For the treatment of mild eye symptoms (ocular rosacea), a doctor may recommend lubricating drops or an ointment to relieve dryness. Good hygiene measures, such as cleaning the eyelids with a warm compress, may also help. In severe cases of rosacea, a long-term antibiotic medication may be prescribed. If complications occur, a doctor may provide a referral to a specialist eye doctor (ophthalmologist).

Light therapies

Redness, flushing and visible blood vessels (telangiectasia) may be improved with intense pulsed light (IPL), or vascular laser treatments. These treatments produce narrow light beams that shrink dilated blood vessels. This reduces facial redness without damaging the surrounding skin. Side effects can include pain during treatment, bruising, crusting and swelling, or in rare cases, blisters and infection. However, most people do not require an anesthetic and the side effects usually last for only a few days after the treatment.

Intense pulsed light (IPL) treatment for rosacea. 

Isotretinoin

Commonly used for the treatment of severe acne, isotretinoin is an oral medication that may also be prescribed occasionally, at a low dose, for treatment of rosacea. However, as it has serious side effects, including potentially causing birth defects, isotretinoin is only prescribed by specialized skin doctors (dermatologists).

Surgery

In cases of rhinophyma, plastic surgery may be suggested to remove excess tissue and reconstruct thickened skin around the nose. This procedure may be carried out with a scalpel, a carbon dioxide laser or a resurfacing laser.

Potential complications

Eye complications

Rosacea affects the eyes in about half of all cases and is known as ocular rosacea. Inflammation of the eyelids (blepharitis) or eyelid linings (conjunctivitis) are the most common symptoms. However, the inflammation can usually be treated with good cleaning habits and antibiotics, as prescribed by a doctor.

In rare cases, rosacea can also lead to inflammation and infection of the cornea. If left untreated, the infection can eventually cause vision loss.

Rhinophyma

Rhinophyma occurs when the oil glands (sebaceous glands) in the skin of the nose become enlarged, causing a red, thick and lumpy appearance. Symptoms are usually more noticeable towards the end of the nose, or very rarely, may affect the cheeks. Rhinophyma falls into the phymatous rosacea subtype.

Psychological effects

For some people, severe or long-term symptoms may affect the quality of life, or result in psychological issues such as distress, low self-esteem, depression or embarrassment.

Prognosis

The outcome for rosacea can vary greatly between people. With mild cases, some people may be unaware of the condition. Similarly, if symptoms are not causing distress or discomfort, others may choose not to seek treatment.

For moderate to severe cases, good results may be achieved using a single treatment, or multiple treatments may need to be trialed before finding an effective option.

Overall, even though there is no cure for rosacea and the condition is for life, it can usually be managed effectively with a combination of self-care measures and prescription medications. Eye damage and vision loss can also be avoided with appropriate treatment of ocular rosacea.

Prevention

While there is no way to prevent rosacea from occurring, steps can be taken to prevent symptoms from returning or becoming worse. In general, these steps closely resemble the self-care treatment options, which include good skincare habits and avoiding factors that can trigger the symptoms. For example, a doctor may recommend a gentle cleansing routine using oil-free soaps, moisturizers or sunscreens. Similarly, avoiding factors such as sunlight, spicy foods or alcohol may be helpful if these factors are known to trigger rosacea.