Rosacea is a chronic, inflammatory skin condition that most often affects the face. Rosacea worsens with time if left untreated. It is often mistaken for acne, eczema, or a skin allergy.
Rosacea appears to be more common among fair-skinned people and affects an estimated 14 million Americans (1 in 20 people). Although the causes are not fully understood and there is no cure, there are a number of ways to relieve symptoms.
As it is frequently misdiagnosed, the incidence may be a lot higher. Rosacea is more common among fair-skinned people of northern European ancestry.
Fast facts on rosacea
- The main symptom of rosacea is the development of facial pustules.
- Around 14 million Americans are thought to have rosacea.
- Other symptoms include blushing easily and inflamed blood vessels.
- The exact causes are not known but a number of factors can trigger symptoms.
- Some foods can worsen the symptoms, such as dairy products and spicy foods
There is no cure for rosacea. However, there are various treatments which can relieve the signs and symptoms.
A combination of medications and lifestyle changes generally give the best results.
The doctor may prescribe camouflage creams that mask blemishes on the skin.
Treatment may involve a combination of prescribed topical medications (applied to the skin) and oral drugs (swallowing pills, tablets, or capsules). These include:
- Topical medications: These help reduce inflammation and redness and are applied to the skin either once or twice a day. They are commonly used in combination with some oral medications. Antibiotics (metronidazole), tretinoin, benzoyl peroxide, and azelaic acid are examples of commonly prescribed topical medications.
- Oral antibiotics: These may be prescribed for their anti-inflammatory properties. Oral antibiotics tend to give faster results than topical ones. Examples include tetracycline, minocycline, and erythromycin.
- Isotretinoin (Accutane): This oral medication is sometimes used for severe cases of inflammatory rosacea if other treatments have not worked. Isotretinoin is a powerful drug that inhibits the production of oil by the sebaceous glands. As side effects may be severe, the patient needs to be monitored closely.
- Blephamide: A specific type of steroid eye drop which is sometimes prescribed for patients with ocular rosacea (eye symptoms). Eye drops are applied daily for 3 days to 1 week, followed by a break or tapered use.
- Tetracyclines: These are sometimes prescribed for patients with symptoms of ocular rosacea. Doxycycline helps improve dryness, itching, blurred vision and photosensitivity (sensitivity to light).
For patients with visible blood vessels (telangiectasia) laser treatment, which uses intense pulsed light, can be used to shrink them. This will be done by a dermatologist. Although the procedure may cause some pain, most patients can tolerate it without the need for an anesthetic.
Laser treatment can sometimes cause bruising, crusting of the skin, swelling, tenderness, and, very rarely, infection. These complications will usually disappear within a few weeks, although if it becomes infected it may require antibiotics.
Plastic surgery for thickened skin (rhinophyma)
If the patient develops a bulbous enlarged red nose and puffy cheeks, and possibly thick bumps on the lower half of the nose and the nearby cheek areas, they might be referred to a plastic surgeon. Laser or scalpel surgery may be performed to remove excess tissue and remodel the nose. A carbon dioxide laser can also be utilized to shrink the tissue.
There are many types of rosacea but four main types, according to the American Academy of Dermatology (AAD):
- Erythematotelangiectatic rosacea features redness and flushing, with visible blood vessels.
- Papulopustular rosacea involves redness, swelling, and breakouts that resemble acne.
- Phymatous rosacea causes the skin to thicken and take on a bumpy texture.
- Ocular rosacea causes redness and irritation in the eyes and swollen eyelids. The person may look as if they have a sty.
Permanent redness may develop and persist in the center of the face.
Experts are not sure what causes rosacea. The following related factors are thought to contribute:
- Abnormalities in facial blood vessels: Skin specialists (dermatologists) suggest that abnormalities in the blood vessels of the face cause the flushing, persistent redness, and visible blood vessels. What causes the inflammation of the blood vessels is still a mystery.
- Light skin color: A much higher percentage of people with fair skin develop rosacea compared with other people.
- Demodex folliculorum (microscopic mite): Demodex folliculorum lives on human skin and usually causes no problems. However, patients with rosacea have much higher numbers of these mites than others do. It is unclear whether the mites cause the rosacea, or whether the rosacea causes the overpopulation of the mites.
- H. pylori bacteria: H. pylori, a bacteria found in the gut, stimulates the production of bradykinin, a small polypeptide known to cause blood vessels to dilate. Experts suggest that this bacterium may play a role in the development of rosacea.
- Family history (inheritance, genes): Many patients with rosacea have a close relative with the condition.
Some factors can aggravate rosacea or make it worse by increasing blood flow to the surface of the skin; these include:
- extremes of temperature
- sunlight, humidity, or wind
- stress, anxiety, anger, embarrassment
- vigorous exercise
- hot baths or saunas
- some medications, such as corticosteroids and drugs for treating high blood pressure
- acute medical conditions, such as a cold, cough, or fever
- some chronic medical conditions – such as hypertension (high blood pressure)
Foods and drinks that may trigger rosacea include:
- hot foods and beverages
- dairy products
- spices and seasonings that contain capsaicin, for example, hot sauce, cayenne pepper, and red pepper
- alcohol, including wines and hard liquors
- foods containing cinnamaldehyde, such as tomatoes, chocolate, and citrus fruits
Many signs and symptoms are associated with rosacea, but they can vary considerably from person to person.
The following signs and symptoms tend to be present in most cases:
Flushing (easily blushing): Flushing episodes can last as long as 5 minutes. The blush can spread from the face down to the neck and chest. Some people say the skin feels unpleasantly hot during flushing episodes.
Facial skin hyper-reactivity: Sensitive blood vessels dilate easily to touch and some other physical stimuli, such as sunlight. Many mistakenly refer to this as “sensitive skin,” but, with rosacea, it is caused by sensitive blood vessels and not sensitive skin cells.
Persistent redness: Sometimes, the flushing episodes may eventually be followed by bouts of persistent facial redness. The redness, like a patch of sunburn, may not go away. This occurs because hundreds of tiny blood vessels near the surface of the facial skin dilate (expand).
Pimples, papules, and pustules (Inflammatory rosacea): Small spots, papules, and pustules sometimes appear on the face – this is also known as inflammatory rosacea. Misdiagnosis is common because of their similarity to teenage acne. However, with rosacea, the skin has no blackheads, unlike acne.
Inflamed blood vessels (vascular rosacea): As the signs and symptoms of rosacea progress and get worse, small blood vessels on the nose and cheeks swell and become visible (telangiectasia) – they sometimes look like tiny spider webs. The skin on the face can become blotchy.
Rhinophyma, or excess facial skin around the nose: Severe rosacea can result in the thickening of facial skin, especially around the nose. The nose can become bulbous and enlarged (rhinophyma). This is a very rare complication, and tends to affect males much more than females.
Ocular rosacea: There is a burning, gritty sensation in the eyes, making them bloodshot. The inside of the eyelid may become inflamed (blepharitis) and appear scaly, causing conjunctivitis. Some people may not tolerate contact lenses and sties may develop. In very rare cases, vision can become blurred.
Facial swelling: Excess fluid and proteins leak out of the blood vessels and eventually overwhelm the lymphatic system, which cannot drain the leakage away fast enough. This results in fluid buildup in the facial skin.
These lifestyle and home measures will help to control symptoms, and can be used alongside any medical treatments. The key here is to minimize exposure to anything that may trigger symptoms or exacerbate them:
- When exposed to the sun, wear a broad-spectrum sunscreen with a sun protection factor (SPF) of at least 15.
- In wintertime, protect the face with a scarf or ski mask.
- Try to refrain from rubbing or touching the skin on the face.
- When washing, apply a gentle cleanser to problem areas.
- Do not use any facial products that contain skin irritants or alcohol.
- If skin is sore, use a moisturizer.
- Only apply moisturizers after topical medication has dried.
- Only use products labeled as noncomedogenic. These do not block the oil and sweat gland openings.
- Do not get too hot.
- Avoid consuming alcoholic beverages.
- An electric shaver is less likely to trigger flareups than normal razors.
- Avoid spicy foods.
- Build up a list of likely foods and drinks that might trigger an outbreak and avoid them.
- Green or yellow pre-foundation creams and powders may help mask the skin redness.
- Avoid over-the-counter (OTC) steroid creams unless your doctor has included them as part of your treatment. In the medium or long-term they may worsen symptoms.
Experts say stress is an important trigger of rosacea. Any measures to reduce stress levels will help prevent flare-ups and existing symptoms from getting worse.
Steps to reduce stress may include regular exercise, getting at least 7 hours of good quality sleep every night, and eating a healthy and well-balanced diet.
As vigorous exercise is often a trigger, patients with rosacea are advised to do low-intensity exercise, such as walking or swimming.
Yoga, tai-chi, breathing exercise, and some meditations may also help reduce stress.
There is no clinical test for rosacea. A doctor reaches a diagnosis after examining the patient’s skin, and asking about symptoms and triggers. The presence of enlarged blood vessels will help the physician distinguish it from other skin disorders.
The presence of a rash on the scalp or ears usually indicates a different or co-existing diagnosis. Rosacea signs and symptoms are mainly on the face.
Early diagnosis and subsequent prompt treatment significantly reduce the risk of rosacea’s progression. If the doctor suspects there may be an underlying medical condition or illness, such as lupus, blood tests may be ordered. The doctor may refer the patient to a dermatologist.
Some complications can arise with rosacea.
If rosacea affects the eyes, the eyelids can become inflamed (blepharitis). Treatment involves a daily application of topical antibiotic creams, and oral antibiotics.
Self-esteem, embarrassment, and frustration
Even though rosacea is not a life-threatening condition, its effect on appearance often leaves the patient embarrassed, frustrated, anxious, and lacking in self-confidence.
Patients who are well informed about rosacea tend to cope better because they are prepared to deal with complications or recurrences.
Emotional health is generally restored when symptoms are successfully addressed. This is more likely to happen if individuals comply with long-term medical therapy and take measures to minimize the factors that aggravate the condition.
It is important for individuals to talk to a doctor if they experience intense feelings of distress, embarrassment, or frustration. Talking to a counselor or medical social worker is also advisable.