Woman with rosacea on her cheeks smiling before speaking with her Phoenix Dermatologist at Saguaro Dermatology

Rosacea

Rosacea is a common skin disease that causes symptoms ranging from facial redness and sensitivity to inflamed bumps, thickening of the skin, and eye irritation. Affecting 10% of the population, rosacea is a relapsing-remitting disorder, which means that the symptoms are sometimes worse (relapse) and at other times improved or absent (remitting). The characteristic flushing associated with rosacea is often accompanied by pain, burning, and increased irritability to topical products (1). The condition can also seriously impact the quality of life of those who have it (2).

There are 4 main subtypes of rosacea (1):

Erythematotelangiectatic rosacea (ETR; erythmato = redness; telangiectatic = spidery veins): This type of rosacea is characterized by prolonged flushing in the center of the face. It is often triggered by emotional stress, hot drinks, spicy foods, exercise, and changes in temperature. Patients with ETR rosacea are more prone to severe itching and burning, have drier skin than patients with other subtypes, and become more easily irritated by products used on the face.

Papulopustular rosacea (papular = tiny, raised bump resembling acne; pustular = pus-filled): This form of the condition primarily affects middle-aged women and is indicated by redness and pinpoint bumps in the central area of the face. Flushing may also occur but to a lesser extent than in ETR rosacea.

Phymatous rosacea (phymata = thickening of the skin): This subtype typically occurs together with the usual redness and bumps but is more pronounced. It commonly occurs on the surface of the nose but may also affect the chin, forehead, ears, or eyelids. The swollen, red, bulbous appearance of this form of rosacea makes it more disfiguring and thus distressing to those who have it. It often requires surgical intervention.

Ocular rosacea (ocular = of the eye): As suggested by the name, this form of rosacea affects the eyes or area near the eyes. Patients with ocular rosacea may experience a burning or itching sensation, increased sensitivity to light, and the sensation that something is in their eye. Ocular rosacea may affect up to 50 percent of patients who also have another form of the condition.

As noted above, the main and earliest identifying features of rosacea are flushing, itching, or sensitive skin over the central part of the face. Primarily occurring on the cheeks, nose, chin, or forehead, rarely does rosacea affect nearby areas such as the neck, upper chest, and scalp (1). Over time, this redness can progress to include pimples or blisters, rash, clusters of spidery veins (telangiectasia), and recurrent episodes of flushing (2). It is important to keep in mind, however, that rosacea varies considerably from one person to the next, and how it manifests in one individual may be very different from how it appears in another.

What Causes Rosacea?

It is unclear what exactly causes rosacea. However, the condition is believed to be related to impairment of the immune, vascular, and nervous systems. In particular, an inadequate immune response is thought to play a critical role in the progression of the disease (2). Moreover, environmental and/or behavioral factors may trigger the development and flaring of the disease (1). Topical substances such as those used in cosmetics and over-the-counter creams (e.g., retinoids and corticosteroids); drugs and tobacco; and spicy food, chocolate, and dairy products may trigger the onset or progression of rosacea. Even such seemingly minor events as changes in the weather or temperature, a person’s emotions or hormones, and exercise can play a part.

Rosacea can develop at any age, but it typically begins after the age of 30. While more women than men are diagnosed with the disease, men tend to have more severe symptoms. Visible signs of the disease can be intermittent at the onset; patients have reported flushing or redness that comes and goes. But over time the symptoms becomes more persistent and noticeable.
Fair-skinned people in general are at higher risk for rosacea. For example, in populations with a Celtic heritage, such as in Ireland, incidence (the number of new cases) of rosacea has been reported as high as 18 percent. In addition, like other skin conditions such as eczema, there may be a genetic factor in who develops rosacea. Studies have shown a connection between a family history of the condition and certain genetic traits, in particular among individuals of European descent. World-wide figures on the disease are not yet conclusive, however, and it is important to rule out other skin conditions that cause redness and sensitivity before undergoing treatment (2).

What Should I Do If I Suspect I Have Rosacea?

Because a number of other dermatological conditions can mimic the different types of rosacea, it is important to consult with a dermatologist if you suspect you have it. For example, the type of acne common in adolescents and adults causes similar lesions, from small, red tender bumps and pus-filled pimples to large solid, painful bumps under the skin. Other skin conditions such as contact dermatitis can also be mistaken for rosacea. Your doctor will be able to distinguish the difference based on the presence of other identifying features of rosacea, such as the frequency and persistence of flushing, the presence of spidery veins, and the age at which the symptoms appear in the individual patient (1).

Rosacea cannot be cured. However, it can be controlled with therapies suited to the particular subtype and individual patient. Treatment focuses on a) reduction in the amount of redness and inflammation; b) decrease in the number, duration, and intensity of flares; and c) easing of associated sensations of itching, burning, and tenderness. Common courses of treatment include the following therapies (1):

Topical antibiotics: The major topical antibiotics used are clindamycin, erythromycin, and metronidazole. Other topical therapies include azelaic acid, pimecrolimus, and sulfacetamide sulfur, antiparasitics, and alpha-agonists.

Oral antibiotics: Tetracyclines are the primary oral antibiotics for treating rosacea, followed by the widely available and easy-to-use doxycycline and minocycline. Azithromycin has also been shown to be beneficial for treating rosacea.

Combination topical and oral antibiotics: A combination of topical metronidazole 1% and oral doxycycline has been shown to be effective and well tolerated.

Other oral therapies: Spironolactone, prednisone, certain psychoactive drugs, β-blockers, ondansetron, and cyclooxygenase-2 inhibitors have shown benefit in treating rosacea.

Hormonal therapy: Use of the oral contraceptive chlormadinone acetate/mestranol and the antiandrogen cyproterone have been shown to be effective in some small case series.

In addition, your doctor may prescribe non-medical therapy. One such treatment is phototherapy, also called photodynamic therapy (PDT) (2, 3). PDT involves the application of a photosensitizer (a chemical that sensitizes the skin to light), followed by brief exposure to a particular wavelength of light. The light activates the drug, resulting in the phototoxic destruction of the affected tissue. Early clinical observations suggest that  PDT may be effective therapy for selected rosacea patients. Results from one study suggested that 2- 3 PDT treatments may be able to bring on remission of symptoms for 3 months or longer (3).  Sun avoidance and the regular use of sunscreen have also been shown to be very beneficial in restoring normal skin, especially when used with moisturizers (1). Exactly which therapy to use for an individual patient will depend on the type of rosacea and triggering events.

Final Word on Rosacea

As rosacea causes increased skin sensitivity, how well an individual patient tolerates the various therapies mentioned above will depend on many factors. While it is important to have as many treatment options as possible, your health care provider can help you find the most suitable therapy for your specific situation. Moreover, your provider will be able to provide counseling and resources for the emotional and psychological stress that accompanies this sometimes disfiguring disease. Our board-certified dermatologist, Dr. Dathan Hamann, and our caring and experienced staff at Saguaro Dermatology are here to address your individual concerns.

National Rosacea Society https://www.rosacea.org/

Articles Cited

  1. Scheinfeld N, Berk T. A review of the diagnosis and treatment of rosacea. Postgraduate Medicine 2010;122(1):139-143
  2. Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000 Res 2018;7(F1000 Faculty Rev):1885
  3. Nybaek H, Jemec GBE. Photodynamic therapy in the treatment of rosacea. Dermatology 2005;211(2):135-138

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Our comprehensive dermatology clinic is dedicated to providing you with the highest quality of care, innovative practices, helpful resources and state-of-the-art technology to prevent and treat a multitude of skin disorders. Led by Carsten R. Hamann, MD, PhD, Dathan Hamann, MD, FAAD, and Millard Thaler, MD, Mohs Surgeon, our passionate team looks forward to serving you with respect and compassion.

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