What is Rosacea?
Rosacea is a common long-term skin condition that comes and goes. It causes symptoms like frequent redness, red lines or patterns due to widened blood vessels (telangiectasia), small red bumps or pus-filled spots, usually appearing on the nose, chin, cheeks, and forehead. The condition comes in four different types based on the main symptoms: a type associated with redness and telangiectasia, a type with red bumps and pus-filled spots, a type affecting the skin structure (phymatous), and a type affecting the eyes. These types can overlap; it’s not uncommon for people to have symptoms of more than one type, and their main symptoms and affected areas can change over time.
It’s worth noting that many people with rosacea (between 50% to 75%) also have symptoms affecting their eyes, such as dryness, redness, watery eyes, a stinging or burning feeling, the feeling of something being in the eye, sensitivity to light, and blurry vision. Beyond its effects on the skin and eyes, rosacea can also cause emotional distress, leading to feelings of embarrassment and anxiety, and in some cases, it may lead to depression. This can significantly affect a person’s quality of life.
Rosacea is typically thought of as a skin condition, but it’s also been linked with other health problems outside the skin, such as certain neurological conditions (affecting the nervous system), inflammatory bowel disease (affecting the digestive system), and cardiovascular diseases (affecting the heart and blood vessels).
What Causes Rosacea?
The exact cause of rosacea, a skin condition that causes redness and visible blood vessels in your face, isn’t entirely known. It’s thought that a combination of things may influence rosacea, including genetics, immune response, microorganisms (like tiny bugs or bacteria), environmental factors, and issues with the regulation of blood vessels in your face.
Just like going out in the sun can trigger rosacea flare-ups, exposure to ultraviolet (UV) light could also play a role in causing the condition. There’s evidence to suggest that rosacea may run in families, so if you have a family history of rosacea, that could increase your chances of getting it. Furthermore, certain genetic markers typically found in white blood cells have been found in people with rosacea.
In terms of microorganisms, tiny mites known as Demodex are often found in high numbers on skin affected by rosacea, but it’s unclear whether they cause rosacea or if their presence is a result of it. There’s also been reports showing a possible link between the bacteria Helicobacter pylori, which is typically known for causing stomach ulcers, and rosacea.
Risk Factors and Frequency for Rosacea
Rosacea is often diagnosed based on symptoms and medical history, meaning a lot of patients, particularly those with milder forms of the disease, may not be diagnosed at all. The condition is thought to affect more than 5% of people worldwide. This skin issue typically affects adults aged 30 to 50. It’s more common in women than men, and is especially prevalent in individuals with lighter skin tones (termed as “phototypes I and II”). Studies also suggest that more than 10% of white people have rosacea.
Signs and Symptoms of Rosacea
Rosacea is a skin condition that usually shows up in adulthood, but can sometimes also affect children. There are 4 different clinical subtypes of this disease that could present themselves. The ‘erythematotelengiectatic’ subtype is often the first sign of rosacea and it leads to continuous redness and temporary flushing of the nose and cheeks. The ‘papulopustular’ form is similar to ‘adult acne’ since it causes bumpy and pus-filled eruptions on the facial area. Unlike acne, rosacea doesn’t have comedones (blackheads or whiteheads), which helps to differentiate the two conditions.
The ‘phymatous’ subtype results in fibrous thickening and enlargement of the oil glands in the skin. It’s typically seen on the nose of male patients (a condition known as ‘rhinophyma’), but can also affect the cheeks, chin, and forehead. Though this subtype is usually a late-stage manifestation of rosacea, there are rare cases of first-time occurrences without prior skin changes. ‘Ocular rosacea’ involves problems with the eyes, such as tearing, dry eyes, a gritty feeling, itchy eyes, eyelid inflammation (hordeola), and inflammation of the eyelid margins (blepharitis).
According to the National Rosacea Society Expert Committee’s latest diagnostic guidelines, having any one of these clinical presentations would be enough to diagnose rosacea:
- Fixed redness in the middle of the face in a characteristic pattern that may intensify intermittently
- Changes related to ‘phymatous’
In addition, having at least two of these major criteria would also be enough for diagnosis:
- Flushing
- Papules and pustules
- Blood vessels seen on the skin surface (telangiectasia)
- Eye-related symptoms like visible blood vessels on the eyelid margin, redness of the white part of the eye (conjunctival injection), irregular shaped inflamed spots in the cornea, and inflammation of the fibrous layer of the eye (scleritis and sclerokeratitis).
Testing for Rosacea
Rosacea is usually diagnosed by a doctor based on your symptoms. You may want to track and discuss any triggers that you’ve noticed causing your rosacea to flare up. If you’re also experiencing eye symptoms, it will be important to have an eye doctor examine you.
Treatment Options for Rosacea
One of the first steps in treating rosacea involves identifying and avoiding things that can make the condition worse. These can include sunlight, spicy food, changes in the weather, and alcoholic beverages. If you have rosacea, it’s generally recommended that you use pH-balanced skin cleansers instead of soaps, always apply a broad-spectrum sunscreen with at least an SPF 30, and moisturize regularly. Since rosacea can make your skin extra sensitive, you should try to avoid any products that irritate your skin. Some people with rosacea find that cosmetics containing green pigments can help to hide the constant blushing or flushing.
Treatment options for rosacea depend on the specific signs and symptoms that you have. Most treatments focus on reducing inflammation. Topical steroids, which are often used to reduce inflammation, should be avoided because they can make rosacea worse over time.
Redness and spider veins caused by rosacea can be treated with medications like brimonidine and oxymetazoline, or with laser surgery which targets the blood vessels in the skin. If rosacea has caused thickened skin (called phymatous changes) surgical treatments may be required.
Some treatments that can be applied directly to the skin to treat rosacea include alpha-2 agonists like brimonidine tartrate, alpha-1 agonists like oxymetazoline hydrochloride, and treatments like ivermectin and azelaic acid, as well as metronidazole. For eye symptoms associated with rosacea, treatments such as artificial tears, fusidic acid gel, metronidazole gel, and cyclosporine eyedrops are available.
Oral medications may also be used to manage symptoms of rosacea, such as propranolol and clonidine for flushing, doxycycline, and minocycline for inflammatory papules and pustules, and isotretinoin for phyma. It is generally recommended that patients with eye symptoms related to rosacea consider taking doxycycline as well.
Procedures like intense pulsed light therapy, NdYAG laser treatment, and pulsed dye laser can treat flushing and spider veins. For phyma or thickened skin, CO2 laser treatment, surgical resection, or electrosurgery may be required.
If you have rosacea and experience eye issues, particularly severe symptoms or changes in vision, it is recommended to seek the help of an eye specialist. Pregnant women with rosacea are advised to use topical treatment and antimicrobial drugs like azithromycin, erythromycin, or clarithromycin, which are safe during pregnancy. Note that systemic therapies, which work throughout the body, are typically used for flare-ups that do not respond to topical treatments. After a flare-up is controlled, it is usually recommended to continue with the topical treatment to prevent further flare-ups.
What else can Rosacea be?
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When it comes to determining the cause of skin issues, there are a few different common conditions that might be at play. Here are a few of these conditions and how they differ from each other:
- Acne: Acne and rosacea share similar features such as raised, red spots (papules) and pus-filled spots (pustules). However, blackheads or whiteheads (comedones) are signs of acne, not rosacea, which can help doctors tell the two apart.
- Seborrheic Dermatitis: this condition also presents as redness and greasy scaling on the face and scalp, especially around the nose and in hair-bearing areas. Sometimes, people will have both seborrheic dermatitis and rosacea, and treatment of one might reveal the other.
- Keratosis Pilaris Rubra: A condition that often affects teenagers, it looks like small red bumps around hair follicles on the cheeks and neck.
- Flushing: If you’re experiencing flushing or redness in the face due to rosacea, it won’t typically spread to other parts of the body. If flushing does spread, it might indicate another medical problem needing further investigation.
- Acute Cutaneous Lupus Erythematosus: The facial rash that appears with lupus may look like rosacea, but it usually does not impact the folds around the nose and doesn’t include papules or pustules.
- Drug-Induced Acneiform Eruption: This type of skin condition is usually linked to taking a certain medication, and it looks like a sudden outbreak of spots. These spots may look similar in appearance and can also appear on the body, not just the face.
Remember, if you’re unsure about a specific skin condition, always consult a medical professional to get an accurate diagnosis.
What to expect with Rosacea
Rosacea isn’t a life-threatening condition, and overall, people with rosacea generally have a good outlook. However, it’s important to note that it can cause depression and anxiety. If not treated, rosacea could eventually result in permanent scarring and constant redness of the skin. Additionally, complications affecting the eyes can arise if rosacea that involves the eyes isn’t dealt with properly.
Recent studies have started to explore a potential link between rosacea and complications with the nervous system, heart, hormone system, and digestive system. If you have rosacea, it may be a good idea to keep these potential complications in mind, although at the moment, there are no science-backed recommendations for screenings specifically for these issues.
Preventing Rosacea
Patients should be encouraged to keep a record or diary of things that seem to trigger their condition. They should then try to avoid these as much as possible. For instance, patients should take particular care to protect their skin from sun damage. This can be done by using sunscreen every day, with mineral-based sunscreens often being a good choice.
Gentle skin care is also essential. It’s recommended to use cleansers that are soap-free and non-comedogenic (which means they won’t clog your pores). When choosing cosmetics and other skincare products, be sure to avoid any that could potentially irritate your skin. These are all things that doctors should discuss with their patients.