What is rosacea?

Rosacea (roz-ay-sha) is a very common benign skin disorder that affects many people worldwide. As of 2008, it is estimated to affect at least 14 million people in the United States alone. The main symptoms of this facial condition include red or pink patches, visible broken blood vessels, small red bumps, red cysts, and pink or irritated eyes. Most people with the disease may not even know they have rosacea or that it is a diagnosable and treatable condition. Many patients may just assume they blush easily or have gotten sunburned.

Rosacea is considered a chronic (long-term), non-curable skin disease with periodic ups and downs. As opposed to traditional acne, most adult patients do not "outgrow" rosacea. It characteristically involves the central region of the face, causing persistent redness or transient flushing over the areas of the face and nose that normally blush -- mainly the forehead, the chin and the lower half of the nose. It is commonly seen in people with fair or light skin, and particularly in those of Irish and Scottish backgrounds. Some famous people with rosacea have included former President Bill Clinton and W.C. Fields.

What does rosacea look like?

The redness, often aggravated by flushing, may cause small blood vessels in the face to enlarge (dilate) and become more visible through the skin, appearing like tiny red lines (called telangiectasias). Continual or repeated episodes of flushing may promote inflammation, causing red bumps that resemble teenage acne. In fact, rosacea can frequently be mistaken for common acne. Rosacea is also referred to as acne rosacea.

Is rosacea like acne?

Rosacea is basically different than acne, although the two can coexist. It is also sometimes called "adult acne." Unlike common acne, rosacea is not primarily a plague of teenagers but occurs most often in adults (ages 30 to 50), especially those with fair skin. Different than acne, there are usually no blackheads or whiteheads in rosacea. Furthermore, most teens eventually outgrow acne whereas patients with rosacea don't generally outgrow it. Rosacea consists mostly of small red bumps that are not "squeezable" or extractable like blackheads. Rosacea patients tend to have a rosy or pink color to their skin as opposed to acne patients whose skin is usually less red.

Rosacea strikes both sexes and potentially all ages. Overall, it tends to be more frequent in women but more severe in men. It is very uncommon in children, and it is very infrequently seen in darker skin tones or black skin. Overall, it is seen in light-featured adults between 30-50 years of age.

Rosacea is sometimes called "adult acne."

What causes rosacea?

The exact cause of rosacea is still unknown and remains a mystery. The basic process seems to involve dilation of the small blood vessels of the face. Suspected causes of rosacea include but are not limited to genetic factors, genetics plus sun exposure, a mite sometimes found in hair follicles (Demodex folliculorum), the bacteria Helicobacter pylori (that is associated with stomach ulcers), gastrointestinal disease, and medications that cause blood vessels to widen. There seems to be a hereditary component in some people.

Rosacea tends to affect the "blush" areas of the face and is more common in people who flush easily. Additionally, a variety of triggers are known to cause rosacea to flare. Emotional factors (stress, fear, anxiety, embarrassment, etc.) may trigger blushing and aggravate rosacea. A flare-up can be caused by changes in the weather like strong winds or a change in the humidity. Sun exposure and sun-damaged skin is generally associated with rosacea. Exercise, alcohol consumption, 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.

What are the signs and symptoms of rosacea?

Typical signs and symptoms include facial flushing, redness, burning, red bumps, and cysts. The symptoms 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 may rarely reverse itself.

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

What happens to the nose?

The nose is one of the first areas to be affected in rosacea. It becomes red and bumpy and develops 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 old 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 repair.

Some people falsely attribute the prominent red nose to excessive alcohol intake, and this stigma can cause embarrassment to those with rosacea. Although a red nose may be seen in patients with heavy alcohol use, not every patient with rosacea abuses alcohol.

What happens to the eyes?

Rosacea may or may not affect the eyes. Not everyone with rosacea has eye issues. A complication of advanced rosacea, known as ocular rosacea, affects the eyes. About half of all people with rosacea report feeling burning, dryness, and grittiness 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, called rosacea keratitis. An ophthalmologist can assist in a proper eye evaluation and prescribe rosacea eye drops. Untreated eye rosacea may cause permanent damage, including impaired vision.

How is rosacea cured?

Rosacea is currently not considered a curable condition. While it cannot be cured, it can usually be controlled with proper, regular treatments.

There are some forms of rosacea that may be significantly cleared using 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 period of time) for months to years.

What about using acne medicine?

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 actually irritate skin that is prone to rosacea. Overall, rosacea skin tends to be more sensitive and easily irritated than that of common acne.

What is used for treating rosacea?

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 cases may require a combination approach, using several of the treatments at the same time. A combination approach may include home care of washing with a prescription sulfa wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, 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.

Topical creams

With the proper treatment, rosacea symptoms can be fairly well controlled. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid (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) is also known to help reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin (Cleocin).

Oral antibiotics

Oral antibiotics are also commonly prescribed to patients with moderate rosacea. Tetracycline, doxycycline, minocycline, and amoxicillin are among the many oral antibiotics commonly prescribed and they actually help reduce inflammation and pimples in rosacea. The dose may be initially high and then be tapered to maintenance levels. Common side effects and potential risks should be considered before taking oral antibiotics.

Short-term topical cortisone (steroid) preparations of minimal strength may in occasional cases also be used to reduce local inflammation. There is a risk of causing a rosacea flare by using topical steroids. Some doctors may prescribe tretinoin (Retin-A) or isotretinoin, prescription medications also used for acne, or permethrin (Elimite) cream, which is also used for the mites that cause scabies.

Isotretinoin

Isotretinoin has been prescribed to patients with severe rosacea. However, close physician monitoring and blood testing are necessary while on isotretinoin.

Cleaners

In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Harsh soaps and lotions should be avoided, whereas 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.

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 to visibly improve the skin and complexion.

Laser treatment may cause some discomfort. While most patients are able to endure the procedure, ice packs and topical anesthetic cream can help alleviate the discomfort. Multiple treatments are typically necessary and the procedure is not covered by most insurances. Treatments are recommended in three- to six-week intervals; during this time, sun avoidance is necessary. Risk, benefits, and alternatives should be reviewed with your physician prior to treatment. Laser treatments may be combined 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 is applied to the skin and a light to activate the sensitizer. Levulan (aminolevulonic acid) and blue light, commonly used to treat pre-cancers (actinic keratosis) and acne vulgaris, can also be used to treat some rosacea patients. The use of PDT in rosacea is considered off-label use to some extent, since it is primarily designed for regular acne. PDT is thought to work at reducing the inflammation, pimples, and also improving the skin texture. PDT is an in-office procedure performed in your 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 is 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 to improve and control rosacea in some patients. The chemical peels can professionally be applied 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 patients.

Sun protection

Sun exposure is a known flare for some rosacea sufferers. Sun protection using a wide-brimmed hat and sunscreens are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, the use of an appropriate daily sunscreen lotion and overall sun avoidance is recommended. Zinc-based sunscreens (SPF 30 or higher) may provide adequate sun protection.

What should be avoided?

While not all rosacea patients are exactly the same, there are some common rosacea triggers. Avoiding these potential triggers may also help relieve symptoms and disease flares.

Smoking, spicy foods, hot drinks, and alcohol may cause flushing and should be avoided. Exposure to sunlight and to extreme hot and cold temperatures should be limited as much as possible.

Potent cortisone medications on the face should be avoided because they can promote widening of the tiny blood vessels of the face. Some patients experience severe rosacea flares after prolonged use of topical steroids.

How should I care for the skin of my face?

Proper skin care involves using a gentle cleanser to wash the face twice a day. Over-washing may cause irritation. A sunscreen lotion is advisable each morning. Your physician may prescribe a topical antibiotic to use once or twice a day under your sunscreen.

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

Facial products such as soap, moisturizers, and sunscreens should be free of alcohol or other irritating ingredients. Moisturizers should be applied very gently after any topical medication has dried. When going outdoors, sunscreens with an SPF of 15 or higher are needed.

How are the telangiectasias (the red lines) treated?

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

Simple cover-up makeup can be used for the telangiectasias. There are some green-based moisturizers or tinted foundations that may help conceal the redness.

Telangiectasias can also be medically treated in your physician's office with a small electric needle, a laser, intense pulse light, or minor surgery to close off the dilated blood vessels. Usually, multiple treatments are required for best results and only a portion of the blood vessels may be improved with each treatment. Not everyone responds the same to these types of treatments, and your physician can help you decide which treatment is best for your skin type, condition, and size of blood vessels.

How is a rhinophyma (the W.C. Fields nose) treated?

Rhinophyma of the nose is frequently treated by surgery. The excess tissue may be removed with a scalpel, laser, or electro surgery. 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.

What effect may rosacea have on my life?

Rosacea may affect your life minimally, moderately, or severely depending on how active the condition is and your overall tolerance of the skin symptoms.

Some patients have absolutely no symptoms and are not bothered at all by their rosacea. They may enjoy perfectly healthy normal lives without any effect from this benign skin condition. Some patients really 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.

People with moderate rosacea may have periodic flares that require treatment with oral antibiotics, lasers, and other therapies. They may continuously take an antibiotic daily for years and years to keep their symptoms under control. Many of these people may complain of embarrassment from the flushing and blushing of rosacea. They may have ups and downs and times that their disease is quiet and other times when it feels like it is on fire. With the help of their physician, these patients can learn the pattern of their rosacea and develop a treatment plan to keep it from interfering in their daily lives.

Other patients have very bothersome rosacea that causes them issues on a daily basis. There are a subset of severe rosacea sufferers who have extreme psychological, social, and emotional symptoms. Some have developed social phobias causing them to cancel or leave situations when their rosacea is flaring or active. 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 wreak havoc in some patient's lives. It is important for these patients to discuss their physical and emotional concerns with their physicians 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.

Rosacea At A Glance

• Rosacea is a common chronic skin disorder.
• Rosacea begins innocently as a blush of the face.
• The rosacea region is the central third of the face including the nose.
• Rosacea causes tiny pimples and red lines appear on the skin.
• Rosacea may be mistaken for rosy cheeks, sunburn, or quite often, acne.
• Rosacea can be a very bothersome and embarrassing condition.
• Rosacea untreated can cause a bulbous red nose (like W.C. Fields).
• Prompt recognition and proper treatment permit people with rosacea to enjoy life.

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