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Rosacea

What is rosacea?

Rosacea is a skin condition that affects the face. It is not contagious, but it is very common: in the United Kingdom, for example, about one in 10 adults are affected,[1] and, according to recent statistics, over 16 million Americans.[2]

Rosacea is not a type of acne, and the term “acne rosacea” is misleading. However, acne and rosacea may occur together. Unlike acne, rosacea is more common among older people, particularly those aged between 40 and 60 years of age.[3] It is somewhat more common among women than men, but tends to be more severe in men.[4] Also, unlike acne, rosacea does not cause scarring.[3]

Rosacea usually affects the skin of the face, particularly the nose, cheeks and forehead.[1] In some cases, it can affect the skin of the neck, chest and ears, and rarely, it can affect the eye. Rosacea is not always itchy or painful, but may cause a stinging or burning sensation. It can also be unsightly and distressing to those affected by it.[1]

Its most prominent symptoms are facial redness and flushing. A rare effect of rosacea is rhinophyma, a thickening of the skin on and around the nose that leads to a characteristic red and bumpy appearance.[1] This is usually found in older male sufferers.

Types of rosacea

There are several subtypes of rosacea:[5][6]

  • Erythromatotelangiectactic, characterized by skin redness and visible small blood vessels.
  • Papulopustular, characterized by papules (small pimples) and pustules (small pimples containing pus).
  • Phymatous (both mild and severe subtypes), marked by thickened skin.
  • Ocular, affecting the eyes.

Treatment depends on which sort of rosacea is present. People suspected of having rosacea, particularly those who suffer from ocular rosacea or from symptoms that are resistant to treatment, should generally be treated by a specialist such as a dermatologist or ophthalmologist.

Symptoms of rosacea

Because rosacea is common, most competent medical practitioners will be able to diagnose it based on the patient’s history and the appearance of their skin. In some cases, doctors may recommend that blood tests are done, in order to rule out other conditions that cause skin redness, such as systemic lupus erythematosus.[1]

The symptoms of rosacea are distinctive. They include:[1][3][4]

  • A tendency to blush or flush easily, leading to transient redness, also known as erythema
  • Dilated and visible blood vessels under the surface of the skin, known as telangiectasia
  • Red bumps, known as papules, and pustules, slightly resembling mild acne
  • Thickened skin, known as phymatous changes
  • Eye problems, such as sore eyelids and dry eyes

The symptoms of rosacea tend to begin mildly, but worsen with time. People affected will first notice an increased tendency to blush or flush, with skin redness taking longer and longer to fade. Over time, the redness will become permanent. The intensity of facial flushing can be affected by emotion, hydration, chemicals and stress.[7]

In some cases of rosacea, small blood vessels under the skin become more prominent. Itching is sometimes present, and redness is often accompanied by a burning sensation. Affected people may find that their skin is hot to the touch during a flushing episode.

###Symptoms of ocular rosacea

Ocular rosacea is a complication of the condition. Symptoms include:[3][5][8]

  • Itchy, burning or stinging eyes.
  • Dry, scratchy eyes.
  • A feeling of grit or a foreign body in the eye.
  • Photosensitivity (sensitivity to light).
  • Inflammation of the eyelid (blepharitis), styes, or cysts.
  • Chalazions, which are small, usually painless lumps on the eyelid, caused by blocked oil or meibomian glands. These are not to be confused with styes, which result from infection. Styes are painful and tend to occur near the eyelashes.

Inflammation of the cornea , the transparent front covering of the eye, is rare but serious, and can affect vision. If corneal inflammation, also known as rosacea keratitis, occurs, seek medical help as soon as possible.[3]

Causes of rosacea

The exact cause of rosacea has not yet been established. It is possible that it is an autoimmune response, a reaction to high skin pH, a response to undiagnosed food sensitivity or the result of a high number of demodex folliculorum mites on the face.[1][7] There may also be a genetic component.

According to present knowledge, there is no way to prevent rosacea from beginning, and there is currently no way to entirely eliminate the condition.[1]

There is some evidence that rosacea’s facial flushing is caused by the body’s sympathetic nervous system becoming stimulated.[7] The sympathetic nervous system is the part of the nervous system that is involved in activating the fight or flight response. It is activated by strong emotion or physical stress.

Research has shown that rosacea can be triggered by various physical and environmental factors, such as weather conditions, exercise, cosmetics or certain foods. Many people with rosacea find it helpful to keep a diary of their outbreaks in order to narrow down what their particular triggers are.

Some common triggers are:[1][7][9]

  • Emotional stress
  • Strenuous exercise
  • Exposure to strong sunlight
  • Hot weather
  • Cold weather
  • Wind
  • High humidity
  • Hot baths/showers
  • Exfoliant, abrasive or astringent facial products
  • Makeup containing oils
  • Perfumed sunblocks
  • Sunblock or skin preparations containing insect repellents
  • Consumption of alcohol
  • Very sugary foods
  • Spicy foods, such as those containing chili
  • Smoking
  • Calcium-channel blockers, also known as calcium antagonists, such as dihydropyridine

Not all rosacea sufferers are vulnerable to all of these triggers.

Many of these triggers, such as exercise, alcohol and calcium antagonists, cause the dilation of the blood vessels (vasodilation), which increases blood flow. Increased blood flow to the skin causes a distinctive appearance of redness. Some of these triggers, for example exposure to sunlight, wind, smoking and cold weather, cause inflammation of the skin, which also causes redness.

Treatment and management of rosacea

Although there is currently no total cure for rosacea, there are many treatment options. Treatment may need to be long-term, but it is easily manageable and very effective.

Treatment for rosacea is mainly concerned with reducing inflammation and managing sensitive skin.[3] Treatment options include topical creams and ointments, oral medications, and lifestyle changes. People with this condition may find that some treatments, or combinations of treatments, work better for them than others do.

Topical medication: creams and ointments

Topical preparations, which are applied to the skin rather than taken orally, can help rosacea sufferers lessen the redness and inflammation they experience. Commonly-prescribed topical rosacea treatments include:[1][3][4][5]

  • Brimonidine cream
  • Azelaic acid cream
  • Sodium sulfacetamide-sulfur cream
  • Doxycycline ointment
  • Metronidazole cream

Some rosacea sufferers find that applying jojoba oil is helpful.[10] However, people with rosacea should never use acne preparations and should avoid topical corticosteroids, unless they are specifically prescribed by a specialist. While topical steroid preparations are helpful in reducing inflammation in the short term, in the long term they can make the problem worse.[3]

In cases where the rosacea is mild, it may be possible to manage it with only topical creams and lifestyle changes.

Laser and light treatment

In cases of severe rosacea, laser and light treatments are an option for the treatment of redness, inflammation, pustules and rhinophyma. Nonablative lasers that do not destroy tissue, in the 500 to 600 nanometer (nm) range, and long-pulsed pulse dye lasers, as well as 532nm potassium-titanyl-phosphate lasers can help alleviate rosacea symptoms. Intense pulsed-light devices in the 515 to 1200nm range are another option.[11]

Phymatous rosacea, which causes thickening of the skin and may cause rhinophyma, can be treated with ablative lasers that destroy tissue, such as erbium or CO2 lasers. The object of this treatment is to remove the overgrowth of tissue from the area.[11]

Oral medication

In severe cases, some people with rosacea find that a course of oral antibiotics helps reduce inflammation. This is true even though it is not known whether there are any particular bacteria involved in causing rosacea. Oral antibiotics that are sometimes used to treat rosacea include the tetracycline class:[3]

  • Tetracycline
  • Oxytetracycline
  • Doxycycline
  • Lymecycline
  • Minocycline

A course of 40mg of oral doxycycline daily is often effective. If doxycycline is not an option, 100mg of oral minocycline daily has been found to be effective as well.[12]

Other oral medications include:[3][5][6]

  • Erythromycin
  • Trimethoprim
  • Trimethoprim-sulfamethoxazole
  • Ampicillin
  • Clindamycin
  • Dapsone

Blushing and redness may also be managed by beta-blockers or clonidine.[3] Very severe rosacea, especially phymatous rosacea that may lead to rhinophyma, or thickening of the skin, may respond well to isotretinoin.[6] The length of time for which an individual may have to take antibiotics depends on how severe their rosacea is and how well they respond to antibiotic treatment. However, it is important that all courses of antibiotics prescribed for rosacea are completed in order to assess whether they were effective.

In most cases, improvement can be expected within two to three weeks of beginning a course of antibiotics, but it may take several months to completely clear up symptoms such as papules and pustules.[1] Moreover, pustules and papules may return when the antibiotic course is over. If this happens, a longer-term course of maintenance doses of antibiotics might be effective.

Antibiotics can have serious side effects, so the use of oral antibiotic treatments should only be considered when topical treatments and lifestyle changes have proved to be ineffective in reducing severe rosacea.

Management of ocular rosacea

Ocular rosacea affects the eyes rather than the skin, and so the treatment program is quite different in some ways. It may cause inflammation of the eyelid (blepharitis), which is painful and may increase the risk of infection.[8] Styes, cysts and chalazions may also occur.[13]

The first line of treatment for ocular rosacea is to improve eyelid hygiene. This is done by using:

  • Artificial tears to moisten and lubricate the eye, and reduce irritation. Care should be taken to use only eye drops that mimic natural tears. Never touch the surface of the eyeball or eyelid with the nozzle of the bottle.[5][8]

  • A warm compress, using a clean cloth soaked with very warm water held against each eye for five to 10 minutes. The cloth should be remoistened with warm water regularly. This reduces inflammation, cleans the eyelid and provides relief from stinging.[8]

  • To remove irritants such as dust, grit and secretions from the eyelid and eyelashes, wipes with a physiological salt solution, i.e.one that mimics the eye’s natural moisture, can be used. Pharmacists can help if necessary.[8]

Thereafter, antibiotics in several forms may be used:

  • Topical antibiotic creams, gels or drops containing ciclosporin or metronidazole
  • Oral antibiotics such as azithromycin or a tetracyline[5]

A course of oral oxytetracycline followed by an eight-week course of topical metronidazole has been found to alleviate symptoms.[13]. Otherwise, oral tetracyline taken once daily, along with topical ivermectin and/or azelaic acid, may be helpful.

People with ocular rosacea or irritated eyes as a result of rosacea should avoid eye makeup, rubbing their eyes and taking Omega 3 supplements. Wearing contact lenses may be uncomfortable with inflamed eyes.[8]

Home management

Aside from using prescription antibiotics, people with rosacea can take easy steps at home to get relief from the discomfort of rosacea and the appearance of symptoms. For many people, this involves, learning to avoid triggers and removing irritants from their care regimes.

Cleansing and skincare[1][3][5]

Generally, people with rosacea will find it helpful to avoid getting sunburned. If exposure to strong sunlight cannot be avoided, a strong sunblock should be used with a sun protection factor (SPF) of 30 or more, as well as UVB and UVA protection.

People with rosacea who regularly shave their faces, should switch from a traditional bladed razor to an electric razor. Electric razors do not come into such tight contact with the skin and are therefore less irritating.

Cleansers used by people with rosacea should not contain abrasives, including organic abrasives such as crushed apricot kernels, alcohol or acetone. Perfumed soaps, moisturisers and washes should be avoided. Oil-based or waterproof makeup should be avoided. Insect-repellent facial moisturisers or sunblock should not be used.

Hypoallergenic, non-greasy, non-perfumed emollient preparations can be used. Over-the-counter acne preparations are not helpful to people with rosacea. They may make the symptoms worse and should be avoided.

Lifestyle changes

People with rosacea, who smoke tobacco cigarettes or regularly consume alcohol, may find it useful to cut back their consumption. Smoking dries the skin, while alcohol widens blood vessels and therefore worsens the redness of skin.

As stress is known to make rosacea symptoms worse, learning to manage stressful situations and general life stress is recommended by many rosacea groups, such as the International Rosacea Foundation and the National Rosacea Society.[7][10]

Weight management can assist in the alleviation of redness, while maintaining good hydration by drinking enough water is believed to help lessen the redness and inflammation characteristic of rosacea. A diet low in processed carbohydrates may also be helpful in some cases, as carbohydrates cause blood glucose to increase, which can lead to vasodilation and thus redness.[10]

In people who have severe rosacea, or feel that the appearance of their symptoms is negatively impacting their quality of life, learning to apply camouflage makeup may be helpful. Many regional health communities can arrange access to camouflage makeup tutorials and workshops.

FAQs

Q: How do I know whether my skin condition is acne or rosacea?
A: Both rosacea and acne are common inflammatory disorders of the skin.[14] Many people with papulopustular rosacea have pimples and spots that resemble the symptoms of acne. Moreover, people with rosacea may also have acne. However, one way to distinguish between acne and rosacea is to compare which areas of the body are affected.

Acne can affect the face, neck, chest, back and shoulders, while rosacea mostly affects only the face. In acne, blackheads are often prominent, but they are seldom found in rosacea. Acne tends not to be accompanied by the reddening of skin that is rosacea’s most obvious characteristic. Acne very seldom causes inflammation of the eyelids or eye discomfort.[15]

Age of onset for rosacea tends to be later in life than for acne; acne is more common among teenagers and young adults, while rosacea is more common among people approaching middle age.[16]

If you are concerned about whether the condition affecting you is acne or rosacea, it is best to consult your primary care physician or a dermatologist.

Q: Will over-the-counter preparations help my rosacea?
A: No, they will not. In fact, some over-the-counter preparations, particularly those for the treatment of acne, may make rosacea worse. The best course of treatment for rosacea involves a very gentle skincare regime and learning to avoid triggers. In severe cases, prescription antibiotics may be used.


  1. Patient.info. “Rosacea”. 4 June 2015. Accessed 27 March 2018.

  2. National Rosacea Society. “If you have rosacea, you are not alone”. Accessed 29 March 2018.

  3. British Association for Dermatologists. “Rosacea”. December 2014. Accessed 27 March 2018.

  4. British Skin Foundation. “Rosacea”. Accessed 27 March 2018.

  5. BMJ Best Practice. “Rosacea”. February 2018. Accessed 28 March 2018.

  6. MD Edge Cutis. “Standard Management Options for Rosacea, Part 2: Options According to Subtype”. August 2008. Accessed 29 March 2018.

  7. International Rosacea Foundation. “Rosacea Symptoms”. Accessed 29 March 2018.

  8. Patient.info. “Blepharitis”. December 2014. Accessed 29 March 2018.

  9. National Rosacea Society. “What to do now”. Accessed 29 March 2018.

  10. International Rosacea Foundation. “Rosacea Lifestyles”. Accessed 29 March 2018.

  11. MD Edge Cutis. “Standard Management Options for Rosacea, Part 1: Overview and Broad Spectrum of Care”. July 2009. Accessed 29 March 2018.

  12. Practice Update. “Doxycycline 40 mg vs Minocycline 100 mg for Rosacea”. 17 November 2016. Accessed 29 March 2018.

  13. BUPA. “How to combat rosacea”. 11 January 2018. Accessed 28 March 2018.

  14. Stanford Medicine 25. “Introduction to Differentiating Acne Vulgaris vs. Acne Rosacea”. Accessed 04 April 2018.

  15. Pimples. “A comparison of Acne Vulgaris vs. Acne Rosacea”. 27 November 2013. Accessed 04 April 2018.

  16. National Rosacea Society. “Acne or Rosacea? A Case of Mistaken Identity”. 04 November 2018. Accessed 04 April 2018.