Rosacea is a chronic condition characterized by facial erythema and sometimes pimples.
Rosacea affects all ages and has four subtypes, three affecting the skin and the fourth affecting
the eyes. Left untreated it worsens over time. Treatment in the form of topical steroids
can aggravate the condition. It primarily affects people of northwestern
European descent and has been nicknamed the 'curse of the Celts' by some in Britain and
Ireland, although recently this has been questioned. Rosacea affects both sexes, but is almost
three times more common in women. It has a peak age of onset between 30 and 60.
Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead,
but can also less commonly affect the neck, chest, ears, and scalp. In some cases, additional
symptoms, such as semi-permanent redness, telangiectasia, red domed papules and pustules,
red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated
nose, may develop.
Classification
There are four identified rosacea subtypes and patients may have more than one subtype
present: Erythematotelangiectatic rosacea: Permanent
redness with a tendency to flush and blush easily. It is also common to have small widened
blood vessels visible near the surface of the skin and possibly intense burning, stinging,
and/or itching sensations. People with this ETR type often have sensitive skin. Skin can
also become very dry and flaky. In addition to the face, symptoms can also appear on the
ears, neck, chest, upper back, and scalp. Papulopustular rosacea: Some permanent redness
with red bumps with some pus filled; this subtype can be easily confused with acne.
Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement
of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement.
Phymatous rosacea can also affect the chin, forehead, cheeks, eyelids, and ears. Small
blood vessels visible near the surface of the skin may be present.
Ocular rosacea: Red, dry, irritated or gritty, eyes and eyelids. Watery eyes. Eyelids often
develop cysts. Some other symptoms include foreign body sensations, itching, burning,
stinging, and sensitivity to light. Eyes can become more susceptible to infection. About
half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and loss
of vision can occur. There are a number of variants of rosacea,
including: Rosacea conglobata
Rosacea fulminans Phymatous rosacea
Cause Triggers that cause episodes of flushing and
blushing play a part in the development of rosacea. Exposure to temperature extremes
can cause the face to become flushed as well as strenuous exercise, heat from sunlight,
severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from
a cold one such as heated shops and offices during the winter. There are also some food
and drinks that can trigger flushing, including alcohol, food and beverages containing caffeine,
foods high in histamines and spicy food. Foods high in histamine can even cause persistent
facial flushing in those individuals without rosacea due to a separate condition, histamine
intolerance. Certain medications and topical irritants
can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported
to cause rosacea include microdermabrasion and chemical peels, as well as high dosages
of isotretinoin, benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given
to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed
for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped
to avoid a flare up. A survey by the National Rosacea Society of
1,066 rosacea patients showed which factors affect the most people:
Sun exposure 81% Emotional stress 79%
Hot weather 75% Wind 57%
Heavy exercise 56% Alcohol consumption 52%
Hot baths 51% Cold weather 46%
Spicy foods 45% Humidity 44%
Indoor heat 41% Certain skin-care products 41%
Heated beverages 36% Certain cosmetics 27%
Medications 15% Medical conditions 15%
Certain fruits 13% Marinated meats 10%
Certain vegetables 9% Dairy products 8%
It should be noted however that there exists significant disagreement amongst sufferers
and clinicians as to the validity of these aggravators/triggers being categorized as
causes of rosacea. The claim of rosacea being caused by the above list has not been established
by epidemiological scientific study. Many sufferers report that elimination of triggers
has little or no eventual impact on the actual progression of the disease. The above list
should in no way be taken as an explanation of rosacea causes, as the spectrum disease
is more complex than simply a direct or sole result of habits and diet.
Cathelicidins Richard Gallo and colleagues recently noticed
that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels
of stratum corneum tryptic enzymes. Antibiotics have been used in the past to treat rosacea
but they may only work because they inhibit some SCTEs.
Intestinal flora
Intestinal flora may play a role in causing the disease. A recent study subjected patients
to a hydrogen breath test to detect the occurrence of small intestinal bacterial overgrowth.
It was found that significantly more patients were hydrogen-positive than controls indicating
the presence of intestinal flora overgrowth. Hydrogen-positive patients were then given
a 10-day course of rifaximin, a non-absorbable antibiotic that does not leave the digestive
tract and therefore does not enter the circulation or reach the skin. 96% of patients experienced
a complete remission of rosacea symptoms that lasted beyond nine months. These patients
were also negative when retested for intestinal flora overgrowth. In the 4% of patients that
experienced relapse, it was found that intestinal flora overgrowth had returned. These patients
were given a second course of rifaximin which again cleared rosacea symptoms and normalized
hydrogen excretion. In another study, it was found that some rosacea
patients that tested hydrogen-negative were still positive for intestinal flora overgrowth
when using a methane breath test instead. These patients showed little improvement with
rifaximin, as found in the previous study, but experienced clearance of rosacea symptoms
and normalization of methane excretion following administration of the antibiotic metronidazole,
which is effective at targeting methanogens. These results suggest that optimal antibiotic
therapy may vary between patients and that diverse species of intestinal flora appear
to be capable of mediating rosacea symptoms. This may also explain the improvement in symptoms
experienced by some patients when given a reduced carbohydrate diet. Such a diet would
restrict the available substrates for the microorganisms thought to be causative.
Demodex mites Studies of rosacea and demodex mites have
revealed that some people with rosacea have increased numbers of the mite, especially
those with steroid-induced rosacea. When large numbers are present they may play a role along
with other triggers. On other occasions demodicidosis is a separate condition that may have "rosacea-like"
appearances. Demodex has also been implicated in rosacea in that it is theorised to be caused
by a reaction to bacteria in the mite's faeces. Diagnosis
Most people with rosacea have only mild redness and are never formally diagnosed or treated.
There is no single, specific test for rosacea. In many cases, simple visual inspection by
a trained person is sufficient for diagnosis. In other cases, particularly when pimples
or redness on less-common parts of the face are present, a trial of common treatments
is useful for confirming a suspected diagnosis. The disorder can be confused with, and co-exist
with acne vulgaris and/or seborrhoeic dermatitis. The presence of rash on the scalp or ears
suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis,
although it may occasionally appear in these other areas.
Treatments Treating rosacea varies depending on severity
and subtypes. A subtype-directed approach to treating rosacea patients is recommended
to dermatologists. Mild cases are often not treated at all, or are simply covered up with
normal cosmetics. Therapy for the treatment of rosacea is not curative, and is best measured
in terms of reduction in the amount of erythema and inflammatory lesions, decrease in the
number, duration, and intensity of flares, and concomitant symptoms of itching, burning,
and tenderness. The two primary modalities of rosacea treatment are topical and oral
antibiotic agents. Laser therapy has also been classified as a form of treatment. While
medications often produce a temporary remission of redness within a few weeks, the redness
typically returns shortly after treatment is suspended. Long-term treatment, usually
one to two years, may result in permanent control of the condition for some patients.
Lifelong treatment is often necessary, although some cases resolve after a while and go into
a permanent remission. Behaviour
Avoiding physical things or mental states that increase the ability to visibly detect
rosacea by a physician are considered a phrase called "trigger avoidance". Trigger avoidance
can help reduce the onset of rosacea but alone will not normally cause remission for all
but mild cases. It is sometimes recommended that a journal be kept to help identify and
reduce food and beverage triggers. Because sunlight is a common trigger, avoiding
excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily
use of a sunscreen; others opt for wearing hats with broad brims.
Like sunlight, emotional stress can also serve as a trigger for rosacea.
People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily,
gentle cleansing of the eyelids with diluted baby shampoo or an over-the-counter eyelid
cleaner and applying warm compresses several times a day is recommended.
A recent publication discusses how managing pre-trigger events such as prolonged exposure
to cool environments can directly influence warm room flushing.
Medications Oral tetracycline antibiotics and topical
antibiotics such as metronidazole are usually the first line of defense prescribed by doctors
to relieve papules, pustules, inflammation and some redness. Topical azelaic acid such
as Finacea or Skinoren may help reduce inflammatory lesions, bumps and papules. Using alpha-hydroxy
acid peels may help relieve redness caused by irritation, and reduce papules and pustules
associated with rosacea. Oral antibiotics may help to relieve symptoms of ocular rosacea.
If papules and pustules persist, then sometimes isotretinoin can be prescribed. Isotretinoin
has many side effects and is normally used to treat severe acne but in low dosages is
proven to be effective against papulopustular and phymatous rosacea. Some individuals respond
well to the topical application of sandalwood oil on the affected area, particularly in
reducing the prevalence of pustules and erythema. The treatment of flushing and blushing has
been attempted by means of the centrally acting α-2 agonist clonidine, but this is of limited
benefit on just this one aspect of the disorder. The same is true of the beta-blockers like
nadolol and propranolol. If flushing occurs with red wine consumption, then complete avoidance
helps. There is no evidence at all that antihistamines are of any benefit in rosacea. However: people
with underlying allergies and who respond strongly to foods that are high in histamine
or that release a lot of histamine in the body do find sometimes that their flushing
symptoms diminish with oral antihistamines. Another medication that can help some people
with facial flushing and burning is mirtazapine. In 2008, a clinically trialled topical product
combining plant-sourced methylsulfonylmethane and silymarin showed effectiveness in one
study treating rosacea, skin redness and flushing. Laser
Dermatological vascular laser or intense pulsed light machines offer one of the best treatments
for rosacea, in particular the erythema of the skin. They use light to penetrate the
epidermis to target the capillaries in the dermis layer of the skin. The light is absorbed
by oxy-hemoglobin, which heat up, causing the capillary walls to heat up to 70 °C,
damaging them, causing them to be absorbed by the body's natural defense mechanism. With
a sufficient number of treatments, this method may even eliminate the redness altogether,
though additional periodic treatments will likely be necessary to remove newly formed
capillaries. CO2 lasers can be used to remove excess tissue
caused by phymatous rosacea. CO2 lasers emit a wavelength that is absorbed directly by
the skin. The laser beam can be focused into a thin beam and used as a scalpel or defocused
and used to vaporise tissue. Low level light therapies have also been used to treat rosacea.
Photorejuvenation can also be used to improve the appearance of rosacea and reduce the redness
associated with it. Notable cases
Famous people with rosacea include: Margaret Bobonich
Meg Cabot Mariah Carey
Bill Clinton Cristina Fernández de Kirchner
Lisa Faulkner Sir Alex Ferguson
W. C. Fields Diane Kruger
J. P. Morgan Cynthia Nixon
Rosie O'Donnell Carol Smillie
Lucius Cornelius Sulla Dita Von Teese
Ricky Wilson See also
Keratosis pilaris Demodicosis a rash caused by the Demodex mite
that may have rosacea-like appearances. List of cutaneous conditions
References
Rosacea Uncovered - Symptoms, Causes and Treatments Interview with Michelle Osbourne
External links Rosacea photo library at Dermnet
National Rosacea Society