What is rosacea?
Rosacea is a common chronic skin condition that presents as a facial rash or redness. It usually affects individuals between the ages of 30-60 years and is more common in fair skin types. Women are affected more frequently than men, but men often have more severe disease.
What causes rosacea?
We do not know the exact cause of rosacea but it seems to develop due to a complex interplay between genetic, environmental, inflammatory and vascular factors. Trigger factors in a susceptible individual result in dilatation of blood vessels in the skin of the face. Common described trigger factors include alcohol, exercise, changes in temperature, hot drinks, spicy foods, stress, and ultraviolet light.
What are the clinical features?
There are a number of clinical features associated with rosacea. Patients may display these common signs and symptoms to varying degrees:
- Facial redness
- Prominent blood vessels (telangiectasia)
- Papules and pustules on nose, forehead, cheeks and chin
- Facial flushing
- Skin sensitivity
- Enlargement of the nose (rhinophyma)
Less frequently, there may be ocular (eye) involvement. Diagnosis is usually made clinically, although occasionally skin biopsy may be required. This shows chronic inflammation and vascular changes on histology. Rosacea cannot be cured but there are effective long-term measures that can provide disease control.
General management measures for patients:
- Wear a sunscreen SPF 50 throughout the year. UV light is a major trigger for most rosacea patients and this should be incorporated as part of your daily skincare routine. Protection is needed against both UVA and UVB light. Often mineral sunscreens are better than chemical sunscreens in this scenario as they cause less skin sensitivity. Look for products containing titanium dioxide or zinc oxide.
- Use skincare products designed for sensitive skin and avoid products containing alcohol, witch hazel, fragrance, menthol and harsh exfoliating agents.
- Choose make-up products that contain a green-tinted base – these will visually correct underlying skin redness making it less visible. Mineral-based cosmetic products are often preferred as they will cause less skin sensitivity.
- Avoid known triggers, e.g. alcohol or certain foods; and engage in activities that may reduce stress (e.g. exercise, meditation) if this is known to trigger flare-ups.
- Never apply a topical steroid to rosacea. Although short-term it will cause an improvement due to anti-inflammatory effects, over time it is likely to cause worsening of the condition.
Specific treatment measures
Successful control of rosacea relies firstly on understanding what aspects of the disease need treatment. Someone that has predominantly papules and redness is likely to need different treatment than another who is mainly troubled by prominent blood vessels and flushing. Careful history and examination by your doctor are vital to pick out the correct treatment plan. This is not a case of “one-size fits all”.
There are a large number of topical therapies that can be used to combat facial redness. However, these have limited benefit if the main issue is prominent blood vessels. Common topical treatments include:
- Metronidazole gel or cream
- Pimecrolimus cream or tacrolimus ointment
- Azelaic acid cream
- Brimonidine gel
- Ivermectin cream
Often oral antibiotics are combined with topical therapies to treat papulopustular rosacea. These are usually prescribed for 6-12 weeks in the first instance. Tetracyclines are the drug of choice and work by reducing inflammation. Lymecyline and doxycycline are used most commonly. Disadvantages of long-term antibiotics include development of bacterial resistance, so occasionally low doses of treatment are used for their anti-inflammatory rather than anti-microbial effect, e.g. doxycycline 50mg once daily. Less frequently, oral metronidazole can be used for this purpose.
When antibiotics are ineffective, contraindicated or poorly tolerated, then oral isotretinoin (Roaccutane) may be very effective. It is often prescribed by dermatologists at low dose, for long periods of time to achieve control. There are side effects associated with the drug so may not be suitable for everyone.
Medications like clonidine and propranolol can be prescribed by your doctor to control symptomatic flushing. These drugs are generally well tolerated but should be prescribed by a specialist familiar with their use in this context.
Prominent blood vessels and background redness respond well to light and laser therapies and can be life changing for patients in terms of cosmesis. Intense pulsed light and vascular lasers provide good results for patients in experienced hands. Several treatment sessions are usually required for satisfactory results and maintenance therapy may be required long-term as the underlying disease process of hyper-reactive blood vessels is still present.
This affects men more often than women. The best treatment is either by reshaping the nose surgically or resurfacing via laser therapy with a carbon dioxide laser. This is usually carried out by a dermatologist or plastic surgeon.
Patient education is always vital in controlling chronic skin disease, the www.rosacea.org website is an excellent resource for information.
If there is interest in skincare and tips and tools for concealing redness, the skin camouflage service available via www.changingfaces.org.uk is invaluable.
Skin disease can often cause significant psychological distress leading to problems with low self-esteem, altered body image, social isolation and even depression. Do discuss this with your doctor and consider further specialist input with dermatology and psychology if needed.
When should I see a dermatologist?
If you have trialed topical therapy combined with an oral antibiotic for 6-12 weeks with no benefit, or if you are suffering with psychological distress as a result of rosacea, then consider referral to a dermatologist for further input.