Rosacea is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide. It begins as flushing and redness on the central face and across the cheeks, nose, or forehead but can also less commonly affect the neck, chest, scalp or ears. As rosacea progresses, other symptoms can develop such as permanent redness, red bumps (some with pus), red gritty eyes, burning and stinging sensations, small blood vessels visible near the surface of the skin, and in some advanced cases a bulbous nose. The disorder can be confused and co-exist with acne vulgaris and/or seborrheic dermatitis. People that are fair-skinned are disproportionately affected. Rosacea affects both men and women of all ages, but middle-aged women are more susceptible because of hot flushes caused by menopause.
Rosacea subtypes and Rosacea symptoms
There are four identified rosacea subtypes and patients may have more than one subtype present.
- Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning sensations.
- Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules), this subtype can be easily confused with acne.
- Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargenent of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea on appear on the nose, chin, forehead, cheeks, and ears. Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
- Ocular rosacea: Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.
The precise pathogenesis of rosacea still remains unknown, but most experts believe that rosacea is a disorder where the blood vessels become damaged when repeatedly dilated by stimuli. The damage causes the vessels to dilate too easily and stay dilated for longer periods of time or remain permanently dilated, resulting in flushing and redness. Immune cells and inflammatory mediators can leak from the microvascular bed causing inflammatory pustules and papules, especially with those with papulopustular rosacea.
Rosacea has a hereditary component and those that are fair-skinned of European or Celtic ancestry have a higher genetic predisposition to developing it. Women are more commonly affected but when men develop rosacea it tends to be more severe. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.
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, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include alcohol, foods high in histamine and spicy food.
Certain medications and topical irritants can quickly progress rosacea. If redness persists after using a treatment then it should be stopped immediately. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of isotretinoin, benzoyl peroxide and retin-A. 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.
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.
Treating rosacea varies from patient to patient depending on severity and subtypes. Dermatologists are recommended to take a subtype-directed approach to treating rosacea patients.
Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. The National Rosacea Society recommends that a diary be kept to help identify and reduce triggers.
It is important to have a gentle skin cleansing regimen using non-irritating cleansers. Protection from the sun is important and regular use of a sunscreen containing a physical blocker such as zinc oxide or titanium dioxide is advised.
Oral tetracycline antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defence prescribed by doctors to relieve papules, pustules, inflammation and some redness. Oral antibiotics may also 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.
Flushing and blushing can be reduced with a centrally-acting α-2 agonist clonidine. Clonidine has side effects of drowsiness and lowered blood pressure. Monoxidine can be used as an alternative to clonidine as it has less side effects but most people find to be less effective. Beta-blockers like propanolol are similar to α-2 agonists but work better for anxiety and chronic social blushing than general flushing triggers. If flushing occurs with red wine consumption and with other foods containing high amounts of histamine then antihistamines such as zyrtec or claritin may help.
People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily scrubbing the eyelids gently with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.
Dermatological vascular laser (single wavelength) or Intense Pulsed Light (broad sprectrum) machines offer one of the best treatments for rosacea. 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 70ºC, damaging them, causing them to be absorbed by the body's natural defense mechanism.
CO 2 lasers can be used to remove excess tissue caused by phymatous rosacea. CO 2 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.
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