WHAT IS ROSACEA
Rosacea (rose-AY-sha) is a common skin disease. It often begins with a tendency to blush or flush more quickly than other people. The redness can slowly spread beyond the nose and cheeks to the forehead and chin. Even the ears, chest, and back can be red.
A treatment plan includes avoiding triggers and using gentle skincare products. Many skincare products can irritate the skin. Some skincare habits, such as scrubbing your skin clean, can cause aflare. Using mild skincare products and being gentle with your skin can help prevent flare-ups.
If you have trouble finding soft skincare products, ask your dermatologist for recommendations-best and results achieved with patient education. While medicine or laser treatment can help reduce apparent signs of rosacea, your everyday habits may cause a new flare-up.
What Are Rosacea Types?
There are so many signs and symptoms that rosacea has four subtypes:
- Erythematotelangiectatic rosacea: Redness, flushing, visible blood vessels.
- Papulopustular rosacea: Redness, swelling, and acne-like breakouts.
- Phymatous rosacea: Skin thickens and has a bumpy texture.
- Ocular rosacea: Eyes red and irritated, eyelids can be swollen, and the person may have what looks like a stye.
With time, people who have rosacea often see permanent redness in the center of their faces. The signs and symptoms cause more than a red look. There are many signs (what you can see) and symptoms (what a person feels) of the disease. Because it has so many signs and symptoms, scientists created four subtypes of rosacea. Each subtype requires a different treatment. Some people have more than one at the same time.
Subtype 1: Facial redness, flushing, visible blood vessels
- Flushing and redness in the center of the face
- Visible broken blood vessels (spider veins)
- Swollen skin may be susceptible
- The skin may sting and burn
- Dry skin, roughness, or scaling
- tend to flush or blush more quickly than other people
This subtype is most common in middle-aged women.
Subtype 2: Acne-like breakouts
- Acne-like breakouts, usually where the skin is very red
- Acne-like breakouts tend to come and go
- Oily skin
- The skin may be susceptible
- The skin may burn and sting
- Visible broken blood vessels (spider veins)
- Raised patches of skin called plaques
Subtype 3: Thickening skin
Rhinophyma: Although rare, rosacea can cause the skin to thicken and have a bumpy texture. When this happens, it is called rhinophyma. This subtype is rare. When it does occur, the person often has signs and symptoms of another subtype of rosacea first. The signs of this subtype are:
- Bumpy texture to the skin
- Skin begins to thicken, especially common on the nose. When the skin thickens on the nose, it is called rhinophyma (rye-NO-fie-ma)
- The skin may thicken on the chin, forehead, cheeks, and ears
- Visible broken blood vessels appear
- Pores look large
- Oily skin
Subtype 4: In the eyes
- When affecting the eye, it is called ocular rosacea.
- Watery or bloodshot appearance
- Feel gritty, often feels like sand in the eyes
- Eyes burn or sting
- Eyes are dehydrated
- Eyes itch
- Eyes sensitive to light
- Blurry vision visible broken blood vessels on an eyelid
- Cyst on the eyelid
Treatment improves a person’s quality of life. Studies show that when people have fewer signs and symptoms of rosacea, their quality of life improves.
Who gets Rosacea?
Rosacea is common. More than fourteen million people live with rosacea, according to the U.S. government. Most people who get rosacea are:
- Between 30 and 50 years of age
- Fair-skinned and often have blonde hair and blue eyes
- From Celtic or Scandinavian ancestry
- It is likely to have someone in their family tree with rosacea or severe acne
- Likely to have had lots of acne — or acne cysts and nodules
Children get it. Women are a bit more likely than men to get rosacea. Women, however, are not as likely as men to get severe rosacea. Some people are more likely to get rosacea, but anyone can get this skin disease. People of all colors get rosacea.
What causes Rosacea?
Scientists are still trying to find out what causes rosacea. By studying rosacea, scientists have found some important clues:
- It runs in families.
- The immune system may play a role.
- A bug that causes infections in the intestines may play a role.
- Demodex, a mite that lives on everyone’s skin, may play a role.
- A protein that usually protects the skin from infection, cathelicidin, may cause redness and swelling.
A treatment plan for rosacea includes avoiding triggers, using gentle skincare products, and treating the rosacea.
How do dermatologists diagnose Rosacea?
Flushing and blemishes.
Rosacea skincare: available OTC products
Rosacea patients often self-describe their skin as “sensitive.” This non-specific, non-medical term can vary from patient to patient. Therefore, patients should be encouraged to be specific about their skin symptoms. I should counsel patients with rosacea to avoid astringents, soaps, fresheners, toners, facial scrubs, masks, and most OTC skincare “programs.”
However, even though the list of verboten agents is long, numerous safe and effective cleansers, moisturizers, sunscreens, and cosmetics are available for rosacea patients. Disease management aims to achieve synergy between prescription and OTC products to ensure maximum efficacy of active drugs, extend remission, and conceal redness and blemishes.
People with rosacea tend to have susceptible skin to chemical irritants and patulous follicles in the phymatous area. Patients must try to avoid all sources of irritation.
Furthermore, the skincare regimen of a rosacea patient needs to be simple; the more the skin is specifically manipulated, the more opportunity there is for unnecessary irritation. Additionally, simplified regimens are expected to encourage adherence.
Cleansing and moisturizing
A proper cleansing and moisturizing routine are an essential part of rosacea management. I should counsel patients that daily cleansing is important to rid the skin of surface dirt, makeup, dead skin, and excess oil, but they should avoid scrubbing the skin and wash with only cool water. The ideal cleanser is a product that leaves a minimal residue, is non-comedogenic and lipid-free, and contains non-ionic surfactants with a neutral or slightly acidic pH. Moisturizing is essential to maintain the softness and elasticity of the skin, and therapeutic moisturizers devoid of irritants are crucial adjunctive therapy.
Many patients have clinically dry skin, and some topical medications (e.g., topical metronidazole) can cause further drying and irritation. Furthermore, there is increasing evidence that epidermal barrier dysfunction, associated with trans-epidermal water loss and contributes to skin dryness and inflammation, is linked.
Epidermal barrier dysfunction is associated with the elevation of inflammatory serine proteases in various dermatoses. In rosacea specifically, epidermal barrier dysfunction has been identified, involving the central facial region in inflammatory (papulopustular) and erythemato-telangiectatic subtypes.
Moisturizers formulated with emollients and humectants are recommended to help keep the stratum corneum intact to either repair or prevent skin barrier dysfunction. Furthermore, moisturizing dry skin lessens the itchiness and irritation that rosacea patients often experience as a part of their condition.
Some OTC moisturizers are now available to incorporate high lipids and ceramides ratios to support epidermal barrier function. Given the finding of epidermal barrier dysfunction in rosacea, the use of prescription barrier repair agents may be considered for some rosacea patients who do not respond to OTC moisturizers.
Until recently, there has been no medical treatment for the erythema of rosacea. Nonetheless, cosmetics will continue to camouflage disease signs and symptoms, an integral part of disease management. Patients should be counseled to avoid menthol, camphor, or sodium lauryl sulfate products, as these can be irritating. It is also recommended that rosacea patients avoid using waterproof cosmetics and heavy foundations because they are more challenging to apply mechanically. Their removal often requires irritating solvents.
Mineral-based make-ups have become increasingly popular in recent years. Some products appear to be well-suited for patients because they contain all or primarily inert ingredients, including preservatives and fragrances. However, I found some mineral makeup formulations in a recent analysis to contain irritants and allergens.
I can camouflage pigmentation irregularities by applying foundations of complementary colors. For example, I can camouflage red skin by applying a green foundation, a complementary color to red; the combination of green and red creates a brown tone. This can be covered further, if desired, by a light foundation that spreads quickly. Furthermore, a yellow skin tone will turn brown when complemented with a purple foundation. Fortunately, many tinted cosmetics and skincare products are available to help camouflage redness.
The daily, uninterrupted use of sunscreen is a cornerstone of long-term management. Sun exposure is the leading cause of rosacea flares, and patients should be advised to use sunscreen daily, irrespective of cloud coverage, with a sun protection factor (SPF) of at least thirty.
However, patients should be advised that an appropriate sunscreen contains UVB blockers (e.g., octyl methoxycinnamate, homosalate) and UVA blockers (e.g., avobenzone, ecamsule, titanium dioxide, oxybenzone, sulisobenzone, and zinc oxide.
New FDA sunscreen labeling requirements have been met with mixed reactions by clinicians. Considering label revisions, patients should be advised to select a formulation that confers broad-spectrum protection and adhere to label instructions for frequency of reapplication.
Mineral make-ups often provide broad-spectrum protection against ultraviolet (UV) radiation and can be used as a physical sunblock. It is also important that the sunscreen be non-irritating, and patients may have better tolerance to products containing dimethicone or Cyclomethicone. Alternatively, patients may only use formulations containing physical sunscreens – zinc oxide or titanium dioxide.
Cleansing, moisturizing, camouflaging, and sunscreen are the primary elements of a skincare regimen. OTC products with a green tint or cosmetically elegant can be applied during the day, and prescription products used to treat erythema and redness that are less cosmetically elegant can be applied at night. Patients with long-term problems often have sensitive skin and can be the most difficult to treat.
Available prescription agents
Oral and topical prescription agents are fundamental in the management. Mild to moderate rosacea can be treated with topical monotherapy or topical combination therapy with or without an oral antibiotic.
Moderate to severe disease necessitates oral antibiotic therapy until remission, usually 3–4 months. I can often maintain remission by continuing the topical therapy alone or in combination with a low-dose oral antibiotic.
Because rosacea pathogenesis is so poorly understood, management is focused on treating disease endpoints rather than the underlying disease. In general, inflammation is treated with an anti-inflammatory agent, papules and pustules are treated with antibiotics (with no target organism), flushing is treated with vasoconstrictors, and telangiectasias are treated with light-based therapies.
Oral antibiotic therapy
Papular-pustular type responds well to oral antibiotics, although their efficacy is brought about by their anti-inflammatory effects more than their antimicrobial effects. Standard antibiotic agents include tetracyclines (tetracycline, doxycycline, minocycline), erythromycin, and co-trimoxazole. However, the latter is usually reserved for use in Gram-negative patients who have not responded to other therapies.
These agents have been used for decades and are associated with a good safety profile. Tetracyclines are the most prescribed oral antibiotics, but there is apprehension about antibiotic resistance with the long-term use of these and other antibiotic agents.
An anti-inflammatory dose formulation of doxycycline (40 mg delayed-release formulation) has been formulated in response to this concern. Long-term use of this delayed-release formulation did not alter bacterial susceptibility to antibiotics for nine months.
Topical therapy reduces inflammatory lesions (papules and pustules), decreases erythema, improves pruritus, burning, and stinging, and reduces the incidence and intensity of flares. Standard topical therapies include sulfacetamide 10%/sulfur 5%, metronidazole, and azelaic acid (AzA). Topical erythromycin and clindamycin are second-line agents, but data regarding their efficacy in rosacea treatment are limited.
Sulfacetamide-sulfur has anti-inflammatory properties, and the gel is available in a green-tinted formulation, which has the advantage of simultaneously treating inflammation and toning down redness. Sulfacetamide-sulfur also has been combined with avobenzone (UVA filter) and octinoxate (UVB filter) in an SPF 18 formulation, which has shown superior efficacy to topical metronidazole in investigator global severity scores, percent reductions in inflammatory lesions, and improvement.
Overall, these leave-on products have demonstrated favorable safety and tolerability profiles. Furthermore, sulfacetamide-sulfur cleansers also have demonstrated efficacy as adjunctive therapy in combination with other topical and systemic agents.
Other treatment modalities
Flushing is a challenging aspect of rosacea management and a source of frustration for most patients. Low-dose beta-blockers, selective serotonin reuptake inhibitors, and clonidine have been used off-label to treat the flushing of rosacea.
A topical prescription gel containing the alpha-agonist brimonidine tartrate 0.5% is new to the market. Reduction in background erythema is evident as early as 30 minutes after applying the gel. Data showed that topical brimonidine gel applied once daily was significantly more effective than vehicle gel for 12 hours.
Many patients are frustrated with the poor efficacy of oral and topical therapies in resolving telangiectasia and persistent erythema. However, light-based and laser therapies have demonstrated efficacy in improving vascular disease features.
Potassium titanyl phosphate (KTP), pulsed dye lasers (PDL), neodymium:yttrium-aluminum-garnet (Nd: YAG), and intense pulsed light (IPL) have all been used for telangiectases.
More recently, intense pulsed light (IPL) therapy has been used successfully to treat rosacea’s vascular symptoms. IPL utilizes selective photothermolysis with a broad light spectrum to destroy targeted vessels by coagulation while sparing surrounding tissue. IPL and ELOS have advantages because they can penetrate the skin more effectively than lasers. IPL’s increased spot size allows a more extensive treatment area, and sequential pulsing provides epidermal cooling between pulses. Furthermore, variable light durations can target vessels of varied sizes at multiple depths.
Cosmetic products with natural actives can be helpful to soothe irritation. Vitamin C is an antioxidant with numerous positive effects on the skin, including collagen repair, normalization of photodamage, and anti-inflammatory properties. A 5.0% vitamin C preparation demonstrated efficacy in objective and subjective improvement in erythema, which might be because of its anti-inflammatory effects.
A is a principal phenolic constituent of the licorice species Glycyrrhiza inflata, which exhibits anti-inflammatory and antimicrobial effects, and improves redness and irritation. The Eucerin® Redness Relief line has an SPF lotion and spot concealer containing licochalcone A with a green-tinted base, which provides both an anti-inflammatory component and redness camouflage.
Chrysanthellum indicum is a plant-based extract containing phenylpropanoic acids, flavonoids, and saponosids with documented effects on vascular wall permeability and the increase of the mechanical resistance of capillaries.
Furthermore, this cream has vitamin P properties, which may be responsible for reducing or preventing microcirculation disorders.
Alfa-hydroxy acid-based cosmetic peels and at-home regimens also have shown promise for rosacea treatment. A regimen of a daytime cream containing SPF 15 and gluconolactone 8% and an evening cream with gluconolactone 8% demonstrated significant improvement in texture, fine lines, photodamage, dryness, and erythema, and 80% of patients rated the cosmetic acceptability of these products as good to excellent.
A polyhydroxy acid skincare regimen (cleanser and moisturizer) also demonstrated good tolerability and efficacy with AzA 15% in patients with sensitive skin conditions. This regimen significantly added to the reduction of facial erythema, did not interfere with the efficacy of AzA 15%, and smoothed the skin, which could further enhance patient satisfaction with the products.
Glycolic acid peels and topical glycolic acid products added to an antibacterial regimen also have demonstrated dramatic improvement in skin texture and follicular pores and the resolution of comedones, papules, and pustules. An additional benefit of these products and procedures is that they provide a treatment option for pregnant women because glycolic acid products and AzA 15% are not contraindicated in pregnancy.
The Treatment outcome for people who have Acne Rosacea
There is no cure for rosacea, but you can successfully control it. Making some lifestyle changes and treating rosacea can prevent flare-ups. It can also prevent the rosacea from worsening. Many people find that living with rosacea becomes more accessible by doing these things. They also say they feel and look better.
Management of rosacea requires avoiding disease triggers and an appropriate skincare regimen – including moisturizers and oral and topical prescription agents to address specific symptoms. While I cannot cure rosacea, treatment aims to achieve remission, maximize time to flare, conceal redness, and now use topical agents or light-based devices to treat redness and telangiectasis.