Rosacea

Rosacea is a common dermatologic disorder that presents as areas of redness on the face, particularly the cheeks.  According to some estimates, it may affect 10% of the population.  Rosacea is more common in light-skinned people, but people with darker complexions may develop it too.

Older literature referred to this condition as “acne rosacea,” because, like adolescent acne, rosacea may produce facial pimples and has the added feature of prominent redness.   Unlike acne, however, acne features comedones (whiteheads and blackheads), while rosacea does not.  Also, rosacea tends to affect people starting in their 30s and 40s, whereas acne is common much earlier in life.  The two conditions, however, may overlap in some patients, since acne can last into the 30s, and rosacea can start to appear during the 20s.  Drawing a bright line between acne and rosacea is therefore not always possible, but since the treatments for each are similar in many ways, distinguishing between the two is not essential.

What does rosacea look like?

For many people “rosacea” conjures the image of a ruddy alcoholic with a big nose (like W.C. Fields, or any number of prominent politicians.)  This is one reason why many people view even mild rosacea with disproportionate anxiety: they’re afraid they’re going to end up looking like that.  In fact, women hardly ever develop a bulbous nose (called rhinophyma—see below.)  Besides, there are many simple and effective treatments to keep rosacea under control.

What causes rosacea?

The cause of rosacea is unknown.  Current theories center on the following:

1.  Vascular instability (blushing and flushing).  Many rosacea patients are what dermatologists call “blusher-flushers.”  This means they turn red, often in response to heat or embarrassment, when they drink red wine or hot liquids, or for no obvious reason.  Turning red embarrasses them even more, because it elicits remarks from bystanders “(You’re all red!”) and raises suspicions that they drink too much.  
Medical scientists speculate about the basis for the vascular instability underlying blushing and flushing.  Whatever its cause may turn out to be, people with rosacea should keep the following facts in mind:

•    Not everyone who blushes and flushes will develop rosacea.
•    If rosacea does develop, treating it does not stop the blushing and flushing.
•    Avoiding the purported “trigger factors” that promote blushing can be impossible (cold wind),     undesirable activities (exercise), or very unpleasant tastes (spicy foods, red wine, hot liquids.)  

Rosacea literature often says that documenting and avoiding such triggers may, or will, limit progression of rosacea, but there is little evidence that it does.  My own clinical experience tells me that avoiding triggers makes life much more complicated and less enjoyable, but does little for the overall course of rosacea.

2. Bacteria and mites.  An association between rosacea and the bacteria Helicobacter pylori has not been supported by further studies.  For many years, some doctors have blamed rosacea on Demodex, a mite that lives normally in our follicles.  Current evidence regards the presence of these mites as coincidental to rosacea, not its cause.

3.  Steroid (cortisone) creams.  Strong creams of this kind, often prescribed by doctors for use elsewhere on the body or for a different patient, can induce rosacea.  (See below.)

Is rosacea chronic?

Yes and no.  The word “chronic” has two senses: that of always being there and that of always having a tendency to come back.  Rosacea is chronic for many patients only in the second sense.  This means that constant treatment (avoidance of trigger factors, application of therapeutic creams) is often not needed when there are no clinical manifestations.  There is little evidence that constantly treating rosacea, even when no symptoms are present, prevents or delays its recurrence. 

What does rosacea look like?

Rosacea is typically classified as follows:

•    Redness and superficial blood vessels:  At some point flushing stops coming and going and becomes permanent, leaving constant redness on the middle third of the face along with superficial blood vessels.  Classifying this combination as a stage of rosacea may be technically correct but has limitations:
Some people with redness and visible blood vessels just have ruddy complexions, not rosacea.
Medical treatments that helps rosacea (like oral or topical antibiotics—see below) don’t help this form.  Lasers and related devices can treat redness, but such methods are considered cosmetic and not covered by most health insurance carriers.

•    Inflammatory rosacea.  In this common form, patients develop papules (pimples) and pustules in the middle of their faces, in addition to redness.  

•    Sebaceous rosacea.  This type involves exuberant growth of sebaceous (oil) glands, especially on the nose.  This is called rhinophyma, which refers to the bulbous nose established in the popular imagination as the hallmark of a drunk (which is isn’t).

•    Ocular rosacea.  Some patients report eye symptoms like a feeling of dryness, blurry vision, and styes.  In recent years I have seen more patients referred by ophthalmologists with “ocular rosacea,” even though they have nothing on the skin to support the diagnosis—no redness and no pimples.  

•    Perioral dermatitis.  This is an eruption of pimples and pustules around the mouth.  Because it can also occur around the eyes, a more accurate designation is “periorificial rosacea” (rosacea around the openings).  Patients with this form of the condition often do not have the cheek redness so typical of ordinary rosacea.  

•    Steroid rosacea.   Although mild steroid creams can be safely used on the face, patients with rosacea seem especially prone to problems from using them.  In particular, what happens is that the steroids seem to help up to a point, but as soon as they are stopped, the eruption flares and gets even worse, leading to repeated steroid use in a vicious circle.  When skin “hooked on steroids” is treated properly, there is usually a period of worsening as the skin adapts to not being bathed in cortisone.  After a week or two, improvement proceeds.

What else looks like rosacea?

•    Acne produces pimples, but it also shows comedones (whiteheads and blackheads), whereas rosacea does not.  Also, acne tends to occur in younger people, though there can be overlaps in patients in their 20s and 30s.

•    Lupus erythematosus.  Lupus is a serious, connective tissue disease that can show a facial flush.  Lupus is far less common than rosacea, however, and does not produce pimples and pustules.  Most of the time doctors can diagnose (and reassure) at a glance, but sometimes a simple blood test makes the distinctions reliably.

How is rosacea treated?

•    Topical therapy:  Antibiotic creams containing metronidazole (1% or 0.75%) or azelaic acid (15% or 20%) are effective, as are those containing sodium sulfacetamide 10% and clindamycin 1%.

•    Oral therapy.  Tetracycline antibiotics are very effective in treating rosacea, usually working in 4-6 weeks.  They appear to work not by killing bacteria, which do not cause this condition, but by reducing inflammation.  Typical doses are 250-500 milligrams twice a day for tetracycline, 100-200 milligrams per day of doxycycline, or 100-200 milligrams per day of minocycline.  Recently very low doses of doxycycline have been used, 20-40 milligrams per day, a practice adopted from periodontists, who use such “sub-antimicrobial” doses to treat gum disease.  These very low doses appear to work quite well.  Oral antibiotics are best used together with topical creams, so that the pills can be discontinued as soon as possible and resumed only from time to time.

•    Isotretinoin (Accutane).  This drug, very effective in severe acne, can also be helpful in cases of extensive, resistant rosacea.  It may not, however, result in the long-term suppression of rosacea that it often produces in acne.

•    Surgical treatment.  Pulsed-dye lasers and other light devices like intense pulsed light do a good job of reducing or eliminating superficial blood vessels and redness.  The carbon dioxide laser can smooth out the bulbous overgrowth of nasal oil glands in the rhinophyma type of rosacea.   Such treatments are generally considered cosmetic and therefore are not covered by most health insurers.

Overall, rosacea is not a serious skin condition and does not predispose to other skin or internal medical problems.

References:

    Pamphlet of the American Academy of Dermatology: http://www.aad.org/public/publications/pamphlets/common_rosacea.html
    Rosacea.org.  http://www.rosacea.org/index.php