What is Rosacea?
Rosacea is a very common chronic skin condition which is usually characterized by redness and flushing of facial skin but may also include acne-like blemishes, enlargement of the nose (rhinophyma) and ocular rosacea (rosacea of the eyes)[1]. Usually the first sign you may have rosacea is a tendency to flush easily. Symptoms then tend to progress until persistent redness is present on and around the nose and cheeks. It is estimated in medical literature that 10% of the population suffers from rosacea, however I believe it likely to be much higher than that. It is more common among light-skinned patients, though it can occur in patients of any skin type.
Rosacea can worsen if left untreated. I recommend treatment to all my patients who exhibit signs of rosacea. The veins we see on the nose and cheeks which are the hallmark of rosacea take a long time to first make an appearance on your face. This is why rosacea is most common among patients after the age of 30[2]. Once the veins have been produced, they are generally followed by many more quickly thereafter.
Acne Rosacea
Perhaps the most frustrating thing for a physician who is familiar with how effective treatment of rosacea can be is the confusion of rosacea with acne by so many suffering with it. This is not helped by the fact that for many years rosacea was called “acne rosacea” due to the pimples often seen in patients with rosacea. Rosacea is not a form of acne, nor is it caused by acne. The pimples associated with rosacea are caused by overactive sebaceous glands, similar to acne, however the root cause is not the same.Rosacea Causes
Rosacea is caused by two things, in my opinion, our genes and the sun. People with rosacea have a genetic predisposition to develop veins and flushing from sun exposure. The sun itself is the second factor and the one which I believe is the most significant[3]. We can see this in our patients who have rosacea. Patients who drive often will usually have symptoms which are much worse on their driver’s side. There will typically be more veins and flushing on that side than on the side which is more sun-protected. This indicates that since UVB is blocked by car windows, UVA may be a significant contributor to the development of these veins.
For patients who have this genetic predisposition and have developed these veins, we see that these veins are much more reactive than ordinary veins in our body. All our bodies’ veins are equipped with little flood gate-like structures called arterials which regulate blood flow in and out of the vein. Arterials in veins caused by the sun are much more reactive so when we drink a hot beverage or alcohol, these highly reactive arterials are much more likely to cause us to flush and blush. Once these reactive veins are created, it is a snow-ball effect. It becomes much easier for these veins to multiply. This is why the onset of initial symptoms may take decades, but once they begin, they generally will worsen much more quickly. These additional veins significantly alter our skin’s characteristics. Once the veins are present we are much more likely to develop the additional symptoms of rosacea such as acne-like blemishes.
Rosacea "Triggers"
There is a great deal of discussion about “managing the triggers” of rosacea. Coffee and caffeine, spicy foods, alcohol, exercise, cold things like ice cream, all of these have been identified by some as triggers of rosacea. Basically anything that is any fun or takes good can be a trigger. It couldn’t be broccoli or cabbage, of course. Triggers can vary from person to person, but my personal philosophy about rosacea is to treat the underlying veins that are causing all the trouble rather than restrict things which are enjoyable in the hopes this will minimize embarrassment from rosacea. These triggers are only temporarily going to cause a flare-up, however the problem is still there lurking. Generally you will know your own triggers, however consultation with a dermatologist will help you understand your long-term treatment options.Prevention
Since genes play a role in the development of rosacea, it is impossible to completely remove your risk of developing symptoms. You can, however, minimize your risk of developing the symptoms by protecting yourself from sun exposure. The best way of doing this is to wear sunscreen, everyday.
Treating Rosacea
The good news about rosacea is that patients who have it are no longer consigned to dealing only with the triggers. Fortunately we now have technologies that can effectively treat the underlying issue of vascularity, those unwanted and irregular veins. Most treatment regimens will involve both topical/oral medications and laser therapy. These combination treatments are highly effective and my patients are usually very satisfied with the results they are seeing.
Laser Treatment
To me, the only treatment that really addresses the underlying cause of the symptoms of rosacea is laser treatment of the offending veins. We were not born with these veins and we do not need them to function. In fact, they are abnormal and they cause our skin to do bad things, like make acne-like pimples or flushing and redness. Using laser treatment helps moderate the range of symptoms of rosacea. It tones down the flushing and the general redness. The lasers we have now work extremely well[4][5][6].My favorite laser for treating rosacea is the newest long pulse-duration pulsed-dye laser, which happens to be the laser which I use far and away more in my practice than any other laser. The facial blood vessels along the nose and cheeks which are a trademark of rosacea can be effectively treated with the 532 nm Nd:YAG and 595 nm long pulse-duration pulsed dye lasers[7][8][9]. Studies have also shown that laser treatment can also improve the pimples which often accompany rosacea. After I treat a patient with rosacea with laser therapy I highly recommend that they avoid sun exposure which will aggravate their rosacea yet again. This can be done with proper sun avoidance (no sun bathing) and wearing high SPF (UVA & UVB) sunscreen every day. If they are diligent about this often they will not see a reoccurrence of these spider veins for many years.
Oral & Topical Medications for Rosacea
In addition to laser therapy oral and topical medications are often used as a part of the treatment regimen for rosacea. We use antibiotics to treat some of the symptoms of rosacea, most commonly the tetracycline drugs. These drugs have an anti-inflammatory affect which is beneficial for people with rosacea and it is also thought that they may have an impact on the blood vessels themselves. In addition to their anti-inflammatory properties, antibiotics are also used to manage acne symptoms, which are also often present in people with rosacea. Often metronidazole is used topically for patients with rosacea. Originally this was thought to address demodex mites which were found in higher concentrations in people with rosacea. It now seems that these mites are coincidental to rosacea rather than a cause, and metronidazole does not seem to work well on the types of mites people with rosacea tend to get. Paradoxically, metronidazole seems to improve symptoms of rosacea anyway[10]. This may have to do with some anti-inflammatory property in the drug, however we do not know for certain why this is.
Choosing a Treatment & Physician
External References
Rosacea TreatmentNational Rosacea Society
American Academy of Dermatology
[1] Bikowski JB, Goldman MP. Rosacea: where are we now? J Drugs Dermatol. 2004 May-Jun;3(3):251-61.
[2] Cohen AF, Tiemstra JD. Diagnosis and treatment of rosacea. J Am Board Fam Pract. 2002 May-Jun;15(3):214-7.
[3] Bernstein EF, Kligman A. Rosacea Treatment using the new-generation, high-energy, 595 nm, long pulse-duration pulsed-dye laser. Lasers Surg Med. 2008 Apr;40(4):233-9.
[4] Woo WK, Jasim ZF, Handley JM. 532-nm Nd:YAG and 595-nm pulsed dye laser treatment of leg telangiectasia using ultralong pulse duration. Dermatol Surg 2003;29:1176-1180.
[5] Bernstein EF. The new generation, high-energy, 595 nm, long pulse-duration pulsed-dye laser improves the appearance of photodamaged skin. Lasers Surg Med 2007;39-157-163.
[6] Tan SR, Tope WD. Pulsed dye laser treatment of rosacea improves erythema, symptomatology and quality of life. J Am Acad Dermatol 2004;51:592-599.
[7] Tan ST, Bialostocki A, Armstrong JR. Pulsed dye laser therapy for rosacea. Br J Plast Surg 2004;57:303-310.
[8] Lonne-Rahm S, Norlind K, Edstrom DW, Ros AM, Berg M. Laser treatment of rosacea: A pathoetiological study. Arch Dermatol 2004;140:1345-1349.
[9] Bernstein EF, Kligman A. Rosacea Treatment using the new-generation, high-energy, 595 nm, long pulse-duration pulsed-dye laser. Lasers Surg Med 2008;40-233-239.
[10] Elewski BE, Fleischer AB, Pariser DM. A comparison of 15% azelaic acid gel and 0.75% metronidazole gel in the topical treatment of papulopustular rosacea. Arch Dermatol 2003;139:1444-1450.
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Accutane might also casuse rosacea flare-ups