All About Rosacea

Woman with Rosacea on Face

 

Rosacea is an incredibly common, chronic inflammatory skin condition characterized by redness of the skin of the face. It affects around 15 million people in the United States.  It is often misinterpreted or misdiagnosed as a sunburn, acne, allergic reaction, eczema or even lupus. Yet, when appropriately treated it can be greatly improved. 

What are the Most Common Signs and Symptoms of Rosacea?

Rosacea affects the face, eyes, neck and even chest. Signs include facial redness or flushing, swollen reddish bumps, small visible blood vessels called telangiectasias or thickened skin, often of the nose. Skin is often dry and sensitive with symptoms of burning, stinging and tightness.  

What are the 4 Types of Rosacea?

Inflammation is the driving force behind the four classical described types of rosacea although in real life rosacea is often a combination of these.


1. Erythematotelangiectatic (ETR): This is the most common type.  Small blood vessels under the facial skin become enlarged and cause persistent redness.  It most commonly affects the cheeks, nose and chin.  In early stages it just looks like visibly dilated blood vessels. Over time, patients develop more persistent redness. Many patients report a sensation of warmth, tingling, stinging or swelling in their face skin as the redness becomes more prominent

 

2. Papulopustular: This type of rosacea is also referred to as acne rosacea.  It has the appearance of small red bumps that resemble acne. However, there are some key differences between papulopustular rosacea and acne.  First, this type of rosacea is seen in an older demographic than the typical acne patient.  It also generally develops in the midface, whereas acne happens all over the face.   It is also accompanied by small ‘spider veins’ on the face. Unlike normal acne, which includes blackheads, whiteheads and pimples, rosacea is just the pimple-like lesions with surrounding redness and flushing.

 

3. Phymatous Rosacea: This type of rosacea causes pronounced thickening of the skin, primarily on the nose but can involve the chin as well.  When left untreated, skin becomes thick, spongy and bumpy. Severe cases on the nose are called rhinophyma. 

 

4. Ocular Rosacea: This type of rosacea affects the eyes and surrounding skin.  It causes redness of the white part of the eye as well as the eyelids. Symptoms include watery eyes, itching, or a burning sensation and irritation akin to feeling like a piece of sand is in the eye. On occasion blurred vision and photosensitivity can happen. It is often confused with other eye conditions like conjunctivitis, blepharitis, a stye or hordeolum.  In ocular rosacea there are visible blood vessels on the eyelids, redness, and swelling around the skin of the eye.  

What are the Main Risk Factor For Rosacea?

The biggest risk for having rosacea is genetics. If your family members have rosacea, it is likely you will too. The risk factors include:

  1. Fair skin with light colored hair and eyes
  2. Abnormal blood vessel development like a vascular birthmark or vascular malformation
  3. Between 30-50 years old
  4. Female (although men often have more severe cases)
  5. Having Helicobacter pylori in the intestinal tract. These individuals have more gastrin in their system, which has a link to flushed appearance
  6. Overgrowth of the skin mite Demodex on their skin
  7. Excess production of the protein cathelicidin in their skin

What are the Most Common Triggers for Rosacea?

Not everyone has the same triggers, so you and your dermatology will need to work together to figure this out. The most notorious triggers are:

  1. Foods: Spicy foods (ex. jalapenos, hot peppers, wasabi, hot wings), foods associated with an increase in histamine (tomatoes, avocados, citrus, chocolate)
  2. Beverages: Alcohol (red wine is particularly notorious), hot drinks (ex: tea or hot chocolate), coffee
  3. Temperature changes: Sun exposure, hot showers, saunas, dry air, heavy wind, vigorous exercise that causes a lot of sweat and increased body heat
  4. Medications: Blood pressure medications (ACE inhibitors, calcium channel blockers, and nitrates), topical steroids (hydrocortisone), high dose niacin (for cholesterol management), SSRI antidepressants (fluoxetine, sertraline), hormonal replacement therapy
  5. Stress
  6. Skin irritation from skin care be it over exfoliation or irritating ingredients. 

What Shouldn’t I Use During a Rosacea Flare?

You want to avoid any potential irritants that can trigger inflammation.  This includes fragrance, essential oils, sodium lauryl sulfate, exfoliants (physical or chemical), astringents, toners, witch hazel, AHAs, BHAs, camphor, and menthol.

Active products including vitamin C serums, cell turnover treatments such as tretinoin, retinol, bakuchiol, AHA and BHA should also be stopped until the rosacea flare is over. 

How is Rosacea Treated?

Rosacea is approached in a multifactorial approach depending on the cause for each individual. It is also important to note that there is no cure. There will be great weeks and there will be terrible weeks. The goal of treatment is to maximize the number of great weeks.

Lifestyle Optimization 

This starts with identifying triggers and subsequent avoidance.  You’ll want a gentle skincare routine formulated for sensitive skin.  Find a mild face wash and a high quality moisturizer that is oil free, fragrance free, allergen free, and ideally contains niacinamide. 

You also need to protect yourself from the elements when you go outside. This includes the sun, wind, and even cold weather as they all can trigger a flare. Long sleeved shirts and pants, a large hat and maybe even a scarf.  Use mineral sunscreen with zinc, which has been shown to have calming properties for rosacea. 

Sleep and stress management should also be optimized, as imbalances here can also trigger flares.

Topical Treatments

Simplifying and streamlining your skincare regimen. Only wash your face at night with a gentle, non-drying cleanser. Skip toners, use lower percentage of actives like vitamin C, acids or retinol if you use them at all. Use lots of moisturizer, ideally formulated with squalane, glycerin, niacinamide, centella asiatic and other supportive ingredients for strengthening the skin barrier. For sunscreen products, pick those with zinc oxide which is also anti-inflammatory. 

Azelaic Acid has several characteristics that help with rosacea, including anti-inflammatory properties, anti-microbial properties, decrease in pustules/papules, and also has antioxidant properties.

Prescription Options

Metronidazole gel or a sulfa-based gel have antimicrobial and anti-inflammatory properties that help reduce redness and pustules. 

Vasoconstrictors such as oxymetazoline or brimonidine can temporarily narrow down blood vessels to decrease visible redness and flushing. 

Ivermectin cream is antiparasitic and anti-inflammatory that is useful for the papules and pustules of rosacea.

Calcineurin inhibitors like pimecrolimus or tacrolimus block inflammation resulting in decreased redness, swelling and hypersensitivity.

Oral treatments

OTC oral probiotic supplements formulated especially for the skin help to build a healthy skin biome that is less reactive. 

Antibiotics like doxycycline and minocycline are also anti inflammatory and help limit flares..

Beta blockers such as propranolol can help with flushing.

Oral steroids are sometimes used in short duration to decrease inflammation associated with rosacea.

Procedures

Lasers and light therapy can be good to target various aspects of rosacea. The Pulsed Dye Laser (PDL) and Intense Pulsed Light (IPL) target both the redness and the enlarged blood vessels.  KTP, Ndyag can also help.

Resurfacing lasers like the C02 laser can help treat rhinophyma. 

Rarely surgery is used to debulk a bulky skin of the nose seen in rhinophyma. 

 

These recommendations are not sponsored. They are the result of Dr. Heather D. Rogers, MD evidence-based research and extensive clinical experience. 

To learn more, sign-up HERE to receive weekly educational newsletters from our founder and dermatologist, Dr. Heather D. Rogers, MD.  

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