Acne rosacea affects over fourteen million Americans, the majority of them women. Fair skinned descendents from northwest Europe – Scandinavian, British, and Celtic ethnicities – are particularly prone, with onset usually occurring between the ages of 30 and 60. While not disabling, rosacea can result in significant social stigmatization and isolation. Anyone with this condition knows all too well the angst and trepidation that occurs every time there is a major increase in symptoms – the dreaded “flare-up”. Stepping out the door to take on the day is not easy when bright red patches on your face announce to the world you have rosacea. The stinging, burning, and tenderness remind you even when cosmetics make the visible signs less obvious.
In surveys by the National Rosacea Society, more than 76 percent of rosacea patients said their condition had lowered their self-confidence and self-esteem, and 41 percent reported that it had caused them to avoid public contact or cancel social engagements. Among rosacea patients with severe symptoms, 88 percent said the disorder had adversely affected their professional interactions, and 51 percent said they had even missed work because of their condition. Rosacea has no cure but can be managed to reduce its potentially life-disruptive impact.
The hallmark of rosacea is persistent redness resulting from networks of superficial blood vessels (telangiectasias) in the skin of the nose, cheeks, chin, forehead, or eyes. There are four major subtypes.
Subtype 1 (erythematotelangiectatic) rosacea is characterized by flushing and persistent facial redness. Visible blood vessels may be present, and stinging and burning discomfort is common. Because this subtype is difficult to treat with medical therapy, it may be especially important to identify and avoid lifestyle and environmental factors that trigger flushing or irritate the skin. (see the list of rosacea triggers below). A personal diary helps to identify and avoid those factors that affect an individual case. The appearance of flushing, redness and visible blood vessels may also be concealed with cosmetics, and facial discomfort may benefit from appropriate skin care. (See Skin Care and Cosmetics below) Visible blood vessels and severe background redness may be reduced with lasers or intense pulsed light therapy. Several sessions are typically required for satisfactory results, and touch-up sessions may later be needed as the underlying disease process is still present. In specific cases, extensive flushing may be moderated somewhat through the use of certain drugs.
Subtype 2 (papulopustular) rosacea is characterized by persistent facial redness and acne-like bumps and pimples, and is often seen after or at the same time as subtype 1. Fortunately, a number of medications have been studied and approved for this common form of rosacea, and may be used on a long-term basis to prevent recurrence. In mild to moderate cases, doctors often prescribe oral and topical rosacea therapy to bring the condition under immediate control, followed by long-term use of the topical therapy to maintain remission. A version of an oral therapy with less risk of microbial resistance has also been developed specifically for rosacea and has been shown to be safe for long-term use. Higher doses of oral antibiotics may be prescribed, and other drugs may be used for patients who are unresponsive to conventional treatments.
Subtype 3 (phymatous) rosacea is characterized by skin thickening and enlargement, most frequently around the nose. This condition develops primarily in men. Although mild cases may be treated with medications, moderate to severe manifestations typically require surgery. A wide range of surgical options is available, including cryosurgery, radiofrequency ablation, electrosurgery tangential excision combined with scissor sculpturing and skin grafting. A surgical laser may be used as a bloodless scalpel to remove excess tissue and re-contour the nose, often followed by dermabrasion
Subtype 4 (ocular) rosacea is characterized by any one of many eye symptoms, including a watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity and blurred vision. A history of having styes is a strong indication, as well as having “dry eye” or blepharitis. Treatment for mild to moderate ocular rosacea may include artificial tears, oral antibiotics and the daily cleansing of the eyelashes with baby shampoo on a wet washcloth. More severe cases should be examined by an eye specialist, who may prescribe ophthalmic treatments, as potential corneal complications may involve the loss of visual acuity.
1. Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J. Standard management options for rosacea, part 2: Options according to subtype. Cutis 2009;84:97-104.
Most people have only mild redness and are never formally diagnosed or treated and there is no single, specific test for rosacea. What is common, however, among nearly all patients is a relationship between worsening of symptoms and certain, food, beverages, emotional states, and environmental factors, so called triggers. There are numerous triggers that can tend to lead to exacerbations. The following triggers were cited by 1066 rosacea patients surveyed by the National Rosacea Society.
- Sun exposure 81%
- Emotional stress 79%
- Hot weather 75%
- Wind 57%
- Heavy exercise 56%
- Alcoholic drinks 52%
- Hot baths 51%
- Cold weather 46%
- Spicy foods 45%
- Humidity 44%
- Indoor heat 41%
- Skin products 41%
- Hot beverages 36%
- Some cosmetics 27%
- Medications 15%
Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments reported to cause rosacea include microdermabrasion and chemical peels, high doses of isotretinoin, benzoyl peroxide, and tretinoin.
Management and Treatment
Patients should determine which triggers cause flare-ups. A diary of foods, beverages, or activities is helpful. Avoidance of such triggers does not prevent all recurrences except in very mild cases. Use of daily sunscreen protection or hats with wide brims is widely recommended to prevent sun exposure. Sunscreen should have aSPFof 15 or higher and block both UVA and UVB ultraviolet light as well as infrared.
Medical treatment for rosacea depends on severity and subtype. Mild cases may not be treated at all or simply covered up with cosmetics (something easier and more familiar to female patients.) No therapy is curative and is best measured in terms of reduction in the amount of erythema (redness) and inflammatory lesions, decrease in the number and severity of flare-ups, and associated itching, burning and tenderness.
Mainstays of treatment are topical (metronidazole) and oral antibiotics (tetracyclines) to reduce pimples (pustules), bumps (papules), inflammation and some redness. Topical azelaic acid may be helpful. Improvement can take one to two months or longer. For advanced cases, dermabrasion, cryosurgery, or laser (intense pulsed laser or laser surgery) treatment may be recommended. Rosacea patients should seek professional consultation from specialists in the field to determine their own specific recommended treatments. Nonetheless, there are many things that are helpful and easy to do.
Skin Care and Cosmetics
Consistent gentle skin care and effective use of cosmetics can make a visible difference in managing rosacea and improving the look of one’s skin. The key is to use only skin care products that minimize irritation. Select products marked for use on sensitive skin, avoiding any that sting or burn. Examine the list of ingredients of any product that touches your face to avoid irritants known to worsen rosacea symptoms. Common problem ingredients include alcohol, witch hazel, menthol, peppermint, and eucalyptus oil. Astringents and exfoliating agents are often too harsh for sensitive skin. Fragrances are especially troublesome and are responsible for more allergic contact dermatitis than any other ingredient according to the American Academy of Dermatology.
It is a good idea to test any new product on unaffected skin prior to using them on the areas of rosacea. An unaffected peripheral area of the face or neck is a good choice. Using a product with multiple functions instead of multiple products is also recommended to reduce the number of ingredients. This applies equally to cosmetics – the fewer the better.
Cleansers should be selected according to skin type and some are formulated specifically for sensitive or redness-prone skin. Unless your skin is oily, non-soap cleanser is a good option. They contain less than 10% soap, rinse off easily, and have a neutral pH that is close to that of the skin. If skin is very oily, a mild soap should be used, taking care to avoid scrubbing as aggressive rubbing or over-cleansing is often irritating.
Many dermatologists consider the proper moisturizer as key for preventing burning, stinging, itching, and irritation. A strong moisture barrier is important in helping to keep our impurities and irritants that may aggravate sensitive skin. There are moisturizers specifically developed with ingredients intended to calm and sooth the skin. They may contain green color neutralizers to offset the red appearance.
Before applying makeup, cleanse and moisturize gently, avoiding scrubbing or rubbing. Use gentle tools to apply cosmetics, keeping the number of products to a minimum to reduce chances of applying an irritating ingredient. Green tinted bases are available that contain UVA/UVB sunscreen protection. Foundation should be oil free and match your natural skin tone as closes as possible.
Dermatologists recommend a gentle cleansing routine for people with rosacea. A suggested method is:
1. Using your fingertips, wash skin with a cleanser suitable for your skin type. Avoid using an abrasive washcloth or sponge, which may irritate.
2. Rinse away cleanser with lukewarm water. Hot or cold water may cause flushing or irritation. If your face is irritated by water at any temperature, try using a soothing cream cleanser you can simply tissue off.
3. Gently blot your face dry with a thick-pile cotton towel. Don’t rub skin, as this may cause irritation.
4. Since stinging most often occurs on damp skin, wait 30 minutes for the face to dry completely before applying any topical medication. Slowly reduce the drying time until you find the least amount of time your skin needs to avoid a stinging sensation.
5. After applying topical medication, wait five to 10 minutes more before applying moisturizer, sunscreen or makeup.
6. If you have ocular rosacea, be sure to follow your doctor’s directions for eyelid scrubbing and medication.
Shaving Tips for Men
Shaving poses a unique challenge for men with rosacea, but there are ways to cope. It may be preferable to use an electric razor, thus avoiding the irritation of a less than perfectly sharp blade. Shaving creams or lotions that sting or burn should be avoided. Use of a post-shave balm and/or moisturizer will help sooth the skin.