Understanding Rosacea

Notes in Dermatology, Skin concerns

chillies with text flushing burning rash rosacea

UNDERSTANDING ROSACEA:
Flushing, redness & ‘acne’

Rosacea is a chronic inflammatory facial skin rash which affects primarily women from their forties and fifties, mainly with fair complexions. There is increasing evidence of Rosacea being widespread in middle-aged men, and in darker skins also. There is a subset of younger women, in their twenties who develop Rosacea.

Skin becomes highly sensitive, inflammatory and reactive, especially across the cheeks and nose, chin and forehead. The skin around the eyes is spared. Rosacea is characterised by increased sebaceous activity in these areas – oil glands increase in size, pores enlarge and can become inflamed. The rash of papules and pustules earns rosacea the sometimes-used term ‘acne rosacea’. Contradictorily skin is also dehydrated, and difficult to balance. Melanocytes are activated, resulting in a muddying of skin tone. Generalised post-inflammatory hyperpigmentation occurs.

 

Rosacea types & progression

01.

REDNESS (Erythema)

Rosacea starts with temporary flushing of the cheeks and nose, sometimes spreading to forehead and chin. This can be prolonged, uncomfortable and embarrassing. With time this flushing can result in a more persistent redness as the fine vessels in the cheeks and nose become permanently dilated (known as telangiectasia); they don’t resume their size after flushing. Capillaries become damaged and obvious in a fine broken network over the cheeks. The rash is often described as stinging or burning.

02.

PAPULAR-PUSTULAR (‘Acne’)

Papular pustular Rosacea, the second type, is often mistaken for ‘adult’ acne because of the appearance of papules and pustules across the nose, cheeks, chin as the condition progresses. These papules can be differentiated from acne in that they are more uniform in appearance (acne will tend to have a range of papules, pustules, comedones and less background redness). Significantly, there are no comedones or blackheads with rosacea pustular rashes.

03.

RHYNOPHYMA (Nose)

A third, uncommon form results from a further progression of rosacea, with thickening of the tissue of the face, affecting the nose in particular, termed rhynophyma. This is very rare in women.

04.

OCULAR ROSACEA (Eyes)

Eye  symptoms are common, including dryness, grittiness and redness.

05.

WHAT CAUSES ROSACEA?

Rosacea is a chronic condition, and tends to follow a relapsing-remitting pattern. The cause is largely unknown; many theories exist and a range of contributing factors have been identified:

  • Genetics (familial link)
  • Internal factors (hormonal, such as menopause; stress, vascular and inflammatory pathologies)
  • External factors (chronic ultraviolet light exposure, exposure to Demodex mites. Demodex, common on human skin, has been reported to have increased intensity on skin with rosacea and may be a factor in its inflammation).

Triggers – different from causes! – are factors which seem to exacerbate the condition. Triggers vary from person to person, and will be anything which promotes flushing – including emotional triggers, environmental changes and common lifestyle-related behaviours.
These are varied but include: sun, exercise, spicy foods, alcohol, temperature changes, hot showers, central heating.
Some medications, such as topical corticosteroids, vasodilators and calcium channel blockers can aggravate symptoms and flare-ups.

06.

WHAT CAN BE DONE ABOUT ROSACEA?

Rosacea can be well managed and controlled, but not cured.
Treatment will help to minimise risk of progression of the disease.

The first aim with Rosacea is to try to avoid inflammation – rather than deal with the consequences. The most important start is to work out what the triggers are – these vary from person to person. In practice some of these triggers can be hard to avoid

The second aim is to restore as far as possible the normal functionality of skin – its ability to repair itself. This is done through care and repair of the skin’s balance and natural moisture barrier.

Treatment

WHAT CAN YOU DO?

Skin care is important. Use non-foaming, soap-free, non-stripping cleansers. Pay attention to hydration, even, and especially if the skin is appearing to become more oily and with enlarged pores. Sunblock is essential.

There is a growing body of evidence that niacinamide topically applied can assist in repair of the barrier function, with particular respect to Rosacea patients (ie Draelos et al). Non-prescription strength azelaic acid (10%) is an antioxidant and will have an anti-inflammatory effect, reducing redness and swelling. These can be added to your skin-care routine (depending on ingredients already in your routine).

Mineral make-up is effective as a camouflage for persistent redness.

Skin health and barrier can be improved by considering diet and supplements.

High factor (SPF 30+) broad-spectrum sunblock is essential. All year round.

Topical Steroids should be avoided as they can make matters worse.

Treatment

WHAT CAN MUTI DO?

Thorough consultation is always the starting point at Muti, working with you to understand your individual rosacea pattern, triggers, and skin health. We will always work in partnership with and refer to your GP for the long-term management of Rosacea. Muti in-clinic treatments will work alongside and in relation to topical and oral medications which may have been prescribed to you. It is important to review your home skincare products and ensure that these are right for your particular needs. Basic effective skincare routines will be established with you.

Highly effective treatments can help to manage the symptoms of Rosacea – IPL intense pulsed light is excellent at targeting the redness of sustained flushing, and damaged capillaries. It can also target enlarged pores and refine the skin texture.

Dermapen medical microneedling builds up the thickness and elasticity of the skin and supports its general health and resilience (by stimulating the skin to heal and produce more collagen). A course of dermapen has been shown to significantly improve the ability of the skin to withstand long-term fixed erythema. It also improves pore size and skin texture (see case study for further information).

A course of treatments combining IPL and dermapen will be worked out to suit your unique skin situation.

See a Muti Rosacea Case Study for further information.

Treatment

WHAT CAN YOUR GP DO?

Your GP will have several options following consultation, and depending on what your primary Rosacea presentation is (erythema or persistent redness, pustules, ocular rosacea, or rhynophyma).
They will review triggers and other medications which may contribute to flushing or flares.

Treatment options:
For erythema or redness as the primary symptom, Brimonidine is a vasoconstrictor which can help to reduce redness by reducing blood flow in surface capillaries (topical cream.)

Papules and pustules can respond well to topical gels and creams –
-antibiotic metronidazole (Rozex) to reduce inflammation and control bacteria
-prescription strength azelaic acid 15% (Fincacea, Azelex) to reduce inflammation
-insecticidal ivermectin (Soolantra), anti-inflammatory and reduces the demodex mite count on the skin.
(topical Tretinoin can sometimes be considered when antibiotics fail, to reduce inflammation, but they can also increase erythema and telangiectasia.)

For more severe papular rosacea, oral antibiotics may be prescribed.

Rhynophyma can be treated surgically or using ablative laser.

DIFFERENTIALS

What else could it be?
Seborrhoeic dermatitis – with symptoms of scale or flaking of naso-labial folds, eyebrows, ears, scalp (may co-exist with rosacea)
Acne – comedones (blackheads and whiteheads), sebaceousness or oiliness, lack of background redness
Peri-oral dermatitis – rash around mouth or eyes (sparing lip margins), uniform pustules on a red scaly base, frequently seen in younger women
Keratosis pilaris rubra – redness of cheeks since childhood, follicular (around each hair follicle) scale or plugging on upper arms and thighs

REFERENCES

Draelos, Z.D, Ertel, K and Berge, C., (2005).‘Niacinamide-containing facial moisturizer improves skin barrier and benefits subjects with rosacea. [Online abstract] Cutis. Volume 76(2) pages 135-41. Available at https://www.ncbi.nlm.nih.gov/pubmed/16209160. (Accessed: 26 June 2018)
NICE (2016) ‘Inflammatory lesions of popular pustular rosaceaL Ivermectin 10mg/g cream’ [Online evidence summary] Available at: https://www.nice.org.uk/advice/esnm68/chapter/full-evidence-summary#context-2 (Accessed: 29 October 2018)
NICE (2016) ‘Rosacea – acne’ [Online clinical management summary] Available at https://cks.nice.org.uk/rosacea-acne#!scenario (Accessed: 29 October 2018)
NICE (2014) ‘Facial erythema of rosacea: briomidine tartrate gel’ [Online evidence summary]. Available at https://www.nice.org.uk/advice/esnm43/chapter/Key-points-from-the-evidence (Accessed: 29 October 2018)
Oakley, A., Ngan, V. and Morrison, C. (2014) Rosacea. Available at: https://www.dermnetnz.org/topics/rosacea/ (Accessed: 24 June 2018).
PCDS ‘Rosacea – primary Care Treatment Pathway’ Available at http://www.pcds.org.uk/ee/images/uploads/general/Rosacea-Guidelines-FINAL.pdf (Accessed: 29 October 2018)
Strazzula, L., Burgin, L. and Goldsmith, L. A. (2018) Rosacea. Available at: https://www.visualdx.com/visualdx/diagnosis/rosacea?moduleId=101&diagnosisId=51025 (Accessed: 24 June 2018).
Taieb A, Ortonne JP, Ruzicka T et al. (2015) Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial. British Journal of Dermatology 172: 1103–10

Photograph credits

Rosacea photo gallery © DermNet New Zealand
Chillies Photo by Ricardo Gomez Angel on Unsplash