Rosacea

Dr Haran Sivapalan
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Rosacea is a condition characterised by episodes of flushing of the face, redness of the skin, small red (papules) or pus-filled (pustules) spots and dilated blood vessels (telangiectasia). It tends to affect the cheeks, forehead, nose and chin and symptoms often come and go throughout life. Rosacea most commonly affects fair-skinned people between the ages of 30 and 60.

Rosacea, pink cheeks, Harley Street Emporium

 

 

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The main symptoms of rosacea include:

  • Flushing – flushing is similar to when you blush, when the face suddenly becomes red for a short period of time. Flushes tend to last a few minutes and can also occasionally affect the neck and chest. People with rosacea may also report a feeling of heat when they have a flush. Flushing is often the first symptom of rosacea to develop. Certain things such as exposure to sunlight or drinking alcohol can trigger episodes of flushing.
  • Long lasting facial redness – the skin on the face may become red and appear similar to sunburn. This is known as erythema. Unlike flushing, the red patches of erythema persist for a long time.
  • Small red spots – small red spots called papules may appear on the face. These spots look similar to those seen in acne.
  • Small pus-filled spots – small spots filled with pus are known as pustules. They are yellow or white and appear similar to those in acne.
  • Visible, dilated small blood vessels – small blood vessels under the surface of skin can dilate in rosacea, becoming visible. They are known as telangiectasia and may appear on the forehead and cheeks.

Less commonly, rosacea can cause:

  • Thickening of the skin – in some cases, the skin may thicken and form extra tissue. Rarely, this can affect the nose causing it to appear enlarged and bulbous. This is known as rhinophyma and usually only affects men.
  • Eye symptoms – In about half of rosacea cases, there may be inflammation of the eye and eyelids. People may experience a burning, itching or stinging sensation in the eyes, or have a feeling of ‘grittiness’ or of a foreign body being in the eyes. They may also be more sensitive to light.

Rosacea tends to affect the cheeks, forehead, nose and chin. Less frequently, symptoms may also affect the neck, chest, arms and back.

Rosacea does not usually cause any pain or itchiness, but affected areas of skin may occasionally produce a burning sensation. The appearance of rosacea can often be a source of psychological distress.

The exact cause of rosacea is not known. Current research points to several different factors thought to play a role in the development of rosacea.

Recent studies have pointed to an abnormal immune system response in the skin, causing inflammation and dilation of blood vessels. It is possible that UV rays from sunlight exposure can activate this immune response.

Another possibility is that the immune response happens in response to a microscopic mite living the skin. The mite, called Dermodex folliculorum, is found on normal skin and is usually harmless. People with rosacea, however, have higher numbers of the mite on their skin; this may trigger an immune response. Researchers are unsure as to whether the Dermodex mites cause or simply aggravate rosacea.

Genes may also play a role in the development of rosacea, as the condition seems to run in families.

In some people, certain things may trigger flushing and other symptoms of rosacea. These include:

  • exposure to sunlight
  • changes in temperature
  • strong winds
  • alcohol in drinks
  • caffeine
  • stress
  • spicy foods
  • hot drinks
  • menopause in women
  • certain medications e.g. amiodarone (a drug used to treat some heart conditions), topical and nasal steroids.

A GP may diagnose based on a simple examination of the skin. Further investigations are not usually required. Your GP may want to ask questions about any potential triggers.

Referral to a specialist

Your GP may want to refer you to see a dermatologist if current treatment for rosacea is not working. Rosacea affecting the eyes may require referral to an ophthalmologist. Excess skin growths on the nose (rhinophyma) may require referral to a dermatologist or plastic surgeon.

Treatment

There are various types of treatment available for rosacea. They do not cure rosacea, but help reduce symptoms. The exact treatment prescribed by your GP for rosacea depends on the type and severity of symptoms.

Treatment of flushing and redness (erythema)

Treatment of facial flushing and redness (erythema) can be quite difficult. Initially, your GP will advise you to try to adapt your lifestyle in order to avoid any known triggers of flushing (e.g. caffeine or spicy foods).

If these lifestyle changes do not work, a doctor may prescribe 0.5% brimonidine gel.

  • -Brimonidine

Brimonidine tartrate is a drug that reduces flushing and redness (erythema) of the face. It works by causing the dilated blood vessels in the skin to constrict. It comes in the form of a gel which is applied to the skin one daily. It has shown to be effective in reducing erythema and flushing for up to 12 hours.

Brimonidine may temporarily cause burning or itching when applied to the skin. Less commonly, it may cause dry mouth, dry skin and headaches.

  •  Clonidine

Clonidine is a drug in a similar class to brimonidine. Your GP may consider prescribing clonidine to treat flushing. It is taken orally and helps to reduce the dilation of blood vessels that cause flushing.

A possible side effect of reducing erythema is that it may cause telangiectasia to become more visible by contrast.

  • -Skin camouflage

Skin camouflage products may also help reduce the appearance of redness. Skin camouflage clinics are accessible free of charge via the British Red Cross.

Treatment of telangiectasia

Telangiectasia, visible dilated small blood vessels, may be treated by a dermatologist using laser or intense pulled light treatment. The treatments are also of benefit in flushing.

  • Laser and Intense Pulled Light Treatment

These treatments involve directing a powerful beam of light onto the telangiectasia. This causes the dilated blood vessels to shrink, thereby becoming less visible. Between two and four treatment sessions are required to reduce the appearance of telangiectasia.

The procedures may cause small side effects such as bruising or crusting of the skin. Laser and intense pulled light treatments are not widely available on the NHS and may need to be paid for privately.

 

Treatment of spots (papules and pustules)

Topical and oral antibiotics are generally used to treat papules (small red spots) and pustules (small pus-filled spots) in rosacea. It is not known exactly why antibiotics help in rosacea, as there is not evidence of any bacterial infection of the skin. It is possible they work by reducing inflammation of the skin.

For mild-to-moderate rosacea with only a few spots, topical treatments, which are applied directly to the skin, are usually the first choice.

  • Topical metronidazole

Metronidazole is an antibiotic that comes as a gel or cream. It is applied to the skin twice daily for between 6 and 9 weeks. 0.75% metronidazole cream is normally prescribed and has been shown to be effective in several studies.

  • Topical azelaic acid

Azelaic acid is prescribed as an alternative to topical antibiotics. It may also work by reducing inflammation. It is usually applied to the skin twice daily for several weeks. Azelaic acid may cause temporary burning, stinging or itching when it is applied to the skin.

  • Topical ivermectin

Ivermectin is a newer treatment that is sometimes prescribed for rosacea. It is, however, not widely available on the NHS. It works by reducing inflammation and killing Dermodex folliculorum mites on the skin.

For moderate-to-severe rosacea with extensive papules and pustules, oral antibiotics are prescribed. These also reduce inflammation of the skin.

  •  Oral antibiotics

There are various different oral antibiotics that can be prescribed for rosacea. Usually, erythromycin or tetracycline antibiotics are used over a period of 6-12 weeks. Tetracycline antibiotics include drugs such as doxycycline, lymecycline, tetracycline and oxytetracycline.

  •  Oral isoretinoin

Very occasionally, a dermatologist may prescribe isoretinoin for rosacea. Isoretinoin is a retinoid drug (related to Vitamin A) that is normally prescribed for severe acne. It has various side effects (such as headaches and mood changes) and cannot be used in pregnancy.

Treating eye problems

Rosacea affecting the eyes and eyelids may require treatment. Treatment depends on the severity of eye problems. Initially your GP may advise you to regularly clean your eyes and eyelids using a clean cloth warmed with hot water.

For dry eyes, you may require lubricant eye drops or artificial tears. If the eye or eyelids become inflamed, a GP may prescribe oral antibiotics.

Treating thickened skin

Thickened skin, particularly excess tissue on the nose (rhinophyma), may need to be surgically removed. Laser treatment to remove the skin is also a treatment option.

There are several lifestyle measures that can help control the symptoms of rosacea.

Use sun protection – UV rays in sunlight may trigger flare-ups or aggravate an existing episode of rosacea. It is advised to regularly apply a sun cream with a sun protection factor (SPF) of at least 30, before being exposed to sunlight. Similarly, wearing a hat will also protect the face from sunlight.

Keep your skin moisturised – rosacea can worsen dry skin. It is best to use hypoallergenic emollients to keep the skin moisturised. These are available from most pharmacies.

Avoid products that may aggravate sensitive skin – erythema from rosacea can cause the skin to become sensitive. It is best to avoid cleansers containing alcohol or acetone, perfumed sunblocks and exfoliant products, as these can aggravate sensitive skin.

Avoid known triggers – things such as caffeine, alcohol, strong wind, extremes of temperature, spicy foods etc. may cause flare-ups of rosacea. If possible, try to avoid the things which you know trigger your rosacea.

Keep your eyes and eyelids clean – good eye hygiene help reduce symptoms when the eyes are affected by rosacea. Your GP or optician can advise you on good eye hygiene practice.

Rosacea. NHS Choices. Available online at: www.nhs.uk/Conditions/Rosacea

Rosacea. Patient.info. Available online at: http://patient.info/health/rosacea-leaflet

Rosacea and Rhinophyma. Patient.info – Professional Reference article. Available online at: http://patient.info/doctor/rosacea-and-rhinophyma

NICE CKS: Rosacea – acne (January 2016). Available online at: http://cks.nice.org.uk/rosacea-acne

van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MMD, Charland L. Interventions for rosacea. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD003262.