Rosacea

Picture of rosacea, a skin condition that affects the face causing a blushing redness or tiny red pimples. By Interactive Medical Media LLC.

• Rosacea (commonly referred to as adult acne) is a chronic inflammatory condition affecting the central face of adults (it is rare in children) and manifested by redness of the forehead, eyelids, cheeks, nose, and chin.
• Rosacea is often accompanied by inflammatory papules (raised bumps) and pustules (bumps containing pus), or rarely with enlargement of the connective tissues beneath the skin (termed phymatous rosacea), including the nasal tissues (known as rhinophyma).

The cause of rosacea is unknown, but it is generally agreed that affected people have an unusual degree of vascular hyper-reactivity in that they tend to manifest vigorous and prolonged facial flushing in response to a number of stimuli including the ingestion of hot liquids. After a time, the flushing becomes permanent due to persistent enlargement of small facial blood vessels (telangiectasia).

It seems likely that genetic factors also play some role in this condition. The frequency of rosacea has been estimated to be as high as 10% of an adult Swedish population. It is most common among those of Celtic ancestry and is less common in darkly pigmented races. In a recently published study, a family history of rosacea, smoking, and sensitivity to sunlight were the significant predictive factors for rosacea.

Many people with rosacea seem to have a lowered threshold for facial irritation. This predisposition seems to be correlated with elevated levels of certain inflammatory chemicals and a defective barrier function of the skin. When the skin's normal barrier function is restored, levels of these inflammatory substances decrease to normal.

Excessive use of potent topical steroids on facial skin can induce a rosacea-like condition. Although the relationship to rosacea is controversial, some people have facial follicles that are infested by a mite, Demodex folliculorum, which may cause signs and symptoms that are easily confused with rosacea. This diagnosis can be made by a physician and then treated successfully with appropriate topical medications (permethrin cream).

People with rosacea have red faces often accompanied by inflammatory papules and pustules. The skin changes can be similar to acne, but comedones (blackheads) are not present. Occasionally, the eyelids and conjunctiva (lining of the eye) can become involved, resulting in eye irritation and rarely chronic corneal damage. Rarely, there is fibrosis (scarring) of the connective tissue of the facial skin associated with hypertrophy (enlargement) of the sebaceous glands, resulting in a thickened appearance. Thickening of the skin of the nose (rhinophyma) can be cosmetically debilitating.

Adults with persistently red facial skin associated with red bumps (papules and pustules) should visit a physician. This is especially true if the eyelids are involved.

• The correct diagnosis requires the presence of persistent facial redness that may be accompanied by inflammatory papules and pustules.
• There are no confirmatory laboratory tests to diagnose rosacea, although occasionally a skin biopsy will be necessary to support the diagnosis.
• Rosacea may be confused with a variety of other conditions, including systemic lupus erythematosus, seborrheic dermatitis, commonly cutaneous sarcoidosis.
• Since the diagnosis of rosacea depends upon its clinical appearance, it may be necessary to perform certain laboratory tests to exclude some of these other conditions.

Depending on the severity of this condition, topical or systemic treatment may be necessary. Topical therapy includes the application of topical antibiotics such as

• metronidazole (MetroCream, MetroGel, MetroLotion, Noritate),
• sulfacetamide (Novacet, Plexion, Plexion SCT, Plexion TS, Rosanil Cleanser, Rosula, Rosula Cleanser, Sulfacet-R, Zetacet Wash), or
• azelaic acid (Azelex, Finacea, Finevin).

If topical therapy is insufficient, oral antibiotics are frequently beneficial. Frequently used oral antibiotics include

• tetracycline (Ala-Tet, Sumycin) or one of its analogues like
• doxycycline (Adoxa, Alodox, Avidoxy, Doryx, Monodox, Oracea, Oraxyl, Periostat, Vibramycin, Vibramycin Calcium, Vibramycin Monohydrate, Vibra-Tabs) and
• minocycline (Dynacin, Minocin, Minocin PAC, Myrac, Solodyn).

Systemic treatment with antibiotics may inhibit the development of rhinophyma and is effective in controlling blepharitis (inflammation of the eyelid). Rarely, very severe cases may require isotretinoin (Amnesteem, Claravis, Sotret), an oral retinoid. The overall goal of treatment is to control the symptoms rather than cure the condition.

Treatment of the telangiectatic component (dilated blood vessels) of rosacea with lasers or intense pulsed light of the appropriate wavelength can diminish the redness. Individual blood vessels can also be treated with electrosurgical destruction. There is also a novel form of medical therapy currently being used, which utilizes a drug similar to that present in long-acting nasal decongestant sprays (like Afrin). Rhinophyma can be improved by "paring down" excess nasal tissues using electrosurgical or microwave devices.

• Diminish facial flushing by limiting exposure to hot liquids or foods.
• Avoid unprotected sun exposure. Apply sunscreens to minimize the acute and chronic effects of sunlight.
• If possible, avoid substances that are thought to exacerbate rosacea, including:
  • nitrates,
  • certain anti-hypertensive medications,
  • nicotine,
  • niacin, and
  • MSG (monosodium glutamate).
• Avoid exercising in hot environments and windburn, which may lead to facial redness.
• Avoid smoking tobacco products.

Makeup, Moisturizers, and Creams

• Green-tinted cosmetic makeup can be useful in camouflaging the red component of rosacea.
• People with rosacea may have a low threshold for facial irritation, so bland emollients (moisturizers) may work best. Appropriate emollients are stiff creams that come in wide-mouthed jars and do not flow. They should be applied to wet skin.
• Although the overuse of potent topical steroids is known to produce a condition called steroid rosacea, the use of 1% hydrocortisone cream (available without a prescription) can reduce the redness and inflammation in rosacea.
• Certain commercially available topical creams containing ceramides, niacinamide, and hyaluronic acid (CeraVe Facial Moisturizing Lotion PM) may improve some of the signs of rosacea.
• There is some evidence to suggest that oxymetazoline, the active component of many long-acting nasal decongestants, may also be effective in reducing vasodilatation seen in rosacea.

Those on topical therapy should see their physician regularly to insure their continued response to treatment. If a patient requires oral antibiotics, appropriate follow-up with a physician is necessary every three to six months.

There is little one can do to prevent this condition but, as mentioned previously, triggering factors such as tobacco, niacin, spicy food, alcohol, and sun- or windburn should be minimized.

Rosacea is a chronic condition characterized by exacerbations and remissions. Appropriately aggressive therapy can diminish the inflammatory component of the disease, perhaps decreasing the likelihood of the development of disfiguring changes. Ocular damage to the cornea and subsequent decrease in vision can be avoided with appropriate treatment of ocular rosacea.