Islamabad Clinic Address:
House 25A, Street 52, Sector F6/4,
Super Market, Islamabad, Pakistan
Tel : 92 51 8733552
92 51 8733553

 

Rosacea

What is rosacea?

Rosacea is a very common red, acne-like benign skin condition that affects many people worldwide. Most people with rosacea have fair skin. The main symptoms of rosacea include red or pink patches on the central part of face, visible tiny broken blood vessels, small red bumps, sometimes containing pus, red cysts, and pink or irritated eyes. Most people with the disease may not even know they have rosacea or that it is a diagnosable and treatable condition. Many people who have rosacea may just assume they blush or flush easily or are just very sun sensitive.

Rosacea is considered a chronic (long-term), noncurable skin condition with periodic ups and downs. As opposed to traditional or teenage acne, most adult patients do not “outgrow” rosacea. Rosacea characteristically involves the central region of the face, causing persistent redness or transient flushing over the areas of the face and nose that normally blush – mainly the forehead, the chin, and the lower half of the nose. Some famous people with rosacea include the former U.S. President Bill Clinton and W.C. Fields.

The redness in rosacea may cause small blood vessels in the face to enlarge (dilate) and become more visible through the skin, appearing like tiny red lines (called telangiectasias). Continual or repeated episodes of flushing and blushing may promote inflammation, causing small red bumps that often resemble teenage acne. In fact, rosacea can frequently be mistaken for common acne. Rosacea is also referred to as acne rosacea.

Is rosacea contagious?
Rosacea is not considered contagious or infectious. There is no evidence that rosacea can be spread by contact with the skin, sharing towels, or through inhalation.
Is rosacea like acne?

Rosacea is basically different than acne, although the two can coexist. It is also sometimes called “adult acne.” Unlike common acne, rosacea is not primarily a plague of teenagers but occurs most often in adults (ages 30-50), especially in those with fair skin. Different than acne, there are usually no blackheads or whiteheads in rosacea. Furthermore, most teens eventually outgrow acne whereas patients with rosacea don’t generally outgrow it. Rosacea consists mostly of small red bumps that are not “squeezable” or extractable like blackheads. Squeezing a rosacea pimple usually causes a scant amount of clear liquid to expel. Unlike traditional acne where professional extractions can help remove whiteheads and blackheads, squeezing or extracting rosacea bumps does not help improve the rosacea. People with rosacea tend to have a rosy or pink color to their skin as opposed to acne patients whose skin is usually less red.

Rosacea strikes both sexes and potentially all ages. It tends to be more frequent in women but more severe in men. It is very uncommon in children, and it is very infrequently seen in darker skin tones or black skin.

What are the causes and risk factors of rosacea?

The exact cause of rosacea is still unknown and remains a mystery. The basic process seems to involve dilation of the small blood vessels of the face. Suspected causes of rosacea include but are not limited to genetic factors, genetics plus sun exposure, a mite sometimes found in hair follicles (Demodex folliculorum), gastrointestinal disease, and medications that cause blood vessels to widen. There seems to be a hereditary component to rosacea in a large number of people. Often people have close family members with rosacea.

Rosacea tends to affect the “blush” areas of the face and is more common in people who flush easily. Additionally, a variety of triggers are known to cause rosacea to flare. Emotional factors (stress, fear, anxiety, embarrassment, etc.) may trigger blushing and aggravate rosacea. A flare-up can be caused by changes in the weather like strong winds or a change in the humidity. Sun exposure and sun-damaged skin is generally associated with rosacea. Exercise, alcohol consumption, emotional upsets, and spicy food are other well-known triggers that may aggravate rosacea.

Rosacea risk factors include fair skin, easy blushing, and having other family members with rosacea (called “positive family history”). Additional risk factors include female gender,menopause, and being 30-50 years of age.

What are rosacea symptoms and signs?

Typical signs and symptoms of rosacea include facial flushing, blushing, redness, burning, red bumps, and small cysts. The symptoms tend to come and go. The skin may be clear for weeks, months, or years and then erupt again. Rosacea tends to evolve in stages and typically causes inflammation of the skin of the face, particularly the forehead, cheeks, nose, and chin.

When rosacea first develops, it may appear, then disappear, and then reappear. However, the skin may fail to return to its normal color and the enlarged blood vessels and pimples arrive in time. Rosacea may rarely reverse itself.

Rosacea generally lasts for years, and, if untreated, it tends to gradually worsen.

How is rosacea diagnosed?

Rosacea is usually diagnosed based on the typical red or blushed facial skin appearance and symptoms of easy facial blushing and flushing. Rosacea is largely under-diagnosed and most people with rosacea do not know they have the skin condition. Many people may not associate their intermittent flushing symptoms with a medical condition. The facial redness in rosacea may be transient and come and go very quickly.

Dermatologists are physicians who are specially trained in the diagnosis of rosacea. Generally no specific tests are required for the diagnosis of rosacea.

Blood tests are not generally required but may be used to help exclude less common causes of facial blushing and flushing including systemic lupus, other autoimmune conditions, and dermatomyositis.

While most cases of rosacea are fairly straightforward, there are some atypical cases that are not as easy to diagnose. Other conditions and rosacea look-alikes include

  • Acne vulgaris
  • Demodex folliculitis
  • Staph infection
  • Systemic lupus erythematosus
  • Medication reaction (for example, niacin)
  • Seborrheic dermatitis
  • Allergic or contact dermatitis
  • Eczema
  • Seasonal allergies
  • Allergic conjunctivitis
  • Perioral dermatitis
  • Carcinoid syndrome
  • Impetigo
  • Herpes simplex
What happens to the nose and the eyes?

The nose is typically one of the first facial areas to be affected in rosacea. It can become red and bumpy and develop noticeable dilated small blood vessels. Left untreated, advanced stages of rosacea can cause a disfiguring nose condition called rhinophyma, literally growth of the nose, characterized by a bulbous, enlarged red nose and puffy cheeks (like the old comedian W.C. Fields). There may also be thick bumps on the lower half of the nose and the nearby cheek areas. Rhinophyma occurs mainly in men. Severe rhinophyma can require surgical correction and repair.

Rosacea may or may not affect the eyes. Not everyone with rosacea has eye issues. A complication of advanced rosacea, known as ocular rosacea, affects the eyes. About half of all people with rosacea report feeling burning, dryness, and grittiness of the eyes (conjunctivitis). These individuals may also experience redness of the eyelids and light sensitivity. Often the eye symptoms may go completely unnoticed and not be a major concern for the individual. Many times, the physician or ophthalmologist may be the first one to notice the eye symptoms. Untreated, ocular rosacea may cause a serious complication that can damage the cornea, called rosacea keratitis. An ophthalmologist can assist in a proper eye evaluation and prescribe rosacea eyedrops. Oral antibiotics may be useful to treat skin and eye rosacea. Untreated eye rosacea may cause permanent damage, including impaired vision.

How is rosacea cured?

Rosacea is currently not considered a curable condition. While it cannot be cured, it can usually be controlled with proper, regular treatments.

There are some forms of rosacea that may be significantly cleared for long periods of time using laser, intense pulse light,photodynamic therapy, or isotretinoin(Accutane). Although still not considered a “cure,” some patients experience long-lasting results and may have remissions (disease-free period of time) for months to years.

What about using acne medicine?
Since there is some overlap between acne and rosacea, some of the medications may be similar. Acne and rosacea have in common several possible treatments, including (but not limited to) oral antibiotics, topical antibiotics, sulfa-based face washes, isotretinoin, and many others. It is important to seek a physician’s advice before using random over-the-counter acne medications since they can actually irritate skin that is prone to rosacea. Overall, rosacea skin tends to be more sensitive and easily irritated than that of common acne.
What is the treatment for rosacea?

There are many treatment choices for rosacea depending on the severity and extent of symptoms. Available medical treatments include antibacterial washes, topical creams, antibiotic pills, lasers, pulsed-light therapies, photodynamic therapy, and isotretinoin.

Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition. More resistant cases may require a combination approach, using several of the treatments at the same time. A combination approach may include home care of washing with a prescription sulfa wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, intense pulsed light, or photodynamic therapies may also be used in combination with the home regimen. It is advisable to seek a physician’s care for the proper evaluation and treatment of rosacea.

Topical creams

With the proper treatment, rosacea symptoms can be fairly well controlled. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole  applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid  is another effective treatment for patients with rosacea. Both metronidazole and azelaic acid work to control the redness and bumps in rosacea.

Some patients elect combination therapies and notice an improvement by alternating metronidazole and azelaic acid: using one in the morning and one at night. Sodium sulfacetamide is also known to help reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin.

 

Oral antibiotics

Oral antibiotics are also commonly prescribed to patients with moderate rosacea. Tetracyclinedoxycycline (Vibramycin) Adoxa,, minocycline, and amoxicillin (Amoxil) are among the many oral antibiotics commonly prescribed and they actually help reduce inflammation and pimples in rosacea.The dose may be initially high and then be tapered to maintenance levels. Common side effects and potential risks should be considered before taking oral antibiotics.

 

Miscellaneous medications

Short-term topical cortisone (steroid) preparations of minimal strength may in occasional cases also be used to reduce local inflammation. Some mild steroids include desonide lotion or hydrocortisone 0.5% or 1% cream applied sparingly once or twice a day just to the irritated areas. There is a risk of causing a rosacea flare by using topical steroids. Prolonged use of topical steroids on the face can also cause irritated skin around the mouth (perioral dermatitis).

Some doctors may also prescribe tretinoin (Retin-A), tazarotene (Tazorac), or adapalene (Differin), which are prescription medications also used for acne.

 

 Isotretinoin (Accutane)

Isotretinoin is infrequently prescribed for severe and resistant rosacea. Often it is used after multiple other therapies have been tried for some time and have failed. It is used as a daily capsule for four to six months. Isotretinoin is not typically used in rosacea, and it is most commonly used in the treatment of severe, common acne called acne vulgaris. Close physician monitoring and blood testing are necessary while on isotretinoin. Generally, at least two forms of birth control are required for females using this medication, as pregnancy is absolutely contraindicated while on isotretinoin.

 

 Cleansers

In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Harsh soaps and lotions should be avoided. Patients should avoid excessive rubbing or scrubbing the face.

 

Other recommended cleansers include

  • sulfa-based washes
  • benzoyl peroxide washes

 

 Sun protection

Sun exposure is a well known flare for many rosacea sufferers. Sun protection using a wide-brimmed hat (at least 6 inches) and physical sunscreens (like zinc or titanium) are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, the use of an appropriate daily sunscreen lotion and overall sun avoidance is recommended. Zinc-based sunscreens (SPF 30 or higher) provide superior sun protection.

 

What should be avoided? What foods are good for rosacea?

While not all rosacea people are exactly the same, there are some common rosacea triggers. Avoiding these potential triggers may also help relieve symptoms and disease flares. It may be helpful to keep a personal diary of foods and other triggers that flare rosacea symptoms.
Smoking, spicy foods, hot drinks, and alcohol may cause flushing and should be avoided. Exposure to sunlight and to extreme hot and cold temperatures should be limited as much as possible. Red wine and chocolate are two well known rosacea triggers. Some listed foods may have no effect on your rosacea but severely affect someone else. Individual reaction patterns vary greatly in rosacea. Therefore, a food diary may help you to avoid your special triggers.
Possible rosacea dietary triggers include

 

  • Dairy including yogurt, sour cream, cheese (except cottage cheese)
  • Alcohol including red wine, beer, vodka, gin, bourbon, and champagne
  • Chocolate
  • Soy sauce
  • Yeast extract
  • Eggplants, avocados, spinach
  • Citrus fruits, including tomatoes, bananas, red plums, raisins, or figs
  • Spicy and temperature hot foods

Potent cortisone or steroid medications on the face should be avoided because they can promote widening of the tiny blood vessels of the face (telangiectasis). Some patients experience severe rosacea flares after prolonged use of topical steroids.
Vasodilator pills can also flare rosacea. Vasodilators include certain blood pressure medications like nitrates, calcium channel blockers, and thiazide diuretics.
These potential triggers are found in many skin cleansers and should be avoided in rosacea.

 

  • Alcohol
  • Witch hazel
  • Peppermint
  • Eucalyptus oil
  • Clove oil
  • Fragrance
  • Menthol
  • Salicylic acid

Foods that decrease rosacea flares include less spicy meals, nonalcoholic cool beverages, caffeine-free drinks, nondairy cheese, and thermally cooler meals.

What natural remedies can help rosacea?

Rosacea skin tends to be fairly sensitive and may easily flare with self-treatment or common acne therapies. Any home treatment or attempts for natural remedies should be approached with some caution. As with any rosacea therapy, some people may experience sensitivity or irritation with treatment.
Green tea soaks to the face may also help decrease the redness and inflammation seen in rosacea. Green tea is thought to have anti-inflammatory properties. A few commercially available products also use green tea as the active ingredient.

Does rosacea get worse with age?
Yes. Although rosacea has a variable course and is not predictable in everyone, it tends to gradually worsen with age, especially if untreated. In small studies, many rosacea sufferers have reported that without treatment their condition had advanced from early to middle stage within a year. With good therapy, it is possible to prevent progression of rosacea.
How should I care for the skin of my face?

Proper skin care involves using a gentle cleanser to wash the face twice a day. Over-washing may cause irritation. A sunscreen lotion is advisable each morning. Your physician may prescribe a topical antibiotic to use once or twice a day under your sunscreen.
Rubbing the face tends to irritate the reddened skin. Some cosmetics and hair sprays may also aggravate redness and swelling.
Facial products such as soap, moisturizers, and sunscreens should be free of alcohol or other irritating ingredients. Moisturizers should be applied very gently after any topical medication has dried. When going outdoors, sunscreens with an SPF of 30 or higher are needed.

How are the telangiectasias (the red lines) treated?

Telangiectasias are the small blood vessels that arise on the surface of the skin, commonly on around the nose, cheeks, and chin.
Simple cover-up makeup can be used for the telangiectasias. There are some green-based moisturizers or tinted foundations that may help conceal the redness.
Telangiectasias can also be medically treated in your physician’s office with laser or intense pulsed light to close off the dilated blood vessels. Usually, multiple treatments are required for best results, and only a portion of the blood vessels may be improved with each treatment. Not everyone responds the same to these types of treatments, and your physician can help you decide which treatment is best for your skin type, condition, and size of blood vessels. These are

  • Long Pulse Nd Yag Laser
  • Intense pulsed light therapy
  • Red Light Emitting Diode Therapy
How is a rhinophyma (the W.C. Fields nose) treated?
Rhinophyma of the nose is frequently treated by surgery. The excess tissue may be removed with a scalpel, laser, or electro surgery. Follow-up treatments with laser or intense pulsed light may help lessen the redness. Medical maintenance therapy with oral and or topical antibiotics may be useful to decrease the chance of recurrence.

Treatments

 

Red Light Emitting Diode Therapy
Long Pulse Nd Yag Laser
Intense pulsed light (IPL)