Introduction to rosacea

Rosacea, also referred to as acne rosacea, is different from acne vulgaris, which normally effects younger people. Rosacea affects mostly adults over the age of 30, with a higher incidence in women.1-2 People with fair skin are more often affected, although darker skin types may also experience symptoms.2 Rosacea is fairly common (worldwide estimates average about 5% of people), and while its symptoms may wax and wane, it is most often referred to as a chronic condition. Rosacea is usually a progressive disease, and without treatment may continue to worsen over time. Rosacea can also cause emotional repercussions.

Flushing

The most common sign of rosacea is frequent or sustained blushing or flushing of the skin. The skin of the central face appears red and inflamed. In women, this is not to be confused with monthly flushing before menstruation.

Papules / pustules

Red, inflamed lesions that may or may not have a white/yellow center. Rosacea does not include non-inflamed whiteheads or blackheads, although one can have rosacea and acne vulgaris simultaneously, so whiteheads or blackheads may be present if this is the case.

Dilated blood vessels

Called telangiectasia, these dilated blood vessels resemble small squiggles on the surface of the skin. They may be obvious or they may be hidden by the redness of the surrounding skin.

Rosacea symptoms may also include any combination of the following2-3,5

  • Burning or stinging sensation to the skin
  • Elevated red plaques
  • Dry appearance to the skin
  • Fluid under the skin – edema
  • Burning or itching eyes, eyelid inflammation, styes, red eyes
  • Skin thickening, bulbous growths, rhinophyma

Rocacea is often confused with

  1. Acne vulgaris
  2. Seborrheic dermatitis
  3. Seborrhea
  4. Keratosis pilaris
  5. Demodicosis
  6. Pyoderma faciale
  7. Steroid-induced acneiform eruptions
  8. Perioral dermatitis

Physicians experience a challenge when diagnosing rosacea because of the numerous ways it can present itself. The National Rosacea Society has broken rosacea into four main categories:2-3

Erythematotelangiectatic Photo

Erythematotelangiectatic

  • Characterized by flushing and redness
  • May also include burning, stinging, roughness & scaling
  • Some dilated blood vessels may be present
Papulopustular Photo

Papulopustular

  • Characterized by redness with papules and pustules present
  • May resemble acne vulgaris, but no comedones are present (unless the person has acne vulgaris simultaneously)
  • Burning and stinging may be present
  • Some dilated blood vessels may be present
Erythematotelangiectatic Photo

Phymatous

  • Thickening of skin
  • Irregularities of skin surface, bumpy appearance
  • Rhinophyma: thickening of skin on the nose, resulting in an irregular, bumpy appearance
  • Dilated blood vessels
Ocular Photo

Ocular

  • May include any of the following eye symptoms: watery, bloodshot, burning/stinging, itching, lid redness, stye, light sensitivity, blurred vision, foreign body sensation
  • Ocular rosacea is usually present in conjunction with other signs of rosacea on the skin, however, skin symptoms are not required
  • Treatment may require topical as well as opthamologic treatment
  1. Berg M and Liden S. "An epidemiological study of rosacea." Acta Dermato-Venereologica. 1989; 69(5): 419-23.
  2. Wilkin J, et al. "Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea." Journal of the American Academy of Dermatology. 2002; 46(4): 584-7.
  3. Wilkin J, et al. "Standard grading system for rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea." Journal of the American Academy of Dermatology. 2004; 50(6): 907-12.
  4. Goldgar C, Keahey DJ and Houchins J. "Treatment options for acne rosacea." American Family Physician. 2009; 80(5): 461-468.
  5. Del Rosso JQ, Baldwin H and Webster G. "American Acne & Rosacea Society rosacea medical guidelines." Journal of Drugs in Dermatology. 2008; 7(6): 531-533.

According to a thorough and informative 2009 Review on Rosacea published by Thomas Jefferson University (Jefferson Medical College), "...the cure for rosacea remains elusive, and all currently used medications are for symptomatic control only. No precise treatment algorithm has become the standard of care; treatment remains empirical."1 This may sound ominous, but in reality, we have several methods of tackling rosacea which are proven effective.

Common treatments

  • Metronidazole (MetroGel, MetroCream)

    An often prescribed treatment, studies show this topical antibiotic providing superior results to placebo.1-2 [72% reduction in rosacea lesions, 45% redness reduction, statistically significant improvement in dilated blood vessels.]
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  • Azelaic acid (Azelex)

    Studies have shown effectiveness [73.4% reduction in rosacea lesions, significant redness reduction, no improvement in dilated blood vessels] with concentrations up to 20%. 15% is standard.3-5
  • Sodium sulfacetamide 10% and sulfur 5% (Sulfacet)

    Studies hint toward good results.6 [80% reduction in rosacea lesions, 69% redness reduction. No data on dilated blood vessels.]
  • Benzoyl peroxide or benzoyl peroxide + clindamycin (Benzaclin)

    Trial results from benzoyl peroxide administration show significant improvement in rosacea lesions,7 but no improvement in dilated blood vessels. [Benzoyl peroxide + clindamycin shows a 71.3% reduction in rosacea lesions, and significant redness reduction.8-9 No data regarding dilated blood vessels for benzoyl peroxide + clindamycin.]
  • Isotretinoin (Accutane)

    This is particularly effective for younger patients and also those with phymatous rosacea.10
  • Oral antibiotics (most notably doxycycline)11

    Patient and doctor should be in close contact and limit exposure to short term therapy (no longer than one year). [Results from trials show a 48%-59% improvement in rosacea lesions. No evidence of reduction in dilated blood vessels.]
  • IPL (Intense pulsed light) and long-pulsed dye lasers

    These machines provide treatments that can help with redness and dilated blood vessels, but are impermanent solutions.
  • Regular opthamologist care for eye symptoms

    . Be sure to see your opthamologist if you suspect ocular rosacea.

Less common treatments

  • Oral nicotinamide + zinc (Nicomide, Nic/Zn)

    [79% of patients showed moderately better or much better improvement in appearance (based on patient global evaluation) after 4 weeks of treatment.]12
  • Hormonal treatment—Spironolactone, Prednisone, Oral Contraceptives13

  • Mite, parasite, fungal treatment--Permethrin cream (Nix), Ivermectin (Stromectol), Crotamiton (Eurax), Ketoconazole (Nizoral)

  • Alpha blockers

Experimental treatments

  • Rifaximin (SIBO treatment)14

    An interesting study in the journal Clinical Gastroenterology and Hepatology showed a much higher prevalence of intestinal bacteria (SIBO) in people with rosacea than those without. Patients were given Rifaximin, an antibiotic which does not penetrate the intestinal wall, effectively reducing or eradicating SIBO. After SIBO was controlled, 20 of 28 patients cleared completely, and 6 more greatly improved. Results lasted for at least 9 months at follow-up.

Other things you can do to help your symptoms

  • Wear sunscreen

    Sunscreen is an important adjunct to rosacea care.15 Pharmaceutical manufacturers incorporate sunscreen into prescription preparations at times. Zinc oxide and titanium dioxide are effective broad spectrum sunscreen ingredients that seem to be well tolerated by people with rosacea.
  • Avoid

    Products that strip or irritate the skin such as soap (use soap-free cleanser instead), sodium lauryl sulfate (avoid cleansers with this ingredient), astringents, toners, menthol, and camphor.
  1. Culp B and Scheinfeld N. "Rosacea: a review." Pharmacy & Therapeutics. 2009; 34(1): 38-45.
  2. Tan JK, et al. "Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea." Journal of Cutaneous Medicine and Surgery. 2002; 6(6): 529-34.
  3. Bjerke R, Fyrand O and Graupe K. "Double-blind comparison of azelaic acid 20% cream and its vehicle in treatment of papulo-pustular rosacea." Acta Dermato-Venereologica. 1999; 79(6): 456-9.
  4. Gupta AK and Gover MD. "Azelaic acid (15% gel) in the treatment of acne rosacea." International Journal of Dermatology. 2007; 46(5): 533-8.
  5. Liu RH, et al. "Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials." Archives of Dermatology. 2006; 142(8): 1047-52.
  6. Torok HM, et al. "Combination sodium sulfacetamide 10% and sulfur 5% cream with sunscreens versus metronidazole 0.75% cream for rosacea." Cutis. 2005; 75(6): 357-63.
  7. Montes LF, et al. "Topical treatment of acne rosacea with benzoyl peroxide acetone gel." Cutis. 1983; 32(2): 185-90.
  8. Breneman D, et al. "Double-blind, randomized, vehicle-controlled clinical trial of once-daily benzoyl peroxide/clindamycin gel in the treatment of patients with moderate to severe rosacea." International Journal of Dermatology. 2004; 43(5): 381-7.
  9. Kapes B. "P. acnes possible factor in rosacea: BenzaClin a significant Tx in lesion reduction." Dermatology Times. 1 Apr. 2003.
  10. Hoting E, Paul E and Plewig G. "Treatment of rosacea with isotretinoin." International Journal of Dermatology. 2007; 46(5): 533-8.
  11. Del Rosso JQ, et al. "Two randomized phase III clinical trials evaluating anti-inflammatory dose doxycycline (40-mg doxycycline, USP capsules) administered once daily for treatment of rosacea." Journal of the American Academy of Dermatology. 2007; 56(5): 791-802.
  12. Fivenson DP. "The mechanisms of action of nicotinamide and zinc in inflammatory skin disease." Cutis. 2006; 77(1 Suppl): 5-10.
  13. Jansen T, Plewig G and Kligman AM. "Diagnosis and treatment of rosacea fulminans." Dermatology. 1994; 188(4): 251-4.
  14. Parodi A, et al. "Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication." Clinical Gastroenterology and Hepatology. 2008; 6(7): 759-64.
  15. Goldgar C, Keahey DJ and Houchins J. "Treatment options for acne rosacea." American Family Physician. 2009; 80(5): 461-468.

Because of its wide ranging symptoms, rosacea can easily be confused with other conditions. Be sure to educate yourself and be your own advocate when speaking to a medical professional.

When choosing a doctor<, be certain to find someone experienced in treating patients with rosacea (this will often mean a dermatologist). Then don't be afraid to ask some tough questions such as:

  1. Are you certain what I have is rosacea and not a similar condition?
  2. How many patients with rosacea have you treated?
  3. What is the effectiveness of the treatments you've prescribed? Why have you decided on this treatment for my particular case?

Most importantly, trust your gut. Your dermatologist's diagnosis and strategy for treatment should be strong and confident. If you feel uncomfortable, simply visit another dermatologist. Very often with dermatology as well as with other conditions, a second or third opinion is incredibly valuable.

Then, once your doctor prescribes a treatment protocol, stick with it closely and orchestrate regular follow-up visits. If you do not improve, a second opinion may be in order.