Rosacea

Rosacea Symptoms and Treatment

Rosacea

Article Summary

Rosacea is a skin condition that tends to worsen over time and affects mostly people over 30 years old. Rosacea may sometimes look similar to acne, but it is a different disease and requires different treatment. 


What Is Rosacea?

Rosacea, also referred to as acne rosacea, is different from acne vulgaris, which normally affects younger people. Rosacea affects mostly adults over the age of 30, with a higher incidence in women.1-2People with fair skin are more often affected, although darker skin types may also experience symptoms.2Rosacea 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. 


Symptoms

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.

Rosacea Symptoms: Flushing


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.

Rosacea Symptoms: Papules and Pustules


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: Dilated Blood Vessels


Rosacea Symptoms May Also Include Any Combination of the Following:

  • 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, rhinophyma2-5

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


Diagnosis

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

#1 Erythematotelangiectatic

  • Burning or stinging sensation to the skinCharacterized by flushing and redness
  • May also include burning, stinging, roughness & scaling
  • Some dilated blood vessels may be present
Subtype 1: Erythematotelangiectatic Rosacea



#2 Papulopustular

  • Characterized by redness with papules and pustules presentg
  • 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
Subtype 2: Papulopustular Rosacea



#3 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
Subtype 3: Phymatous Rosacea



#4 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
Subtype 4: Ocular Rosacea


Treatments

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."1This 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.]
  • 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,7but no improvement in dilated blood vessels. [Benzoyl peroxide + clindamycin shows a 71.3% reduction in rosacea lesions, and significant redness reduction.8-9No data regarding dilated blood vessels for benzoyl peroxide + clindamycin.]
  • Accutane (isotretinoin)
    This is particularly effective for younger patients and also those with phymatous rosacea.10
  • Oral antibiotics (most notably doxycycline)
    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.]11
  • 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.]1
  • 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)
    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.14


Other Things You Can Do to Help Your Symptoms

  • Wear sunscreen. Sunscreen is an important adjunct to rosacea care.15Pharmaceutical manufacturers incorporate sunscreen into prescription preparations at times. Zinc oxide is an effective broad spectrum sunscreen ingredient that seems 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.


Finding a Doctor

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.

The Experts at Acne.org

Our team of medical doctors, biology & chemistry PhDs, and acne experts work hand-in-hand with Dan (Acne.org founder) to provide the most complete information on all things acne. If you find any errors in this article, kindly use this Feedback Form and let us know.

References:

What Is Rosacea?
  1. Berg, M. & Liden, S. An epidemiological study of rosacea. Acta Derm. Venereol. 69, 419-23 (1989).
  2. Wilkin. J. et al. Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea. J. Am. Acad. Dermatol. 46, 584-7 (2002).
  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. J. Am. Acad. Dermatol. 50, 907-912 (2004).
  4. Goldgar, C., Keahey, D. J. & Houchins, J. Treatment options for acne rosacea. Am. Fam. Physician 80, 461-468 (2009).
  5. Del Rosso, J. Q., Baldwin, H. & Webster, G. American Acne & Rosacea Society rosacea medical guidelines. J. Drugs Dermatol. 7, 531-533 (2008).

Treatments:
  1. Culp, B. & Scheinfeld, N. Rosacea: a review. P. T. 34, 38-45 (2009).
  2. Tan, J. K. et al. Randomized placebo-controlled trial of metronidazole 1% cream with sunscreen SPF 15 in treatment of rosacea. J. Cutan. Med. Surg. 6, 529-534 (2002).
  3. Bjerke, R., Fyrand, O. & Graupe, K. Double-blind comparison of azelaic acid 20% cream and its vehicle in treatment of papulo-pustular rosacea. Acta Derm. Venereol. 79, 456-459 (1999).
  4. Gupta, A. K. & Gover, M. D. Azelaic acid (15% gel) in the treatment of acne rosacea. Int. J. Dermatol. 46, 533-538 (2007).
  5. Liu, R. H., Smith, M. K., Basta, S. A. & Farmer, E. R. Azelaic acid in the treatment of papulopustular rosacea: a systematic review of randomized controlled trials. Arch. Dermatol. 142, 1047-1052 (2006).
  6. Torok, H. M. et al. Combination sodium sulfacetamide 10% and sulfur 5% cream with sunscreens versus metronidazole 0.75% cream for rosacea. Cutis 75, 357-363 (2005).
  7. Montes, L. F., Cordero, A. A., Kriner, J., Loder, J. & Flanagan, A. D. Topical treatment of acne rosacea with benzoyl peroxide acetone gel. Cutis 32, 185-190 (1983).
  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. Int. J. Dermatol. 43, 381-387 (2004).
  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. & Plewig, G. Treatment of rosacea with isotretinoin. Int. J. Dermatol. 46, 533-538 (2007).
  11. Del Rosso, J. Q. 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. J. Am. Acad. Dermatol. 56, 791-802 (2007).
  12. Fivenson, D. P. The mechanisms of action of nicotinamide and zinc in inflammatory skin disease. Cutis 77, 5-10 (2006).
  13. Jansen, T., Plewig, G. & Kligman, A. M. Diagnosis and treatment of rosacea fulminans. Dermatology 188, 251-254 (1994).
  14. Parodi, A. et al. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin. Gastroenterol. Hepatol. 6, 759-764 (2008).
  15. Goldgar, C., Keahey, D. J. & Houchins, J. Treatment options for acne rosacea. Am. Fam. Physician 80, 461-468 (2009).
See More References

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