Rosacea is a long-term skin condition that typically affects the face. It results in redness, pimples, swelling, and small and superficial dilated blood vessels. Often, the nose, cheeks, forehead, and chin are most involved. A red, enlarged nose may occur in severe disease, a condition known as rhinophyma.
The cause of rosacea is unknown. Risk factors include a family history of the condition. Factors that may potentially worsen the condition include heat, exercise, sunlight, cold, spicy food, alcohol, menopause, psychological stress, or use of steroid cream on the face. Diagnosis is based on symptoms.
Rosacea is not curable, but treatment usually improves symptoms. Treatment is typically with metronidazole, doxycycline, minocycline, or tetracycline. When the eyes are affected, azithromycin eye drops may help. Other treatments with tentative benefit include brimonidine cream, ivermectin cream, and isotretinoin. Dermabrasion or laser surgery may also be used. The use of sunscreen is typically recommended.
Rosacea affects between 1% and 10% of people. Those affected are most often 30 to 50 years old and female. Fair-skinned people seem to be more commonly affected. The condition was described in The Canterbury Tales in the 1300s, and possibly as early as the 200s BC by Theocritus.
Signs and symptoms
Rosacea typically begins with reddening (flushing) of the skin in symmetrical patches near the center of the face. Common signs may depend on age and sex: flushing and red swollen patches are common in the young, small and visible dilated blood vessels in older individuals, and swelling of the nose is common in men. Other signs include multiple lumps on the skin (papules, pustules), and swelling of the face. Many people experience stinging or burning pain and rarely, itching.
Rosacea is often triggered or worsened by specific stimuli. The exact risk factors vary from person to person. Some people with rosacea may not be able to identify any consistent factors associated with flare-ups. Common triggers are ultraviolet light, weather temperature, food temperature, spicy foods, exercise, and emotional stress.Stein S (2020). Rosacea. Stern S.C., & Cifu A.S., & Altkorn D(Eds.), Symptom to Diagnosis: An Evidence-Based Guide, 4e. McGraw-Hill Education.
Erythematotelangiectatic rosacea Erythematotelangiectatic rosacea (also known as "vascular rosacea") is characterized by prominent history of prolonged (more than 10 minutes) flushing reaction to various stimuli, such as emotional stress, hot drinks, alcohol, spicy foods, exercise, cold or hot weather, or hot baths and showers.James, William; Berger, Timothy; Elston, Dirk (2005). Andrews' Diseases of the Skin: Clinical Dermatology. (10th ed.). Saunders. Page 245. .
Glandular rosacea In glandular rosacea, men with thick sebaceous skin predominate, a disease in which the papules are edematous, and the pustules are often 0.5 to 1.0 cm in size, with nodulocystic lesions often present.
Cause
The exact cause of rosacea is unknown. Triggers that cause episodes of flushing and blushing play a part in its development. Exposure to temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one, such as heated shops and offices during the winter, can each cause the face to become flushed. Certain foods and drinks can also trigger flushing, such as alcohol, foods, and beverages containing caffeine (especially hot tea and coffee), foods high in histamines, and spicy foods.
Medications and topical irritants have also been known to trigger rosacea flares. Some acne and wrinkle treatments reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin.
Steroid-induced rosacea is caused by topical use of steroids, which are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not stopped abruptly to avoid a flare-up. Cathelicidins In 2007, Richard Gallo and colleagues noticed that patients with rosacea had high levels of cathelicidin, an antimicrobial peptide, and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea, but they may only work because they inhibit some SCTEs.
Demodex mites, Demodex folliculitis and mange Studies of rosacea and Demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid-induced rosacea. Demodex folliculitis (demodicidosis, also known as "mange" in other animals) is a condition that may have a "rosacea-like" appearance.
A 2007 National Rosacea Society-funded study demonstrated that Demodex folliculorum mites may be a cause or exacerbating factor in rosacea. The researchers identified Bacillus oleronius as a distinct bacterium associated with Demodex mites. When analyzing blood samples using a peripheral blood mononuclear cell proliferation assay, they discovered that B. oleronius stimulated an immune system response in 79% of 22 patients with subtype 2 (papulopustular) rosacea, compared with only 29% of 17 subjects without the disorder. They concluded, "The immune response results in inflammation, as evident in the papules (bumps) and pustules (pimples) of subtype 2 rosacea. This suggests that the B. oleronius bacteria found in the mites could be responsible for the inflammation associated with the condition."
Intestinal bacteria Small intestinal bacterial overgrowth (SIBO) is more prevalent in people with rosacea, and treating it with locally acting antibiotics improved rosacea lesions in two studies. Conversely, in rosacea patients who were SIBO-negative, antibiotic therapy had no effect. The effectiveness of treating SIBO in rosacea patients may suggest that gut bacteria play a role in the pathogenesis of rosacea lesions.
Inflammatory bowel disease Inflammatory bowel disease (IBD), including both Crohn's disease and ulcerative colitis, is known to be associated with rosacea, with certain studies even suggesting a causal impact of IBDs on rosacea. Other research suggests the inverse, that rosacea might lead to IBDs. A high-quality meta-analysis (including both of the key studies supporting the single-direction hypotheses, among others) favors a relationship between the two diseases that is bidirectional, or causative in both directions.
Regardless of the direction of causality, it is known that IBD and rosacea share certain pathologic contributors. For example, the single-nucleotide polymorphism rs763035 is located around the BTNL2 gene, a gene that is known to be associated with ulcerative colitis and various autoimmune diseases.
Diagnosis Most people with rosacea have only mild redness and are never formally diagnosed or treated. No test for rosacea is known. In many cases, a simple visual inspection by a trained healthcare professional is sufficient for diagnosis. In other cases, particularly when pimples or redness on less common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis. The disorder may be confused with or co-exist with acne vulgaris or seborrheic dermatitis.
The presence of a rash on the scalp or ears suggests a different or coexisting diagnosis because rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.
Classification
Four rosacea subtypes exist, and a patient may have more than one subtype:Marks, James G; Miller, Jeffery (2006). Lookingbill and Marks' Principles of Dermatology (4th ed.). Elsevier Inc. .
Erythematotelangiectatic rosacea exhibits permanent redness (erythema) with a tendency to flush and blush easily. Also, small, widened blood vessels visible near the surface of the skin (telangiectasias) and possibly intense burning, stinging, and itching are common. People with this type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp. Papulopustular rosacea presents with some permanent redness with red bumps (papules); some pus-filled pustules can last 1–4 days or longer. This subtype is often confused with acne. Phymatous rosacea is most commonly associated with rhinophyma, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Telangiectasias may be present. In ocular rosacea, affected eyes and eyelids may appear red due to telangiectasias and inflammation, and may feel dry, irritated, or gritty. Other symptoms include foreign-body sensations, itching, burning, stinging, and sensitivity to light. Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Keratitis is a rare complication that is characterized by blurry vision and vision loss as the cornea is affected.
Variants Variants of rosacea include:Freedberg, et al. (2003). Fitzpatrick's Dermatology in General Medicine. (6th ed.). McGraw-Hill. . Pyoderma faciale, also known as rosacea fulminans, is a conglobate, nodular disease that arises abruptly on the face. Rosacea conglobata is a severe rosacea that can mimic acne conglobata, with hemorrhagic nodular abscesses and indurated plaques. Phymatous rosacea is a cutaneous condition characterized by overgrowth of sebaceous glands. Phyma is Greek for swelling, mass, or bulb, and these can occur on the face and ears.
Treatment The type of rosacea a person has will influence treatment choice. Mild cases are often not treated at all, or are covered up with normal cosmetics.
Therapy for rosacea is not curative and is best measured in terms of a reduction in the amount of facial redness and inflammatory lesions, a decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents. Laser therapy has also been classified as a form of treatment. While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually 1–2 years, may result in permanent control of the condition for some patients. Lifelong treatment is often necessary, although some cases resolve after a while and go into permanent remission. Other cases, if left untreated, worsen over time. Some people have also reported better results after changing their diet. This is not confirmed by medical studies, even though some studies relate the histamine production to the outbreak of rosacea.
Behavior