Rosacea is estimated to affect over 45 million people worldwide. It affects white-skinned people of northern European descent, however it has been seen in patients of Indian ancestry or Asian ancestry. It begins as erythema (flushing and redness) on the central face and across the cheeks, nose, or forehead but can also less commonly affect the neck and chest. There are four identified rosacea subtypes:
- Erythrotelangiectatic rosacea: Permanent redness with a tendency to flush easily. It is also common to have small blood vessels visible near the surface of the skin. Flushing may be associated with a sensation of burning or itching.
- Papulopustular rosacea: These patients have a background of diffuse redness with variable pustules and papules (pink papules and pus-filled papules)—often mistaken for traditional acne.
- Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement.
- Ocular rosacea: These patients complain of “gritty eyes” which are red, dry and irritated, often red vessels are visible on the whites of the eyes.
Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes. Antibiotics have been used in the past to treat rosacea, but antibiotics may only work because they inhibit some stratum corneum trypic enzymes. (August 5, 2007 Nature Medicine).
It has also been suggested that triggers that cause episodes of flushing and blushing stimulate development of rosacea. Exposure to temperature extremes can cause the face to become flushed—other triggers include strenuous exercise, sunlight, sunburn, stress, and cold wind. Certain food triggers include alcohol, foods and beverages containing caffeine, and spicy food.
Treatment: A gentle skin cleansing regimen is key—with no use of scrubs or exfoliants. A good brand of cleanser is Skinceuticals® Gentle Cleanser (available at our office). Other brands to try are Dove® sensitive skin bar, Purpose® cleanser, and Cetaphil® gentle cleanser. Protection from the sun is imperative and daily use of a sunscreen of a physical blocker with either zinc or titanium will prevent progression of the disease and will not irritate the skin or eyes (we prefer Skinceuticals® Physical 30, also available at our office).
Oral antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defense for pustules, inflammation and some redness. Topical azelaic acid such as Finacea® (15%) may help reduce inflammatory lesions, bumps and papules. Oral antibiotics will help to relieve symptoms of ocular rosacea.
Redness of the skin is possibly the most difficult aspect to treat. Laser treatments offer the most efficacious treatments for the redness. They use light to penetrate the top layers of the skin to target the vessels. The laser’s energy is absorbed by oxy-hemoglobin in the vessels which heats capillary walls, damaging them. Over the next few weeks, the vessels are absorbed by the body. Most patients note a decrease in redness and flushing with the first treatment. With several treatments, this method may even eliminate the redness altogether, though additional periodic treatments will likely be necessary to remove newly-formed capillaries. Unfortunately, this treatment is not covered by insurances and is considered cosmetic and the patient is responsible for the cost of the laser treatment.