More Than Skin Deep Rosacea

By Valerie Carlberg, BS, and Anna A. Bar, MD
Oregon Health and Science University

What Is Rosacea?

Rosacea (pronounced “roh-zay-sha”) is a common facial skin disorder with a characteristic flushing that comes and goes on the nose, cheeks, chin, or forehead. Considered one of the most common skin disorders, rosacea affects an estimated 14 million American men and women.1

It is most common in fair-skinned individuals, particularly those of northern European decent, but it also affects Asians and African Americans.2 Although rosacea may occur at any age, most individuals experience symptoms beginning around age 30, with peak severity occurring between 30 and 60.1,2 Women tend to be diagnosed more often than men, yet men often develop more-severe symptoms as a result of delayed diagnosis and treatment. Left untreated, flushing may become permanent, and small bumps—sometimes filled with pus—or visible blood vessels may appear. In more-severe cases, the skin on the nose may become thickened due to repeated swelling and inflammation. Severe rosacea may also affect the eyes.

Combined or alone, these symptoms may cause distress to affected individuals, and a recent survey by the National Rosacea Society found that nearly 70 percent of rosacea patients had lowered self-esteem as a result of the disorder.1 Despite an unclear understanding of the cause and the progression of rosacea, numerous lifestyle modifications and medical therapies are available, and these treatments have been shown to greatly improve physical, social, and emotional well-being.1

What Are the Symptoms of Rosacea, and How Is It Diagnosed?

Individuals with rosacea often experience one or more of the following signs or symptoms:

Flushing that comes and goes

Persistent redness, small bumps (papules), and pimples (pustules)

Visible blood vessels (“spider veins” or telangiectasias)3

Patients may notice that these symptoms are provoked by certain foods, by temperature, or by stress, which may cause an inflammatory reaction affecting the face. In some cases the small bumps may contain pus (pustules) and can be confused with adult-onset acne. Unlike acne, however, rosacea is not associated with blackheads (comedones).

Some individuals experience facial burning, stinging, swelling, eye irritation, dry skin, or skin thickening. Additionally, symptoms may spread to the ears, chest, and back. Because each person may experience a combination of these signs and symptoms, the National Rosacea Society Expert Committee created staging criteria to categorize and diagnose four subtypes of rosacea:

Vascular rosacea is generally the earliest stage recognized and is characterized by a recurrent blush that becomes longer lasting and eventually permanent.3 Small blood vessels may become visible, and swelling may also occur around the nose and the cheeks.

Papulopustular rosacea involves a central swelling of the face and breakouts consisting of small bumps and pimples.

Phymatous rosacea causes the skin to thicken due to sebaceous gland inflammation and excess tissue formation. Phymatous rosacea affecting the nose leads to a bulbous appearance. Phymatous rosacea usually occurs later in the course of the disorder and is more typical in men, often as the result of delayed treatment.

Ocular rosacea3 is associated with watery, dry, or bloodshot eyes; burning, swollen eyelids (sties); blurred vision; and light sensitivity. Ocular rosacea may occur with or without the symptoms of flushing.

A variant of rosacea, known as granulomatous rosacea, is characterized by hard brown, yellow, or red bumps of uniform size. It is not associated with the inflammatory symptoms previously described.2 Individuals may experience one or a combination of symptoms, progressing from mild to moderate to severe. Ideally, to slow the progression and to prevent more-severe skin and eye complications, individuals should seek treatment when the first signs of rosacea appear.

Treatment

Rosacea is a chronic condition that persists for the duration of an individual’s life. Although the cause is not well understood, many physicians and scientists agree that blood vessel hypersensitivity plays a role in the disorder.2 Triggers of the immune system may also worsen symptoms. While there is no cure for rosacea, the condition can be controlled, and affected individuals should be reassured that lifestyle modifications and medical treatments can reduce and sometimes reverse symptoms. Most importantly, people with rosacea should seek the help of a dermatologist or other knowledgeable physician as soon as signs appear, as home remedies can often worsen symptoms.

Because every individual is sensitive to different stimuli, personal identification and avoidance of triggers are the first steps in managing the disorder. For mild symptoms green-tinted makeup can help conceal small blood vessels that play a role in blushing. For bumps and pimples, medications may be most effective. Fortunately, both topical medications and oral treatments have been approved by the Food and Drug Administration and in existence for more than 30 years.2 A combination of topical antibiotics, topical anti-inflammatory medications, and oral antibiotics are initially used to treat breakouts, with continuation of topical antibiotics for long-term therapy.

For persistent ruddy complexions or visible blood vessels that do not respond to topical or oral treatments, pulsed dye laser therapy is a safe and effective therapeutic option.2 The treatment uses a pulsed dye laser at a wavelength of 595 nanometers, which can safely target blood vessels without damaging surrounding tissue. Skin thickening of the nose that occurs with rhinophyma can also be treated with electrocautery and CO2 laser, used to vaporize excess superficial skin while stimulating new collagen production.2 These combined therapies can help recontour the nose.

For More Information

Although rosacea is a chronic disorder, current therapies may help alleviate symptoms and manage the condition. For more information, visit the National Society of Rosacea website at www.rosacea.org or consult a dermatologist.

References

What Is Rosacea? National Rosacea Society website: Available at http://www.rosacea.org/index.php. Accessed January 10, 2011.

Webster GF. Rosacea and Related Disorders. In Bolognia JL, Jorizzo JL, Rapini RP, eds. Dermatology, Vol 1. New York: Elsevier; 2003:545-51.

Wilkin J, Dahl M, Detmar M, 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.