Some people will blush easily when faced with an embarrassing situation, but others seem to be almost continually flushed. Men and women who develop a chronic redness in their face, and sometimes red bumps and visible blood vessels, are likely to be among the 14 million Americans with the skin condition rosacea. While the cause of rosacea is not well understood, it is theorized that it is due to factors such as sensitive blood vessels, inflammation and possibly infection.
James Del Rosso, DO, a dermatologist in private practice at the Las Vegas Skin and Cancer Clinic and a clinical assistant professor in the department of dermatology at the University of Nevada School of Medicine, emphasizes that avoiding one's personal triggers for rosacea flare-ups, as well as a commitment to a treatment plan, is key in successfully controlling this chronic condition. Below, Dr. Del Rosso explains how to care for skin affected by this commonly misunderstood condition.
What is rosacea?
Rosacea is a very common condition that predominantly affects the face. It's characterized by the development of redness, which is usually on the cheek, though it could be on the forehead and the chin area and the nose. Patients will notice a fluctuating redness. Some will have more of a tendency to flush than others. It's not uncommon for the redness to be associated with some red bumps, similar to what you would see in acne, and also some pus-filled bumps. It's also common for patients to develop little, thin, visible red blood vessels on their skin; they develop more of these than they would develop normally with age.
In some individuals with rosacea, the nose will become very bulbous. That's actually fairly uncommon and it only occurs in a small subset of men. This bulbous nose has been talked about as the W.C. Fields nose. That's why people equated rosacea with being caused by alcohol, but the bulbous nose is not caused by alcohol. Alcohol is only a flare factor.
Rosacea is not a condition that is curable, but there are ways that you can try to control the severity of it: the intensity and frequency of the flare-ups and the associated symptoms, which include a feeling of warmth, burning, stinging and skin that is easily irritated.
Who gets rosacea?
Rosacea usually develops after the teenage years, probably after 30, but it could also develop later. It tends to be more common in Caucasians, especially very fair-skinned Caucasians that are of Northern European origin such as people from Ireland, England, Scandinavia, Celtic origins, though it can affect anyone.
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I think it's relatively equally distributed between women and men, though there is some suggestion that it may be a little bit more common in women. That may be because more women come in to the doctor even if they have a milder rosacea, whereas not as many men are as bothered by the milder cases. But many men and many women want to improve their condition.
Does rosacea affect other parts of the body?
It's not uncommon for individuals with rosacea on the skin to also have what's called ocular rosacea because there's an inflammatory process that's going on in the skin that also affects the eye. Many patients that have rosacea will have a gritty sensation in their eyes. Their eyes will be easily irritated and sensitive, and they may have some redness of their eyelids.
People will sometimes think that they have allergies or something else that they don't correlate with their skin condition. So when they go in to see someone for their skin, they don't tell them about their eye symptoms. And, if they're not asked, the diagnosis will be missed, and they will miss out on the appropriate treatment.
What can trigger or worsen rosacea?
Anything that causes the blood vessels in the skin to dilate will tend to cause flares of rosacea. That includes anything that creates a lot of heat, such as drinking hot liquids, eating hot foods and drinking alcoholic beverages, especially red wines. Medications that dilate the skin like niacin, which is a vitamin, can also cause flushing. Rosacea can sometimes worsen with menopause because flushing is a part of menopause. Ultraviolet light exposure, whether from the sun or tanning beds, will worsen rosacea and make it more difficult to control.
What is a good treatment approach?
The first thing to do in treatment is to make sure you understand your condition. There is no quick fix. People will have rosacea for their entire life, so they will need treatment indefinitely.
One of the first things in treating rosacea is for the individual to address what they think might be flaring it. If someone wants to have two glasses of wine a day, and if that's a flare factor for them, then they are accepting that they are going to worsen their rosacea.
The second part of treatment is gentle skin care. It's very important that patients with rosacea not run to pharmacies or department stores and buy the expensive XYZ product that's being promoted. They need to use gentle skin care products, and those are best selected by a dermatologist or a professional at the dermatologist's office. They need to cleanse very gently, not use astringents, drying-type products or products with a lot of additives like glycolic acid, which will further irritate their skin.
What medications are used to treat rosacea?
The next step is for the dermatologist to select the best medications for the patient. Depending on the severity, it may only be one or a few topical medications. They are not cures, but if they are used in a compliant fashion, the patient should expect considerable improvement over a period of one to three months of compliant use. If they're noncompliant, patients should expect not as optimal results.
There are three main initial topical medications, which will typically be used if the patient has milder to moderate disease. Topical metronidazole has been been around for a long time. The newest on the market is topical azelaic acid. Another group of products are the sulfacetamide sulfur formulations, which include cleansers and a variety of different leave-on formulations that are applied to the skin.
If the patient has more severe disease, the dermatologist will typically use one or more of those topical products and an oral medication, usually an oral tetracycline antibiotic. The tetracycline antibiotics have distinct anti-inflammatory properties that have absolutely nothing to do with their antibiotic effect. The antibiotics will be used for a period of time to get the disease under control, and then they'll try to get the patient down to just the topical program for long-term maintenance.
When is laser treatment appropriate?
After you determine the individual's response to medical treatment, depending on what's left behind—a persistent rouge-type redness or a significant number of the linear blood vessels—people may choose what we call the physical modalities, and that includes specific types of lasers or intense pulse light.
Are there any treatments in the pipeline?
One drug that's being investigated is a sub-antimicrobial dose of doxycycline. Doxycycline is a tetracycline that behaves as an antibiotic if you give it above a certain dose, but a lower dose has no antibiotic activity. So there's no problem with antibiotic resistance, but a low dose has anti-inflammatory effects, so that has been shown to be helpful in rosacea and is currently under evaluation.
What are common mistakes that people with rosacea make?
They get better and then they get lax. Treatment requires a commitment to use the topical therapy every day. The other thing is that some patients try to pick out miracle cures. People have to remember that "natural" does not mean better. Arsenic is a natural product too. If people come across something that they think might be beneficial, rather than just use it on their own and sabotage their program, they should bring it to the attention of their doctor.
The other thing that people should avoid is cortisone cream. Topical cortisones may cause an initial improvement, but they can actually create a much more severe rosacea that's much more difficult to control. One of the side effects of cortisone, in fact, is the production of persistent redness, dilated blood vessels, thinning of the skin and a rosacea-like eruption.
What is your advice to someone with rosacea?
If a patient has what they believe to be rosacea, they should seek the care of a dermatologist, write down their symptoms, write down the products that they are currently using on their skin and embark on what is selected as an appropriate skin care program and treatment program and follow it through, realizing that it may take two to three months to evaluate the initial benefits. It may take a few adjustments in their treatment until they get control of the condition, and then they need to follow through on the long-term maintenance of the condition.
