Rosacea is a chronic relapsing disease of the facial skin. It is characterised by recurrent episodes of facial flushing with persistent erythema, telangiectasia, papules and pustules. Ocular rosacea is usually bilateral and causes a foreign-body sensation.
- A characteristic feature is flushing that may have a number of triggers.
- It is a chronic acneform disorder of the facial pilosebaceous glands with an increased reactivity of capillaries to heat, causing flushing and eventually telangiectasia.
- Rhinophyma is an enlarged nose associated with rosacea which occurs almost exclusively in men.
- The actual aetiology of the disease is unknown.
- Recent molecular studies propose that an altered innate immune response is involved in the pathogenesis of the rosacea disease.
- Histologically, dilated lymphatics and blood vessels, as well as perivascular infiltration of CD4+ helper T cells, macrophages and mast cells can be readily seen.
- Medications which can cause a recurrence include amiodarone, topical steroids, nasal steroids and vitamins B6 and B12.
- Recent research has highlighted the importance of skin-environmental interactions. The impairment of the skin barrier function and the activation of the innate immune defences are major and connected pathways contributing to an ongoing inflammatory response in the affected skin.This becomes modulated by endogenous factors like neurovascular, drugs, and also by psychological issues.
- There has been a long debate on the role of Demodex mites (which usually inhabit human hair follicles) in rosacea. The prevalence of Demodex mites in rosacea patients has been estimated to be as high as 60% (clinically) and 80% (in skin biopsies).However, increased Demodex density in rosacea is considered to be an aggravating factor but not a causative one.
- The prevalence of rosacea is highest among Indo-Eurasians.In Europe, there is an increasing prevalence from South to North: in Germany prevalence is 2.2%, in Sweden 10% and in Estonia 22%.
- Rosacea is primarily a condition of the white population, is three times more common in women than in men and has a peak age of onset between 30 and 60 years.
- For a diagnosis to be confirmed the erythema should have been present for at least three months.
- Patients usually complain of the skin condition but direct enquiry may often reveal a long history of flushing back to early teens or before.
- The symptoms are initially intermittent but progress to a constant flushing with obvious telangiectasia.
- A few complain of gritty eyes and facial oedema.
The disease tends to be progressive but that does not mean that everyone will develop all features.
- The skin is not greasy as in acne and may be rather dry.
- Erythema and telangiectasias over the forehead and cheeks are variable.
- Although the usual areas affected are the nose, cheeks and forehead, other areas, such as the neck, chest and ears, can become involved.
- Sebaceous glands are prominent.
- The nose may be enlarged and distorted by rhinophyma.
- There may be peri-orbital oedema.
The image below shows rosacea on the face - note the marked telangiectasia:
The image below shows rosacea on forehead - note the acne-like comedones on the red telangiectasia:
Rosacea is usually classified into one of four types, each having a different presentation:
- Papulopustular rosacea (PPR) is the classical presentation. Patients are typically middle-aged women with a red central portion of their face that contains small erythematous papules surmounted by pinpoint pustules. They may have flushing. Telangiectasias are often present but may be difficult to distinguish from the erythematous background in which they exist.
- Phymatous rosacea shows marked skin thickenings and irregular surface nodularities of the nose, chin, forehead, one or both ears and/or the eyelids. There are four histological types of rhinophyma that include glandular, fibrous, fibroangiomatous and actinic.
- Ocular rosacea may precede the cutaneous form by years but often they develop together. The ocular signs include blepharitis, conjunctivitis, inflammation of the lids and meibomian glands, interpalpebral conjunctival hyperaemia and conjunctival telangiectasia. There may be stinging or burning of the eyes, dryness, irritation with light, or foreign body sensation. This may sometimes be confused with blepharitis.
- Erythematotelangiectatic rosacea shows central facial flushing, often with burning, stinging or itching. The redness usually spares around the eyes. They usually have skin with a fine texture that lacks a sebaceous quality typical of other types. The erythematous areas of the face at times appear rough with scale likely due to chronic, low-grade dermatitis. The burning or stinging is exacerbated when topical treatments are applied. The flushing often progresses to a permanent erythema and telangiectasias over the affected areas.
Causes of flushing are many and include:
- Heat or changes in temperature.
- Spicy foods.
- Stress or embarrassment.
- Sun or wind.
- Medication that causes vasodilatation.
- Acne vulgaris, especially if it presents early in life. However, there are usually no comedones in people with rosacea. In addition, rosacea also tends to worsen with ultraviolet light, whereas acne tends to improve.
- Seborrhoeic dermatitis which is more likely to cause flaking and dryness of the skin. It can co-exist with rosacea though.
- Perioral dermatitis from use of potent steroids on the face.
- Systemic lupus erythematosus or discoid lupus erythematosus.
- Polymyositis and dermatomyositis.
- Photosensitive eruptions.
- Rhinophyma may resemble lupus pernio from sarcoidosis.
- Especially when flushes start in a woman aged around 50, hot flushes may suggest the menopause.
- Ophthalmic symptoms may not be recognised as part of the disease although they occur to some extent in over 50%.
In all types of rosacea the diagnosis is usually made clinically after taking a history and examining the patient. Many patients only have mild symptoms and do not actually consult their doctor. A history of flushing preceding onset of the erythema and an association with triggers can be helpful.
Where the diagnosis is in doubt a skin biopsy can be helpful; however, this is unnecessary in most cases.
Treatment of rosacea depends on the severity and type of rosacea present. Although rosacea's impact on physical health is limited, it has profound effects on a person's psychological well-being.Therefore, treating rosacea can greatly affect a person's quality of life. Although there are numerous treatments available, none of these is completely curative.
- Reassure patients of the benign nature of the condition and the relative rarity of any complications (including development of rhinophyma).
- Avoid precipitating or aggravating factors for their trigger factors of flushing.
- Facial massage may reduce oedema.
- Sunscreens should be applied daily.
- Avoid astringents, toners, menthols, camphor, waterproof cosmetics requiring solvents to be removed, or products containing sodium lauryl sulfate.
- Judicious use of cosmetics may improve appearance significantly and, in doing so, greatly reduce distress. If the skin is dry use emollients (hypoallergenic and non-comedogenic emollient creams).
- Avoid topical steroids.
- Mild-to-moderate rosacea should be treated with a topical preparation.
- Topical metronidazole 0.75% is a common first-line option.
- Azelaic acid 15% gel is an alternative, especially in those with more inflammatory rosacea. It may be more effective but can cause sensitivity reactions in some patients.
- Moderate-to-severe papulopustular rosacea usually requires oral antibiotics. These are thought to act by virtue of their anti-inflammatory rather than antimicrobial action.
- Commonly used preparations are oxytetracycline 500 mg bd, lymecycline 408 mg od or doxycycline 40 mg od.
- Erythromycin 500 mg bd can be given as an alternative.
- There is some evidence that oral doxycycline as well as minocycline with topical azelaic acid or topical metronidazole leads to substantial improvements in inflammatory lesion counts compared to monotherapy.
- Isotretinoin is occasionally used for refractory cases.
- Ivermectin 1% is a topical cream which acts by binding selectively to glutamate-gated chloride ion channels that are present in invertebrate (but not mammalian) nerve and muscle cells. It causes parasite death by enhancing cell membrane permeability. In addition to killing the Dermodex mites, ivermectin displays antimicrobial, antibacterial, and anti-inflammatory activities.
- Ivermectin 1% cream has been demonstrated to be significantly superior to metronidazole 0·75% cream and has achieved high patient satisfaction.
- Brimonidine is a novel therapeutic agent targeting the facial flushing and erythema of rosacea through its alpha-2 adrenergic receptor agonist activity.
- Once-daily brimonidine gel 0.5% has a good safety profile and has been demonstrated to provide significantly greater efficacy relative to vehicle gel for the treatment of moderate-to-severe erythema of rosacea, as early as 30 minutes after application.
- However, rebound erythema secondary to use of brimonidine can occasionally occur.
- A Cochrane review of treatments for rosacea has summarised that there is high-quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate-quality evidence is available for topical metronidazole and oral tetracycline. There is low-quality evidence for low-dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea.
- Laser treatment can obliterate telangiectasia.
- Rhinophyma responds poorly to medical treatment and surgery is usually required. Several options are available, including mechanical dermabrasion, carbon dioxide laser peel and various surgical techniques.
- Camouflage treatments (available via The Red Cross) can be really effective.
- Patients with ocular rosacea should undertake regular lid hygeine (as in the treatment of blepharitis) using diluted baby shampoo (diluted 1:10 in warm water) and a cotton bud with warm compress.
- Artificial tears should be used at frequent intervals.
- Systemic tetracyclines are an effective treatment for ocular rosacea.
- Retinoids should be avoided in these patients. Retinoids can worsen their symptoms and lead to severe keratitis.
- If the patient is currently using topical corticosteroids on the face, these must be stopped.
- Persistent symptoms that are causing psychological or social distress.
- Papulopustular rosacea that has not responded to 12 weeks of oral plus topical treatment.
- Uncertain diagnosis.
- Severe phymatous disease.
- Prominent rhinophyma.
- Ocular symptoms are severe.
- Ocular symptoms fail to respond to maximal treatment in primary care.
- Suspected keratitis when there is eye pain, blurred vision or sensitivity to light.
Rosacea has a variable duration and prognosis. It is usually a chronic disease, punctuated by episodes of acute inflammation. There is no cure.
As mentioned above, there is a common misconception associating rhinophyma with excessive alcohol consumption. In William Shakespeare's Henry IV, Part 2, Bardolph has become Sir John Falstaff's corporal as well as his friend. He is described as 'an arrant malmsey-nose knave' since his nose is red, supposedly from too much wine. Other traditional terms have included 'brandy nose' and 'rum nose'.
Further reading and references
Rosacea – Primary Care Treatment Pathway; Primary Care Dermatological Society (2016)
Tuzun Y, Wolf R, Kutlubay Z, et al; Rosacea and rhinophyma. Clin Dermatol. 2014 Jan-Feb32(1):35-46. doi: 10.1016/j.clindermatol.2013.05.024.
Weinkle AP, Doktor V, Emer J; Update on the management of rosacea. Clin Cosmet Investig Dermatol. 2015 Apr 78:159-77. doi: 10.2147/CCID.S58940. eCollection 2015.
Two AM, Wu W, Gallo RL, et al; Rosacea: Part II. Topical and systemic therapies in the treatment of rosacea. J Am Acad Dermatol. 2015 May72(5):761-770. doi: 10.1016/j.jaad.2014.08.027.
Rios-Yuil JM, Mercadillo-Perez P; Evaluation of Demodex folliculorum as a Risk Factor for the Diagnosis of Rosacea In Skin Biopsies. Mexico's General Hospital (1975-2010). Indian J Dermatol. 2013 Mar58(2):157. doi: 10.4103/0019-5154.108069.
Holmes AD; Potential role of microorganisms in the pathogenesis of rosacea. J Am Acad Dermatol. 2013 Dec69(6):1025-32. doi: 10.1016/j.jaad.2013.08.006. Epub 2013 Sep 5.
Wollina U, Verma SB; Rosacea and rhinophyma: not curse of the Celts but Indo Eurasians. J Cosmet Dermatol. 2009 Sep8(3):234-5. doi: 10.1111/j.1473-2165.2009.00456.x.
Wollina U; Recent advances in the understanding and management of rosacea. F1000Prime Rep. 2014 Jul 86:50. doi: 10.12703/P6-50. eCollection 2014.
Rosacea; UK Primary Care Dermatology Society (2014)
Abokwidir M, Fleischer AB; An emerging treatment: Topical ivermectin for papulopustular rosacea. J Dermatolog Treat. 2015 Jan 30:1-2.
Taieb A, Ortonne JP, Ruzicka T, et al; Superiority of ivermectin 1% cream over metronidazole 0.75% cream in treating inflammatory lesions of rosacea: a randomized, investigator-blinded trial. Br J Dermatol. 2015 Apr172(4):1103-10. doi: 10.1111/bjd.13408. Epub 2015 Feb 11.
Tong LX, Moore AY; Brimonidine tartrate for the treatment of facial flushing and erythema in rosacea. Expert Rev Clin Pharmacol. 2014 Sep7(5):567-77. doi: 10.1586/17512433.2014.945910. Epub 2014 Aug 4.
Fowler J Jr, Jackson M, Moore A, et al; Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013 Jun 112(6):650-6.
Werner K, Kobayashi TT; Dermatitis medicamentosa: severe rebound erythema secondary to topical brimonidine in rosacea. Dermatol Online J. 2015 Jan 121(3). pii: 13030/qt93n0n7pp.
van Zuuren EJ, Fedorowicz Z, Carter B, et al; Interventions for rosacea. Cochrane Database Syst Rev. 2015 Apr 284:CD003262. doi: 10.1002/14651858.CD003262.pub5.
Ferneini EM, Banki M, Paletta F, et al; Surgical management of rhinophyma: a case report and review of literature. Conn Med. 2014 Mar78(3):159-60.
Curnier A, Choudhary S; Rhinophyma: dispelling the myths. Plast Reconstr Surg. 2004 Aug114(2):351-4.
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