Rosacea

Rosacea: Overview

Rosacea is a chronic, acne-like condition that occurs in middle-aged men and women.  Rosacea used to be called "acne rosacea" but it is different from acne.  The red spots and pustules are dome-shaped rather than pointed and there are no blackheads, whiteheads, deep cysts, or lumps.  Rosacea affects the cheeks, nose and forehead – rarely, it involves the trunk and upper limbs. One survey found that:

  • 75% of sufferers have low self-esteem
  • 70% feel embarrassed
  • 69% feel frustrated
  • 56% feel robbed of pleasure/happiness
The image of one famous sufferer, W.  C.  Fields, helped to mistakenly link rosacea with alcoholism.  Although drinking alcohol can make rosacea worse, even people who never drink alcohol can develop rosacea.

Incidence; Causes and Development

Rosacea is three times more common in women, but usually more severe in men.  As at the time of writing (2004) it is thought to affect as many as 13 million Americans.

Rosacea is usually seen in adults in their 30s and 40s.  It seems to affect fair-skinned, blue-eyed people more often, though it can affect any skin type.  Most people who get rosacea have a history of flushing or blushing more easily and more often than the average person (they are sometimes described as having "peaches and cream" complexions).  Women get rosacea a little more often than men, but men are more likely to develop rhinophyma.

The cause of rosacea is unknown, but many factors have been suspected of influencing it: alcoholism, menopausal and other flushing, a tendency towards seborrhea, local infection, B-vitamin deficiencies and gastrointestinal disorders.  Most cases are associated with moderate to severe seborrhea, although in many cases sebum production is not increased.  Flushing is prevalent, and migraine headaches are three times more common amongst sufferers.

Facial flushing can make symptoms worse and even cause flare-ups in patients whose rosacea had been under control.  It is the chronic flushing in rosacea which causes the telangiectasia.  Flushing can be triggered by many things, the most common being hot drinks, alcohol, spicy foods, stress, sunlight and extreme heat or cold.  Other causes of flushing and telangiectasia include heredity, exercise, emotions, hormones, cortisone medications and other rare skin diseases.

Signs and Symptoms

In most people, the first sign of rosacea is rosy cheeks; the face gets red in patches and stays red – eventually redness doesn't go away at all.  Rosacea is a chronic condition.  In most people symptoms come and go in cycles.  These flare-ups are common.  Although the condition may improve (go into remission) for a while without treatment, it is often followed by a worsening of symptoms (redness, pimples, red lines or nasal bumps) that progresses over time.

It typically first appears when people reach their 30s and 40s as a flushing or subtle redness on the cheeks, nose, chin or forehead that comes and goes.  This early stage is often mistaken for a simple complexion problem or sunburn and ignored.  Left untreated, the redness becomes more permanent and tiny blood vessels may become visible.

As the condition progresses, the redness becomes more persistent, bumps and pimples called papules and pustules appear and small dilated blood vessels may become visible.  In some cases the eyes also may be affected, causing them to be irritated and bloodshot.  In advanced cases.  In more advanced cases of rosacea, a condition called rhinophyma may develop.  The oil glands enlarge, causing a bulbous, enlarged red nose and puffy cheeks.  Thick bumps can develop on the lower half of the nose and near to the cheeks.

Women are more likely to experience symptoms on the cheeks and chin while men are more likely to have swelling of the nose (rhinophyma) associated with advanced rosacea.

Early stage:

  • Redness (that comes and goes) appears on cheeks, nose, forehead or chin
  • Tiny blood vessels may become visible on the surface of the skin
  • In some cases, the eyes may feel gritty
Middle stage:
  • Facial redness becomes ruddier and more permanent
  • Bumps and pimples may appear
  • Tiny blood vessels may become increasingly visible
  • In some cases, the eyes may become bloodshot
Advanced stage:
  • Inflammation of the skin grows increasingly severe
  • The nose may become red, bumpy and swollen from excess tissue
  • In some cases, the eyes and surrounding areas may become inflamed, potentially resulting in loss of vision.
Many rosacea patients have only one or two symptoms; here is a detailed list of the most common ones:
  • Redness
    This looks like a blush or sunburn and it is caused by flushing (when a larger amount of blood flows through vessels quickly and the vessels expand under the skin to handle the flow).  The redness gradually becomes more noticeable and will not go away.  Facial skin may get very dry.
  • Pimples
    Later, pimples may appear on the face.  These pimples may be inflamed – small, red and solid (papules) or pus-filled (pustules) like teenage acne.  Because they look alike, rosacea has been called "adult acne" or "acne rosacea." But people with rosacea do not normally have the blackhead or whitehead type of pimples (called comedones) that are usually seen in teenage acne.
  • Red lines
    When people with rosacea flush, the small blood vessels of the face get larger – eventually showing through the skin.  These enlarged blood vessels look like thin red lines on the face, usually on the cheeks.  These lines may be hidden at first by flushing, blushing or redness, but they usually reappear when the redness is cleared up.  Doctors call these lines telangiectasia.
  • Nasal bumps
    When rosacea is not treated, some people – especially men – may eventually get small knobby bumps on the nose.  As more bumps appear, the nose looks swollen.  This condition is called rhinophyma.

Treatment and Prevention

Rosacea can not be cured, but its symptoms can be reduced and its progression arrested through medical treatment and lifestyle modifications.  Because it is a chronic disorder, research has found that sufferers usually must adhere to long-term medical therapy prescribed by physicians to maintain remission.  Another important component to minimizing the effects of rosacea is lifestyle management: moderating or eliminating those lifestyle and environmental factors that may aggravate the condition.

Several medications are available by doctor's prescription.  They control redness and reduce the number of papules and pustules.  Some are applied to the skin (topically) and others are taken by mouth (orally) – different types can be used in combination.  In most cases, it may take several weeks to see results – don't worry.  Once symptoms have cleared, patients may need to continue taking medication to keep rosacea under control.

Controlling the causes of flushing and blushing can help prevent rosacea from getting worse and blood vessels from getting larger.  But once red lines appear, they can only be covered up by makeup or removed by a surgical method.  Surgery can also be used to correct a nose enlarged by rhinophyma.

Keep a diary of flushing episodes and note associated foods, products, activities, medications or other triggering factors.

Statistics from one survey showed that medical therapy improved emotional well-being in 70% of cases, professional interactions in 60% of cases and social life in 57%.

Environment
Sun exposure, hot weather, humidity, cold and wind have all been known to aggravate rosacea for many individuals.  The following are defense strategies you can use:

  • Always protect your face from the sun.  Wear a sunscreen with an SPF (sun-protection factor) of 15 or higher year round.  If necessary, use a formulation developed for children to avoid irritation.  Wear a broad-brimmed hat.  Minimize midday (10am to 2pm) exposure to the sun during summer months.
  • Keep your face cool.  Experts say you should avoid anything that causes flushing.  However, what bothers one person may not cause a problem in another.  Stay in a cool, air-conditioned environment on hot, humid days.  If this is impossible, those affected should sip cold drinks and try not to overexert themselves.  If necessary, chew on ice chips to lower facial temperature or spray the face with cool water.
  • Combat cold by covering your cheeks and nose with a scarf.  In winter, rosacea sufferers also may don a ski mask when participating in outdoor sports or activities, as well as cover up on windy days.  If these conditions aggravate your rosacea, limiting your time outdoors in cold weather may also help.
  • Use a moisturizer daily during cold weather.  This protects against the naturally drying effects of cold and wind.
Stress
Stress ranks high on the list of tripwires for many rosacea sufferers.  However, in a survey of rosacea patients affected by stress, most of those using stress management techniques said they had successfully reduced their flare-ups.  When feeling overwhelmed, try some of the following stress reducers:
  • Take care of your whole self.  Eat healthy, exercise moderately and get the right amount of sleep.  It may also help to cut down on caffeine.
  • When under stress, try deep-breathing exercises.  Inhale and count to 10, then exhale and count to 10.  Repeat this exercise several times.
  • Use visualization techniques.  Sit in a quiet place, close your eyes and visualize a beautiful vacation spot or favorite pleasurable activity or painting to reduce stress.  Hold the image for several minutes to feel its peacefulness and beauty.
  • Stretch out and relax all your muscles.  Relax muscles starting at the top of the head and work down to the toes for a whole-body stress reliever.
Foods and Beverages
Steaming hot soup or coffee, spicy nachos, a glass of wine – no matter how appetizing they sound, these foods and beverages may be a problem for some rosacea sufferers.  Hot liquids may cause flushing.  Spicy foods like oriental mustard sauce or salsa can raise a sweat, and alcoholic beverages may trigger flare-ups in many cases.  These tips will help you select rosacea-friendly meals:
  • Monitor how your rosacea reacts to alcoholic beverages.  Alcoholic beverages often induce flare-ups in rosacea sufferers.  If alcohol aggravates your condition, reduce your intake or avoid alcohol entirely.
  • Avoid "hot" spices such as white and black pepper, paprika, red pepper and cayenne, which are common rosacea tripwires.  Try these flavor substitutes:
    • Chili powder – 2 tsp cumin, 1 tsp oregano.
    • Poultry seasoning – 1/2 tsp sage, 1/2 tsp coriander, 1/4 tsp thyme, 1/8 tsp allspice, 1/8 tsp marjoram.
    • Curry powder – 4 tsp coriander, 2 tsp turmeric, 1 tsp cinnamon, 1 tsp cumin, 1/2 tsp basil or oregano, 1/2 tsp cardamom.
  • Reduce the heat in beverages.  Decreasing the temperature may be all that's necessary to keep enjoying coffee, tea and hot chocolate, for example.  Or try reducing the number of cups you drink from three or four to one or two instead.
  • Identify and avoid any foods that aggravate your individual condition.  Some rosacea sufferers have reported a wide variety of foods that trigger flare-ups in their individual cases.  Examples have included cheese, sour cream, yogurt, citrus fruit, liver, chocolate, vanilla, soy sauce, yeast extract (though bread is OK), vinegar, eggplant, avocados, spinach, broad-leafed beans and pods, and foods high in histamine or niacin.  Taking an antihistamine about two hours before a meal may counter the effects of histamine, while aspirin may reduce the effects of niacin-containing foods in sufferers affected by these substances.
Exercise
While exercise may be part of a healthy lifestyle, it could actually be harmful to rosacea sufferers if it causes their condition to flare up.  Moderation is the key.  And even then, take these precautions:
  • Avoid heavy exertion or high-intensity workouts that cause overheating and bring on flushing.  Replace them with low-intensity exercise routines, which often can be just as effective.
  • Try exercising for shorter, more frequent intervals.  For instance, exercise for 15 minutes three times a day, rather than exercising all at once.
  • When exercising outdoors during warm weather, choose early morning or early evening hours when it's cooler.  No matter what time of day, protect your face from the sun and avoid hot weather exercise.
  • When exercising indoors, make sure the room is well ventilated.  Run a fan, open the window for a breeze or turn on the air conditioning to avoid overheating.
  • Try to stay as cool as possible when exercising.  Drape a cool, damp towel around your neck, drink cold fluids or chew on ice chips.  You can also keep a bottle filled with cool water to spray your face.
Bathing and Cleansing
Rosacea sufferers often must modify their approach to cleansing and bathing.  The following tips can help you adopt a personal-care routine that soothes and calms your facial redness:
  • Avoid hot water, hot tubs and saunas.  These can bring on flushing and aggravate your condition.
  • Begin each day with a thorough and gentle facial cleansing.  Use a gentle cleanser that is not grainy or abrasive and spread it with your fingertips.  Rinse your face with lukewarm water to remove all dirt and soap, and use a thick cotton towel to gently blot the face dry.
  • Never pull, tug, scratch or treat your face harshly.  Avoid any rough washcloths, loofahs, brushes or sponges.
  • Let your face thoroughly air dry before applying any medication or skin-care products.  Let your face rest for a few minutes before applying topical medication.  Then allow the medication to dry completely for five to 10 minutes before applying any moisturizer or makeup.
  • Men should use an electric shaver rather than a blade.  If a blade is preferred, never use a dull blade that requires extra scraping for a clean shave.  Avoid shaving lotions that burn or sting.
  • Repeat the cleansing process at night.  Gently cleanse your face each night to remove any makeup or dirt accumulated throughout the day.  Air dry and apply your topical medication.
Skin Care Products
Rosacea sufferers can use a variety of skin-care products to their advantage.  Moisturizers can reduce flakiness and makeups can camouflage symptoms and improve appearance.  You may have to experiment until you find the products that work best for your individual condition.  Here are some general guidelines that will help you select products carefully:
  • Steer clear of ingredients that sting, burn or cause facial redness.  Some ingredients to avoid include alcohol, witch hazel, menthol, peppermint, eucalyptus oil or clove oil.
  • Select fragrance-free products.  If you must choose a product that contains a fragrance, be sure that it appears at the end of the list of ingredients.  The further down it appears, the less fragrance the product contains.
  • Use makeup to hide blemishes and cover redness.  Spot application of makeup may be used to cover blemishes and visible blood vessels, and green-tinted prefoundations are available at most cosmetic counters to mask general redness.  They can be followed by a skin-tone foundation.  Avoid powders, which can make dry flaky skin look worse.
Pre-existing Medical Conditions
Physicians have found that some underlying health conditions and temporary ailments can stimulate a flushing response and trigger rosacea flare-ups.  The following conditions should be ruled out or treated by your doctor as appropriate to help bring flare-ups under control:
  • Hot flashes associated with menopause.  The hot flashes that often occur before or during menopause have brought on rosacea's first appearance in some women.
  • Fevers, coughs and colds.  Although intermittent, these ills may provoke the flushing that begins a rosacea flare-up.
  • Systemic diseases.  Occasionally systemic diseases, such as high blood pressure, have been identified as causes of rosacea flare-ups.  When flushing is accompanied by itching, breathing difficulties or diarrhea, seek medical attention.
Drugs
Certain drugs can cause facial flushing, resulting in rosacea flare-ups.  If you experience flare-ups as a result of the following drugs, discuss the problem with your doctor:
  • Vasodilator drugs.  These drugs are used in the treatment of cardiovascular disease because of their ability to dilate the blood vessels.  In some patients, they have been reported to cause symptoms called "vasodilator rosacea."
  • Topical steroids.  Long-term use of topical steroids has been found to aggravate rosacea or induce rosacea-like symptoms.  In one study, symptoms improved for patients who discontinued the steroids and were prescribed antibiotics.
Psychosocial Aspects
The conspicuous redness, blemishes and swelling caused by rosacea can take a significant toll on an individual's emotional health.  You may find your self-confidence and self-esteem are suffering as a result of your appearance, but you can turn the situation around by taking appropriate action to bring your rosacea symptoms under control.

The first step is to accept that you have a medical condition, rather than denying it.  Although rosacea is not life threatening, it is usually a chronic disorder of flare-ups and remissions that becomes increasingly severe without long-term therapy.  Although this fact cannot be changed, you can personally take control of your condition and restore your appearance by complying with long-term medical treatment and avoiding those lifestyle factors that aggravate your individual case.

The good news is that emotional health generally returns when rosacea symptoms are successfully addressed.  70% of rosacea sufferers responding to a National Rosacea Society survey said their emotional well-being improved when their rosacea was effectively treated, and most also reported improvement in their professional interactions and social lives.

It also may help you to know that you are not alone.  An estimated 13 million or more Americans suffer from rosacea, although many may not be fortunate enough to realize it and seek treatment.

If you find yourself the object of stares or comments during a flare-up, try turning this awkward situation into a positive educational opportunity by openly discussing your rosacea and educating the offender.  Recognize that most individuals are unaware of rosacea, so take into account that most reactions are simply caused by curiosity and ignorance of the disease, rather than some negative intent.

Take the initiative for explaining the condition to people you see regularly – especially your employer and co-workers, who may have real concerns about whether the condition will affect your job performance or their own health.  Put to rest the common misconceptions that rosacea's symptoms are caused by poor hygiene or excessive drinking, or that the disorder may be contagious.  Pass along educational materials on rosacea if appropriate.

Through this approach, you can turn potentially negative situations into constructive opportunities to create understanding.

Living with Rosacea
Millions of people suffer from rosacea, yet increasing numbers of sufferers have achieved substantial control over their disorder.  The best defense in conquering rosacea is to comply with long-term medical therapy and minimize lifestyle factors that aggravate your individual condition.  Through these strategies, rosacea can be managed successfully.

Prognosis; Seek medical attention if...

Without regular treatment, redness and pimples can return.  Studies of patients who stopped treatment after their symptoms were successfully cleared show that rosacea came back in many of the patients within a week to 6 months.

Individuals who suspect they may have rosacea are urged to see a dermatologist for diagnosis and treatment.  It is easy to mistake skin disorders and doctors know best how to identify and treat rosacea.

Signs, symptoms & indicators of Rosacea:

Symptoms - Head - Eyes/Ocular

Irritated eyes is often a sign or symptom of Rosacea Irritated eyes

Red, sore or 'gritty' eyelids are sometimes caused by rosacea.  Ocular manifestations may include many different eye problems and may precede skin involvement, thus delaying the diagnosis of rosacea.

Symptoms - Head - Nose

An/a very enlarged nose is often a sign or symptom of Rosacea An/a very enlarged nose

Rosacea may cause the nose to slowly enlarge.  When rosacea is not treated, some people – especially men – may eventually get small knobby bumps on the nose.  As more bumps appear, the nose looks swollen.

Symptoms - Nervous

Symptoms - Skin - Conditions

Symptoms - Skin - General

Facial flushing is often a sign or symptom of Rosacea Facial flushing

Rosacea is often accompanied by a red face due to flushing.  Sometimes the affected skin is swollen and hot.

Counter-indicators
Counter-indicators

Conditions that suggest Rosacea:

Metabolic

Symptoms - Skin - Conditions

Counter-indicators

Risk factors for Rosacea:

Infections

Helicobacter Pylori Infection may increase risk of Rosacea Helicobacter Pylori Infection

A high incidence of Helicobacter pylori infection in the stomach has been found amongst rosacea patients.

Supplements and Medications

Minor/moderate/major steroid use may increase risk of Rosacea Minor/moderate/major steroid use

If you are using or have used steroid drugs, you may have 'steroid rosacea', a rosacea-like condition on the face caused by potent topical steroids.  After several weeks of applying a topical steroid to the eyelids, cheeks or chin the affected area becomes red.  Small papules (bumps) and pustules appear intermittently, and may be especially severe when the topical steroid cream is discontinued.  If the steroid creams are used for months or years, broken capillaries (telangiectasia) may develop.

A similar condition can arise in other areas treated with topical steroids, particularly the groin and genitals where the absorption of the steroid through the skin is higher.  Occasionally steroid rosacea is confused with tinea faciei incognito, a fungal infection masked by topical steroids.

Rosacea suggests the following may be present:

Infections

Rosacea suggests Helicobacter Pylori Infection Helicobacter Pylori Infection

A high incidence of Helicobacter pylori infection in the stomach has been found amongst rosacea patients.

Rosacea can lead to:

Metabolic

Recommendations for Rosacea:

Diet

Caffeine/Coffee Avoidance often helps with Rosacea Caffeine/Coffee Avoidance

Avoid coffee, alcohol, hot beverages, spicy foods and any other food or drink that causes flushing.

Spicy Foods Avoidance often helps with Rosacea Spicy Foods Avoidance

A 2003 survey by the National Rosacea Society has identified a broad range of hot spicy foods that often trigger or aggravate Rosacea.  In the survey of more than 500 rosacea patients, published in Rosacea Review, 61% of those affected by spicy foods listed hot peppers as a trigger for their rosacea signs and symptoms; 52% listed Mexican-style foods; 47% chili and 46% salsa.

Digestion

Digestive Enzyme (Trial) is highly recommended for Rosacea Digestive Enzyme (Trial)

Rosacea patients often have a reduced secretion of pancreatic lipase, an enzyme which aids in fat digestion.  Pancreatic or plant enzyme supplementation, especially when prepared with extra lipase, will improve this digestive weakness.

Hydrochloric Acid (Trial) may help with Rosacea Hydrochloric Acid (Trial)

Gastric analysis of rosacea patients has led to the theory that it may be the result of hypochlorhydriaHCL supplementation results in marked improvement in rosacea patients who have achlorhydria or hypochlorhydria.

Hormone

Not recommended
Hydrocortisone is sometimes not recommended for Rosacea Hydrocortisone

Never apply a topical steroid like cortisone to rosacea unless directed to do so by your doctor for a specific reason.  Cortisone treatments can worsen rosacea over the long term and make it even more resistant to treatment.

Lab Tests/Rule-Outs

Test for Food Allergies often helps with Rosacea Test for Food Allergies

The incidence of migraine headaches and flushing accompanying rosacea points to some form of food intolerance.

Mineral

Skin

Not recommended
Cosmetics / Moisturizers is often not recommended for Rosacea Cosmetics / Moisturizers

Avoid oil-based facial creams.  Use a water-based make-up and sunscreen.  The skin may be very sensitive to local applications.

Vitamins

Vitamin B-Complex often helps with Rosacea Vitamin B-Complex

The administration of large doses of B-vitamins has been shown to be effective, riboflavin being the most important.  While B-vitamins are important, some rosacea patients may be aggravated by large dosages of these nutrients.

KEY

Weak or unproven link: may suggest; may increase risk of
Weak or unproven link:
may suggest; may increase risk of
Strong or generally accepted link: is often a sign or symptom of; often leads to
Strong or generally accepted link:
is often a sign or symptom of; often leads to
Definite or direct link: is a sign or symptom of; strongly suggests
Definite or direct link:
is a sign or symptom of; strongly suggests
Strong counter-indication: often contraindicates
Strong counter-indication:
often contraindicates
Definitely or absolutely counter-indicates: strongly contraindicates
Definitely or absolutely counter-indicates:
strongly contraindicates
May be useful: may help with
May be useful:
may help with
Moderately useful: often helps with
Moderately useful:
often helps with
Very useful: is highly recommended for
Very useful:
is highly recommended for
Caution: is sometimes not recommended for
Caution:
is sometimes not recommended for
Often counterindicated: is often not recommended for
Often counterindicated:
is often not recommended for