Rosacea

Symptoms Of Rosacea

The symptoms of rosacea are complex. The appearance and pattern of symptoms vary among individuals. The symptoms often cycle between occurrence and remission when the individual does not experience any symptoms.

The condition usually affects the face but other body parts such as sides of the face, ears, neck, scalp and chest can also be involved.

The symptoms progress from having red skin of the nose and cheeks to long lasting redness. These symptoms often lead to the appearance of a rash and small blood vessels beneath the skin.
 

Because of the complexity of signs and symptoms, the condition is divided into 4 subtypes. Individuals can have more than one subtype at the same time. The treatment approaches of every subtype are different.
 

1. Subtype 1: Erythemato-telangiectatic rosacea (ETR)

This subtype usually affects the face. Individuals with this subtype have very sensitive skin. The classical symptoms include:

• Persistent redness of the central face 

• Telangiectasia (visible blood vessels on the face)

• Stinging and burning sensation on the skin

• Dry skin

• Swollen skin

• Scaling 

• Tendency to blush more easily 

• Increased sensitivity to skin

2. Subtype 2: Papulopustular rosacea

The most common symptom of this subtype is the appearance of acne like breakouts. The spots resemble acne but there are no blackheads and white-heads. The breakouts do not remain permanently and usually come and go. This type is more common in middle aged females.

Most of the symptoms are the same as type 1. The other distinguishing symptoms include: 

• Papules (solid raised spots on the skin)

• Pustules (small, inflamed pus filled lesions on the skin)

• Plaques (raised scaly patches on the skin)

• Oily skin

3. Subtype 3: Phymatous rosacea

This subtype primarily affects the nose but may also involve chin, forehead, ears, and eyelids. It is mainly characterized by the thickening of skin.

This subtype is rare and include the following symptoms: 

• Bumpy texture of the skin

• Larger pores on the skin

• Oily skin

• Thickened skin on the chin, forehead, cheeks and ears

• Rhinophyma (thickening of the skin of the nose)

4. Subtype 4: Ocular rosacea

This subtype affects the eye and individual can have one or more of the following symptoms:

• Bloodshot or watery appearance

• Feeling of having sand in the eyes

• Burning/stinging sensation in the eyes

• Dry eyes

• Itching in the eyes

• Increased sensitivity to light

• Blurred vision

• Visible broken blood vessels on an eyelid

• Cyst on the eyelid

Causes Of Rosacea

The exact cause of rosacea is not known. While the causes of inflammation are not fully understood, the following theories have been postulated:

1. Genes

Some theories suggest the role of genes in developing rosacea and making some individuals more prone to skin inflammation.

2. Alterations in immunity (first line of defense)

Our body has a natural immunity against disease causing microbes. This immunity is provided by specific chemicals, which are released after stimulation of receptors present on the skin.

Individuals with rosacea have an increased expression of these receptors, leading to elevated levels of specific chemicals which trigger skin inflammation even in the absence of any microbes. 

3. Ultraviolet  (UV) light

Both UVA and UVB light contribute to the development of rosacea by triggering the inflammatory cascade mentioned above. 

4. Abnormalities in the blood vessels

Triggers such as sun rays may be responsible for the degeneration of the elastic tissue of the skin and dilation of blood vessels of the face. This may cause rosacea symptoms such as flushing, persistent redness and visible broken blood vessels. 

5. Triggers that initiate inflammation

External triggers such as ultraviolet rays (UV), spicy food, alcohol, exercise, and stress may stimulate the immune system and nerves to cause dilation of blood vessels. This can lead to inflammation and redness seen in rosacea.

6. Role of mites and bacteria

Mites known as demodex folliculorum live harmlessly on the skin of human beings. However, studies suggest that these mites are present in large numbers in rosacea patients. 

Other microbes that may cause rosacea is Staphylococcus epidermidis. This bacteria is not found on normal skin and triggers an immune response that may cause rosacea. 

H.pylori, a bacteria known to cause gastritis, gastric cancer, and gastrointestinal ulcers is also known to be associated with rosacea. 

7. Defective skin barrier

A defective skin barrier function can also lead to symptoms of inflammation, redness, and blisters that are characteristic of rosacea. 

Risk Factors For Rosacea

The risk factors that are associated with rosacea include:

1. Age

Individuals between the age of 30 to 50 years of age are more prone to rosacea. 

2. Gender

Females are at higher risk of having rosacea. However, the symptoms tend to be more severe in males. 

3. Ethnicity

People of specific European ancestry such as Celtic or Scandinavian are more likely to have rosacea. 

4. Skin tone

It is seen that lighter skin individuals are more susceptible to the development of rosacea. 

5. Positive family history

It is seen that many people with rosacea have a family history of rosacea. Individuals having a familial history of acne are also at a higher risk of developing rosacea. 

6. Medical history 

Individuals who have a lot of acne, acne cysts, and/or nodules are at higher risk of developing rosacea. 

7. Sunlight exposure

Long term sunlight exposure especially during peak sun hours can increase the susceptibility to rosacea.  

8. Weather 

Windburn is a painful skin inflammation that occurs after prolonged exposure to winds. It is commonly associated with rosacea flare-up, especially in the winter.

9. Cosmetics

The use of waterproof cosmetics, heavy foundations that require a makeup remover are associated with an increased risk of rosacea. 

10.Stress

Stress also serves as a trigger for rosacea by increasing the level of hormone cortisol. Consistently high levels of cortisol can lead to inflammation and a weakened immune system, triggering rosacea.

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11. Menopause

The hormonal fluctuations during menopause also serve as a trigger for rosacea. 

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Other triggers that can increase rosacea flare ups include:

• Strenuous exercise 

• Hot baths

• Humidity 

• Alcohol

• Spicy food containing capsaicin, mostly found in red chili peppers, cayenne pepper, jalapeno peppers, bell peppers, paprika and green peppers.

• Food items containing the compound cinnamaldehyde, such as cinnamon, cassia, tomatoes, citrus fruits.

• Foods high in histamine, such as aged cheese, wine, nuts, legumes, smoked fish and processed meats

• Hot caffeinated drinks like coffee, tea, cider, and cocoa 

• Chocolate

• Dairy products

Diagnosis Of Rosacea

There is no specific diagnostic test for rosacea. Diagnosis is usually made after a physical examination of the skin and eyes. The patients are also asked about any potential triggers, symptoms, and medical history. 

In some cases, medical tests are performed to rule out the presence of any other disease with resembling symptoms such as lupus and allergic skin reaction.

Are Rosacae and Psoriasis the same?

While rosacea and psoriasis can both be caused by genetic and age-related factors, they are different conditions. Rosacea usually causes flushing which is limited to the face. In severe cases, acne and thickened skin can be seen in rosacea. On the other hand, psoriasis usually causes red, scaly plaques on the entire body, amongst other symptoms.

Read this detailed account on psoriasis.
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Specialist To Visit 

The early recognition and treatment can help in the prevention of permanent changes in the face. The following speciality of doctor might help in preventing the same:

• General physician

• Dermatologists: The doctor who specializes in conditions of the skin, hair, and nails.

• Ophthalmologist (in case of ocular rosacea): The specialist who manages and treats eye problems. 

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Prevention Of Rosacea

1. Avoidance of triggers

Rosacea can have multiple triggers such as:

• Sunlight

• Humidity 

• Cold winds

• Strenuous exercise 

• Hot baths

• Stress

• Alcohol

• Spicy food 

• Caffeinated drinks

• Dairy products

• Makeup and cosmetic 

Avoiding and limiting these triggers are helpful in preventing the flare-ups but not the occurrence of disease.

However, limiting sun exposure can play an important role in preventing the disease. The following measures can be taken to prevent exposure of sun:

2. Spend less time in direct sun

The exposure to the sun should be restricted to prevent rosacea. The person should avoid going outdoors when the sun is at its peak, which is usually 11 am to 3 pm. Additionally, sunbathing should be avoided at all costs.

3. Cover yourself up in the sun

• Wear lightweight clothing

• Use wide-brimmed hats

• Wear long-sleeved shirts and long pants

• Use clothes made from tight woven fabric

• Use thoroughly dry clothes

• Wear dark colored clothes as they absorb more UV rays

• Wear clothes with ultraviolet protection factor (UPF) above 30

4. Use shade while going out

Staying under an umbrella, tree, or any surface also protects the skin to get exposed to the sun when needed. 

5. Wear sunglasses

Sunglasses should be used while moving out under the sun. They not only protect eyes but also the soft skin around the eyes. 

6. Use sunscreens diligently

A strict sunscreen regimen is the cornerstone of sun protection. All individuals, especially people with high risk should wear a high-quality sunscreen with Sun protection factor (SPF) 30 or more to protect their skin under the sun. 

Tips to use sunscreen effectively!

How much to use: An FTU or Fingertip Unit is used to measure the amount of cream that covers the end of the finger to the first crease of a finger. For the face and neck, use 2.5 FTU. To cover the other exposed parts of the body, you need an ounce of sunscreen, which is sufficient to fill a shot glass.

When to apply: Always apply sunscreen around half an hour before going out because it takes at least 30 minutes for the chemicals in sunscreen to get absorbed and start working.

When to reapply: If you are going out, playing sports or exercising outdoors, it is advised to re-apply the sunscreen every 2 hours. The same rule applies when you go swimming.

How to store: Usually, it is recommended to store in a cool, dry place, away from sunlight. Also, do remember to close it properly after every use.

When to discard: Do not use sunscreen that has passed its expiry date or if there are any visible changes in the sunscreen such as a change in color, smell or consistency. It is advised to buy a new one every year.

Looking for the right sunscreen? Watch our doctor discuss how to choose the best sunscreen for yourself.
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Treatment Of Rosacea

The treatment approach of rosacea depends upon its type and symptoms and is individualized for every patient. The following points are taken into consideration before initiating treatment:

• Symptoms 

• Triggers

• Patient’s wish of the appearance

• Psychological aspect

1. Goals of the treatment

• Easing the discomfort 

• Preventing rosacea from worsening

Due to the multiple symptoms observed in rosacea, there is a stepwise approach to combat them. It includes: 

Step 1: Controlling the inflammatory lesions through anti-inflammatory medications and antibiotics

Step 2: Getting rid of the blood vessels using laser technology

Step 3: Minimizing the background redness by using brimonidine 

The best treatment outcome is offered by a combination of the following therapies:

2. Topical therapies

These are the first line of therapy and are available in the form of cream, gel, and ointments. The medications that are given via topical therapy include anti-inflammatory medications and antibiotics. 

 US-FDA approved topical agents include:

• Azelaic acid

• Metronidazole

• Sodium sulfacetamide 

• Brimonidine 

Other topical medications include:

• Retinoids like adapalene, tretinoin 

• Calcineurin inhibitors like tacrolimus and pimecrolimus

• Macrolides like erythromycin, azithromycin, and clarithromycin 

• Benzoyl peroxide

• Permethrin 

• Ivermectin

• Clindamycin

• Oxymetazoline 

• Minocycline

• Tranexamic acid

Note: Ciclosporin ophthalmic emulsion is usually recommended for ocular rosacea.

3. Oral therapies

Oral therapies are generally used in combinations to treat moderate to severe papulopustular rosacea. 

 US-FDA-approved oral medications include:

• Tetracycline, doxycycline, and minocycline 

Other oral medications include:

• Macrolides like erythromycin, azithromycin, and clarithromycin
• Beta- blockers like Carvedilol and propranolol
• Isotretinoin
• Oral Ivermectin
  
  

4. Laser and light-based therapy

Some clinical symptoms of rosacea such as telangiectasias, persistent facial erythema, and phymas (especially rhinophyma) do not respond well to the above-mentioned approaches. 

Lasers and light-based therapies are used to destroy the dilated blood vessels present in the superficial skin.

Commonly used lasers include:

• Intense pulsed light laser

• Pulsed dye laser

• Potassium titanyl phosphate (KTP) laser

• Diode laser

• Ablative laser
  
  

5. Surgery

It is used rarely to remove the thickened skin in phymatous rosacea. The skin is excised with razor blades and tangential excisions using scalpel under either local or general anesthesia.

Radiofrequency ablation (uses heat to target the affected tissue) is very effective in the treatment of rhinophyma. It has a better safety profile than lasers as it produces less heat in the tissues. 

Injectables are also used to treat severe rosacea, resistant to topical and oral medications.

Examples include:

• Intradermal botulinum toxin 

• Secukinumab 

Home-care For Rosacea

1. Incorporate lifestyle interventions

Rosacea remains for life as there is no permanent cure of the condition. Some lifestyle interventions are important to prevent the flare-ups and to improve the overall quality of life.

Do’s

• Wear sunscreen daily

• Choose low-intensity workouts in an air-conditioned gym 

• Cleanse your face at least twice a day gently

• Apply moisturizer daily, especially after taking a shower
  
  

Don’ts

• Do not go out in the sun, if not necessary

• Do not try cosmetics without consulting dermatologist

• Do not consume alcohol
  
  

2. Eat consciously 

Foods to limit/avoid

• Spicy food containing capsaicin, mostly found in red chili peppers, cayenne pepper, jalapeno peppers, bell peppers, paprika and green peppers.

• Food items containing the compound cinnamaldehyde, such as cinnamon, cassia, tomatoes, citrus fruits.

• Foods high in histamine, such as aged cheese, wine, nuts, legumes, smoked fish and processed meats

• Hot caffeinated drinks like coffee, tea, cider, and cocoa 

• Chocolate

• Dairy products

• Artificial sweeteners

• Processed foods containing preservatives, dietary emulsifiers or additives

Foods to include

Foods that promote a healthy gut microbiome should be included in the diet. This includes a fiber-rich diet and probiotics (foods containing good bacteria). The examples of such food include:

• A variety of vegetables including beans, broccoli, cauliflower, cabbage

• Whole grains like wheat, oats and barley

• Yogurt

• Pickled vegetables

• Kale

• Kefir (fermented milk drink)

• Kombucha tea

• Kimchi

• Sauerkraut

3. Try home remedies

Some traditional and old age home remedies can give respite from rosacea. However, it is important to take consent from your doctor before using any of these in rosacea:

Lavender: It is known from centuries for its use in rashes and other skin ailments such as rosacea. The topical application of lavender oil eases inflammation and shrinks blood vessels.

Licorice (Mulethi): The strong anti-inflammatory activity of licorice can be used to control redness of rosacea. It can be applied in powdered form directly on the skin. 

Feverfew: This plant prevents blood from pooling in facial capillaries and reducing the appearance of facial blood vessels in rosacea. The dried leaves of the feverfew can be directly consumed. The extract of feverfew (made by boiling the leaves with water followed by straining) can also be applied topically.

Green tea: It is loaded with anti-inflammatory properties and helps reduce sun-triggered rosacea flare ups. Studies have also shown that consumption of green tea is associated with the prevention of papules and pustules associated with rosacea.

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Oatmeal: The application of oatmeal reduces itchiness and dryness in rosacea patients. Oatmeal can be easily prepared at home by boiling oats with water for about 20 minutes. 

Chamomile: It has several active compounds that reduce inflammation. According to studies, chamomile-based creams are effective in managing mild to moderate rosacea. 

Aloe vera: It minimizes inflammation of the skin in rosacea. Aloe vera can be directly applied on the skin for the effect. 

Coconut oil (Nariyal tel): It is a wonderful remedy for rosacea due to its anti-inflammatory, antioxidant, and moisturizing benefits. The coconut oil can be directly applied on the affected skin. 

Raw honey (Shehad): Raw honey keeps the skin moist which is helpful in rosacea patients as dry skin worsens rosacea.

Tea tree oil: The application of tea tree oil is associated with reducing inflammation and itching associated with rosacea. 

Turmeric (Haldi): It possesses anti-inflammatory properties and is used to reduce pain and inflammation in rosacea. It can be consumed in food or can be applied on the skin as a thick paste.

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Complications Of Rosacea

In most of cases, rosacea does not lead to any complications. But, if left untreated, it can develop permanent scarring and persistent redness.

The prevalence of rosacea is also found to be associated with a series of cardiovascular diseases, gastrointestinal diseases, neurologic disorders, and psychiatric disorders. 

Alternative Therapies For Rosacea

Plant-based therapies

• Ginkgo biloba: It is a herbal supplement that possesses antioxidant properties. It is also known to reduce redness of the skin by reducing blood circulation. 

• Chrysanthellum indicum: This plant has been found to possess anti-inflammatory properties. Its extract protects the skin from UVB induced skin damage. In a study, a reduction in the redness and overall improvement of rosacea was seen after the application of C. indicum cream. 

• Quassia extract: Quassia amara is a small South American tree thought to have anti-inflammatory properties.  Studies have shown that application of quassia gel is associated with an improvement in rosacea.

Living With Rosacea

Living with rosacea is challenging due to its longer duration. The relapses and remissions of the condition also makes the journey exhausting. It also affects psychological and mental health due to changes in the facial appearance. 

The following measures are proven to help ease symptoms:

1. Avoid triggers

Rosacea is triggered by several factors such as spices, caffeinated drinks, sunlight, stress, strenuous exercise, waterproof cosmetics, and heavy foundations. Patients should understand these triggers and should avoid them. This will help in relieving symptoms that are aggravated by the triggers. 

2. Establish a good cleansing regimen

Patients should clean their skin regularly with a cleanser before going to bed. The skin cleansing regimen should also be followed after coming home from outside. This helps in removing oil and dirt that might irritate the skin. The following tips proves to help reduce the symptoms:

• Choose mild cleanser 
• Avoid soaps as they are harsh which can further damage the skin
• Rinse off the cleanser with lukewarm water 
• Use only fingertips to clean the face

3. Moisturize your skin regularly

The dry skin is more prone to sun damage. So, use a good moisturizer after applying serum to restore the lipid barrier of the skin. Studies have also shown that moisturizers improve the results of treatment. 

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4. Protect your skin from the sun every day

Sun is the most important trigger for rosacea. It is very important to protect the skin from the sun even on cloudy days. Sunscreen should be applied daily irrespective of the weather.  

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5. Choose gentle skin care products

Many skin care products and cosmetics can irritate the skin. Waterproof and opaque makeup should be used. The products containing the following ingredients should be avoided: 

• Alcohol
• Camphor
• Fragrance
• Glycolic acid
• Lactic acid
• Menthol
• Sodium lauryl sulfate (often found in shampoos and toothpaste)
• Urea
• Witch Hazel

To reduce irritation, it’s also best to:

• Use a cream instead of lotion or gel
• Creams containing allantoin
• Avoid astringent or toner

6. Test skin care products

Individuals having rosacea should test skin care products before applying to the face. This can be done by applying a very small amount of product near rosacea prone skin. The product should be avoided if it irritates the skin within 72 hours. 

7. Consider cosmetic camouflage

Makeup products like green color correctors can be used to mask or camouflage the red appearance of the skin in rosacea patients.

8. Last but not the least! Cope with mental stress

Rosacea has a significant psychosocial impact due to the changes in the appearance of the individual. It has an overall impact on self-esteem which can lead to anxiety and embarrassment in some individuals.

Studies suggest that rosacea affects 77.7% patients emotionally, 67% patients socially and 53% are affected in their relationships and dating behavior. 

The following measures might help: 

• Engage yourself in activities you like such as crafting, painting, and singing

• Do regular exercise as it helps in reducing stress

• Join any support group either online or offline

• Ask help from a professional counselor

• Meet someone who is undergoing the same type of treatment

• Be patient. Even with treatment, it may take months for rosacea to clear up. 

• Be diligent. Rosacea will be quick to return if you're not careful about sun protection. So, long-term maintenance requires an ongoing commitment to protecting your skin.