Rosacea : Conditions, Causes, Cautions and Control

You look at yourself in the mirror. You have always had fair skin and flush easily. Of late there has been persistent redness in your cheeks, across the bridge of the nose and your forehead. You find it embarrassing. The skin feels dry and flaky sometimes. If you have a hot drink, spicy food or alcohol your face goes bright red like traffic lights especially in these areas.

You are getting more embarrassed these days as you can feel your face reddening as it goes really warm and it can feel like burning. Sometimes it makes your face puffy and swollen. You feel everyone can see this and sometimes children and adults can ask you if you’re ok as they notice you looking very red. You have recently noticed broken capillaries on your nose and also small spots and blemishes that worry you.

Your eyelids feel constantly itchy and flaky, your eyes go red and feel like there is grit on them all the time. Everyone thinks you are tired and have not had any sleep while in fact you have. You have notices that your eyelashes get matted with dry yellow skin. You are annoyed. You have started noticing broken capillaries on the white of your eye- the conjunctiva.

There are times you wish you could hide away. You’ve tried various cosmetics, foundations and blemish covering agents but no major benefit as yet. You think it is getting worse and you wish someone would help you. You are embarrassed to go to the Doctor as you think maybe it is just your skin type and you should just put up with it.

Sometimes it feels like it is better and you feel happy that it may go but just when you get relaxed it may flare up again. You think it is too trivial to bother your Doctor.

Let me tell you, You've got Rosacea. And you can get it treated.

Rosacea ( Ro-Zay-sha) is a inflammatory skin condition, usually affecting the face ( cheeks, forehead and nose) and characterised by facial flushing, broken blood vessels, redness, burning, spots and skin thickening.

Symptoms vary from person to person. Some may get all or few of the symptoms which can further frustrate patient and doctor in reaching a diagnosis. Even though it can affect 2-5% of the population in many it is quite mild and does not cause major problems apart from redness. It is a disease of over 20s and more likely to happen between the ages of  30- 50.

Women get more affected than men. However men get it far more severe because they tend to seek treatment late and may leave it for years.

The signs and symptoms will vary from individual to individual and not all signs occur in everyone.

Common

Flushing This is one of the commonest symptoms and can also happen as ‘prerosacea’ in people who will develop rosacea in the future- high colouring of the cheeks and frequent warm flushing are hallmarks

Redness Persistent high colour of the cheeks, nose and forehead may resemble sunburn or a permanent blush

Visible blood vessels small capillaries will be visible under the skin

Spots and bumps almost look like common acne pus filled pimples may occur on the nose, the nasal folds and cheeks and sometimes on scalp, ears and neck also.

Eye irritation dry flaky margins on the eyelids, gritty eyes and matted eyelashes can also occur. You cna get similar problems with eyes in psoriasis and seborrhoeic dermatitis.

Dryness – rough and dry facial skin ( in about 50%)

Less Common

Skin thickening is less common and may be seen more in men, In severe cases the nose resembles a potato and is called Rhinophyma

Swelling may occur rarely as puffiness and edema of the face, making it look ‘baggy’

Although no single cause has been identified as a main reason several factors can influence development of Rosacea:

• Immune Response: Abnormal immune response may trigger inflammation of the skin

• Inflammation:The inflammatory changes under the skin surface makes skin leaky and develop several tiny new blood vessels

• Solar Damage: Sun damage can worsen this process

• Skin Mite: A tiny skin mite called Demodex follicularum may be responsible but it is also present in normal skin – in Rosacea patients it is present in high numbers (may be cause or effect)

• Inherited: Over 50% of patients with Rosacea have been identified to have a Celtic ancestry ( Irish or Scottish Descent) it is also found in eastern European and Scandinavian heritage far more than others .The usual assumption is it doesn’t affect brown or black skins but recent research has shown that it does but is harder to diagnose for obvious reasons.

• Capillaropathy: New blood vessel formationhappens due to repeated inflammation

A good medical history and examination of the skin will confirm Rosacea. It does not need any skin testing or investigations.

As  the other causes of redness across the cheeks ( butterfly rash) without spots or blemishes can be Systemic Lupus, Underactive thyroid or Cushing's Syndrome the doctor may organise a blood test to rule this out.  

However,Rosacea rash is very different to the lupus and other rashes even though it may affect the same area of the face. IT will be easy for a experienced clinician to diagnose just from history and appearance alone.

General Principles

A lot of Rosacea therapy is common sensible measures that rely predominantly on trying to avoid too much of the triggers. While this is feasible it can be very hard to avoid all the triggers permanently.

Antibiotic and other treatments help to reduce how you react to the triggers. Rosacea cannot be permanently cured as it is partly to do with our skin type. However excellent control of symptoms can be obtained. It can be quite frustrating that after a long treatment break it can creep back. It is often wise to maintain a therapy of simple measures like trigger avoidance and using moisturisers, cleansers etc and use the antibiotics periodically under Clinician advice and supervision.

Sun protection

The key protection to the skin is to wear sun cream as sun exposure makes Rosacea considerably worse. An UVF higher than 25 should be useful depending on the fairness of your skin.

Moisturisers A simple, non greasy hypo-allergenic moisturiser will help a lot in reducing dryness, irritation and flakiness

Avoiding Triggers: the following is a list of triggers that can make rosacea worse

Flushing

Camouflague creams . although there is no direct treatment for flushing restricting triggers, moisturisers will help. Treatment of spots and blemishes will aalso help reduce redness

Spots and blemishes

There are special antibiotics that also have an effect in reducing skin inflammation and promote healing. Such antibiotics help enormously in Rosacea. I have found using antibiotics not only helps reduce redness it actually helps to reduce majority of the other symptoms like flushing and burning. It also improves tolerance to triggers and patient s appreciate this so they can enjoy an occasional glass o f wine or hot, spicy food without fear of embarrassment.

For mild topical antibiotics like Metronidazole (Rozex ^TM, Roseclear^{TM )} help greatly. Apply gently across affected areas usually once a day as well as doing other measures.

A newer gel called Azelaic Acid ( Finacea ^TM ) has also been found really useful in topical treatment.

For spots, blemishes and advanced rosacea oral antibiotics like tetracyclines ( oxytetracycline, doxycycline, Lymecycline) are a great help. Treatment usually needs to be done over 3-6 months and may need to be repeated in periodic intervals. There is no harm in taking this long term as it is specially designed to help. As symptoms can return after the initial treatment it may be better to take a regular’ low ‘dose maintenance therapy.

Eyelid irritation

Gentle washing with a baby shampoo and a cotton bud to clear the eyelid margins, oral antibiotic therapy, artificial tears like hypromellose and lacrilube will help. In severe cases where the eye surface is involved it needs specialist care by ophthalmologist.

a) Dont ignore the symptoms and keep postponing a Doctor visit, early treatment helps and the longer you leave it untreated the worse it gets!

b) It is not contagious and even though antibiotics are used to treat it is not an infection

c) There are currently no tests for Rosacea and it is a clinical diagnosis based on history and examination

d) While it is not the same as Eczema sometimes eczema sufferers may have facial features that can look like Rosacea – the key is eczema also occurs in the rest of the body while Rosacea doesn’t.

e) It can co-exist with seborrheoic dermatitis that affects scalp margins, eyebrows and nasolabial folds ( the skin crease than runs between the nose and the corner of the mouth)

f) There is no connection between lupus and rosacea- although the butterfly rash of lupus may mimic rosacea. Closer examination will tell the difference

g) Ocular rosacea can be a severe problem and will need advise and treatment from an ophthalmologist especially if it affects the eye surface ( conjunctiva) and not just the eyelids.

h) If you are using steroid creams for other conditions be careful on using it continuously on the skin. Long term steroid use on the face can lead to rosacea but only if you use it continually for many months/years.

How do I care for the skin

In general a simple cleansing and moisturising routine is useful for all genders and ages. Men especially should consider using a gentle moisturiser, as most women do anyway. A mild aopy wash is recommended. It is better to avoid strong exfoliants, harsh soaps and tough face cloth. Men should consider an electric razor for a gentle shave and avoid harsh razors.

Is laser therapy useful

In advanced cases of dilated blood vessels and skin thickening -  laser theray is useful to reduce skin thickness and eliminate dilated capillaries. It is best done by a licensed practitioner under advice by qualified professionals.

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Copyright  © Mohan Kumar 2011