THE SKIN CENTER

What is rosacea?

Rosacea (roz-ay-sha) is a very common red, acne-like benign skin condition that affects many people worldwide. As of 2010, rosacea is estimated to affect at least 16 million people in the United States alone and approximately 45 million worldwide. Most people with rosacea are Caucasian and have fair skin. The main symptoms of rosacea include red or pink patches, visible tinybroken blood vessels, small red bumps, red cysts, and pink or irritated eyes. Most people with the disease may not even know they have rosacea or that it is a diagnosable and treatable condition. Many people who have rosacea may just assume they blush or flush easily or are just very sun sensitive. .

Rosacea is considered a chronic (long-term), non-curable skin condition with periodic ups and downs. As opposed to traditional or teenage acne, most adult patients do not "outgrow" rosacea. Rosacea characteristically involves the central region of the face, causing persistent redness or transient flushing over the areas of the face and nose that normally blush -- mainly the forehead, the chin and the lower half of the nose. It is most commonly seen in people with light skin, and particularly in those of English, Irish and Scottish backgrounds. Some famous people with rosacea have included former President Bill Clinton and W.C. Fields.

The redness in rosacea, often aggravated by flushing, may cause small blood vessels in the face to enlarge (dilate) and become more visible through the skin, appearing like tiny red lines (called telangiectasias). Continual or repeated episodes of flushing and blushing may promote inflammation, causing small red bumps that often resemble teenage acne. In fact, rosacea can frequently be mistaken for common acne. Rosacea is also referred to as acne rosacea.

Is rosacea like acne?

Rosacea is basically different than acne, although the two can coexist. It is also sometimes called "adult acne." Unlike common acne, rosacea is not primarily a plague of teenagers but occurs most often in adults (ages 30 to 50), especially those with fair skin. Different than acne, there are usually no blackheads or whiteheads in rosacea. Furthermore, most teens eventually outgrow acne whereas patients with rosacea don't generally outgrow it. Rosacea consists mostly of small red bumps that are not "squeezable" or extractable like blackheads. Squeezing a rosacea pimple usually causes a scant amount of clear liquid to expel. Unlike traditional acne where professional extractions can help remove whiteheads and blackheads, squeezing or extracting rosacea bumps does not help improve the rosacea.  People with rosacea individuals  tend to have a rosy or pink color to their skin as opposed to acne patients whose skin is usually less red.

Rosacea strikes both sexes and potentially all ages. Overall, it tends to be more frequent in women but more severe in men. It is very uncommon in children, and it is very infrequently seen in darker skin tones or black skin. Overall, it is seen in light-featured adults between 30-50 years of age.

What causes rosacea?

The exact cause of rosacea is still unknown and remains a mystery. The basic process seems to involve dilation of the small blood vessels of the face. Suspected causes of rosacea include but are not limited to genetic factors, genetics plus sun exposure, a mite sometimes found in hair follicles (Demodex folliculorum), the bacteria Helicobacter pylori (that is associated with stomach ulcers), gastrointestinal disease, and medications that cause blood vessels to widen. There seems to be a hereditary component to rosacea in a large number of  people. Often people have close family members with rosacea.

Rosacea tends to affect the "blush" areas of the face and is more common in people who flush easily. Additionally, a variety of triggers are known to cause rosacea to flare. Emotional factors (stress, fear, anxiety, embarrassment, etc.) may trigger blushing and aggravate rosacea. A flare-up can be caused by changes in the weather like strong winds or a change in the humidity. Sun exposure and sun-damaged skin is generally associated with rosacea. Exercise, alcohol consumption, emotional upsets, and spicy food are other well-known triggers that may aggravate rosacea. Many patients may also notice flares around the holidays, particularly Christmas and New Year's holidays.

What are risk factors for rosacea?

Rosacea risk factors include fair skin, English, Irish or Scottish heredity, easy blushing, and having other family members with rosacea called “positive family history”. Additional risk factors include female gender, menopause, and adults in the age range 30-50years old.

Is rosacea contagious?

No. Rosacea is not considered contagious or infectious. There is no evidence that rosacea can be spread by contact with the skin, sharing towels, or through inhalation.

What are the signs and symptoms of rosacea?

Typical signs and symptoms of rosacea include facial flushing, blushing, redness, burning, red bumps, and small cysts. The symptoms tend to come and go. The skin may be clear for weeks, months, or years and then erupt again. Rosacea tends to evolve in stages and typically causes inflammation of the skin of the face, particularly the forehead, cheeks, nose, and chin.

When rosacea first develops, it may appear, then disappear, and then reappear. However, the skin may fail to return to its normal color and the enlarged blood vessels and pimples arrive in time. Rosacea may rarely reverse itself.

Rosacea generally lasts for years, and, if untreated, it tends to gradually worsen.

How is rosacea diagnosed?

Rosacea is usually diagnosed based on the typical red or blushed facial skin appearance and symptoms of easy facial blushing and flushing. Rosacea is largely under diagnosed and most people with rosacea often do not know they have the skin condition. Many people may not associate their intermittent flushing symptoms with a medical condition. The facial redness in rosacea may be transient and come and go very quickly.

Dermatologists are physicians who are specially trained in the diagnosis of rosacea. Generally no specific tests are required for the diagnosis of rosacea.

In unusual cases, a skin biopsy may be required to help confirm the diagnosis of rosacea.  Occasionally, a non-invasive test called a skin scraping may be performed by the dermatologist in the office to help exclude a skin mite infestation by Demodex which can look just like rosacea. A skin culture can help exclude other causes of facial skin bumps like staph infections or herpes infections. Blood tests are not generally required but may be used to help exclude less common causes of facial blushing and flushing including lupus, other autoimmune conditions, and dermatomyositis.

 What else could it be?

While most cases of rosacea are fairly straightforward, there are some atypical cases that are not as easy to diagnose. Other conditions and rosacea look-alikes include:

• Acne vulgaris

• Demodex folliculitis

• Staph  infection

• Lupus

• Medication reaction (example: niacin)

• Seborrheic dermatitis

• Allergic or contact dermatitis

• Eczema

• Seasonal allergies

• Allergic conjunctivitis

• Perioral dermatitis

• Carcinoid Syndrome

• Impetigo

• Herpes Simplex

What happens to the nose?

The nose is typically one of the first facial areas to be affected in rosacea. It can become red and bumpy and develop noticeable dilated small blood vessels. Left untreated, advanced stages of rosacea can cause a disfiguring nose condition called rhinophyma (ryno-fy-ma), literally growth of the nose, characterized by a bulbous, enlarged red nose and puffy cheeks (like the old comedian W.C. Fields). There may also be thick bumps on the lower half of the nose and the nearby cheek areas. Rhinophyma occurs mainly in men. Severe rhinophyma can require surgical correction and repair.

Some people falsely attribute the prominent red nose to excessive alcohol intake, and this stigma can cause embarrassment to those with rosacea. Although a red nose may be seen in patients with heavy alcohol use, not every patient with rosacea abuses alcohol.

What happens to the eyes?

Rosacea may or may not affect the eyes. Not everyone with rosacea has eye issues. A complication of advanced rosacea, known as ocular rosacea, affects the eyes. About half of all people with rosacea report feeling burning, dryness, and grittiness of the eyes (conjunctivitis). These individuals may also experience redness of the eyelids and light sensitivity. Often the eye symptoms may go completely unnoticed and not be a major concern for the individual. Many times, the physician or ophthalmologist may be the first one to notice the eye symptoms. Untreated, ocular rosacea may cause a serious complication that can damage the cornea, called rosacea keratitis. An ophthalmologist can assist in a proper eye evaluation and prescribe rosacea eye drops. Oral antibiotics may be useful to treat skin and eye rosacea. Untreated eye rosacea may cause permanent damage, including impaired vision.

How is rosacea cured?

Rosacea is currently not considered a curable condition. While it cannot be cured, it can usually be controlled with proper, regular treatments.

There are some forms of rosacea that may be significantly cleared for long periods of time using laser, intense pulse light, photodynamic therapy, or isotretinoin (Accutane). Although still not considered a "cure," some patients experience long-lasting results and may have remissions (disease-free period of time) for months to years.

What about using acne medicine?

Since there is some overlap between acne and rosacea, some of the medications may be similar. Acne and rosacea have in common several possible treatments including (but not limited to) oral antibiotics, topical antibiotics, sulfa-based face washes, isotretinoin, and many others. It is important to seek a physician's advice before using random over-the-counter acne medications since they can actually irritate skin that is prone to rosacea. Overall, rosacea skin tends to be more sensitive and easily irritated than that of common acne.

What is used for treating rosacea?

There are many treatment choices for rosacea depending on the severity and extent of symptoms. Available medical treatments include antibacterial washes, topical creams, antibiotic pills, lasers, pulsed-light therapies, photodynamic therapy, and isotretinoin.

Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition. More resistant cases may require a combination approach, using several of the treatments at the same time. A combination approach may include home care of washing with a prescription sulfa wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, intense pulsed light or photodynamic therapies may also be used in combination with the home regimen. It is advisable to seek a physician's care for the proper evaluation and treatment of rosacea.

Topical creams

With the proper treatment, rosacea symptoms can be fairly well controlled. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid (Finacea gel 15%) is another effective treatment for patients with rosacea. Both metronidazole and azelaic acid work to control the redness and bumps in rosacea.

Some patients elect combination therapies and notice an improvement by alternating metronidazole and azelaic acid: using one in the morning and one at night. Sodium sulfacetamide (Klaron lotion) is also known to help reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin (Cleocin).

Common topical medications used either 1-2 times a day:

• (Finacea gel 15%)

• (Klaron lotion)

• gel (Erygel)

• Clindamycin gel, solution, or lotion (Cleocin).

Oral antibiotics

Oral antibiotics are also commonly prescribed to patients with moderate rosacea. Tetracycline, doxycycline, minocycline, and amoxicillin are among the many oral antibiotics commonly prescribed and they actually help reduce inflammation and pimples in rosacea. A newer low dose doxycycline preparation called Oracea 40mg once a day has been used in rosacea. The dose may be initially high and then be tapered to maintenance levels. Common side effects and potential risks should be considered before taking oral antibiotics.

Oral antibiotics include:

• 100mg
• 500mg

Miscellaneous Medications

Short-term topical cortisone (steroid) preparations of minimal strength may in occasional cases also be used to reduce local inflammation. Some mild steroids include desonide lotion or hydrocortisone 0.5% or 1% cream applied sparingly once or twice a day just to the irritated areas. There is a risk of causing a rosacea flare by using topical steroids. Prolonged use of topical steroids on the face can also cause Perioral dermatitis.

Some doctors may also prescribe tretinoin (Retin-A), tazarotene (Tazorac), or adapalene (Differin) which are prescription medications also used for acne. Rarely, permethrin (Elimite) cream is prescribed for rosacea cases that are associated with skin mites. Permethrin is also used for the body mites that cause scabies.

Isotretinoin (Accutane)

Isotretinoin is infrequently prescribed in cases of  severe and resistant rosacea. Often it is used after multiple other therapies have been tried for some time and have failed. It is used as a daily capsule for 4-6 months. Isotretinoin is not typically used in rosacea and it is most commonly used in the treatment of severe, common acne called acne vulgaris. Close physician monitoring and blood testing are necessary while on isotretinoin. Typically at least 2 forms of birth control are required for females on this medication and pregnancy is absolutely contraindicated while on isotretinoin.

Cleansers

In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Harsh soaps and lotions should be avoided, whereas simple and pure products such as Cetaphil or Purpose gentle skin cleanser may be less irritating. Patients should avoid excessive rubbing or scrubbing the face.

• Cetaphil Cleanser

• Purpose Soap

• Sulfa based washes ( example: Rosanil)

• Benzoyl Peroxide washes  (example: Clearasil)

Laser and intense pulsed light

Many patients are now turning to laser and intense-light treatments to treat the continual redness and noticeable blood vessels on the face, neck, and chest. Often considered a safe alternative, laser and intense pulse-light therapy may help to visibly improve the skin and complexion.

Laser treatment may cause some discomfort. While most patients are able to endure the procedure, ice packs and topical anesthetic cream can help alleviate the discomfort. Multiple treatments are typically necessary and the procedure is not covered by most insurances. Treatments are recommended in three- to six-week intervals; during this time, sun avoidance is necessary. Risk, benefits, and alternatives should be reviewed with your physician prior to treatment. Laser treatments may be combined with photodynamic therapy (light-activated chemical using Levulan) for more noticeable results.

Photodynamic therapy

Photodynamic therapy (PDT) is one of the newly available treatments. PDT uses a topical photosensitizer liquid that is applied to the skin and a light to activate the sensitizer. Levulan (aminolevulonic acid) and blue light, commonly used to treat pre-cancers (actinic keratosis) and acne vulgaris, can also be used to treat some rosacea patients. The use of PDT in rosacea is considered off-label use to some extent, since it is primarily designed for regular acne. PDT is thought to work at reducing the inflammation, pimples, and also improving the skin texture. PDT is an in-office procedure performed in your physician's office. The treatment takes anywhere from one to one and a half hours to complete. Strict sun avoidance for approximately one to three days is required after the treatment. Mild discomfort during the treatment and a mild to moderate sunburn appearance after the treatment is common. Some patients have experienced remissions (disease free periods) of several months to years from these types of treatments. Other patients may not notice significant improvement.

Glycolic peels

Glycolic-acid peels may additionally help improve and control rosacea in some people. The chemical peels can professionally be applied for approximately two to five minutes every two to four weeks. Mild stinging, itching, or burning may occur and some patients experience peeling for several days after the peel. Any peel can irritate very sensitive skin and cause flares for some people. Peels should be used with caution in rosacea as not everyone is bale to tolerate these treatments.

Sun protection

Sun exposure is a well known flare for many rosacea sufferers. Sun protection using a wide-brimmed hat (at least 6 inches) and physical sunscreens  (like zinc or titanium) are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, the use of an appropriate daily sunscreen lotion and overall sun avoidance is recommended. Zinc-based sunscreens (SPF 30 or higher) provide superior sun protection.

What should be avoided?

While not all rosacea people are exactly the same, there are some common rosacea triggers. Avoiding these potential triggers may also help relieve symptoms and disease flares. It may be helpful to keep a personal diary of foods and other triggers that flare rosacea symptoms.

Smoking, spicy foods, hot drinks, and alcohol may cause flushing and should be avoided. Exposure to sunlight and to extreme hot and cold temperatures should be limited as much as possible. Red wine and chocolate are two well known rosacea triggers. Some listed foods may have no effect on your rosacea but severely affect someone else. Individual reaction patterns vary greatly in rosacea and therefore a food diary may help to elucidate your special triggers.

Possible rosacea dietary triggers include:

• Dairy including yogurt ,sour cream, cheese (except cottage cheese)

• Alcohol including red wine, beer, vodka, gin, bourbon, and champagne

• Chocolate  

• Soy sauce

• Yeast extract

• Eggplants, Avocados, Spinach

• Some beans and pods, including lima, navy or peas

• Citrus fruits, including tomatoes, bananas, red plums, raisins or figs

• Spicy and temperature hot foods

Potent cortisone or steroid medications on the face should be avoided because they can promote widening of the tiny blood vessels of the face. Some patients experience severe rosacea flares after prolonged use of topical steroids.

Vasodilator pills can also flare rosacea. Vasodilators include several blood pressure medications like nitrates, calcium channel blockers, and thiazide diuretics.

These potential triggers are found in many skin cleansers and should be avoided in rosacea.

• Alcohol

• Witch hazel

• Peppermint

• Eucalyptus oil

• Clove oil

• Fragrance

• Menthol

• Salicylic acid

What foods are good for rosacea?

Foods that help avoid rosacea flares include less spicy meals, non-alcoholic cool beverages, caffeine-free drinks, non-dairy cheese, and thermally cooler meals.

What natural remedies can help rosacea?

Rosacea skin tends to be fairly sensitive and may easily flare with self treatment or common acne therapies. Any home treatment or attempts for natural remedies should be approached with mild caution. As with any rosacea therapy, some people may experience sensitivity or irritation with treatment. Several possible natural remedies including dilute vinegar cleansing and green tea applications may be useful in rosacea.

Dilute white vinegar facial soaks or cleansing daily or weekly using approximately 1 part regular table vinegar to 6 parts water may be helpful. Vinegar is thought to help as a natural disinfectant and can help decrease the number of yeasts and bacteria on the skin. Since vinegar may flare rosacea in some people, a small test area should be tries before applying to the entire face.

Green tea soaks to the face may also help decrease the redness and inflammation seen in rosacea. Green tea is thought to have anti-inflammatory properties. A few commercially available products also use green tea as the active ingredient.

Does rosacea get worse with age?

Yes. Although rosacea has a variable course and is not predictable in everyone, overall it tends to gradually worsen with age, especially if untreated.  In small studies, many rosacea sufferers have reported that without treatment their condition had advanced from early to middle stage within a year.  With good therapy, it is possible to prevent progression of rosacea.

How should I care for the skin of my face?

Proper skin care involves using a gentle cleanser to wash the face twice a day. Over-washing may cause irritation. A sunscreen lotion is advisable each morning. Your physician may prescribe a topical antibiotic to use once or twice a day under your sunscreen.

Rubbing the face tends to irritate the reddened skin. Some cosmetics and hair sprays may also aggravate redness and swelling.

• Gentle skin cleanser twice a day

• Sunscreen in AM

• Sun avoidance

Facial products such as soap, moisturizers, and sunscreens should be free of alcohol or other irritating ingredients. Moisturizers should be applied very gently after any topical medication has dried. When going outdoors, sunscreens with an SPF of 15 or higher are needed.

How are the telangiectasias (the red lines) treated?

Telangiectasias are the small blood vessels that arise on the surface of the skin, commonly on around the nose, cheeks, and chin.

Simple cover-up makeup can be used for the telangiectasias. There are some green-based moisturizers or tinted foundations that may help conceal the redness.

Telangiectasias can also be medically treated in your physician's office with a small electric needle, a laser, intense pulse light, or minor surgery to close off the dilated blood vessels. Usually, multiple treatments are required for best results and only a portion of the blood vessels may be improved with each treatment. Not everyone responds the same to these types of treatments, and your physician can help you decide which treatment is best for your skin type, condition, and size of blood vessels.

• Electrocautery

• Laser

• Intense Pulse Light Therapy

How is a rhinophyma (the W.C. Fields nose) treated?

Rhinophyma of the nose is frequently treated by surgery. The excess tissue may be removed with a scalpel, laser, or electro surgery. Dermabrasion can help improve the look of the scar tissue. Follow-up treatments with laser or intense pulsed light may help lessen the redness. Medical maintenance therapy with oral and or topical antibiotics may be useful to decrease the chance of recurrence.

What effect may rosacea have on my life?

Rosacea may affect your life minimally, moderately, or severely depending on how active the condition is and your overall tolerance of the skin symptoms.

Some people have absolutely no symptoms and are not bothered at all by their rosacea. They may enjoy perfectly healthy normal lives without any effect from this benign skin condition. Some patients really like the pink glow to their cheeks and find it gives them a pleasant color without having to use blush. They may not even know they have rosacea. They usually do not want to use any treatment.

People with moderate rosacea may have periodic flares that require treatment with oral antibiotics, lasers, and other therapies. They may continuously take an antibiotic daily for years and years to keep their symptoms under control. Many of these people may complain of embarrassment from the flushing and blushing of rosacea. They may have ups and downs and times that their disease is quiet and other times when it feels like it is on fire. With the help of their physician, these patients can learn the pattern of their rosacea and develop a treatment plan to keep it from interfering in their daily lives.

Other patients have very bothersome rosacea that causes them issues on a daily basis. There are subsets of severe rosacea sufferers who have extreme psychological, social, and emotional symptoms. Some have developed social phobias causing them to cancel or leave situations when their rosacea is flaring or active. Some patients complain of looking like they have been drinking alcohol when in fact they don't drink at all. Although rosacea is not a grave medical situation, severe cases may wreak havoc in some patient's lives. It is important for these patients to discuss their physical and emotional concerns with their physicians and to get professional help in treating their rosacea.

Overall, promptly diagnosed and properly treated, rosacea should not prevent people with the condition from enjoying long and productive lives.

Additional information is available from the American Academy of Dermatology at www.aad.org. Names of U.S. board certified dermatologists are available on this website.

Rosacea at a Glance

• Rosacea is a common, chronic, incurable, adult, acne-like skin condition.

• It has periodic ups and downs (flares and remissions).

• Rosacea symptoms tend to come and go.

• It is easily controllable and medically manageable.

• Rosacea may begin with easy facial blushing or flushing.

• Rosacea  commonly affects the central third of the face, especially the nose.

• Rosacea causes tiny red pimples and fine red lines on the facial skin.

• Rosacea may be mistaken for rosy cheeks, sunburn, or quite often, acne.

• Rosacea triggers include alcohol, hot or spicy foods, emotional stress, and heat.

• Rosacea can be a very bothersome and embarrassing condition.

• Untreated rosacea tends to worsen over the time and be a progressive disease.

• Rosacea untreated can cause a bulbous red nose (like W.C. Fields).

• Prompt recognition and proper treatment permit people with rosacea to enjoy life.

Information in this publication and site is not intended to serve as medical advice. Individuals may use the information as a guide to discuss their treatments with their own physicians. This site does not promote nor endorse the unauthorized practice of medicine by non-physicians or state licensed health care providers.
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