Rosacea

Rosacea: Facial Redness

Rosacea is a skin condition that is often chronic and mainly causes redness and flushing of the face. In addition to redness there may be burning or stinging over the affected area, reddish spots that persist and visible tiny blood vessels under the skin. Over time the skin may become thick and enlarge usually over the nose causing significant deformity.

Rosacea commonly affects around 10% of all individuals and is particularly severe among fair skinned Caucasians. It can also, however, be seen in people of Asian and African origin. It affects persons of both genders and usually affects middle aged persons.

Diagnosis of Rosacea depends on clinical examination and some rarely used laboratory confirmatory tests.

Diagnosis more often than not is made based on clinical symptoms and appearance of the lesions.

History of trigger factors and symptoms

A detailed history of trigger factors and clinical symptoms of the condition are obtained. Some of the common triggers for Rosacea flare ups include exposure to sunlight, stress, cold weather exposure, heat, vigorous exercise, alcoholic and caffeine containing beverages, spicy foods, certain medicines and after menopause. These may be present in many individuals. There are usually periods when the symptoms disappear or are less severe than others. History of similar lesions in the family are also enquired.

Examination of the skin lesions

The skin lesions are examined in detail. Typically the lesions appear red and over time there may be enlargement of the skin over the nose leading to nose deformity. The blood vessels underlying the skin may be visible under the skin surface.

Ruling out other conditions

Other conditions that also manifest with similar facial lesions include systemic lupus erythematosus (SLE) which is an autoimmune condition where the immune system attacks healthy tissues of the body. Menopause may also give rise to similar symptoms.

These conditions need to be differentiated from Rosacea via blood tests that include immunological tests for ruling out SLE.

Skin biopsy

In rare cases a small scraping of the affected area of skin is taken and examined under the microscope. This is called a skin biopsy. This may reveal microscopic skin mites like Demodex folliculorum or skin infections.

Rosacea Symptoms

Rosacea is a skin condition affecting the face and leads to redness and flushing of the face. Rosacea commonly affects around 10% of all individuals and is particularly severe among fair skinned Caucasians. It can however also be seen in people of Asian and African origin. It affects persons of both genders and usually affects the middle aged.

The common symptoms of the condition include:-

  • Flushing leading to warmth and redness over the face. Flushing with redness may be more common in children and adolescents who grow up to be patients with rosacea compared to those who grow up to be normal adults.

Episodes of flushing can last up to five minutes. Flushing may spread to the neck and chest and is usually a result of vigorous exercise, heat or cold exposure or taking hot beverages.

  • Persistent redness that leads to a blotchy red appearance over the face. The blotchiness usually is seen in alcoholics and patients with rosacea may be mistaken for alcoholics. The red appearance spreads over the cheeks, nose and chin down to the neck and chest. The skin appears dry and scaly.
  • Burning or stinging sensation over the affected skin.
  • Papules and pustules over the affected areas. These may or may not be painful. Papules are reddish bumps while pustules are filled with pus.
  • Visible capillaries and blood vessels underneath the surface of the skin. These thread-like veins appearing over the skin are termed telangiectasia.
  • Thickening and pitted skin that enlarges over a period of time leading to deformities of the face. Scarring however is rare. Once the skin over the nose is swollen the nose becomes bulb like and the condition is called rhinophyma. Rhinophyma is a rare symptom of rosacea. It is more common in men than women.
  • Irritation, redness, watering and itching of the eyes. Eyes may be increasingly sensitive to bright lights.

Rosacea Causes

The cause of rosacea is unknown. Rosacea is typically characterized by redness and discoloration over the face with persistent red spots and prominence of blood vessels visible under the skin. Over time the skin enlarges and may become deformed.

Rosacea. Erythema and telangiectasia are seen over the cheeks, nasolabial area and nose. Inflammatory papules and pustules can be observed over the nose. The absence of comedos is a helpful tool to distinguish rosacea from acne.

Hypothesized causes

The cause of rosacea is not clear but there are several hypothesis regarding the cause of this condition:-

An abnormality of blood vessels

Rosacea is typically characterized by abnormal flushing, redness and prominence of blood vessels over the face. There may be damage to the matrix or collagen over the skin due to exposure to excessive sunlight. Sun exposure leads to dilation of skin vessels and release of inflammation mediators that may be the cause of redness.

Genetic causes

Although the exact gene that is connected to Rosacea has not been found, it has been seen that Rosacea runs in some families. This suggests a genetic mode of inheritance.

Mites

Demodex folliculorum is a type of a tiny mite that has been hypothesized to cause Rosacea. These mites usually reside on human skin harmlessly. They have been seen to exist in higher number on the affected skin of Rosacea patients.

Helicobacter pylori bacteria

This bacterium has been implicated in peptic ulcer and other diseases of the digestive system. However, some research suggests that this bacteria produces a protein called bradykinin that can cause blood vessels to dilate and this may be the cause of Rosacea.

Environmental toxins

Several caffeine containing medications, alcohol, spicy foods and some medications like amiodarone (used in abnormal heart rhythms), locally applied steroid creams, pills containing high doses of vitamins B-6 and B-12 have been implicated in causation of Rosacea.

Triggering factors for Rosacea

There are several triggers that may lead to worsening of the symptoms. These include:-

  • Exposure to  excess sunlight
  • Stress
  • Cold weather exposure
  • Exposure to wind
  • Heat and hot baths and excessive humidity
  • Vigorous exercise
  • Alcohol
  • Caffeine containing beverages
  • Dairy products
  • Spicy foods
  • Flu or short term illnesses like fever and colds
  • High blood pressure
  • Certain medicines including amiodarone, certain vitamins, blood vessel dilators (vasodilators used in several heart conditions)
  • Hormonal changes after menopause

Rosacea Treatment

Rosacea can't be cure, but can be controlled. Using your medications faithfully can give you much clearer skin and actually help keep the symptoms from coming back. Your provider will recommend treatment designed for you. In most cases this will include an oral antibiotic and/or a topical antibiotic (applied directly to your skin). Most people begin to notice some improvement in 3 to 4 weeks and significant improvement in 2 to 3 months. Once your symptoms have cleared up you will need to continue using your pill or topical therapy every day to keep your skin looking it's best. Without this regular therapy your symptoms will return.

For skin:

  • Sometimes antibiotics can be put right on the skin. Other times, oral antibiotics can be used. The skin bumps may get better quickly, but redness and flushing are less likely to improve.
  • Small red lines can be treated with electrosurgery and laser surgery. For some people, laser surgery improves the skin without much scarring or damage.
  • Patients with a swollen, bumpy nose can have extra skin tissue taken off to make it smaller. Usually patients feel this process helps their appearance.
  • Some people find that green-tinted makeup is good for hiding the skin's redness.

For the eyes:

  • Most eye problems are treated with oral antibiotics.
  • People who get infections of the eyelids must clean them a lot. The doctor may say to scrub the eyelids gently with watered-down baby shampoo or an over-the-counter eyelid cleaner. After scrubbing, you should apply a warm (but not hot) compress a few times a day.
  • If needed, the doctor may prescribe steroid eye drops.

You play a key role in taking care of your rosacea. Here are a few steps to take:

  • Keep a written record of when flareups happen. This can give you clues about what bothers your skin.
  • Use a sunscreen every day that protects against UVA and UVB rays. Make sure it has a sun-protecting factor (SPF) of 15 or higher.
  • Use a mild moisturizer if it helps. Don't put irritating products on the face.
  • If your eyes have problems, follow your doctor's treatment plan, and clean your eyelids as told.
  • Talk with a doctor if you feel sad or have other signs of depression. Some people with rosacea feel bad because of the way their skin looks.

Rosacea Complications

Rosacea is a chronic skin condition characterized by reddish discoloration and flushing over the face. There may be prominence of the blood vessels underneath the skin along with deformities of the skin leading to rhinophyma.

The course of the disease includes a waxing and waning pattern. Patients with the condition experience periods of remission with little or no symptoms followed by periods of flare ups with exacerbated symptoms. The disease in many individuals progresses in stages. In yet others there is no set pattern for progression of the disease.

The early stage or prodromal stage of the disease is usually episodic erythema or redness over the face. These patients are usually more prone to blushing and flushing due to no specific triggers like sun exposure, ultraviolet radiation, heat, cold, stress, alcohol, hot drinks, spices, chemicals or cosmetics etc. This stage is followed by a stage of a permanent erythema on the central part of the face, cheeks, nose, chin, and forehead and even neck and chest. This stage is mediated by chemical mediators of inflammation present in the body that includes substance P, histamine, serotonin and prostaglandins.

The stages of progression of the disease include:

  • Stage 1 characterized by persistent erythema or redness and telangiectasia or prominence of skin blood vessels over the cheeks, nose and forehead. These patients develop allergic reactions to cosmetics, facial cleansers and sunscreens. There may be inflammation, redness, watering and burning of the eyes as well
  • Stage 2 – this stage usually follows around a year after stage 1. In this stage there are persistent red bumps or papules and pus filled bumps pustules, edema, redness, prominence of blood vessels etc.
  • Stage 3 – stage 3 is rarely seen among Rosacea patients. There is a deeper redness, papules, pustules, nodules, granulomas and enlargement of skin tissues over the affected areas. This may give rise to rhinophymas. The face becomes pitted and coarse in appearance and becomes edematous. Rhinophymas are more common in men than in women.
  • Ocular Rosacea – In nearly half of the patients with Rosacea there is eye involvement. The patient experiences burning, stinging, tearing along with a gritty sensation within the eyes that feels like sand has gotten into the eyes. There may be eye pain, photophobia or sensitivity to light, redness of the conjunctiva, swollen and inflamed eye lids (blepharitis), scaling around the eyes, contact lens intolerance etc. Eye involvement of Rosacea is independent of facial symptoms and may come before the facial redness in some individuals. Over time ocular Rosacea may have serious complications like opacity of the cornea, scarring and even blindness.

References

  1. http://www.drtedwilliams.net/cop/729/AzelaicAcidProject/RosaceaManagement.pdf
  2. http://europepmc.org/articles/PMC1296179/pdf/jrsocmed00042-0030.pdf
  3. http://jddonline.com/articles/dermatology/209
  4. http://www.ccjm.org/content/67/8/587.full.pdf

Rosacea and Genetics

Rosacea is typically characterized by a flushing and reddish discoloration of facial skin, followed by increased prominence of blood vessels, swelling and scaling of skin, and the formation of subcutaneous bumps and pustules. Some patients also develop deformities of the nose, a condition called rhinophyma.

Rosacea is more prevalent among Caucasians compared with other ethnic groups and has a slightly higher incidence among females than males. Rhinophyma, however, is more common among males. The condition typically affects people aged 30 to 60 years.

Causes

The causes of rosacea are currently unclear but are thought to include:

  • Genetic predisposition
  • Altered blood vessel or vascular response to stimuli
  • Altered immune response

Studies have shown that among patients with rosacea who develop reddish discoloration of the face with no presence of inflammatory papules, bumps or pustules, there is overactivation of genes that regulate the inflammatory process as well as blood vessel dilation and constriction in response to inflammation.

Research also supports an increased inflammatory response following an enhanced innate immune response to various “triggers” including exposure to ultraviolet rays, certain foods and medications. Although many studies favour a genetic element to the pathology of rosacea, no predisposing gene has yet been identified in humans.

There is a large body of research that is ongoing in understanding the pathology and possible genetic connection to the immune responses associated with the development of rosacea.

References

  1. http://www.nature.com/jidsp/journal/v15/n1/full/jidsymp20113a.html
  2. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3315879/
  3. http://www.ncbi.nlm.nih.gov/pubmed/22076321
  4. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2700634/

Rosacea and Menopause

There are several skin conditions that affect women throughout their lifetime. These include acne during adolescence, striae or stretch marks due to drastic weight gain or loss, sun damage, skin cancer and rosacea.

The increasing life expectancy of the general population is accompanied by a greater risk of people being affected by sun damage, skin cancer and rosacea, especially among those who are middle aged or elderly. Of these conditions, rosacea is significantly more common among women than men, especially in the menopausal age group.

Complications of rosacea

Rosacea commonly leads to complications including:

  • Redness and flushing of the face
  • Persistent red spots
  • Prominent skin capillaries
  • Spider veins (telengiectasia)
  • Inflammation of the eye lids (blepharitis)
  • Conjunctivitis
  • A warm, burning, or tingling sensation in affected facial regions

Causes and triggers

Pathophysiological and aetiologic studies into rosacea have not yet identified a specific cause of the condition, although spicy food, hot beverages, heat exposure and emotional stress include some of the factors that have been indicated.

However, most patients with rosacea report flushing episodes and this has led to the hypothesis that hyper-reactivity or overactivity of the skin blood vessels could play a role in causing rosacea. Studies also show that rosacea lesions express an excess of vascular endothelial growth factor, CD31, and the lymphatic endothelium marker D2-40.

The menopause

Flushing and the sensation of warmth in the face are also common features of menopausal hot flashes and the menopause has been found to trigger or worsen rosacea in some sufferers.

Rosacea management

Although there is no known cure for rosacea, the condition can be managed and controlled with medication. The use of skin creams and lotions containing antibiotics such as metronidazole has been reported to be beneficial and oral pills containing antibiotics such as tetracycline, clarithromycin, and doxycycline, have also proven effective.