Rosacea - symptoms, treatment, skin-care

Rosacea is a chronic (long term) skin condition characterised by a red facial rash. It most commonly affects the nose, cheeks, forehead and chin but some people can experience symptoms on their neck, back, scalp, arms and legs. Antibiotics are the primary treatment, while changes to your skin care regimen may help prevent recurences.

Rosacea can have a similar appearance to acne but the two conditions are unrelated. Rosacea does not produce the blackheads, deep cysts or lumps that are symptomatic of acne. It mostly affects fair-skinned Caucasians (especially those of Celtic origin) aged 30–60 years.

Signs and symptoms

Identifying the disease is the first step to controlling it. Self-diagnosis and treatment is not recommended, especially as some over-the-counter skin applications may make the problem worse.

Rosacea often begins with episodes of flushing of the skin. As the condition progresses the skin become persistently red and spider-like veins (telangiectasia) become visible on the skin. Other symptoms characteristic of rosacea include:

Pimples that may be hard (papules) or pus filled (pustules).
Dry and flaky facial skin.
Burning and stinging of the skin.
Red, sore eyelids and a tendency to develop styes and conjunctivitis.
Swelling of the face and eyelids.
In advanced cases, the pores of the skin may become prominent and the nose may become enlarged and unshapely (rhinophyma) due to skin thickening.

Causes

The exact cause of rosacea is not known but may be due to a combination of hereditary (genetic) and environmental factors. It is known, however, that a variety of factors can trigger an overreaction of facial blood vessels and increased blood flow to the skin surface, causing skin flushing and inflammation.

Factors are known to trigger or aggravate the condition, include:

Excess alcohol
Hot drinks and spicy foods
Smoking
Application of topical steroids
Stress
Excessive exposure to sunlight or extreme hot or cold temperatures
Strong winds
Some facial creams and cosmetics.

Treatment

The mainstay of treatment for rosacea is oral antibiotics. Most commonly, tetracycline based antibiotics, such as doxycycline and minocycline, are used. Other antibiotics that may be used include metronidazole and cotrimoxazole. Antibiotic treatment usually lasts for between six and 12 weeks. It is not uncommon for repeat courses of antibiotics to be required. It is believed that the antibiotics work by reducing inflammation in the small blood vessels and structures of the skin. Severe cases are treated with higher doses of antibiotics.

Once the symptoms are under control, an antibiotic ointment may be prescribed on a long-term basis. Other treatments that may be used include:

Isotretinoin – a vitamin A derivative that may be recommended in cases of rosacea that have not responded to antibiotics, or where antibiotic treatment is not well tolerated. Taken orally, isotretinoin can help to reduce the papules and pustules that occur with rosacea. This medication must not be used by pregnant women however as it can cause birth defects
Azelaic acid – a topical cream or lotion, often used to treat acne, which has proven effective in treating rosacea
Brimonidine, a relatively new medication, also helps to reduce the facial redness caused by rosacea. Applied to the face once a day as a gel, brimonidine works by restricting the widening (dilation) of the blood vessels in the skin
Vascular laser treatment – this can be effective in treating persistent telangiectasia
Other medications – Non-steroidal anti-inflammatory drugs (NSAIDs), such as diclofenac, can help to reduce redness and discomfort of the skin. Clonidine and carvedilol, which are used to treat high blood pressure, can help to reduce flushing of the skin
Surgery – this can help to treat rhinophyma by reshaping the nose.

Usually an improvement in the condition should be noticed within three to four weeks of antibiotic treatment. A referral to a dermatologist (skin specialist) may be recommended if the disease does not respond to the antibiotic treatment.

When treatment is followed correctly, there is gradual improvement. In some cases rosacea can recur and in others it can clear up completely. If left untreated, rosacea will worsen and become more difficult to treat. The success of treatment depends upon how early rosacea was diagnosed and if the full course of treatment is followed correctly.

Skin care / self help

To help prevent further irritation of rosacea and promote healthy skin, these general steps can be taken:

Gently clean your skin twice daily using a gentle, soap-free, non-abrasive cleanser
Avoid oil based cosmetic products that require solvents for removal.
Use alcohol-free facial products
Avoid smoking, alcohol, hot beverages and hot spicy food
Protect against exposure to extreme hot and cold temperatures e.g. hot baths or showers
Use a non-irritating sunscreen with a sun protection factor (SPF) of 30+ to protect your skin from the sun
Reduce stress levels.

References

O’Toole, M.T. (Ed.) (2013). Rosacea. Mosby’s Dictionary of Medicine, Nursing & Health Professions (9th ed.). St Louis, MI: Elsevier Mosby.
NHS Choices (2016). Rosacea (Web Page). Redditch: National Health Service (NHS). http://www.nhs.uk/Conditions/Rosacea/Pages/Introduction.aspx [Accessed: 28/09/17]
Ngan, V., Oakley, A. (2014). Rosacea (Web Page). Hamilton: DermNet New Zealand. https://www.dermnetnz.org/topics/rosacea/ [28/09/17]

Last reviewed – September 2017