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 the sides of the face, ears, neck, scalp, and chest can also be involved. The symptoms progress from having red skin on 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.

Due to the complexity of signs and symptoms, the condition is divided into four subtypes. Individuals can have more than one subtype at the same time, and the treatment approaches for each subtype differ.

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 or whiteheads. 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 the chin, forehead, ears, and eyelids. It is mainly characterized by thickening of the skin. This subtype is rare and includes 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 eyes, and individuals 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

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

• Genes: Some theories suggest the role of genes in developing rosacea and making some individuals more prone to skin inflammation.
• 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 that trigger skin inflammation even in the absence of any microbes.
• Ultraviolet (UV) light: Both UVA and UVB light contribute to the development of rosacea by triggering the inflammatory cascade mentioned above.
• 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 in the face. This may cause rosacea symptoms such as flushing, persistent redness, and visible broken blood vessels.
• 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.
• 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 include Staphylococcus epidermidis, which 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.
• Defective skin barrier: A defective skin barrier function can lead to symptoms of inflammation, redness, and blisters that are characteristic of rosacea.

The risk factors that are associated with rosacea include:

• Age: Individuals between the ages of 30 to 50 years are more prone to rosacea.
• Gender: Females are at a higher risk of developing rosacea; however, symptoms tend to be more severe in males.
• Ethnicity: People of specific European ancestry, such as Celtic or Scandinavian, are more likely to have rosacea.
• Skin tone: Lighter-skinned individuals are more susceptible to the development of rosacea.
• Positive family history: Many individuals with rosacea have a family history of the condition. Those with a familial history of acne are also at a higher risk of developing rosacea.
• Medical history: Individuals with a history of acne, acne cysts, or nodules are at a higher risk of developing rosacea.
• Sunlight exposure: Long-term exposure to sunlight, especially during peak hours, can increase susceptibility to rosacea.
• Weather: Windburn, a painful skin inflammation caused by prolonged exposure to wind, is commonly associated with rosacea flare-ups, especially in winter.
• Cosmetics: The use of waterproof cosmetics and heavy foundations that require makeup removers is associated with an increased risk of rosacea.
• Stress: Stress serves as a trigger for rosacea by increasing cortisol levels. Consistently high levels of cortisol can lead to inflammation and a weakened immune system, triggering rosacea.
• Menopause: Hormonal fluctuations during menopause can also trigger rosacea.

Other triggers that can increase rosacea flare-ups include:

• Strenuous exercise
• Hot baths
• Humidity
• Alcohol
• Spicy foods containing capsaicin, mostly found in red chili peppers, cayenne pepper, jalapeno peppers, bell peppers, paprika, and green peppers
• Food items containing cinnamaldehyde, such as cinnamon, cassia, tomatoes, and 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

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

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

Are Rosacea 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 that is limited to the face. In severe cases, acne and thickened skin can be seen in rosacea. On the other hand, psoriasis typically causes red, scaly plaques on the entire body, among other symptoms.

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 cosmetics

Avoiding and limiting these triggers can help prevent flare-ups, although they may not prevent the occurrence of the disease. However, limiting sun exposure is crucial in preventing rosacea. The following measures can be taken to minimize sun exposure:

2. Spend Less Time in Direct Sun

Limit exposure to the sun, particularly during peak hours, which are typically between 11 am and 3 pm. Sunbathing should also be avoided.

3. Cover Yourself Up in the Sun

• Wear lightweight clothing
• Use wide-brimmed hats
• Wear long-sleeved shirts and long pants
• Choose tightly woven fabric
• Ensure clothes are thoroughly dry
• Opt for dark-colored clothes as they absorb more UV rays
• Select clothing with an ultraviolet protection factor (UPF) above 30

4. Use Shade While Going Out

Stay under an umbrella, tree, or any surface to protect the skin from sun exposure when necessary.

5. Wear Sunglasses

Sunglasses should be worn outdoors to protect not only the eyes but also the delicate skin around them.

6. Use Sunscreens Diligently

A strict sunscreen regimen is essential for sun protection. Individuals, especially those at high risk, should use a high-quality sunscreen with a sun protection factor (SPF) of 30 or more.

Tips to Use Sunscreen Effectively!

• How much to use: An FTU (Fingertip Unit) measures the amount of cream that covers the end of the finger to the first crease. For the face and neck, use 2.5 FTU. To cover other exposed body parts, one ounce of sunscreen is sufficient to fill a shot glass.
• When to apply: Always apply sunscreen about half an hour before going outdoors, as it takes at least 30 minutes for the chemicals to be absorbed and start working.
• When to reapply: Reapply sunscreen every 2 hours if outdoors, playing sports, or exercising. The same rule applies when swimming.
• How to store: Store sunscreen in a cool, dry place, away from sunlight, and ensure it is properly closed after each use.
• When to discard: Do not use sunscreen past its expiry date or if there are visible changes in color, smell, or consistency. It is advisable to purchase a new one every year.

The treatment approach for rosacea depends on its type and symptoms and is individualized for each patient. The following factors are considered before initiating treatment:

• Symptoms
• Triggers
• Patient’s wish for appearance
• Psychological aspects

1. Goals of the treatment

• Easing discomfort
• Preventing rosacea from worsening

Due to the multiple symptoms observed in rosacea, a stepwise approach is taken to address them. This includes:

• Step 1: Controlling inflammatory lesions through anti-inflammatory medications and antibiotics
• Step 2: Reducing blood vessels using laser technology
• Step 3: Minimizing background redness with brimonidine

The best treatment outcomes are achieved through a combination of the following therapies:

2. Topical therapies

These are the first line of therapy and are available in the form of creams, gels, and ointments. The medications administered 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 and 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 combination 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 aforementioned approaches. Lasers and light-based therapies are used to destroy the dilated blood vessels 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

Surgery is rarely used to remove thickened skin in phymatous rosacea. The skin is excised with razor blades and tangential excisions using a scalpel under either local or general anesthesia. Radiofrequency ablation, which uses heat to target the affected tissue, is very effective in treating rhinophyma and has a better safety profile than lasers as it produces less heat in the tissues.

Injectables are also used to treat severe rosacea that is resistant to topical and oral medications. Examples include:

• Intradermal botulinum toxin
• Secukinumab

1. Incorporate lifestyle interventions

Rosacea remains for life as there is no permanent cure for the condition. Some lifestyle interventions are important to prevent flare-ups and improve 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 a 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, and 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). Examples of such foods include:

• A variety of vegetables including beans, broccoli, cauliflower, and 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 home remedies can provide relief from rosacea. However, it is important to obtain consent from your doctor before using any of these remedies:

• Lavender: Known for its use in rashes and skin ailments, topical application of lavender oil eases inflammation and shrinks blood vessels.
• Licorice (Mulethi): Its strong anti-inflammatory activity can help 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 reduces the appearance of facial blood vessels. The dried leaves can be consumed, or the extract can be applied topically.
• Green tea: Loaded with anti-inflammatory properties, it helps reduce sun-triggered rosacea flare-ups. Studies show it may prevent papules and pustules associated with rosacea.
• Oatmeal: Its application reduces itchiness and dryness. Oatmeal can be prepared at home by boiling oats with water for about 20 minutes.
• Chamomile: Contains active compounds that reduce inflammation. Chamomile-based creams are effective in managing mild to moderate rosacea.
• Aloe vera: Minimizes skin inflammation in rosacea and can be directly applied to the skin.
• Coconut oil (Nariyal tel): A remedy for rosacea due to its anti-inflammatory, antioxidant, and moisturizing benefits. It can be applied directly to the affected skin.
• Raw honey (Shehad): Keeps the skin moist, which is helpful for rosacea patients as dry skin worsens the condition.
• Tea tree oil: Associated with reducing inflammation and itching in rosacea.
• Turmeric (Haldi): Possesses anti-inflammatory properties and can be consumed in food or applied as a thick paste on the skin.

In most cases, rosacea does not lead to any complications. However, if left untreated, it can result in:

• Permanently scarring
• Persistent redness

The prevalence of rosacea is also associated with a series of:

• Cardiovascular diseases
• Gastrointestinal diseases
• Neurologic disorders
• Psychiatric disorders

Plant-based therapies

• Ginkgo biloba: A herbal supplement with antioxidant properties, known to reduce skin redness by decreasing blood circulation.
• Chrysanthellum indicum: This plant exhibits anti-inflammatory properties. Its extract protects the skin from UVB-induced damage. A study demonstrated a reduction in redness and overall improvement of rosacea after applying C. indicum cream.
• Quassia extract: Quassia amara, a small South American tree, is believed to have anti-inflammatory properties. Studies indicate that the application of quassia gel is associated with an improvement in rosacea.

Living with rosacea is challenging due to its prolonged duration. The relapses and remissions of the condition also make the journey exhausting. It affects psychological and mental health due to changes in 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 avoid them to relieve symptoms aggravated by these factors.
2. Establish a good cleansing regimen
   Patients should clean their skin regularly with a cleanser before going to bed and after returning home. This helps remove oil and dirt that may irritate the skin. The following tips can help reduce symptoms:
   
   • Choose a mild cleanser
   • Avoid soaps as they can be harsh and further damage the skin
   • Rinse off the cleanser with lukewarm water
   • Use only fingertips to clean the face
3. Moisturize your skin regularly
   Dry skin is more prone to sun damage. Use a good moisturizer after applying serum to restore the lipid barrier. Studies have shown that moisturizers improve treatment outcomes.
4. Protect your skin from the sun every day
   The sun is a significant trigger for rosacea. It is essential to protect the skin from the sun even on cloudy days. Sunscreen should be applied daily, irrespective of the weather.
5. Choose gentle skin care products
   Many skin care products and cosmetics can irritate the skin. Waterproof and opaque makeup should be used. Avoid products containing:
   
   • 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
   • Choose creams containing allantoin
   • Avoid astringents or toners
6. Test skin care products
   Individuals with rosacea should test skin care products before applying them to the face. This can be done by applying a small amount of product near rosacea-prone skin. If irritation occurs within 72 hours, the product should be avoided.
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. Cope with mental stress
   Rosacea has a significant psychosocial impact due to changes in appearance, affecting self-esteem and potentially leading to anxiety and embarrassment. Studies suggest that rosacea impacts 77.7% of patients emotionally, 67% socially, and 53% in their relationships and dating behavior. The following measures might help:
   
   • Engage in activities you enjoy, such as crafting, painting, and singing
   • Do regular exercise to help reduce stress
   • Join a support group, either online or offline
   • Seek help from a professional counselor
   • Connect with someone undergoing similar treatment
   • Be patient; even with treatment, it may take months for rosacea to clear up
   • Be diligent; rosacea can quickly return if sun protection is neglected. Long-term maintenance requires ongoing commitment to protecting your skin.