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Understanding rosacea

Rosacea is a common skin disorder that causes redness of the skin of the face of many Irish people (Figure 1). It is seen in all countries and races but is most frequently seen in people who have fair, sun-sensitive skin, especially those of Celtic origin.

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Figure 1 – Rosacea

Rosacea is sometimes called acne rosacea or adult acne. It has a superficial resemblance to acne vulgaris of teenagers, however these are completely separate disorders. Rosacea causes an unsightly redness of the central part of the face and in many cases, red bumps and pimples. Rarely, patients with rosacea can develop an enlargement of the nose, a condition called rhinophyma (Figure 2).

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Figure 2 – Rhinophyma

People who develop rosacea may have a tendency to flush (or blush) very easily. This occurs especially with change in environmental temperature (going from a hot to a cold atmosphere), or taking hot drinks, or drinking alcoholic beverages. Because the redness of rosacea is made worse with alcohol intake, some people have wrongly attributed the cause of this disorder to alcohol excess.

This misconception causes additional social problems for people who suffer from rosacea. Not only do these people have an unsightly skin condition on the most prominent part of their body, some of their friends may wrongly suspect that they are abusing alcohol.

That is one of the reasons that public education about rosacea is so important.

Until this message gets across, there is a form of social stigmatisation of people with rosacea. This has led us to use the term ‘the curse of the Celts’ for rosacea, because it typically occurs in people of Celtic origin and the common misconception that excessive alcohol intake is the basis of the problem makes it a further handicap for the rosacea sufferer.

Features of rosacea

Rosacea is a skin condition that usually affects people in their 30s or 40s. Both men and women are affected, but the disorder appears to be more common in women, with men generally having more severe disease.

Once the rosacea starts, it usually persists, fluctuating in severity over many months or even years. Eventually, rosacea clears or ‘burns itself out’ and it is rarely seen in elderly persons.

A person who develops rosacea notices initially small red spots on their nose, chin, forehead or the cheeks. There is a slight stinging sensation from these spots, but no real itch, soreness or discomfort. The red spots typically appear in groups of two or three that persist for about 10 days.

These spots gradually flatten and merge into the skin, leaving behind a slight red blotch, like a ‘footprint’ of where they have been. Unlike the lesions of teenage acne, there is no tendency to scarring of the skin.

New spots frequently appear as the old ones settle. The eruption fades and then reactivates without any identifiable cause in most cases. If no treatment is given, this process continues over many months and gradually gets worse. The red blotches become more widespread and blend together so that the rosacea sufferer progressively develops a striking and embarrassing redness of the centre of their face.

In addition to developing spots, rosacea sufferers may notice that their face reddens or flushes easily, especially if they go from a cold atmosphere into a warm one.

Common features of rosacea

  • Dry, easily-irritated facial skin
  • Red spots on the face and nose
  • Persistent redness of the central face
  • A tendency to flush easily
  • Irritation of the eyelids
  • Enlargement of the nose (rarely)

Other factors that may cause increased facial redness or flushing include hot drinks (tea, coffee, soup, hot water), large hot meals, spicy foods and alcohol. These are sometimes called triggers of flushing (Table 1). This list is not exhaustive and patients with rosacea often find it helpful to keep a diary of the things to avoid that make them flush.

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Table 1 

Redness may be worsened by the appearance of tiny fine broken blood vessels (telangiectasias) on the cheeks and sides of the nose, which may form part of the clinical picture, especially in long-standing cases.

About half the people who get rosacea notice an itchy, stinging sensation of their eyes. This can be followed by the development of spots (styes) along the eyelids. The inflammation of the eyes is common but rarely serious.

A complication that occurs rarely, and mostly in male sufferers, is an overgrowth of the oil glands of the nose, causing rhinophyma. This is a very distressing condition. Inappropriate terms such as ‘clown nose’, ‘rum blossom’, and ‘whiskey nose’ have been used to in the past to describe rhinophyma. This gives an idea of the poor level of understanding of rosacea and its manifestations.

Another skin condition that sometimes accompanies rosacea is called seborrhoeic dermatitis. This shows up as a persistent dandruff of the scalp that is accompanied by a dry flakiness of the eyebrows and the sides of the nose. Seborrhoeic dermatitis usually responds well to medicated shampoos and creams. However, like rosacea, seborrhoeic dermatitis relapses after the treatment is stopped so maintenance therapy is usually necessary to keep the skin clear.

What causes rosacea?

The cause of rosacea is not known. About one-in-five people who get rosacea have a family member who also has developed the disorder. This suggests that there is a genetic vulnerability to the disorder in some families.

We know that people with fair skin are most susceptible to rosacea, but there is no evidence that sun exposure causes the problem. In fact, some people feel that a moderate amount of sun exposure is helpful to their condition. Some doctors have suggested that repeated episodes of facial flushing lead on to the other changes of rosacea (red spots, eye changes and rhinophyma), but evidence of this is lacking. In fact, most people with rosacea only develop the tendency to flush after the other skin changes have occurred.

There is nothing to suggest that rosacea is due to an infection of the skin, but strangely, it responds well to antibiotic treatment. This apparent paradox is explained by the fact that antibiotics used to treat rosacea have many other actions apart from their ability to kill bacteria, including anti-inflammatory activities.

Although certain dietary elements (including alcohol) may act as triggers to flushing or more rarely, flare the skin eruptions, it is unlikely that these triggers are the cause of the problem and following strict diets does not clear the disorder.

A consistent but often overlooked finding in the skin of patients with rosacea is the presence of tiny skin mites called demodex folliculorum. These microscopic creatures live in the oil canals of the face and the eyelids. Patients with rosacea have about four times as many demodex mites in their skin compared with people with clear skin.

Research funded by the Health Research Board (HRB) has helped to determine what the relationship is between these mites and rosacea. This research has shown that the oil in the skin of rosacea patients is different, and possibly conducive to the multiplication of these mites.

Interestingly, some anti-mite treatments can clear skin lesions in rosacea patients, but these treatments have not yet been studied in sufficient detail to ensure they are safe and effective in the long-term.

Treatment

The redness of the face seen in patients who experience repeated flushing episodes is difficult to treat. These skin changes may be mainly due to wind and weathering of fair skin and therefore the consistent (winter and summer) use of sun-block protective creams is important for all patients with rosacea.

Avoidance of potential trigger factors (Table 1) is also important. Promising new creams and gels with the ability to reduce redness are being investigated in clinical trials and should be available in the near future.

The spots of rosacea usually respond well to antibiotic treatment. This treatment may be given in oral form (for moderate or severe rosacea) or used topically (in the form of a cream or gel for milder rosacea).

Sometimes a combination of the tablets and the topical treatments are prescribed. The treatment takes up to six weeks to completely flatten the red bumps and pimples. Initially the spots reduce in number; they don’t persist as long and flatten quickly on to the skin surface. The redness reduces as the spots clear.

When the skin lesions settle, maintenance therapy is often prescribed in the form of a cream or gel to be applied to the facial skin at night. When the skin remains uninflamed for several months, the redness gradually fades. If the skin remains clear after six months, the maintenance treatment can gradually be stopped.

Remember that rosacea is a disorder that comes and goes for many months or even years in most people, so patients should be advised that they could experience a reoccurrence.

Usually this responds well to the same treatment as was given before.

If a rosacea sufferer develops rhinophyma, they will probably require a surgical approach to remedy the problem. This is usually done by a plastic surgeon who may use traditional surgical excision techniques, or alternatively a form of laser (CO2 laser). Either of these approaches can lead to very satisfactory results, with a marked improvement in appearance. Occasionally after some years, a patient may notice a mild re-occurrence of the rhinophyma and repeated treatment may be needed.

Interestingly, the eye symptoms of rosacea (burning, stinging, dry or watery eyes) often respond to the same antibiotic treatment that is prescribed for the skin lesions. There are also eye drops and gels that can be prescribed.

Sometimes, if the eye symptoms are severe, or if the patient experiences pain or blurred vision, they should be advised to see an eye specialist.

In most cases rosacea is mild, can be successfully treated, and leaves no permanent damage in the skin.

*Article is an abridged version of the bookletROSACEA: The Curse of the Celts — A Handbook for Patients and the General Public,reproduced with permission from the Irish Skin Foundation. www.skinfoundation.ie

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