Rosacea

Rosacea is a chronic inflammatory skin disorder affecting the central face. It is an episodic and variable condition but classically presents as acne-like bumps (papules and pustules), red or pink patches and broken capillaries facial flushing. It is more common in people with fair skin, blue eyes, and those of Northern European or Celtic origin. Rosacea usually affects those aged 30 to 50. It is more common in females than males but males are more likely to develop phymatous rosacea. Triggers can make rosacea so the best you can do to help yourself is to learn everything you can about rosacea.

Causes

A number of factors may be involved and they often overlap:

• Genetic vascular reactivity results in increased blood vessel density near the skin surface. Increased blood flow to the facial vasculature then leads to flushing or transient erythema. This is controlled by vasodilatory mechanisms. Rosacea is thought to have a genetic component, with a higher incidence found in fair-skinned individuals of Celtic or northern European descent.
• Demodex follicularum (a microscopic mite that lives in the hair follicles). D. follicularum has antigens that react with blood from patients with rosacea to cause inflammation. Studies have shown that treatment of Demodex mites with topical ivermectin improves inflammatory rosacea.
• Cathelicidins – Patients with rosacea have high levels of antimicrobial peptides such as cathelicidins. Canthelicidins are important for our skin’s defence against microbes but they are also pro-inflammatory and stimulate the release of cytokines that leak into the dermis, causing inflammation.
• Matrix metalloproteinases (MMPs) such as collagenase and elastase are also found in high concentrations. They can cause inflammation on their own or through activation of cathelicidins.

Learn about the triggers or aggravating factors of rosacea

Anything that predisposes to flushing aggravates rosacea.

• Consumption of alcohol, hot fluids and spicy foods such as curries.
• Exposure to the sun, cold and wind, hot baths, showers and saunas.
• Vigorous exercise.
• Vasodilating drugs (drugs that open out the blood vessels so as to improve the circulation or reduce blood pressure).
• Use of strong topical steroids on the face.
• Menopause.
• Stress, anger or embarrassment

Types of rosacea
There are four sub-types and they may overlap:

• Erythematotelangiectatic rosacea (ETR), also known as vascular rosacea
  • Frequent blushing and flushing.
  • Temporary or persistent facial redness in the central portion of the face.
  • Telangiectasias (broken capillaries ) on the nose, cheeks and chin; and occasionally,  the ears, neck or upper chest.

• Papulopustular rosacea (PPR) or inflammatory rosacea – can be confused with acne, but affects the central area of the face and an older age group, commonly women.
  • Persistent or episodic development of red papules and pustules on the central face.
  • There may be background ETR.
  • Patients are typically middle-aged women.

• Phymatous rosacea
  • Phymatous rosacea is characterised by hyperplasia (thickened skin) because of chronic inflammation.
  • The nose is most commonly affected, leading to rhinophyma (craggy enlargement of the nose).
  • The skin pores (pilosebacous openings) are prominent on the nose and discharge sebum (oil). Sebaceous discharge may be elicited from the dilated follicles.
  • Telangiectasia and pustules are often present.
  • Usually affects older men.

•  Ocular rosacea
  • Occurs in more than 50% of people with rosacea.
  • Presents with red, sore or gritty eyelid margins or eyes. This can result in inflammation of the eyelids (blepharitis), conjunctivitis and inflammation of the white part of the eye (episcleritis).
  • In some cases, ocular rosacea may also be associated with corneal damage. In severe cases, assessment by an ophthalmologist is recommended.
  • It can affect males and females alike.

Variants

• Granulomatous rosacea is a rare variant of rosacea characterised by firm, yellow, red-brown or flesh-coloured papules or nodules on otherwise normal skin around the eyes, nose, and mouth. The diagnosis has to be confirmed on skin biopsy showing granulomas.
• Rosacea fulminans – Previously called pyoderma faciale is characterised by the sudden eruption of inflamed nodules, pustules and abscesses with draining sinuses accompanied by low-grade fever, elevated ESR, and possibly elevated white blood cell count. Patients may complain of a sudden increase in seborrhoea (oiliness) prior to the eruption. It usually affects women in the 20s and 30s.

Complications

• Bulbous enlargement of the nose known as  rhinophyma which is more common in men.
• Morbihan disease or oedematous rosacea is characterized by persistent red swollen skin on the face. It is believed to be due to lymphatic obstruction.

 Learn how you can help rosacea

• Avoid triggers of flushing.
• Use mild cleansers.
• Avoid alcohol containing skincare products, scrubs and other harsh products.
• Protect your skin with sunscreen and wear a hat.
• Keep your face cool to reduce flushing.
• Use cosmetics to hide the ruddy complexion.

Treatment

Rosacea is usually diagnosed clinically except in cases of granulomatous rosacea where a skin biopsy is necessary. There’s no permanent cure but treatment can control symptoms and clear the spots and learn the self-help tips that can help reduce the severity of rosacea.

• Topical treatments can be used in combination with oral treatment.
  • Metronidazole, azelaic acid and ivermectin creams or gels.
  • Brimonidine to reduce redness.
• Oral treatments:
  • Oral antibiotics such as tetracyclines (doxycycline or minocycline) or erythromycin to reduce inflammation.
  • Isotretinoin (a retinoid)
• Lasers such as pulsed-dye lasers and long-pulsed NdYag or Alexandrite lasers can be used to treat redness and telangiectasias. However several treatments are required and recurrences are common.

Watch Dr Lim’s video on Acne Rosacea: