Rosacea is a Fairly Common Condition of the Face in Adults: By David Robles, MD, PhD

Rosacea (rose-AY-sha) is a fairly common chronic inflammatory skin condition of the face.  It most frequently affects those with fair skin (Caucasians) and blue eyes and blonde hair. In about 10–20% of cases, there is a familial history of rosacea.  

Rosacea is characterized by persistent facial redness (also called erythema), dilated capillaries (telangiectasias), inflammatory papules and pustules (small acne-like lesions), and a tendency for frequent facial flushing. These skin changes primarily affect the nose, cheeks, forehead and chin.  A subset of patients (roughly 10-15%) develop symptoms of the eye known as ocular rosacea.

The exact cause of rosacea is unknown. But several contributing factors include an abnormal immune response in the skin (associated with upregulation of cathelicidin and serine protease), an increase in blood flow (rosacea patients flush more easily), increased skin sensitivity, and sometimes demodex mites.  

Demodex mites (folliculorum and brevis) are normally appearing organisms (commensals) on our face and live in the hair follicle.  Rosacea patients tend to have greater numbers of these mites. Demodex mites harbor a bacterium (Bacillus oleronius) which has been shown to increase inflammation. Its is thought that Demodex mites and their associated bacteria contribute to rosacea. 

Demodex Mites

UV exposure tends to worsen rosacea by producing reactive oxygen species, which lead to an upregulation of matrix metalloproteinases that ultimately damage the blood vessels and dermal matrix. This may lead to the redness and dilated blood vessels. There are four subtypes of rosacea. 

FOUR SUBTYPES: 

1. Erythematotelangiectatic rosacea: Redness, flushing, and visible blood vessels.
2. Papulopustular rosacea: Redness and acne-like breakouts.
3. Phymatous rosacea: Skin is oily, thickened, has a bumpy texture, and large pores.
4. Ocular rosacea: Eyes red and irritated and eyelids can be swollen. 

Erythematotelangiectatic rosacea is characterized by flushing and persistent redness, with visible blood vessels and the absence of significant papules or pustules. Topically applied vasoconstrictors like Mirvaso can be useful.  Mirvaso (brimonidine tartrate 0.5%) is a α-adrenergic receptor agonist that reduces persistent facial erythema. It starts working within 30 minutes and works up to 12 hours.  

Afrin Nasal Spray may also be used. The active ingredient in Afrin Nasal Spray is topical oxymetazoline 0.1% solution and can be applied once daily to affected facial areas.  A decrease in facial redness occurs in about 1-2 hours.  Several lasers may be used to treat the blood vessels including, the flashlamp-pumped long-pulse dye laser “V-beam”. Nonlaser intense pulsed light (IPL) is also effective for treating the redness

Erythematotelangiectatic rosacea

           

Papulopustular rosacea is characterized by redness with papules and pastules. (see below)

Phymatous rosacea is characterized by hypertrophy (enlargement) of the sebaceous glands in the nasal skin.  This characteristic enlargement is called, “rhinophyma”. Male patients are more often affected by rhinophyma. In severe cases,  hypertrophy of tissue causes nasal distortion. This can be treated with CO2 laser, electrocautery and dermabrasion.

Ocular rosacea is associated with keratitis (inflammation of cornea, the front part of the eye), blepharitis (inflammation of the eyelids), and conjunctivitis (inflammation of the white part of the eye). 

Ocular rosacea

Prolonged use of high potency topical steroids can cause an eruption of papules around the face called “steroid rosacea”. These patients need to be weaned off their topical steroids and rosacea treatment should be initiated.

TREATMENT:

• Avoid exposure to heat or hot temperature extremes.
• Avoid sunlight (seek shade, use sunscreens) and avoid sunburns.
• Avoid emotional stimuli like stress and anxiety.
• Avoid alcohol, caffeine, spicy foods, and strenuous exercise.

TOPICAL CREAMS/GELS: 

Topical metronidazole, sodium sulfacetamide, azelaic acid, sulfur cleansers, ivermectin, retinoids and calcineurin inhibitors may prescribed by your dermatologist.  Daily use of sunscreen is necessary. Topical steroids on the face should be avoided. 

SYSTEMIC TREATMENTS: 

Tetracycline antibiotics are the gold standard for systemic treatment of rosacea. The anti-inflammatory effects of tetracyclines are the main mechanism of action in reducing rosacea symptoms. Isotretinoin may be used in severe cases.

FAMOUS PEOPLE WITH ROSACEA

Bill Clinton

Prince Harry

W.C. Fields (film star in the 1920s and 1930s) 

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