This is one of the more common skin diseases seen in light–skinned humans. It usually appears in early to late adult years as a facial rash. Manifestations include facial redness, easy or pronounced flushing, acne-like bumps and pustules, swelling and blunting of the fine curves of the nose, eye irritation and skin irritation (dryness and intolerance of many washes and cosmetics).
Flaring of rosacea may be triggered by sun exposure, emotional stress, alcohol consumption, cold weather, spicy foods, as well as several other factors.
Several subtypes of rosacea are commonly recognized:
- Facial redness with flushing and dilated capillaries. Just recently, several new ways of treating this type have emerged.
- Bumps and pustules. This type is often seen along with facial redness.
- Rhinophyma, or thickening and blunting of the soft tissues of the face, particularly the nose. With this subtype, we often think of unfortunate W. C. Fields, who as an aging man developed the characteristic bumpy, enlarged and disfigured nose so frequently attributed to alcohol excess. While this is mostly a male feature, some females may also be afflicted; and it may well occur without alcohol excess.
- Ocular, or eye irritation. This may include styes, dandruff of the eyelids, eyelid infections, and stinging or foreign body sensation. The eyes may appear bloodshot and sore.
The cause(s) of this disease remain mysterious. Genetics may play a role, as there does seem to be a familial trend toward having rosacea. Awe-inspiring basic scientific research has revealed some clues about its origins, but each new fact raises further questions. Suspected causes include:
- Infection: The mites that live in our skin pores may be present in greatly increased numbers in this condition, and treating these mites can lead to improvement. H. pylori, the bacterium believed to be the cause of most stomach ulcers, has been implicated in causing rosacea, though the evidence is weaker.
- Sunlight exposure: While rosacea can flare after recent bright sun exposure, there does not seem to be much correlation between rosacea and the degree of chronic sun damage in the skin.
- Nerve function: Several of the known factors that can flare rosacea (spicy food, heat and cold exposure) seem to signal the body through nerves.
- Abnormal skin barrier function: People with rosacea seem to have increased water loss from the skin and to also have greater vulnerability to the irritating effects of skin care products.
- “Twitchy” skin: Normal skin fortunately has chemicals that act as local killers of microorganisms, even before the immune system can react to signals of infection from the skin. In rosacea, some of these systems seem to be overly active, promoting inflammation and soft tissue proliferation (causing the rhinophyma nose blunting).
Treatment for rosacea may involve better skin care and the use of drugs, orally and on the surface of the skin. The defect in the skin barrier function allows us to improve the skin with the frequent use of gentle moisturizers. The known sun aggravation suggests regular use of a sunscreen (preferably SPF 30 or higher and Broad Spectrum).
Topical (on the surface) medications found useful for rosacea include antibiotics (metronidazole, sodium sulfacetamide), azelaic acid, and anti-mite products (ivermectin and permethrin). Recently a novel approach to the facial redness became available in a brimonidine tartrate gel used once daily.
Oral treatment for rosacea can be very effective, though there is no known cure and maintenance treatment may be required. The mainstay of treatment is the tetracycline group of drugs (doxycycline and minocycline). These drugs are probably not working in their known antibiotic action, as they can be effective for rosacea in doses well below the amount needed for killing bacteria. At these lower doses, they do not seem to contribute to development of antibiotic resistance. The anti-acne drug isotretinoin (Accutane) is very effective. Recently, the beta-blocker carvedilol has been used off-label in a few very difficult cases with great results.
Additionally, surgery can be used for those suffering from rhinophyma, and laser can be very effective for persistent excessive redness.
Excellent resources for learning more about rosacea (from which I have borrowed) include the National Rosacea Society (rosacea.org), and an article by Dr. Two and others in the Journal of the American Association of Dermatology, May 2015. FBN
EDWARD KAUFFMAN, M.D., FAAD, has been practicing dermatology since 1977. After graduating from the University of Arizona in Tucson in 1968, Dr. Kauffman went on to receive his medical degree in 1972 from Washington University in Saint Louis, Missouri. Dr. Kauffman completed his formal dermatology training at the same school, and became board certified in Dermatology. Most of his medical practice has been based in Bellingham, Washington, where he was also Chief of Staff at Saint Joseph’s Hospital from 1988 to 1989. Since moving back to his home state of sunny Arizona, Dr. Kauffman has become certified in Mohs surgery and enjoys practicing general dermatology. Most every weekend will find Dr. Kauffman hiking the trails near Sedona with his dogs.
