By definition, rosacea is a persistent red rash over the central portion of the face lasting more than 3 months. Other supporting criteria include telangiectasia (dilated blood vessels), papules, pustules (sometimes resembling acne), coarseness of skin and flushing.
It is more common among fair-skinned European and Celtic origin. The onset age ranges from age 30-60 years old.
What causes Rosacea?
There are several theories on the causes of rosacea. The exact cause is unknown. The factors leading to formation of rosacea include:
1.Climate factors: Harsh changes in climate and prolong exposure to ultraviolet light may damage the skin connective tissue and blood vessels.
2.Blood Vessels structure: In patients with rosacea, there is an increased in the number of blood vessels as well as increased blood flow resulting in the constant flushing and redness over the checks area.
3.Medications and food: Medications like topical steroids, nasal steroids, amiodarone and high doses of vitamins B-6 and B-12 may trigger a rosacea flare. Ingested food like hot beverages, spicy food and alcohol are previously suggested to cause the flushing but there are no strong scientific suggestions and links.
4.Skin matrix degeneration: Excess anti-microbial peptides called Cathelicidin promote infiltration of white blood cells in the dermis and dilation of blood vessels. This in turn leads to dilatation of blood vessels and inflammation. Matrix metalloproteinases (MMPs) such as collagenase and elastase which usually helps in wound healing when in excess result in inflammation and coarse skin.
5.Microbial organisms: Demodex species are mites usually found on normal skin hair follicles may also play a role in the development of rosacea.
6.Helicobacter Pylori: there is an increased incidence of rosacea among people with stomach bacteria Helicobacter Pylori. However there is no strong association to link the bacteria as the etiology of rosacea.
Clinical features of rosacea
Patients may complain of intermittent symptoms or in certain patients persistent symptoms. Patients commonly present with flushing/blushing associated with dilated skin blood vessels (telangiectasia). There may also be inflammatory lesions like papules (red spots) and pustules (filled with pus) on the nose, cheek and forehead area. Besides the facial area, sometimes the lesions may also occur on the neck and chest area.
Unlike acne whereby the skin is oily, the skin of patients with rosacea is usually dry and coarse. Unlike acne, there are also no white or black comedones (blackheads) in rosacea.
Some patients may have enlarged unshapely nose with multiple prominent pores called rhinophyma. Rosacea can also affect the eyes (ocular rosacea) resulting in blepharitis (inflammation of eyelid), conjunctivitis, keratitis (inflammation of eye cornea) and episcleritis (inflammation of the sclera of eye). Firm swelling of the eyelid is called blepharophyma.
Lymphatic drainage obstruction will result in persistent swelling and redness of the face described as Morbihan disease.
Diagnosis of rosacea
Diagnosis of rosacea is by its characteristic clinical features. Biopsy is only done to exclude other medication conditions like lupus and sarcoidosis.
Treatment of rosacea
General measure include avoiding triggering factors such as sun-exposure with sunscreens, alcohol, spicy food, extreme temperatures and certain topical products that trigger rosacea. Topical steroid should be avoided as it may cause transient improvement followed by worsening of symptoms.
-topical metronidazole and azelaic acid cream/gel have been found to be useful in rosacea patients.
Topical anti-acne agents
-topical anti-acne agents like benzoyl peroxide can be used on the inflammatory papules and pustules that are present.
-tetracycline antibiotics like doxycycline and minocycline which are also used in acne cases can be used in those with rosacea to reduce inflammation and papules and pustules.
-oral antibiotics and clotrimazole can also be given to cases that are resistant to tetracyclines.
-antibiotic are often given for a period of 6 to 12 weeks to patients who do not respond to topical antibiotics or in those with more severe form of rosacea.
-topical and oral isotretinoin can be given to those who respond poorly to oral antibiotics. It is very effective.
-topical isotretinoin may cause dry cracked skin and sensitivity to sunlight.
-oral isotretinoin needs constant liver and lipid tests as it may cause adverse effects. It is not recommended in patients who are pregnant as it causes fetal abnormality.
-certain medications like carvediliol and clonidine may help reduce flushing and facial redness. They are often well tolerated however sometimes they may lower blood pressure and cause gastrointestinal side effects.
-Laser therapy like pulsed dye laser (585 or 595 nm), the potassium-titanyl-phosphate laser (532 nm), and the diode-pumped frequency-doubled laser (532 nm) are very effective against the dilated vessels hence reducing telangiectasia and redness.
-for patients with disfiguring rhinophyma, plastics surgeon can do a nose reconstruction to reshape the nose surgically.