Rosacea is a
long-term skin condition that typically affects the face.
It results in
redness,
pimple
A pimple is a kind of comedo that results from excess sebum and dead skin cells getting trapped in the pores of the skin. In its aggravated state, it may evolve into a pustule or papules. Pimples can be treated by acne medications, antibiotics, ...
s,
swelling, and
small and superficial dilated blood vessels.
Often, the nose, cheeks, forehead, and chin are most involved.
A red, enlarged nose may occur in severe disease, a condition known as
rhinophyma
Rhinophyma is a condition causing development of a large, bulbous nose associated with granulomatous infiltration, commonly due to untreated rosacea. The condition is most common in older white males.
Colloquial terms for the rhinophyma include ...
.
The cause of rosacea is unknown.
Risk factors are believed to include a family history of the condition.
Factors that may potentially worsen the condition include heat, exercise, sunlight, cold, spicy food, alcohol,
menopause
Menopause, also known as the climacteric, is the time in women's lives when menstrual periods stop permanently, and they are no longer able to bear children. Menopause usually occurs between the age of 47 and 54. Medical professionals often d ...
,
psychological stress
In psychology, stress is a feeling of emotional strain and pressure. Stress is a type of psychological pain. Small amounts of stress may be beneficial, as it can improve athletic performance, motivation and reaction to the environment. Exces ...
, or
steroid cream on the face.
Diagnosis is based on symptoms.
While not curable, treatment usually improves symptoms.
Treatment is typically with
metronidazole
Metronidazole, sold under the brand name Flagyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vaginosis. It is ef ...
,
doxycycline
Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus, an ...
,
minocycline
Minocycline, sold under the brand name Minocin among others, is a tetracycline antibiotic medication used to treat a number of bacterial infections such as pneumonia. It is generally less preferred than the tetracycline doxycycline. It is also ...
, or
tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including Acne vulgaris, acne, cholera, brucellosis, plague (disease), plague, malaria, and sy ...
.
When the eyes are affected,
azithromycin
Azithromycin, sold under the brand names Zithromax (in oral form) and Azasite (as an eye drop), is an antibiotic medication used for the treatment of a number of bacterial infections. This includes middle ear infections, strep throat, pneumon ...
eye drops may help. Other treatments with tentative benefit include
brimonidine
Brimonidine is a medication used to treat open-angle glaucoma, ocular hypertension, and rosacea. In rosacea it improves the redness. It is used as eye drops or applied to the skin.
Common side effects when used in the eyes include itchiness, re ...
cream,
ivermectin cream, and
isotretinoin
Isotretinoin, also known as 13-''cis''-retinoic acid and sold under the brand name Accutane among others, is a medication primarily used to treat severe acne. It is also used to prevent certain skin cancers (squamous-cell carcinoma), and in th ...
.
Dermabrasion
Dermabrasion is a type of surgical skin planing, generally with the goal of removing acne, scarring and other skin or tissue irregularities, typically performed in a professional medical setting by a dermatologist or plastic surgeon trained speci ...
or
laser surgery may also be used.
The use of
sunscreen
Sunscreen, also known as sunblock or sun cream, is a photoprotective topical product for the skin that mainly absorbs, or to a much lesser extent reflects, some of the sun's ultraviolet (UV) radiation and thus helps protect against sunburn and ...
is typically recommended.
Rosacea affects between 1% and 10% of people.
Those affected are most often 30 to 50 years old and female.
People with paler skin or European ancestry are more frequently affected.
The condition was described in ''
The Canterbury Tales
''The Canterbury Tales'' ( enm, Tales of Caunterbury) is a collection of twenty-four stories that runs to over 17,000 lines written in Middle English by Geoffrey Chaucer between 1387 and 1400. It is widely regarded as Chaucer's ''Masterpiece, ...
'' in the 1300s, and possibly as early as the 200s BC by
Theocritus
Theocritus (; grc-gre, Θεόκριτος, ''Theokritos''; born c. 300 BC, died after 260 BC) was a Greek poet from Sicily and the creator of Ancient Greek pastoral poetry.
Life
Little is known of Theocritus beyond what can be inferred from hi ...
.
Signs and symptoms
![Rasacee couperose zones](https://upload.wikimedia.org/wikipedia/commons/e/e2/Rasacee_couperose_zones.svg)
Rosacea typically begins with
reddening(flushing) of the skin in symmetrical patches near the center of the face.
[ Common signs can depend on age and sex: flushing and red swollen patches are common in the young, small and visible dilated blood vessels in older individuals, and swelling of the nose is common in men.][ Other signs include lumps on the skin ( papules or pustules) and swelling of the face.][ Many people experience stinging or burning pain and rarely itching.][
Skin problems tend to be aggravated by particular trigger factors, that differ for different people. Common triggers are ]ultraviolet
Ultraviolet (UV) is a form of electromagnetic radiation with wavelength from 10 nanometer, nm (with a corresponding frequency around 30 Hertz, PHz) to 400 nm (750 Hertz, THz), shorter than that of visible light, but longer than ...
light, heat, cold, or certain foods or beverages.[
]
Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea rosacea (also known as "vascular rosacea") is characterized by prominent history of prolonged (over 10 minutes) flushing reaction to various stimuli
A stimulus is something that causes a physiological response. It may refer to:
*Stimulation
**Stimulus (physiology), something external that influences an activity
**Stimulus (psychology), a concept in behaviorism and perception
*Stimulus (economi ...
, such as emotional stress, hot drinks, alcohol, spicy foods, exercise
Exercise is a body activity that enhances or maintains physical fitness and overall health and wellness.
It is performed for various reasons, to aid growth and improve strength, develop muscles and the cardiovascular system, hone athletic ...
, cold or hot weather, or hot baths and showers
A shower is a place in which a person bathes under a spray of typically warm or hot water. Indoors, there is a drain in the floor. Most showers have temperature, spray pressure and adjustable showerhead nozzle. The simplest showers have a ...
.[James, William; Berger, Timothy; Elston, Dirk (2005). ''Andrews' Diseases of the Skin: Clinical Dermatology''. (10th ed.). Saunders. Page 245. .]
Glandular rosacea
In glandular rosacea, men with thick sebaceous skin predominate, a disease in which the papules are edematous, and the pustules are often 0.5 to 1.0 cm in size, with nodulocystic lesions often present.
Cause
The exact cause of rosacea is unknown. Triggers that cause episodes of flushing and blushing play a part in its development. Exposure to temperature extremes, strenuous exercise, heat from sunlight, severe sunburn, stress, anxiety, cold wind, and moving to a warm or hot environment from a cold one, such as heated shops and offices during the winter, can each cause the face to become flushed. Certain foods and drinks can also trigger flushing, such as alcohol, foods and beverages containing caffeine
Caffeine is a central nervous system (CNS) stimulant of the methylxanthine class. It is mainly used recreationally as a cognitive enhancer, increasing alertness and attentional performance. Caffeine acts by blocking binding of adenosine t ...
(especially hot tea and coffee), foods high in histamine
Histamine is an organic nitrogenous compound involved in local immune responses, as well as regulating physiological functions in the gut and acting as a neurotransmitter for the brain, spinal cord, and uterus. Since histamine was discovered in ...
s, and spicy food
Pungency () refers to the taste of food commonly referred to as spiciness, hotness or heat, found in foods such as chili peppers. Highly pungent tastes may be experienced as unpleasant. The term piquancy () is sometimes applied to foods with a l ...
s.
Medications and topical irritants have also been known to trigger rosacea flares. Some acne
Acne, also known as ''acne vulgaris'', is a long-term Cutaneous condition, skin condition that occurs when Keratinocyte, dead skin cells and Sebum, oil from the skin clog hair follicles. Typical features of the condition include comedo, black ...
and wrinkle treatments reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin
Isotretinoin, also known as 13-''cis''-retinoic acid and sold under the brand name Accutane among others, is a medication primarily used to treat severe acne. It is also used to prevent certain skin cancers (squamous-cell carcinoma), and in th ...
, benzoyl peroxide
Benzoyl peroxide is a chemical compound (specifically, an organic peroxide) with structural formula , often abbreviated as (BzO)2. In terms of its structure, the molecule can be described as two benzoyl (, Bz) groups connected by a peroxide () ...
, and tretinoin
Tretinoin, also known as all-''trans'' retinoic acid (ATRA), is a medication used for the treatment of acne and acute promyelocytic leukemia. For acne, it is applied to the skin as a cream, gel or ointment. For leukemia, it is taken by mouth f ...
.
Steroid
A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
-induced rosacea is caused by the use of topical steroid
A steroid is a biologically active organic compound with four rings arranged in a specific molecular configuration. Steroids have two principal biological functions: as important components of cell membranes that alter membrane fluidity; and a ...
s. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare-up.
Cathelicidins
In 2007, Richard Gallo and colleagues noticed that patients with rosacea had high levels of the antimicrobial peptide cathelicidin and elevated levels of stratum corneum
The stratum corneum (Latin for 'horny layer') is the outermost layer of the epidermis. The human stratum corneum comprises several levels of flattened corneocytes that are divided into two layers: the ''stratum disjunctum'' and ''stratum compact ...
tryptic enzyme
Enzymes () are proteins that act as biological catalysts by accelerating chemical reactions. The molecules upon which enzymes may act are called substrates, and the enzyme converts the substrates into different molecules known as products. A ...
s ( SCTEs). Antibiotic
An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important type of antibacterial agent for fighting bacterial infections, and antibiotic medications are widely used in the treatment and prevention of ...
s have been used in the past to treat rosacea, but they may only work because they inhibit some SCTEs.
Demodex folliculitis and ''Demodex'' mites
Studies of rosacea and '' Demodex'' mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid-induced rosacea. Demodex folliculitis
Demodicosis , also called Demodex folliculitis in humans and demodectic mange () or red mange in animals, is caused by a sensitivity to and overpopulation of '' Demodex spp.'' as the host's immune system is unable to keep the mites under control. ...
(demodicidosis, also known as "mange" in animals) is a condition that may have a "rosacea-like" appearance.
A 2007, National Rosacea Society-funded study demonstrated that '' Demodex folliculorum'' mites may be a cause or exacerbating factor in rosacea. The researchers identified ''Bacillus oleronius
''Bacillus oleronius'' is a Gram-negative bacterium belonging to the genus ''Bacillus''. However, ''Bacillus oleronius'' has Gram-positive cell wall components shared among all bacillus species (Lacey N, 2007). It was first described in 1995 a ...
'' as distinct bacterium associated with ''Demodex'' mites. When analyzing blood samples using a peripheral blood mononuclear cell proliferation assay, they discovered that ''B. oleronius'' stimulated an immune system response in 79 percent of 22 patients with subtype 2 (papulopustular) rosacea, compared with only 29% of 17 subjects without the disorder. They concluded, "The immune response results in inflammation, as evident in the papules (bumps) and pustules
A skin condition, also known as cutaneous condition, is any medical condition that affects the integumentary system—the organ system that encloses the body and includes skin, nails, and related muscle and glands. The major function of this sy ...
(pimples) of subtype 2 rosacea. This suggests that the ''B. oleronius'' bacteria found in the mites could be responsible for the inflammation associated with the condition."
Intestinal bacteria
Small intestinal bacterial overgrowth
Small intestinal bacterial overgrowth (SIBO), also termed bacterial overgrowth, or small bowel bacterial overgrowth syndrome (SBBOS), is a disorder of excessive bacterial growth in the small intestine. Unlike the colon (or large bowel), which is r ...
(SIBO) was demonstrated to have greater prevalence in rosacea patients and treating it with locally acting antibiotics led to rosacea lesion improvement in two studies. Conversely in rosacea patients who were SIBO negative, antibiotic therapy had no effect. The effectiveness of treating SIBO in rosacea patients may suggest that gut bacteria play a role in the pathogenesis of rosacea lesions.
Diagnosis
Most people with rosacea have only mild redness and are never formally diagnosed or treated. No test for rosacea is known. In many cases, simple visual inspection by a trained health-care professional is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face is present, a trial of common treatments is useful for confirming a suspected diagnosis. The disorder can be confused or co-exist with acne vulgaris
Acne, also known as ''acne vulgaris'', is a long-term skin condition that occurs when dead skin cells and oil from the skin clog hair follicles. Typical features of the condition include blackheads or whiteheads, pimples, oily skin, and po ...
or seborrheic dermatitis. The presence of a rash on the scalp or ears suggests a different or co-existing diagnosis because rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.
Classification
Four rosacea subtypes exist, and a patient may have more than one subtype:[Marks, James G; Miller, Jeffery (2006). ''Lookingbill and Marks' Principles of Dermatology'' (4th ed.). Elsevier Inc. .]
# Erythematotelangiectatic rosacea exhibits permanent redness (erythema) with a tendency to flush and blush easily. Also small, widened blood vessels visible near the surface of the skin (telangiectasias
Telangiectasias, also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere on ...
) and possibly intense burning, stinging, and itching are common. People with this type often have sensitive skin. Skin can also become very dry and flaky. In addition to the face, signs can also appear on the ears, neck, chest, upper back, and scalp.
# Papulopustular rosacea presents with some permanent redness with red bumps (papules); some pus-filled pustules can last 1–4 days or longer. This subtype is often confused with acne.
# Phymatous rosacea is most commonly associated with rhinophyma
Rhinophyma is a condition causing development of a large, bulbous nose associated with granulomatous infiltration, commonly due to untreated rosacea. The condition is most common in older white males.
Colloquial terms for the rhinophyma include ...
, an enlargement of the nose. Signs include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnathophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Telangiectasias may be present.
# In ocular rosacea, affected eyes and eyelids may appear red due to telangiectasias
Telangiectasias, also known as spider veins, are small dilated blood vessels that can occur near the surface of the skin or mucous membranes, measuring between 0.5 and 1 millimeter in diameter. These dilated blood vessels can develop anywhere on ...
and inflammation, and may feel dry, irritated, or gritty. Other symptoms include foreign-body sensations, itching, burning, stinging, and sensitivity to light. Eyes can become more susceptible to infection. About half of the people with subtypes 1–3 also have eye symptoms. Blurry vision and vision loss can occur if the cornea
The cornea is the transparent front part of the eye that covers the iris, pupil, and anterior chamber. Along with the anterior chamber and lens, the cornea refracts light, accounting for approximately two-thirds of the eye's total optical power ...
is affected.
Variants
Variants of rosacea include:[Freedberg, et al. (2003). ''Fitzpatrick's Dermatology in General Medicine''. (6th ed.). McGraw-Hill. .]
* Pyoderma faciale, also known as rosacea fulminans, is a conglobate, nodular disease that arises abruptly on the face.
* Rosacea conglobata is a severe rosacea that can mimic acne conglobata
Acne conglobata is a highly inflammatory disease presenting with comedones, nodules, abscesses, and draining sinus tracts.
This condition generally begins between the ages of 18 and 30. It usually persists for a very long time, and often until t ...
, with hemorrhagic nodular abscesses and indurated plaques.
* Phymatous rosacea is a cutaneous condition characterized by overgrowth of sebaceous glands
A sebaceous gland is a microscopic exocrine gland in the skin that opens into a hair follicle to secrete an oily or waxy matter, called sebum, which lubricates the hair and skin of mammals. In humans, sebaceous glands occur in the greatest number ...
. ''Phyma'' is Greek for swelling, mass, or bulb, and these can occur on the face and ears.
Treatment
The type of rosacea a person has informs the choice of treatment. Mild cases are often not treated at all, or are simply covered up with normal cosmetics.
Therapy for the treatment of rosacea is not curative, and is best measured in terms of reduction in the amount of facial redness and inflammatory lesions, a decrease in the number, duration, and intensity of flares, and concomitant symptoms of itching, burning, and tenderness. The two primary modalities of rosacea treatment are topical and oral antibiotic agents. Laser therapy has also been classified as a form of treatment. While medications often produce a temporary remission of redness within a few weeks, the redness typically returns shortly after treatment is suspended. Long-term treatment, usually 1–2 years, may result in permanent control of the condition for some patients. Lifelong treatment is often necessary, although some cases resolve after a while and go into a permanent remission. Other cases, if left untreated, worsen over time. Some people has also reported better results after changing diet. This is not confirmed by medical studies, even though some studies relate the histamine production to outbreak of rosacea.
Behavior
Avoiding triggers that worsen the condition can help reduce the onset of rosacea, but alone will not normally lead to remission except in mild cases. Keeping a journal is sometimes recommended to help identify and reduce food and beverage triggers.
Because sunlight is a common trigger, avoiding excessive exposure to the sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen
Sunscreen, also known as sunblock or sun cream, is a photoprotective topical product for the skin that mainly absorbs, or to a much lesser extent reflects, some of the sun's ultraviolet (UV) radiation and thus helps protect against sunburn and ...
; others opt for wearing hats with broad brims. Like sunlight, emotional stress can also trigger rosacea. People who develop infections of the eyelids must practice frequent eyelid hygiene.
Managing pretrigger events such as prolonged exposure to cool environments can directly influence warm-room flushing.
Medications
Medications with good evidence include topical ivermectin and azelaic acid
Azelaic acid (AzA) is an organic compound with the formula HOOC(CH2)7 COOH. This saturated dicarboxylic acid exists as a white powder. It is found in wheat, rye, and barley. It is a precursor to diverse industrial products including polymers an ...
creams and brimonidine
Brimonidine is a medication used to treat open-angle glaucoma, ocular hypertension, and rosacea. In rosacea it improves the redness. It is used as eye drops or applied to the skin.
Common side effects when used in the eyes include itchiness, re ...
, and doxycycline
Doxycycline is a broad-spectrum tetracycline class antibiotic used in the treatment of infections caused by bacteria and certain parasites. It is used to treat bacterial pneumonia, acne, chlamydia infections, Lyme disease, cholera, typhus, an ...
and isotretinoin by mouth. Lesser evidence supports topical metronidazole cream and tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including Acne vulgaris, acne, cholera, brucellosis, plague (disease), plague, malaria, and sy ...
by mouth.
Metronidazole is thought to act through anti-inflammatory mechanisms, while azelaic acid is thought to decrease cathelicidin production. Oral antibiotics of the tetracycline
Tetracycline, sold under various brand names, is an oral antibiotic in the tetracyclines family of medications, used to treat a number of infections, including Acne vulgaris, acne, cholera, brucellosis, plague (disease), plague, malaria, and sy ...
class such as doxycycline, minocycline, and oxytetracycline are also commonly used and thought to reduce papulopustular lesions through anti-inflammatory actions rather than through their antibacterial capabilities.
Using alpha-hydroxy acid
α-Hydroxy acids, or alpha hydroxy acids (AHAs), are a class of chemical compounds that consist of a carboxylic acid with a hydroxyl group substituent on the adjacent (alpha) carbon. Prominent examples are glycolic acid, lactic acid, mandelic acid ...
peels may help relieve redness caused by irritation, and reduce papules and pustules associated with rosacea. Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescribed. The flushing and blushing that typically accompany rosacea are typically treated with the topical application of alpha agonists such as brimonidine and less commonly oxymetazoline or xylometazoline
Xylometazoline, also spelled xylomethazoline, is a medication used to reduce symptoms of nasal congestion, allergic rhinitis, and sinusitis. Use is not recommended for more than seven days. Use is also not recommended in those less than three m ...
.
A review found that ivermectin was more effective than alternatives for treatment of papulopustular acne rosacea. An ivermectin cream has been approved by the FDA
The United States Food and Drug Administration (FDA or US FDA) is a federal agency of the Department of Health and Human Services. The FDA is responsible for protecting and promoting public health through the control and supervision of food s ...
, as well as in Europe, for the treatment of inflammatory lesion
A lesion is any damage or abnormal change in the tissue of an organism, usually caused by disease or trauma. ''Lesion'' is derived from the Latin "injury". Lesions may occur in plants as well as animals.
Types
There is no designated classifi ...
s of rosacea. The treatment is based upon the hypothesis that parasitic mites of the genus '' Demodex'' play a role in rosacea. In a clinical study, ivermectin reduced lesions by 83% over 4 months, as compared to 74% under a metronidazole
Metronidazole, sold under the brand name Flagyl among others, is an antibiotic and antiprotozoal medication. It is used either alone or with other antibiotics to treat pelvic inflammatory disease, endocarditis, and bacterial vaginosis. It is ef ...
standard therapy. Quassia amara extract at 4% demonstrated to have clinical efficacy for rosacea. When compared to metronidazole 0.75% as usual care in a randomized, double-blinded clinical trial, Quassia amara extract at 4% demonstrated earlier onset of action, including improvement in telangiectasia, flushing, and papules. Quassia amara showed a sustained reduction of global assessment score at day 42 (reduced to 4.68 from baseline 7.65) compared to metronidazole at day 42 (reduced to 6.32 from baseline 7.2), p<0.001.
Laser
Evidence for the use of laser and intense pulsed-light therapy in rosacea is poor.
Outcomes
The highly visible nature of rosacea symptoms are often psychologically challenging for those affected. People with rosacea can experience issues with self-esteem, socializing, and changes to their thoughts, feelings, and coping mechanisms.[
]
Epidemiology
Rosaceae affects around 5% of people worldwide. Incidence varies by ethnicity, and is particularly prevalent in those with Celtic
Celtic, Celtics or Keltic may refer to:
Language and ethnicity
*pertaining to Celts, a collection of Indo-European peoples in Europe and Anatolia
**Celts (modern)
*Celtic languages
**Proto-Celtic language
* Celtic music
*Celtic nations
Sports Fo ...
heritage.[ Men and women are equally like to develop rosacea.][
]
See also
* Seborrheic dermatitis
* Keratosis pilaris
References
External links
*
Rosacea photo library at Dermnet
Questions and Answers about Rosacea
from the US National Institute of Arthritis and Musculoskeletal and Skin Diseases
{{authority control
Acneiform eruptions
Erythemas
Cutaneous conditions