Rosacea

In this article:

• How is rosacea diagnosed?
• Treatments
• Medications
• Laser treatment
• Natural remedies
• Can rosacea be prevented?
• References

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How is rosacea diagnosed?

Most of the people who get rosacea do not even go to the doctor. Rosacea typically presents during adulthood, though it can rarely affect children. By that time, we all know how our skin feels and looks, and just by reading about rosacea, you probably can come up with diagnosis.

If you go to see a dermatologist, rosacea is a clinical diagnosis, and biopsy is not typically necessary. If there is a doubt in the diagnosis, then a dermatologist might recommend to do the biopsy. 

Histologic findings of rosacea can vary across different subtypes. Solar elastosis, telangiectasia, edema, and perivascular lymphohistiocytic infiltration can be seen in the erythematotelangiectatic subtype. 

Papulopustular rosacea presents with neutrophilic infiltration in hair follicles. Hyperplasia of sebaceous glands, fibrosis, and dilation of hair follicles are observed in phymatous rosacea. is sometimes called “adult acne” due to the similarity in the appearance. Thankfully, rosacea lacks comedones, helping to differentiate it from true acne.

Granuloma formation is seen in the granulomatous rosacea subtype.

What else can look like rosacea?

• Acne: While the two diseases share papules and pustules, the presence of comedones is unique to acne. Also, acne affect most teenagers, while rosacea comes later (30-40 years of age)
• Seborrheic dermatitis. It presents with redness and greasy scaling on the scalp and face. It tends to be distributed more in skin folds around the nostrils and hair-bearing areas of the face. You can develop both seborrheic dermatitis and rosacea. Treatment of one may unmask the other.
• Keratosis pilaris rubra. It typically affects teens with tiny small papules of the sides of the cheeks and neck on red skin patches.
• Flushing. Flushing in rosacea is usually limited to the face and more chronic. Flushing that involves other areas warrants further attention. Flushing with anxiety is due to neuro-endocrine reaction, and comes and goes fast.
• Acute cutaneous lupus erythematosus. The malar rash of lupus can appear similar to rosacea, but it usually spares the nasolabial folds and lacks papules and pustules. There are other systemic signs that soon develop.
• Drug-induced acneiform reaction. It is usually abrupt and time-wise related to a new medication intake. All papules or pustules are in the same stage, and also develop on the trunk.
• The symptoms of rosacea are reminiscent of those of alcohol abuse. They can be wrongly interpreted and lead to patients being stigmatized. In Asia, rosacea is called “Ju Sa” (酒皻). The Chinese character “Ju” 酒 means alcohol, which happens to have the same pronunciation as redness, and “Sa” 皻 means enlargement of the nose.

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Treatments

The first step in the treatment of rosacea is to advise the patient to identify and then avoid triggers such as:

• UV light 
• spices
• extreme temperatures outdoors 
• alcoholic beverages. 

Universal skin care recommendations for all patients with rosacea include pH-balanced skin cleansers (as opposed to soaps), broad-spectrum sunscreen with SPF 30 or higher and regular use of moisturizers. 

Rosacea often causes the skin to become sensitive and irritable, and products that cause irritation should be avoided. Cosmetics containing green pigment are best for masking persistent erythema. The choice of therapy is guided by the signs and symptoms present for the individual patient. 

The majority of the therapies aim to reduce inflammation. Though they provide anti-inflammatory properties, topical steroids should be avoided in rosacea as they are associated with rebound flaring or induction of rosacea-like perioral dermatitis. 

The persistent erythema and telangiectasias are not completely secondary to inflammation and often require treatment targeting the skin vasculature, such as brimonidine, oxymetazoline, or vascular laser. The phymatous changes of rosacea result in irreversible changes to the skin that require surgical intervention when indicated.

Medications

As we discussed, most people do not go to the doctors with mild rosacea. As such, they do not take medications. Meanwhile, in certain situations rosacea becomes difficult to manage, and will take you to the dermatologist. Medications can range in side effects and effectiveness.

As rosacea can be the result of taking too many medications, you should consider all pros and cons of any treatment recommendation.

Topical drugs that reduce flushing

• Brimonidine tartrate (alpha-2 agonist) 0.33% gel (Daily application on the face)
• Oxymetazoline hydrochloride (alpha-1 agonist) 1% cream (Daily application on face)
• Ivermectin 1% cream (daily application)
• Azelaic acid 15% gel, foam or 20% cream (daily 1 to 2 times application)
• Metronidazole 0.75% and 1% gel or cream (daily 1 to 2 times application)

Oral antibiotics

We highly do not recommend to use antibiotics for the rosacea. It is now believed that it is the antibiotics that are responsible for the eradicating good bacteria of the skin and gut, and leading to rosacea. 

So, trying to take less antimicrobials actually will help you cure the issue. Antibiotics are used in the treatment of the actual infection. At this point, the biopsy and skin microbial culture should be done.

Oral acne drugs

If the skin inflammation is uncontrollable or disfiguring (papules and pustules), you may try oral acne drugs:

• Subantimicrobial-dose doxycycline, modified-release (40 mg daily, 30 mg immediate-release and 10 mg delayed-release beads, for 8 to 12 weeks)
• Minocycline (50 to 100 mg twice daily for 8 to 12 weeks)
• Tetracycline (250 to 500 mg twice daily for 8 to 12 weeks)
• Azithromycin (250-500 mg 3 times weekly for 4 to 8 weeks)
• Isotretinoin (0.25 to 0.3 mg/kg/day for 12 to 16 weeks)

Laser treatment

Lasers are increasingly used modalities in the treatment of vascular lesions. 595 nm Pulse-dye laser (PDL) is a well-accepted modality in the treatment of diffuse facial erythema. PDL treatment in purpuragenic doses usually produces sufficient cosmetic improvement in 2 treatment sessions. 

Furthermore, it decreases burning, stinging, sensitivity, itching and dryness; thus increases the quality of life of the patient dramatically. However, patient discomfort and facial bruising secondary to the procedure withholds the use of PDL at purpuragenic doses.12 PDL is effective in reducing facial erythema in sub-purpuragenic doses as well, but an increased number of treatment sessions is required.

Recently, intense pulsed light (IPL) which is a flashlight that emits non-coherent light of wavelength between 400–1400 nm, was compared to PDL (at non-purpuragenic doses) in the treatment of diffuse facial erythema. 

Not only was IPL, when filtered at 560 nm, found to be as effective as PDL in the treatment of facial erythema, but also the patients treated with IPL demonstrated greater improvement than those treated with PDL in the 90 days follow-up. Furthermore, it did not produce any major side effects.13 Thus, in patients with persistent diffuse facial erythema; both PDL and IPL may be used for cosmetic improvement.

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Natural remedies

Diet and food intolerance

It has been known for a long time that skin is like a mirror of the gut. What happens in the intestines will show up as a healthy or unhealthy skin. That is why it is hard to reject the idea that food intolerance and eating junk food will affect rosacea development. Here we cite one of the latest peer-review articles, where scientists try to explain what natural doctors know for a long time:

“Dietary change may play a role in the therapy of rosacea. Certain foods and beverages may act as “triggers” for rosacea exacerbations. These may be divided into heat-related, alcohol-related, capsaicin-related, and cinnamaldehyde-related. One potential pathogenic mechanism may be via the activation of transient receptor potential cation channels, which result in neurogenic vasodilatation. Further research is needed on the role of the gut skin connection in rosacea. Epidemiologic studies suggest that patients with rosacea have a higher prevalence of gastrointestinal disease, and one study reported improvement in rosacea following successful treatment of small intestinal bacterial overgrowth. While further research is required in this area, patients may be advised on measures to support a healthy gut microbiome, including the consumption of a fiber-rich (prebiotic) diet.”

Skin care

Research demonstrates that skin changes in rosacea are very similar to the atopic dermatitis. This means the rosacea is also affecting the skin barrier, or may be even caused by the same agents that produce allergic rash. Based on this discovery, the treatment for the rosacea can follow the same recommendations:

1. Avoid any type of chemicals on the face. This includes any cosmetics, wipes, antibacterial soap, commercial creams etc.
2. Use only water or cucumber slice to wash face
3. Restore the softness. Use plant-based oils right after the wash to seal up the skin (olive, avocado, buckthorn, jojoba etc)
4. Do not use scrubs and chemical peels, at least until the rosacea is gone.
5. Try to touch your face less – mechanical irritation promotes redness and inflammation

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Can rosacea be prevented?

Many will agree that rosacea is the result of a bad genetics and bad environment merged together. The authors would agree with that statement. As such, you can try to either prevent or ease up the symptoms of rosacea by a trial of simple modifications:

1. Try to use less cosmetics. Commercial cosmetic products are chemicals that are capable of ruining the skin balance and plug up normal skin breathing.
2. Eat organic natural food
3. Avoid foods that you know will cause gastric discomfort. Eating healthy does not mean following a ‘trend’, it means eating what your body digests best
4. Take vitamins. Insufficient diet (which is most of westernized diets are) may lack skin nourishing factors – vit A, vit E, vit D, niacin, magnesium, lutein, flavonoids and much more
5. Use natural emollients and moisturizers: aloe vera, avocado oil, cucumber.

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References:

Standard management options for rosacea: The 2019 update by the National Rosacea Society Expert Committee. Thiboutot D, Anderson R, Cook-Bolden F, Draelos Z, Gallo RL, Granstein RD, Kang S, Macsai M, Gold LS, Tan J. J Am Acad Dermatol. 2020 Jun;82(6):1501-1510. [PubMed]

Managing Rosacea in the Clinic: From Pathophysiology to Treatment-A Review of the Literature. Johnson SM, Berg A, Barr C.J Clin Aesthet Dermatol. 2020 Apr;13(4 Suppl):S17-S22. Epub 2020 Apr 1.PMID: 32802248 Free PMC article. Review.

Interventions for rosacea. van Zuuren EJ, Fedorowicz Z, Carter B, van der Linden MM, Charland L.Cochrane Database Syst Rev. 2015 Apr 28;2015(4):CD003262. doi: 10.1002/14651858.CD003262.pub5.PMID: 25919144 Free PMC article. Review.

Diet and rosacea: the role of dietary change in the management of rosacea. Weiss E, Katta R.Dermatol Pract Concept. 2017 Oct 31;7(4):31-37. doi: 10.5826/dpc.0704a08. eCollection 2017 Oct.PMID: 29214107 Free PMC article. Review.

Rosacea Management. Abokwidir M, Feldman SR.Skin Appendage Disord. 2016 Sep;2(1-2):26-34. doi: 10.1159/000446215. Epub 2016 May 18.PMID: 27843919 Free PMC article. Review.

The Role of Skin Care in Optimizing Treatment of Acne and Rosacea. Zip C.Skin Therapy Lett. 2017 May;22(3):5-7.PMID: 28492949 Free article. Review.