Rosacea

Rosacea is a non-infectious skin condition that can come and go as flare-ups. Flare-ups occur when the central part of your face becomes red and flushed, alongside small pus-filled lumps (pustules) and spots that can become infected. Your facial skin will often become dry and flaky. Flare-ups can last for weeks or months.

Other symptoms include: 

• A stinging or burning sensation when you wash your face or apply skincare products, sunscreen or make-up
• An enlarged, red nose (rhinophyma) with prominent sweat pores (sebaceous hyperplasia) 
• Pustules on your cheeks, chin, forehead and nose, and in rare cases, your upper chest and upper arms 
• Red, sore or crusty eyelid margins (blepharitis)
• Sore or tired eyes — you may also be more prone to eye infections such as conjunctivitis, keratitis, episcleritis
• Telangiectasia — small blood vessels on your nose and cheeks become visible due to swelling 

You may also develop swellings on some parts of your face, including your eyelids (blepharophyma) and persistent, small yellow-brown bumps (papules). 

Rosacea can lead to Morbihan disease, persistent redness and swelling of your upper face, sometimes with collections of fluid that feel firm to the touch (solid oedema). 

There are four types of rosacea. Your GP will be able to tell you which type you’ve got. In some cases, it can affect you psychologically as well as physically.

There is currently no cure but you can find relief from your symptoms by making lifestyle changes. If these do not work, your GP may prescribe cream or pills to clear it up.

The four main types of rosacea are: 

• Erythematotelangiectatic rosacea — this causes flushing, skin discolouration and visible small blood vessels.
• Ocular rosacea — this irritates the eyes and causes eye redness and swollen eyelids
• Papulopustular rosacea — this causes breakouts similar to acne, flushing and swelling 
• Phymatous rosacea — this causes bumpy, thickened skin

A fifth type of rosacea called steroid rosacea is caused by the long-term use of corticosteroids to treat the skin conditions dermatitis and vitiligo.

Who is affected by rosacea

Rosacea usually affects people aged between 30 and 60, especially if you have fair skin. It can be mistaken for acne or a ruddy complexion. You’re more likely to have it if you’re a woman, although it can be more severe in men who do get it. It can run in families and you are at greater risk of developing rosacea if you are of northern or eastern European descent.

You may find that you’re blushing or have sunburn more often than usual, which doesn’t fade away. Over time, the skin on your face may feel:

• Burning, stinging or more sensitive
• Bumpy — hard, yellow-brown bumps (papules) can develop around your mouth and/or eyes
• Dry, rough or flaky
• Hot, red and sore — flushing can cause your skin to darken and feel hot; flushing can spread from your face to your neck and chest
• Spotty — acne-like bumps that may be filled with pus can develop
• Thicker — this usually occurs on the nose, causing it to become enlarged (rhinophyma) and affects men more than women

You may also see obvious blood vessels (telangiectasia), particularly on your cheeks, the bridge of your nose and central face. Your face may appear swollen in areas as fluid and proteins leak out of your blood vessels. 

If you have darker skin, you may not develop redness of your skin but there are other symptoms you can look out for, including brown or grey skin discolouration and darker patches of skin.

If your rosacea affects your eyes (ocular rosacea), you may also develop eye symptoms, including:

• Red, sore and/or irritated eyes
• Red, swollen and crusty eyelids (blepharitis)
• Styes 
• Watery eyes

Left untreated, ocular rosacea can cause permanent blurred vision.

If you’re worried about your symptoms, especially if they affect your eyes, arrange to see your GP as soon as possible.

Before your appointment with your GP, you may want to make a list of questions to ask. You may have questions about rosacea, such as what causes it and whether it is contagious and/or hereditary. You may also have questions about getting a diagnosis and your prognosis, such as: 

• Can rosacea be diagnosed before I have a flare-up?
• Is there a specific test for rosacea?
• Does rosacea worsen with age?
• How long does rosacea last?

You may have questions about your symptoms and how they may be affected by other conditions, such as:

• Can rosacea affect my eyes?
• Does menopause affect rosacea?
• Is dry, flaky skin common with rosacea?
• Is it common to have rosacea and acne? 
• Is oily skin common with rosacea?

You may have questions about what triggers your rosacea, such as: 

• What are the most common lifestyle and environmental triggers for rosacea?
• How effective is avoiding these triggers in treating rosacea?
• How long after exposure to a trigger, will my rosacea flare up?

You may have questions about your treatment, such as:

• How is rosacea treated?
• Why am I being prescribed antibiotics for my rosacea? 
• Can my rosacea become resistant to antibiotics? 
• Aside from antibiotics, what other treatments are there for rosacea? 

In most cases, your GP will be able to diagnose rosacea by examining your skin. They will look for common symptoms such as flushing, papules, pustules, telangiectasia and eye symptoms (inflammation, irritation, blepharitis). They will also check to see if your skin is dry or flaky and if you have facial oedema, and will ask if your skin feels stingy or burning. This will help them rule out other common skin conditions such as eczema and dermatitis. 

If your eyes are affected, your GP may refer you to an ophthalmologist (a doctor who specialises in treating eye problems).

In some cases, they may refer you to a consultant dermatologist (a doctor who specialises in diagnosing and treating skin conditions). You might have a blood test or a biopsy, where a tiny sample of skin is taken for analysis. This is to check for other conditions such as pityriasis, menopause or lupus and can also detect inflammation and changes in your blood vessels.

It isn’t always possible to know what causes rosacea. It may be to do with: 

• Demodex mites — these mites are present on most people’s skin but usually don’t cause any symptoms; however, people with rosacea have a higher number on their skin, which may trigger the immune system to attack, causing inflammation; inflammation may also be caused by bacteria associated with the mites
• Facial blood vessels — ultraviolet (UV) radiation present in sunlight has been shown to increase the production of a chemical in the body called vascular endothelial growth factor (VEGF), which is linked to the swelling of small blood vessels which occurs in rosacea 
• Genetics — rosacea can run in families 
• Immune system — your body may mistakenly attack healthy tissue in your face causing inflammation
• Nervous system — abnormal stimulation of the sensory nerves around blood vessels in your face may cause rosacea; rosacea has been shown to increase the number of sensory nerves around facial blood vessels

Differences in fatty acids in facial skin and overactivity of chemicals (niacin) involved in flushing may also contribute to rosacea. 

Some things can trigger rosacea or make it worse. These include:

• Eating spicy foods and/or drinking hot drinks or alcohol
• Emotional stress
• Environmental factors — this includes too much exposure to the sun or windy weather, high humidity and very hot or cold weather
• Exposure to high heat indoors and hot baths and showers
• Intense exercise
• Using certain skincare products

Rosacea can’t be cured but it can be treated. Your GP might suggest some lifestyle changes, such as: 

• Avoiding harsh or perfumed products
• Avoiding oil-based facial creams, sunscreens and make-up — you can instead use water-based alternatives
• Cutting out alcohol and/or spicy foods 
• Keeping your face as cool as possible by avoiding hot baths, hot showers and warm rooms
• Using oil-free facial sunscreen to protect your skin from the sun — use a high protection sunscreen that is at least SPF 30

You may want to try holding an ice cube between your gums and cheek to temporarily reduce facial redness. Do not apply a topical steroid to your rosacea — it may temporarily reduce your symptoms but your rosacea will then worsen considerably in the weeks following.

Your GP may prescribe medications to relieve your symptoms. This may include: 

• Antibiotics to treat severe rosacea with papules and pustules eg doxycycline or minocycline — you will usually need to take a course of antibiotics for six to 12 weeks and often will need repeated courses when symptoms return; if doxycycline or minocycline are not effective you may be prescribed cotrimoxazole or metronidazole
• Cream to reduce redness eg brimonidine and oxymetazoline, which constrict your blood vessels — it can take up to eight weeks for the cream to work
• Cream to treat acne-like symptoms in mild rosacea eg azelaic acid, ivermectin and metronidazole — azelaic acid and metronidazole take at least two to six weeks to work; ivermectin takes at least six weeks to work but the effects last longer than azelaic acid and metronidazole
• Eye drops for ocular rosacea
• Isotretinoin tablets to treat severe rosacea with acne-like spots

If your nose has become swollen, your GP may refer you to a consultant dermatologist or to a plastic surgeon who specialises in repairing or reconstructing the face.

Laser therapy and other light-based therapies are also available to reduce redness caused by blood vessels and to treat papulopustular rosacea. Repeated treatments are usually needed.  

Telangiectasia can also be treated with laser or light-based therapies but if these treatments are not successful, telangiectasia can be treated with more invasive procedures ie cautery, diathermy (electrosurgery) or sclerotherapy (strong saline injections).

Rosacea can be mistaken for or occur alongside other skin conditions, such as: 

• Acne vulgaris
• Acute systemic lupus erythematosus
• Demodicosis
• Dermatomyositis
• Dermatitis — this include: 
• Irritant contact dermatitis
• Periocular dermatitis
• Periorificial dermatitis
• Seborrhoeic dermatitis
• Keratosis pilaris atrophicans faciei

Common types of rosacea may also be mistaken for steroid rosacea and rosacea fulminans, while flushing could be caused by other conditions instead of rosacea. Rosacea can also be mistaken for ageing skin.