Rosacea

What is rosacea and what are the symptoms?

Rosacea is a skin condition that affects parts of the face. It is sometimes called 'acne rosacea' as it can look similar to acne. However, it is a different condition to acne. Symptoms of rosacea include one or more of the following:

• Frequent flushing of the face, similar to blushing. This is often the first symptom and may be the only symptom for months or years before anything else develops.
• Redness (erythema) of parts of the face. This can look similar to sunburn.
• Small lumpy red spots (papules) and small cysts (pustules) on the face. The spots and cysts look similar to acne. These may 'come and go' in some cases, but remain long-term unless treated in others.
• Telangiectasia on the face. These are tiny blood vessels under the skin which you can see and can become quite prominent on the face.
• Eye symptoms (also called ocular rosacea) occur in about half of cases, but are often mild. They can include:
  • A feeling of something in the eye
  • Burning, stinging or itchy eyes
  • Dryness
  • Sensitivity to light
  • Eyelid problems such as cysts, styes or eyelid inflammation (blepharitis)
  Inflammation and infection of the cornea (the front of the eye) is an uncommon but serious complication that can affect vision. See a doctor urgently if you develop eye pain or visual problems.
• Thickening of the skin occurs in some cases. The most well known example of this is called a rhinophyma (a bulbous, bumpy nose). This is uncommon.

• Some people only ever get one or two of the symptoms. These may be just mild and not too troublesome. For example, some people just have facial flushing and/or mild redness of the face and never develop any other symptoms.
• Some people may develop several symptoms, but one symptom may dominate.
• Spots are a prominent feature in some cases, but not all.
• Rhinophyma is uncommon, but may occur even without any other symptoms.
• Eye symptoms occur in some people before any skin symptoms develop.

In short, the development and severity of symptoms can vary greatly.

Who gets rosacea?

Around 2 to 5 in 100 people in the UK are thought to develop rosacea. This is a lot of people, but many cases are mild. Symptoms may first appear in your early 20s, but the usual age that symptoms appear is in your 30s-50s. Rarely, rosacea can affect children. Women are more commonly affected than men. However, rosacea is often less severe in women than in men. Rosacea is more common in fair-skinned than dark-skinned people.

What causes rosacea?

The exact cause of rosacea is not known. A number of factors may be involved. However, none of these factors has definitely been proven to be the cause. For example:

• Tiny blood vessels under the affected skin may become abnormal or 'leaky'.
• Sun damage.
• A tiny mite called demodex follicularum may be involved. It lives harmlessly on the skin of many people but has been found in higher numbers in those with rosacea.
• Abnormal immune reactions in the skin which leads to inflammation.
• Genetics may also be involved as rosacea may run in some families.

Long-term use of steroid creams on the face can cause a condition identical to rosacea. This used to be quite common. However, the danger of overusing steroid creams is now well known, and this is now an uncommon problem.

How is rosacea diagnosed?

Rosacea is usually diagnosed by your typical symptoms and its typical appearance on your face. There are no specific investigations that are needed to confirm the diagnosis of rosacea. However, sometimes your doctor may do a test such as a blood test to help exclude other problems that may cause redness of the skin such as systemic lupus erythematosus (a separate leaflet gives more details on this condition).

What are the common treatments for rosacea?

There is no permanent cure for rosacea. There is nothing you can do to prevent rosacea from starting. However, treatments can ease the symptoms. The treatments used may vary, depending on what symptoms develop. Treatment may need to be adjusted over time depending on your response to treatments, and if you develop different symptoms.

General measures

Avoid strong sunlight to the face. Sunlight is thought to make symptoms worse. Use a sun-block cream on the face with a high protection factor (30 or higher and with UVA and UVB protection). It is difficult to say what is 'strong sunlight'. Therefore, many doctors would advise that you apply sun-block every day before you go out, whatever the level of sunshine. A wide brimmed hat will also help to protect your face from the sun.

If you have dry skin, you can try a hypoallergenic, non-perfumed and non-greasy moisturising cream. Also, you should generally avoid using any steroid creams (unless advised by your doctor) or other abrasive creams on your face. Men may also find that using an electric razor rather than shaving with a blade helps their symptoms.

Treatment for facial flushing

There is no medicine that can prevent or stop flushing. However, some people find that certain things aggravate the skin and trigger flushing or make the flushing worse. The most common things reported that may 'trigger' the skin to flush are: extremes of temperature (in particular excessive heat), alcoholic drinks, strenuous exercise, stressful situations, sunlight, spicy food, hot drinks. If any of these seem to trigger bouts of flushing, or make the flushing worse, then avoiding them is sensible.

Some medicines used for other conditions may also trigger flushing. For example, calcium-channel blockers. If you suspect that a medicine is making the flushing worse, then discuss this with your doctor. An alternative medicine may be available.

Treatment for facial redness (erythema) and telangiectasia (tiny blood vessels)

There is little evidence that medication has any effect on clearing erythema or telangiectasia. However, a treatment for spots (listed below) may be advised to prevent spots from developing if you have persistent erythema.

Also, people with erythema often have sensitive skin which can make erythema worse. Therefore, it is best to avoid using anything that may sensitise the skin. For example, cleansers containing acetone or alcohol, abrasive or exfoliant preparations, oil-based or waterproof make-up, perfumed sun-blocks, or those containing insect repellents.

Camouflage creams can help to cover and conceal erythema and telangiectasia. (The British Red Cross provide cosmetic camouflage clinics free of charge - see address below.)

Another option which is becoming more popular is light or laser therapy. Briefly, a laser or very bright light of a certain wavelength can destroy tiny blood vessels under the skin but without damaging the nearby tissue. This can remove telangiectasia and improve erythema. Your doctor or skin specialist will advise if this is an option for you.

Treatment for spots and cysts (papules and pustules)

Certain antibiotics are the usual treatment. They usually work well, but it is not clear why they work as there is no proven bacteria (germ) that causes rosacea. Some antibiotics reduce inflammation in the skin as well as killing bacteria and this may be why they work for rosacea. A topical (rub on) antibiotic called metronidazole is the common treatment if you have just a few small spots. If you have many spots or cysts then antibiotic tablets such as a tetracycline or erythromycin may be used.

Some improvement may occur after 2-3 weeks of treatment. However, it commonly takes a 6-12 week course of antibiotics to clear spots and cysts. One reason why antibiotic treatment fails is that some people give up on treatment after a few weeks without completing the full course.

When a course of antibiotic treatment is finished, the spots or cysts commonly return at some point. Therefore, repeated courses of treatment may be needed from time to time. As an alternative, once the spots have cleared, some people take a regular 'maintenance' dose of antibiotics or use a topical antibiotic (regularly or intermittently) long-term to prevent the spots and cysts from returning.

Topical azelaic acid is an alternative to topical antibiotics to treat mild to moderate spots. However, some people find that it can cause side effects such as burning, stinging, itching, scaling, and dry skin.

Treatment for eye problems

Eye symptoms, if they occur, are often mild and may not need any treatment.

• If dryness of the eyes is a problem then regular use of artificial tears will help. See separate leaflet called 'Dry Eyes' for details.
• If eyelid inflammation (blepharitis) is a problem then regular eyelid hygiene will help. This is described in detail in a separate leaflet called 'Blepharitis'.
• If eye symptoms become troublesome, a course of antibiotic tablets (as described above) will usually settle the symptoms.
• If a more serious eye problem occurs then you will need to be referred to an eye specialist for treatment. For example, steroid drops may be advised by a specialist to treat inflammation of the cornea (an uncommon complication of rosacea).

Treatment for rhinophyma

Rhinophyma (an unsightly bumpy nose) is an uncommon symptom of rosacea. If it occurs, surgical or laser treatment usually works well to 'trim back' the thickened skin. However, these treatments are not generally available on the National Health Service.

Further help and advice

Myrosacea

Web: www.myrosacea.co.uk
A website that provides practical advice for anyone who wants to know more about rosacea. The website is operated by Valeant Pharmaceuticals Limited.

Red Cross Skin Camouflage Service

British Red Cross Association, 44 Moorfields, London, EC2Y 9AL
Tel: 0844 871 11 11 Web www.redcross.org.uk
Aims to teach people how to apply camouflage creams and to help people to feel more confident about their appearance. Clinics are usually held in hospital skin departments or in Red Cross branch offices. A letter of referral from a GP or specialist is needed.