Rosacea

What is rosacea?

Rosacea is a chronic inflammatory skin condition predominantly affecting the central face and most often starts between the age of 30–60 years.

Rosacea is common and is characterised by persistent facial redness. It typically has a relapsing and remitting course, with symptoms controlled by lifestyle measures, general skin care,medications and procedural interventions.

Who gets rosacea?

Rosacea is estimated to affect around 5% of adults worldwide. Although rosacea is often thought to affect women more than men, studies have revealed an approximately equal gender distribution.

Rosacea typically presents after the age of 30 and becomes more prevalent with age. However, it can occur at any age and occasionally presents in children. Although rosacea can affect anyone, it is more common in those with fair skin, blue eyes, and those of Celtic or North European descent. It may be more difficult and under-recognised in patients with skin of colour.

What causes rosacea?

The pathogenesis of rosacea is thought to be multifactorial and includes: 

Genetic susceptibility

Altered microbiome of the skin and gut

Bacterial overgrowth of the small intestine, Helicobacter pylori infection, and increased density of Demodex folliculorum and Staphylococcus epidermidis on the skin may play a role in skin inflammation.

Dysregulation of the immune response

This may lead to excessive inflammation, vasodilation, lymphatic dilatation and angiogenesis.

Neurocutaneous mechanisms

Triggers include ultraviolet (UV) light, temperature change, exercise, spicy foods, alcohol, psychological stress, air pollution and tobacco smoking.

Impaired skin barrier

Affected skin displays features indicating skin barrier impairment, allowing bacterial colonisation and inflammation. 

Innate immunity

In the skin of patients with rosacea, there is increased expression and activity of toll-like receptor 2, cathelicidins, kallikrein 5, and mast cells. Furthermore, cathelicidin LL-37 increases sensitivity of the skin to the sun.

The result is an exaggerated innate immune reaction to the initial trigger. 

Adaptive immunity 

Dominant T-helper (Th)1/Th17 gene expression in all features of rosacea.

Increased Th17 expression can increase levels of cathelicidin LL-37 in keratinocytes and drive further inflammation.

The most significant environmental trigger is UV light; affected skin is more sensitive to exposure. UV light can damage the dermis and increase skin inflammation.

What are the clinical features of rosacea? 

Cutaneous features include:

Transient recurrent redness  ie flushing, Persistent facial erythema Telangiectasia of facial skin other than in the nasal alar region

Eyelid margin telangiectasia

Inflammatory papules and pustules (papulopustular)

Phymatous changes

Thickening of the skin due to hyperplasia/ fibrosis of the sebaceous glands of the face.Most common area affected is the nose (termed rhynophyma) which is more commonly present in men.

Occasionally rosacea induces facial lymphoedema (Morbihan disease), producing redness, and swelling of the face and lids.

Facial tenderness and burning pain accompanied by redness and flushing (neurogenic rosacea) is a rare variant of rosacea.

Non-cutaneous ocular features (affects over 50% of patients with rosacea):

• Dryness
• Foreign-body sensation
• Photophobia
• Conjunctivitis
• Blepharitis
• Keratitis — can lead to long-term eyesight impairment.

How do clinical features vary in differing types of skin?

Rosacea is diagnosed more frequently in fair-skinned patients of Celtic and Northern European descent. 

It may be harder to identify key features of rosacea in patients with skin of colour. These features are likely under-recognised and rosacea may be underdiagnosed in these patients.

What are the complications of rosacea?

The main complications of untreated rosacea are:

• Phymatous rosacea
• Inflammatory eye complications (eg, blepharokeratoconjunctivitis, sclerokeratitis)
• Rosacea patients may experience negative psychosocial effects:
  • Associated with increased anxiety, depression, low self-esteem, and social isolation
  • Some features may cause physical discomfort, eg, ocular symptoms
  • Trigger avoidance leading to lifestyle limitations.

Statistically significant association with rosacea has been demonstrated with depression, hypertension, cardiovascular diseases, anxiety disorder, dyslipidemia, diabetes mellitus, migraine, rheumatoid arthritis, Helicobacter pylori infection, ulcerative colitis, and dementia.

Diagnostic criteria

• Persistent centrofacial erythema associated with periodic intensification by potential trigger factors
• Phymatous changes

Major criteria (must occur in centrofacial distribution)

• Flushing/transient centrofacial erythema
• Inflammatory papules and pustules
• Telangiectasia — visible blood vessels (excluding nasal alar telangiectases which are common in adults)
• Ocular rosacea- lid margin telangiectasia, blepharitis, keratitis/conjunctivitis/sclerokeratitis/anterior uveitis).

Minor features

• Burning sensation of the skin
• Stinging sensation of the skin
• Oedema
• Dry sensation of the skin.

In cases where there is diagnostic uncertainty, skin biopsy be considered.

What is the treatment for rosacea? 

Although there is no cure for rosacea, symptoms can be managed with the following lifestyle measures, medical, and procedural interventions. 

General measures

All patients with rosacea should receive education on general skincare and lifestyle measures. 

Lifestyle advice

Encourage patients to record a symptom diary to aid the identification of triggers:

Common triggers include spicy food, hot/cold temperatures (hot baths), exercise, sun exposure, cosmetic products, medications (those that cause vasodilation), alcohol, fruits and vegetables, dairy, marinated meat products.

Avoid the triggers identified.

General skincare advice

Moisturise frequently

Use gentle over-the-counter cleanser, mild, synthetic detergent-based cleansers rather than traditional soaps due to risk of irritation

Use physical sunscreen (zinc oxide/titanium oxide) with SPF ≥ 30

Provides broad-spectrum UV and visible light protection Which may be better tolerated than chemical sunscreens

Avoid exfoliants

Avoid alcohol-based topical products

Avoid use of topical steroids as they may aggravate the condition

Cosmetics with a green tint are useful to minimise the appearance of redness.

Psychosocial considerations

Assess the patient’s psychosocial burden of disease and consider referral for psychological support where necessary.

Specific measures

Existing treatments for rosacea can be very effective — however, they often target only one feature. This means that a combination of therapies are required where patients present with multiple features and in severe rosacea.

Many of the following treatments are first-line therapies recommended by the 2019 ROSCO panel: 

Transient erythema (flushing)

Alpha-adrenergic agonists (topical brimonidine , topical oxymetazoline) — they are often used infrequently for special occasions only, as persistent use may result in rebound flushing on discontinuation

Oral beta-blockers ( Carvedilol)

Oral clonidine may reduce flushing

Persistent erythema

Alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline, as above)

Intense Pulse Light Laser

Inflammatory papules/pustules

Topical Azelaic (mild/moderate only)

Topical Ivermectin

Topical Metronidazole (for mild/moderate only)

Topical Erythromycin

Oval Tetracyclines (oxytetracycline, lymecycline, doxycycline)

Oral macrolides (erythromycin azithromycin)

Oral metronidazole 

Oral isotretinoin often at low dose (for refractory disease only)

Telangiectasia

• Intense pulsed light therapy
• Vascular laser
•  

Neurogenic rosacea

• Gabapentin
• Amitriptyline
• Oral beta-adrenergic blocker. 

Rhinophyma

• If clinically inflamed: doxycycline, isotretinoin
• If clinically non-inflamed: physical modalities to remove excess tissue and reshape the structures (eg, ablative C02 laser. surgical debulking)

Ocular rosacea

General management

Increase dietary intake of omega-3 fatty acids

Warm compresses

Gentle eyelash/eyelid cleansing to express sebum trapped in the meibomian glands

First-line medical management

If mild-moderate: topical azithromycin/topical calcineurin inhibitors

If severe: azithromycin, doxycycline.

What is the outcome for rosacea?

Although rosacea is not a life-threatening condition, it is a chronic disease that requires long-term management of relapsing and remitting symptoms. Complete resolution of clinical features has been shown to prolong time to symptom relapse and have greater positive impact on quality of life compared with incomplete resolution

How is rosacea diagnosed?

Rosacea is diagnosed clinically in the majority of cases. This requires one  diagnostic criterion or two major  criteria to be fulfilled.

In patients with darker phototypes where erythema and telangiectasia (visible blood vessels) is more difficult to visualise, greater emphasis may be placed on other major and minor features.