Rosacea (pronounced /roʊˈzeɪʃə/ ) is a chronic condition characterized by facial erythema (redness). Pimples are sometimes included as part of the definition. Unless it affects the eyes, it is typically a harmless cosmetic condition. Treatment, if wanted, usually involves topical medications to reduce inflammation.
It primarily affects Caucasians of mainly northwestern European descent and has been nicknamed the 'curse of the Celts' by some in Britain and Ireland, but can also affect people of other ethnicities. Rosacea affects both sexes, but is almost three times more common in women. It has a peak age of onset between 30 and 60.
Rosacea typically begins as redness on the central face across the cheeks, nose, or forehead, but can also less commonly affect the neck, chest, ears, and scalp. In some cases, additional symptoms, such as semi-permanent redness, telangiectasia (dilation of superficial blood vessels on the face), red domed papules (small bumps) and pustules, red gritty eyes, burning and stinging sensations, and in some advanced cases, a red lobulated nose (rhinophyma), may develop.
Types of rosacea
There are four identified rosacea subtypes and patients may have more than one subtype present:
- Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning or itching sensations.
- Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (which typically last 1–4 days); this subtype can be easily confused with acne.
- Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargement of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can also affect the chin (gnatophyma), forehead (metophyma), cheeks, eyelids (blepharophyma), and ears (otophyma). Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
- Ocular rosacea: Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.
Variants of rosacea
There are a number of variants of rosacea including:
Causes
Cathelicidins
Richard L. Gallo and colleagues recently noticed that patients with rosacea had elevated levels of the peptide cathelicidin and elevated levels of stratum corneum tryptic enzymes (SCTEs). Antibiotics have been used in the past to treat rosacea but they may only work because they inhibit some SCTEs.
Intestinal Bacteria
Intestinal bacteria may play a role in causing the disease. A recent study subjected patients to a hydrogen breath test to determine the occurrence of small intestinal bacterial overgrowth (SIBO). It was found that patients had a significantly higher incidence than controls (47% v. 5%, p<0.001).
SIBO-positive patients were then given a 10-day course of rifaximin, an antibiotic that does not leave the digestive tract and therefore cannot reach the skin or circulation. 96% of patients experienced a complete remission of rosacea symptoms that lasted at least 9 months. These patients were also negative when retested for bacterial overgrowth. In the 4% of patients that had experienced relapse, it was found that bacterial overgrowth had returned, and a second course of antibiotic treatment again produced temporary remission.
In another study, it was found that some rosacea patients that tested SIBO-negative using a hydrogen breath test, were still positive when using a methane breath test instead. These patients did not respond to rifaximin, as found in the previous study, but experienced clearance of rosacea symptoms and normalization of breath tests following administration of the antibiotic metronidazole, which is effective at targeting methanogenic anaerobic bacteria, such as would be found in the intestines.
These results suggest diverse strains of intestinal bacteria may be responsible for mediating these effects in patients. It may also explain the improvement in symptoms experienced by some patients when given a reduced carbohydrate diet. Such a diet would reduce the potential for bacterial fermentation and thereby reduce bacterial populations in the intestines. Although controversial, it should be noted that a reduced carbohydrate diet is likely to be more consistent with the diet our ancestors would have eaten prior to the use of agriculture and that modern patterns of carbohydrate consumption could be an important environmental cause of bacterial overgrowth in some patients.
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. When large numbers are present they may play a role along with other triggers. On other occasions Demodicidosis (Mange) is a separate condition that may have "rosacea-like" appearances.
Other Causes
Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as 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. There are also some food and drinks that can trigger flushing, including alcohol, food and beverages containing caffeine (especially, hot tea and coffee), foods high in histamines and spicy food. It should be noted that foods high in histamine (red wine, aged cheeses, yogurt, beer, cured pork products such as bacon, etc.) can even cause persistent facial flushing in those individuals without rosacea due to a separate condition, histamine intolerance.
Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion and chemical peels, as well as high dosages of isotretinoin, benzoyl peroxide, and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.
Diagnosis
Most people with rosacea have only mild redness and are never formally diagnosed or treated. There is no single, specific test for rosacea.
In many cases, simple visual inspection by a trained person is sufficient for diagnosis. In other cases, particularly when pimples or redness on less-common parts of the face are present, a trial of common treatments is useful for confirming a suspected diagnosis.
The disorder can be confused with, and co-exist with acne vulgaris and/or seborrhoeic dermatitis. The presence of rash on the scalp or ears suggests a different or co-existing diagnosis as rosacea is primarily a facial diagnosis, although it may occasionally appear in these other areas.
Treatments
Treating rosacea varies from patient to patient depending on severity and subtypes. A subtype-directed approach to treating rosacea patients is recommended to dermatologists. Mild cases are often not treated at all, or are simply covered up with normal cosmetics.
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 one to two 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.
Behavior
Trigger avoidance can help reduce the onset of rosacea but alone will not normally cause remission for all but mild cases. The National Rosacea Society recommends that a diary be kept to help identify and reduce triggers.
Because sunlight is a common trigger, avoiding excessive exposure to sun is widely recommended. Some people with rosacea benefit from daily use of a sunscreen; others opt for wearing hats with broad brims.
People who develop infections of the eyelids must practice frequent eyelid hygiene. Daily, gentle cleansing of the eyelids with diluted baby shampoo or an over-the-counter eyelid cleaner and applying warm (but not hot) compresses several times a day is recommended.
A recent publication discusses how managing pre-trigger events such as prolonged exposure to cool environments can directly influence warm room flushing.
Medications
Oral tetracycline antibiotics (tetracycline, doxycycline, minocycline) and topical antibiotics such as metronidazole are usually the first line of defense prescribed by doctors to relieve papules, pustules, inflammation and some redness. Topical azelaic acid such as Finacea (15%) or Skinoren (20%) may help reduce inflammatory lesions, bumps and papules. Oral antibiotics may help to relieve symptoms of ocular rosacea. If papules and pustules persist, then sometimes isotretinoin can be prescr
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