DEFINITION
Rosacea is a chronic skin condition that manifests as redness on the cheeks, nose, then forehead and chin. As the disease progresses, this redness becomes permanent, small dilated vessels (telangiectasia or rosacea) appear on the cheeks and sides of the nose, as well as small red pimples (papules).
Rosacea usually begins around the age of 30 and mostly affects people who have fair skin and eyes and a tendency to blush easily.
It is a condition that gets worse over the years, especially if not treated well. In many people, symptoms progress in a cyclical fashion, with periods of worsening alternating with periods of remission.
Long called Acne Rosacea, rosacea should not be confused with acne that occurs during adolescence. Blackheads and whiteheads are almost absent and the course of the disease differs. In addition, the factors causing these two conditions are very different.
PREVALENCE
Rosacea can affect anyone between the ages of 20 and 70, but adults between the ages of 30 and 50 with fair complexions and whose skin tends to redden easily are more often affected. From 3% to 10% of the population are affected by rosacea, to varying degrees. In Canada, over 2 million people suffer from rosacea.
Women are more prone to rosacea than men, with men being more prone to developing rhinophyma, which is characterized by a red, swollen, bumpy nose. This is a very advanced stage of the disease.
Very rarely, rosacea can appear in children, in the form of redness mainly affecting the cheeks. At this age, it is common for ophthalmological symptoms (red eyes, swollen eyelids) to precede skin problems.
CAUSES
The causes are unknown, but according to research, rosacea could be attributed to:
- a dysregulation of the immune system concerning the skin;
- hyperreactivity of the blood vessels in the face, which dilate excessively. This is what creates the redness and the sensation of heat;
- microorganisms (bacteria or Demodex folliculorum type mites);
- an abnormal reaction of the skin to the sun.
Contrary to popular belief, alcoholism does not cause rosacea, although even moderate alcohol consumption can make it worse.
Certain diseases affecting the skin, such as lupus or scleroderma, can be accompanied by skin lesions similar to those of rosacea (telangiectasia, redness). It is therefore essential to consult a doctor to confirm the diagnosis.
Finally, the continual application of cortisone-based cream to the face can lead to skin lesions that are visually identical to those of rosacea. In this case, it is corticosteroid-induced rosacea and the treatment must be stopped.
EVOLUTION OF ROSACEA
Rosacea progresses differently from person to person. Four subtypes have been established, which were previously thought to be the different phases of the disease. However, the disease never progresses to the supreme stage in many people and most patients have a combination of subtypes. It is therefore impossible to predict the course of the disease.
Subtype 1: erythematotelangiectatic rosacea
- Access of redness on the face and neck, after a meal, after the consumption of alcohol or hot drinks or during a change in temperature. These flushes, called flushes or flushes, last a few minutes and then go away. This is often the first symptom of rosacea.
- A redness (erythema) permanently present on the central area of the face, in particular on the cheeks, the nose and the middle of the forehead.
- Small vessels under the epidermis become visible and create fine red lines, especially on the cheeks and sides of the nose. This is called telangiectasia or rosacea. The redness of the skin can mask them, but the red lines usually reappear when the redness fades.
- The skin may become dry, rough, with burning and tingling sensations.
Subtype 2: papulopustular rosacea
- Small, solid, red bumps (papules) or pus-filled bumps (pustules) besiege the face, adding to the erythema.
- Telangiectasias may be present.
- The redness persists on the central area of the face.
Subtype 3: Phymatous rosacea
- This is the subtype with the most marked symptoms. The sebaceous glands in the nose increase in size, the pores enlarge and the skin thickens, forming fleshy bumps or blisters (nodules). The nose is the part of the face that undergoes the most deformations. This enlargement, called rhinophyma, affects men more (95% of cases) than women and occurs after 50 years of age. Rhinophyma requires surgical correction.
Subtype 4: ocular rosacea
- This subtype is characterized by irritation of the eyes, which become red and dry, with excessive tearing and sensitivity to light. Ocular rosacea affects more than half of people with rosacea. Other symptoms are conjunctivitis and inflammation of the eyelids (blepharitis). The irritation remains minimal in the majority of cases. If the situation worsens, it is necessary to intervene quickly under penalty of causing a sharp decrease in vision.
- Ocular rosacea is sometimes the precursor to the first skin symptoms.
SYMPTOMS AND PEOPLE AT RISK FOR ROSACEA
Symptoms
- Redness on the face (erythema);
- Dry and sensitive skin, with burning sensation;
- A tendency to blush easily on the cheeks, but also sometimes on the nose, forehead and chin. Flushing, or flushes, is triggered by emotions and changes in temperature. They often occur after meals;
- Small visible blood vessels on the nose and cheeks (telangiectasia or rosacea);
- Small red, solid pimples (papules) or filled with pus (pustules) on the nose, cheeks, forehead and chin;
- Dry, red and irritated eyes;
- A red nose, swollen and covered with nodules, in the advanced stage of the disease.
People At Risk
- People with pale complexion, usually of Irish, Scottish or Northern European descent (Scandinavian countries);
- People whose parents suffered from rosacea, because certain hereditary factors increase the risk of having it;
- Women, who are twice as affected as men.
ROSACEA RISK FACTORS
The precise origin of rosacea remains unknown, but various factors are known to make it worse or contribute to rosacea flare-ups. This is particularly the case when:
- from prolonged exposure to the sun or under tanning lamps. UVA rays cause dilation of blood vessels which, after a while, can become permanent. Heat also exerts a harmful effect: by dilating the vessels, it accentuates the effect of the rays;
- a sudden change in temperature;
- exposure to extreme weather conditions (cold, rain, heat, etc.);
- consumption of hot drinks, spicy foods or alcohol;
- hormonal fluctuations (during pregnancy and menopause);
- strong emotions (anger, embarrassment, stress);
- taking corticosteroids (cortisone). Whether used in pill or ointment form, corticosteroids cause blood vessels to dilate and the skin to thin, gradually making rosacea worse.
PREVENTION OF ROSACEA
Can Rosacea Be Prevented?
As the causes of rosacea remain unknown, it is impossible to prevent its occurrence.
Measures to prevent the worsening of symptoms and reduce their intensity
First, you have to find out what aggravates the symptoms and then learn how to better manage or avoid these triggers. Keeping a symptom diary can be very helpful.
The measures below often reduce the intensity of the symptoms:
- avoid exposure to the sun as much as possible. If you do, always apply good sun protection SPF 30 or more, against UVA and UVB rays, in summer and winter;
- avoid consuming beverages and foods that contribute to the dilation of blood vessels: coffee, alcohol, hot drinks, spicy foods and any other product that causes redness;
- avoid exposure to extreme temperatures and strong winds. Protect your face well from the cold and wind during the winter. Also avoid rapid temperature changes;
- learn to relax to better manage stress and strong emotions;
- avoid saunas and prolonged hot baths;
- Unless medical advice, avoid applying corticosteroid-based creams to the face.
Facial Care
- Use lukewarm water, at body temperature, and a mild, unscented soap;
- Many skin care products contain ingredients that can make rosacea worse (acids, alcohol, etc.). Ask your pharmacist, doctor or dermatologist to find out which ones are suitable for rosacea;
- Regularly apply a moisturizer on the face, so as to reduce the burning sensation and the dryness of the skin. Ask your pharmacist, doctor or dermatologist to obtain a cream suitable for skin affected by rosacea. Lotions containing 0.1% kinetin (N6-furfuryladenine) appear to be effective in moisturizing the skin and reducing symptoms;
- Avoid overly oily cosmetics and foundations, which can aggravate inflammation.
MEDICAL TREATMENTS FOR ROSACEA
Rosacea is a chronic disease. Various treatments generally improve the appearance of the skin, or at least slow the progression of symptoms. However, several weeks are often necessary before observing a result and no treatment can achieve a total and lasting remission. Thus, the treatments do not act on telangiectasias (dilated vessels) and the redness present on the cheeks and the nose never completely disappears. However, it is essential to consult a dermatologist as soon as the first symptoms appear, because the treatments are more effective when used at the early stage of the disease.
Treatment varies depending on the stage of the disease and the intensity of the symptoms. It can be very effective, but be aware that in the majority of cases, rosacea gets worse after stopping treatment. Usually, near-continuous treatment is required to maintain a satisfactory outcome.
Remarks
- Pregnancy-related rosacea requires no treatment since it usually goes away on its own a few months after delivery.
- Telangiectasias can occur following facial surgery. This is not true rosacea and the symptoms usually subside over time. It is therefore advisable to wait six months before starting treatment.
- The rosacea that affects babies and young children is rarely problematic. Normally, it fades as the child's skin thickens.
Medications
Antibiotics. The most commonly prescribed treatment for rosacea is an antibiotic cream to be applied to the skin, based on metronidazole (Metrogel®, Rosasol® in Canada, Rozex®, Rozacrème®... in France). Clindamycin creams can also be used. When rosacea is extensive or is associated with eye inflammation, the doctor may order an oral antibiotic (tetracycline or sometimes minocycline in Canada) for three months. Although rosacea is not directly linked to bacteria, antibiotics help reduce inflammation in the skin.
Azelaic acid. Applied to the skin in the form of a cream or gel, azelaic acid (Finacea®) helps to reduce the number of pustules and reduce redness. However, this product is quite irritating to the skin, so use a suitable moisturizer in addition.
Oral isotretinoin. Accutane® in Canada, available by prescription, is sometimes used in low doses to treat severe forms of rosacea (in case of phymatous rosacea or papules, pustules or nodules resistant to other treatments). As it causes serious side effects, it is prescribed under close medical supervision. Thus, it increases the risk of birth defects if used during pregnancy. Women of childbearing potential taking this treatment should use effective contraception and have regular pregnancy tests to make sure they are not pregnant. It is advisable to check with your doctor.
Important. Corticosteroids, in cream or in tablets, are contraindicated in case of rosacea. Although they temporarily reduce inflammation, they cause symptoms to worsen later on.
Surgery
To reduce redness and diminish the appearance of telangiectasia (small red lines resulting from the dilation of vessels) or rhinophyma, various surgical treatments exist.
Electrocautery. This is an effective technique on telangiectasia (rosacea) which may require several sessions and which has various disadvantages, including the following: slight bleeding, redness and the formation of small crusts in the following days, risk of scarring orpermanent depigmentation of the skin. This treatment cannot be considered during the summer (risk of formation of brown spots).
Laser surgery. More effective and less painful than electrocoagulation, the laser generally leaves fewer scars. It may, however, cause some bruising or temporary blushing. It takes one to three sessions per area to be treated.
Dermabrasion. This procedure consists of wearing away the superficial layer of the skin using a small, rapidly rotating brush.
COMPLEMENTARY APPROACHES TO ROSACEA
S-MSM (silymarin and methylsulfonylmethane). Silymarin is a flavonoid extracted from milk thistle which, combined with a sulfur compound, MSM, was tested in topical application on 46 patients with rosacea. This study, which dates from 2008 and was carried out in parallel with a placebo, showed that S-MSM significantly reduced symptoms after one month, in particular redness and papules. However, other trials integrating a larger number of patients are necessary to confirm this observation.
Oregano. Oregano oil is traditionally used for its anti-inflammatory properties against rosacea, both internally and externally. However, no clinical trial has proven its effectiveness.
Specialized make-up. The use of specialized makeup can significantly camouflage the manifestations of rosacea. Some dermatology clinics offer information sessions on which products to use and how to apply them. In Quebec, you can contact the Association québécoise des dermatologues to find out which clinics offer this service.
Naturopathy. According to naturopath J.E. Pizzorno, rosacea is often the result of a food or digestive problem. Among the suspected factors are too low acidity in the stomach, a lack of digestive enzymes as well as food allergies or intolerances. The basis of naturopathic treatment is to act on these factors and observe their effect on the symptoms of rosacea. For example, in the event of gastric hypoacidity, we recommend taking hydrochloric acid supplements temporarily. Worries and chronic stress would make the stomach less acidic. Taking pancreatic enzymes before meals may also be considered.
Pizzorno also observed improvements in people who no longer consumed foods containing refined sugar or foods with a high concentration of sugar. He also recommends eliminating trans fats (milk, dairy products, margarine, fried foods, etc.), as they contribute to inflammation. He also suggests avoiding very salty foods. However, no scientific study has confirmed the effectiveness of these measures on the symptoms of rosacea.
Stress reduction techniques. Emotional stress is one of the main triggers of rosacea episodes. As a survey conducted in the United States by the National Rosacea Society indicates, the use of stress reduction techniques can be very effective in reducing the effect of negative emotions on rosacea. The National Rosacea Society offers the following techniques:
- Take care of their general well-being (eat well, exercise regularly, get enough sleep).
- In a stressful situation, try to focus your attention on your breathing. You can inhale, count to 10, then exhale and count again to 10. Repeat this exercise several times.
- Use a visualization technique. Sit in a quiet place, close your eyes and visualize a peaceful and restful scene, an enjoyable activity, etc. Continue the visualization for a few minutes to soak up the peace and beauty that emanates from it.
- Do stretching and muscle relaxation exercises. Go through all the muscle groups in the body starting with the head and ending with the feet.
Chinese pharmacopoeia. It seems that the Chinese preparation Chibixiao can help reduce the symptoms of rosacea. In a clinical trial of 68 women, this Chinese herb was shown to be effective in combination with oral antibiotic treatment (minocycline and spironolactone), but no trials were conducted on this product alone. It is necessary to consult a practitioner trained in Traditional Chinese Medicine (TCM).