Rosacea: Symptoms, Treatment, Care

Brief overview

• Treatment: medication (ointments, creams, lotions, antibiotics), laser treatment, sclerotherapy, photodynamic therapy, surgery; avoidance of typical triggers such as UV radiation, heat, spicy food, alcohol, and certain skin care products and cosmetics
• Causes and risk factors: Suspected genetic predisposition in interaction with immune system, microorganisms, etc.; strong, prolonged UV radiation (sunbathing, solarium), heat, hot bathing and showering, certain cosmetics, washing lotions with alkaline pH (>7), certain medications, coffee and tea, alcohol, nicotine, stress.
• Diagnosis: diagnosis after clinical examination by physician. If necessary, tissue sample to exclude similar diseases.

What is Rosacea?

Rosacea (rosacea, formerly also “copper rose”) is a chronic inflammatory, non-contagious, disease of the skin (dermatosis). It classically affects the face, mostly the nose and cheeks, often also the forehead and chin. Adjacent areas such as the scalp, neck or décolleté also show symptoms in rare cases.

As a rule, people in middle to old age are affected by this skin disease, but in exceptional cases children are also affected. According to current knowledge, both sexes are equally affected.

How is rosacea treated?

By avoiding triggering or promoting factors, the use of special medications and the right cosmetic care, rosacea symptoms can often be kept within tolerable limits. If left untreated, however, rosacea usually worsens in episodes.

In addition or as an alternative to drug treatment, other therapeutic methods are available. These include cauterization, photodynamic therapy and surgical procedures.

How can rosacea be treated by yourself?

A first step in the treatment of rosacea is to avoid things that promote the development or worsening of symptoms. This concerns in particular diet and environmental factors to which the skin is exposed, for example intense sunlight or temperature fluctuations.

He will inform you whether the application is useful and safe in your particular case. If your skin reacts in an undesirable way after treatment, the doctor will also be able to treat any consequences and point out alternatives.

Nutrition

Diet plays an important role in the development and treatment of rosacea, but there is no specific rosacea diet and therefore no “forbidden foods”.

The American Rosacea Association also lists liver, egg and dairy products and some legumes, among others, as possible triggers of a rosacea flare-up.

It is therefore recommended that sufferers avoid these foods as far as possible. According to recent findings, in some cases, foods and stimulants rich in certain nitrogen compounds (amines) also promote the formation of rosacea. Examples of this are (especially red) wine and cheese.

Whether and how your skin reacts to certain foods is very individual. All in all, it is therefore worthwhile to consciously watch individual foods from time to time and observe whether and how the rosacea symptoms change as a result.

Other factors

It is also important that you avoid other typical triggers of a rosacea flare-up. These are in particular:

• Strong, long-lasting UV radiation (sunbathing, solarium)
• Heat, hot baths and showers, sauna visits
• Certain cosmetics
• Certain medications
• Stress

Hormonal changes, such as during pregnancy, may also trigger a flare-up. Talk to your doctor about this.

Rosacea patients react differently to various possible triggers. Therefore, observe closely to which stimuli your skin reacts and adjust your lifestyle accordingly.

Treatment with medication

Local (topical) treatment

In this case, the drug is applied directly to the affected skin areas as an ointment, gel or lotion. Which form of administration is most effective and best tolerated depends on the individual case.

External treatment of rosacea is usually carried out over a very long period of time (as topical maintenance therapy). The two main active ingredients used are:

Side effects are rare and include skin irritation, dry skin, skin redness and burning or stinging of treated skin areas.

Azelaic acid:A naturally occurring acid that has antibacterial and anti-inflammatory properties. It also positively affects the cells of the outermost layer of the skin (keratinocytes), which are involved in inflammation and pain transmission. Mild, temporary stinging and itching have been described as side effects.

• Ivermectin: A macrolide that has anti-inflammatory activity and helps against Demodex mites. Side effects include burning, dry skin and itching.
• Permethrin: Works against demodex mites and nodules (papules), as well as redness around individual skin irritations. It does not help against the permanent redness, pustules, vascular changes (telangiectasias), or growths (phyma) of rosacea.
• Retinoids: Anti-inflammatory and keratolytic (detachment of corneal cells from the cornea) agents. Reduce inflammatory skin changes better, but reduce redness worse than metronidazole.

The above-mentioned drugs act mainly against the nodules and blisters. However, they usually do not help against the typical facial redness. In contrast, a special gel with the active ingredient brimonidine was developed in the USA. It has also been approved in the EU since 2014.

The drug causes the blood vessels in the facial skin to contract. This causes the redness to fade. It also has a mild anti-inflammatory effect.

The very sensitive skin of rosacea patients sometimes reacts unfavorably to topical treatment. It therefore makes sense to agree with the doctor which preparations are used and in what way. In addition, any side effects are sensibly well monitored so that measures can be taken in good time if necessary.

Systemic treatment

In some milder forms of rosacea, local treatment is sufficient. If there is no improvement with local therapy or if the skin changes are severe, additional systemic treatment is necessary.

Mostly antibiotics are used for systemic rosacea therapy, especially two groups:

• Tetracyclines: The most commonly used drugs in this group of agents are called doxycycline and minocycline. They are the first choice in antibiotic treatment because they are better tolerated by the stomach and intestines than macrolides (see below). They are mainly effective against papules and pustules, but hardly against the redness or vascular changes.

Antibiotics are actually used to fight bacteria. In rosacea treatment, however, a different mechanism of action of these substances is utilized.

In addition to antibiotics, active ingredients that are normally used for local treatment – for example, tablets containing metronidazole – are sometimes used for systemic rosacea treatment.

Great caution is required because the use of isotretinoin capsules in some cases leads to sometimes severe side effects, for example irritation of the skin and mucous membranes.

The use of isotretinoin also increases the risk of fetal malformations when used during pregnancy. Therefore, its use is not recommended in women of childbearing potential or during pregnancy.

Laser treatment and cauterization

Laser treatment is usually effective in eliminating vascular dilatation (telangiectasia), but is rarely effective in eliminating extensive reddening of the skin. For this purpose, the affected skin areas are treated with bundled, high-energy light beams. Laser treatment can also be used to remove phyma.

Vascular dilatations are also sclerosed with the aid of electric current.

Photodynamic therapy (PDT)

These areas are then irradiated with light of a specific wavelength. This changes the structure of the photo-sensitizer and subsequently destroys defective skin structures.

Individual studies suggest that PDT stimulates the immune system and has an antimicrobial effect, but more detailed studies on this are still pending.

Surgical therapy

Rosacea can also be treated surgically, for example with dermabrasion (abrasion of the upper skin layers) or dermashaving (layer-by-layer removal of skin thickening).

These methods are mainly used for phyma. They are therefore described in more detail in the article Rosacea: Rhinophyma.

Care

Proper skin care

Take the following tips to heart when it comes to skin care:

• Cleanse facial skin with lukewarm water only. Extreme water temperatures and rapid temperature changes promote sudden skin redness (“flushing”).
• Refrain from facial peelings, as they further irritate rosacea skin.
• Avoid water with a high degree of hardness.
• After washing, gently pat the facial skin dry with a towel instead of rubbing.
• Use soaps and wash lotions with a slightly acidic pH (<7).

In terms of facial cleansing, so-called wash syndets are well suited for rosacea patients. These are artificial washing-active substances with a relatively low pH value (4.5 to 5.5), which are much gentler on the skin than classic soaps.

Watch out, sun!

• Avoid direct sun exposure between spring and fall.
• Refrain from solarium visits.
• Use sunscreen products with a high sun protection factor (50+) and apply them several times a day. Prefer physical sunblocks with titanium dioxide or zinc oxide (pharmacy). These are considered better skin tolerant than chemical sunscreens for rosacea.

Rosacea: cream, ointment or lotion?

Products with a high water content, i.e. creams and lotions, are ideal for rosacea patients. These do not form a greasy film on the skin that closes the pores. They allow the skin to breathe without drying it out. The same applies to preparations based on glycerin or silicone oil (cyclomethicone, dimethicone).

Products with added fragrances or dyes irritate the skin unnecessarily and are therefore not recommended for those affected.

Make-up for rosacea

In principle, make-up can also be used with rosacea. However, it is best to ensure that the products are free of skin-irritating ingredients such as menthol, camphor, sodium lauryl sulfate and astringents. It is also advisable to use cosmetics that do not clog the sebaceous glands, i.e. are non-comedogenic.

Rosacea sufferers react very individually to cosmetics. If you notice that you cannot tolerate a product, it is recommended to stop using it immediately and try an alternative.

Symptoms

Symptoms of rosacea are in particular sudden flushing with a feeling of warmth (“flushing”), persistent reddening of the skin (erythema) and visible dilatation of blood vessels (telangiectasia).

Other skin changes may include dryness, extensive, sometimes raised skin changes (plaques), swelling (edema) and growths of sebaceous and connective tissue (phyma).

Patients complain mainly of tense, burning, stinging skin or a feeling of heat.

In some cases, the eyes are also involved. This is manifested by dilated blood vessels in the eyes and frequently dry and inflamed eyes.

Severity levels

• Preliminary stage – rosacea diathesis: Typical for the onset of rosacea are sudden, fleeting skin redness (“flushing”). This mild form mainly affects the cheeks, nose, chin and forehead area. Rarely, rosacea also appears in other areas such as the eyes, scalp, chest or neck.
• Severity II – Rosacea papulopustulosa: In this stage, additional inflammatory red, sometimes pus-filled blisters (pustules, colloquially: pimples) and nodules (papules) appear as rosacea symptoms. They sometimes persist for several weeks. Sometimes swelling (lymphedema) also develops in the facial tissue.

Since symptoms and their severity vary from patient to patient, they cannot always be clearly assigned to a severity level. Therefore, a modular system for assessing the severity of the disease (Rosacea COnsensus Panel, ROSCO for short) is increasingly gaining acceptance among experts.

Special forms

In addition to classic rosacea, there are some special forms, some of which occur very rarely:

Ophthalmo-Rosacea is observed in about every fifth rosacea patient. It affects the eye, either in addition to the classic skin disease rosacea, or partly independently of it.

If left untreated, it may cause corneal changes and inflammation (keratitis), which in extreme cases can lead to permanent damage and blindness. Ophthalmo-Rosacea is therefore usually monitored particularly closely.

Gram-negative rosacea occurs when the disease has already been treated with antibiotics for several weeks without lasting success. Then, under certain circumstances, only certain pathogens have been destroyed. Others, so-called gram-negative bacteria, have survived. They multiply and subsequently cause further skin reactions.

Granulomatous (lupoid) rosacea is characterized by scattered, brownish-red skin thickening on the eyelids, zygomatic bone and around the corners of the mouth. Other areas of the face are reddened as is typical of rosacea. This form is considered difficult to treat.

Rhinophyma

Rhinophyma is a symptom of rosacea, which in some cases develops in a severe course of the disease. It is a proliferation of connective tissue and sebaceous glands (phyme). Rhinophyma usually occurs on the nose. This so-called “bulbous” or “potato” nose is observed especially in older men.

Read more about this symptom of rosacea in the article Rhinophyma.

Causes and risk factors

About 5% of people worldwide suffer from rosacea. People over the age of 30 are most commonly affected, but children also develop rosacea in exceptional cases.

Women are affected slightly more often than men.

How does rosacea develop?

The typical symptoms of rosacea are based on a permanent dilatation of the blood vessels and a chronic inflammation of the skin. The causes are not yet fully understood. An interplay of different influences is suspected, which makes research into the role and significance of individual factors difficult.

Innate and acquired immune systems also play an important role in the development of rosacea. Immune cells proliferate, stimulated by triggering factors, release pro-inflammatory substances such as cytokines and interferons, and attract further immune cells. This results in a persistent inflammatory process.

The nervous system also plays a role, controlling the dilation and contraction of blood vessels. The nerves dilate the blood vessels when they are hot and constrict them when they are cold.

It is assumed that microorganisms living on the skin, such as bacteria or demodex mites, stimulate the immune cells. These then in turn secrete signal substances that promote inflammation and vascular growth or new formation.

According to some studies, the intestinal microbiome also seems to have an influence in rosacea. Affected individuals are significantly more likely to suffer from small intestinal bacterial overgrowth (SIBO).

Examinations and diagnosis

Course of the disease and prognosis

Rosacea is usually chronic and episodic – phases with more severe symptoms alternate with periods in which the symptoms subside or at least improve.

Although the disease is not completely curable, it can be well controlled with the right treatment, skin care and lifestyle. Sometimes rosacea even comes to a standstill without developing further.