What is Rosacea?

Rosacea is defined as a persistent erythema in a central portion of the face (sparing the periocular skin) lasting for at least 3 months. Supportive criteria include flushing, papules, pustules and teleangectasias of the convex surfaces. Secondary characteristics are burning and stinging, edema, plaques, dry appearance, ocular manifestations, phymatous changes.

There s no laboratory benchmark test.

Who gets Rosacea?

It usually affects people between 40 and 60 years of age of any skin color, even if is more frequent in those with fair skin and blue eyes. Women (particularly around and during menopause) more often than men, who, however, suffer of more severe forms.

What causes Rosacea?

The exact cause of rosacea remains unknown. Probably several factors have been implicated. It is likely that rosacea represents in its various expressions responses to a combinations of  triggering factors.

Which are the possible triggering factors?

• hereditary (tendency to develop the disease).

• environmental exposure (sunlight, very cold temperatures, heat, wind).

• medications (amiodarone, topical steroids, nasal steroids, high doses of vit. B6 and B12, nicotinic acid).

• dietary factors (hot or spicy foods and drinks, alcohol).

• microbial organism (Demodex sp., Helicobacter pylori).

• disorders of vessels (very easy vasodilatation, increased numbers of blood vessels closer to the surface of the face).

• Damage to the connective tissue.

Is there a classification system for rosacea?

Yes. Because there is no understanding of the pathophysiology and etiopathogenesis of the disease, rosacea is defined on the basis of recognizable morphologic characteristics. So rosacea is classified into 4 different subtypes, based upon specific clinical signs and symptoms, highlighting the preponderance of one or more of the clustering signs of presentation.

• Erythematoteleangiectatic rosacea (ETR)

• Papulopustular rosacea (PPR)

• Phymatous rosacea

• Ocular rosacea

What about the erythematoteleangiectatic rosacea (ETR)?

The predominant sign of ETR is central facial flushing (that last longer than 10 minutes) often accompanied by burning of stinging sensation. There is characteristic sparing of the periocular skin. In the erythematous area of the face at times roughness with scaling are seen.

Which are the frequent triggers to flushing?

• Emotional stress

• Hot drinks

• Alcohol (may cause flushing while mushrooms are consumed and in patient with the rare tumor carcinoid)

• Fermented alcoholic beverages (beer, sherry, wine)

• Caffeine

• Spicy foods

• Exercise

• Cold or hot temperatures

• wind

• Hot baths and showers.

• Drugs  causing flushing when the patient drinks acohol(disulfiram, chlorpropamide, calcium carbamide, phentolamine, cephalosporin antibiotics)

What about papulopustular rosacea (PPR)?

PPR is the classic rosacea.  Patients (most often women of middle age) present with a red central portion of the face that contains small erythematous papules some of which may be surmounted by pinpoint pustules. Teleangectasias may be present but are difficult to distinguish from the erythematous background in which they exist.

There is complete sparing of the periocular skin, contrasting with the intense redness at adjacent sites.

What about phymatous rosacea?

This subtype of rosacea, most often seen in males, is defined as marked skin thickenings and irregular surface nodularitis and sebaceous hypertrophy of the nose (rhinophyma), chin (gnatophyma), forehead (metophyma), one or both ears (otophyma), and/or the eyelids (blepharophyma).

And about ocular rosacea?

Ocular manifestations can precede the cutaneous signs by many years. The most common manifestations are blepharitis and conjunctivitis. Other findings are inflammation of the lids with recurrent chalazion, inflammation of the meibomian glands, conjunctival hyperemia and teleangectasias of the lid margin. Patients may describe eye stinging or burning, dryness, light sensitive, foreign body sensation, itching. 

Can Rosacea be cured?

Because we don’t know the mechanism by which rosacea take place, the therapeutics empirically target the signs and symptoms of the disease, suppressing the clinical manifestations, but are not curative.

How can Rosacea be managed?

• Reduce factors causing flushing (no alcohol, food additives-E621,622, 249,250,251,252, 224).

• Avoid oil-based facial creams.

• Avoid topical steroid.

• Protect from the sun, practicing sun avoidance behaviours in addition to the use of a broad-spectrum sunscreen.

• Minimize exposure to hot or spicy foods.

• Avoid alcohol (especially fermented beverages like beer, sherry, wine).

• Avoid hot showers and baths.

• Avoid potentially irritating products such as scrubs, exfoliants and alcohol-based products.

How can rosacea be treated?

Rosacea can be treated in different ways: it depends on severity and duration of the condition, the subtype of rosacea present and it varies between individuals.  Can be treated by applying topical preparations  if it does not respond to topical treatment may require systemic treatment.

What about topical treatment?

Two are the approved medications for the topical treatment of rosacea: metronidazole and azelaic acid, similar in their mechanism of reducing erythema and inflammatory lesions.

Metronidazole is available in 2 strength formulations: 1% and 0.75%, gel or cream. It’s helpful alone for mild-to-moderate disease.

Azelaic acid 15% gel. It’s effective alone against mild-to-moderate papulopustular rosacea.

In patients with more severe disease both can be used in combination with other therapies (such as oral antibiotics).

What about systemic therapy for rosacea?

Systemic therapy for rosacea is based on:

• Metronidazole

• Minocycline

• Doxycline

• Azithromycin

• Clarithromycin

• Isotretinoin: it is the mainstays of therapy for early to moderate phymatous change. In advanced phyma isotretinoin therapy follow surgical approaches to the reshaping of rinophyma. Isotretinoin can also be try when antibiotics are ineffective or poorly tolerated. Because of important side effects, it is not suitable for everyone.

• The papules and pustules may respond quickly to the systemic treatment but the redness and flushing are less likely to improve.

Are sunscreens useful for rosacea?

A daily broad-spectrum sunscreen (against ultraviolet A and B) is recommended for all patients with rosacea. Physical blockers such as titanium dioxide and zinc oxide are well tolerated.

Can cosmetics be used?

Yes, with these guidelines:

• Cleansers should be soap free (synthetic detergents and lipid-free cleansers).

• Cosmetics and sunscreens should contain protective silicones (dimethicone or cyclomethicone).

• Choose a light foundation makeup that is easy to spread and can be set with powder.

• Avoid astringents, toners, menthol and camphor containing products.

• Moisturizers should be used to improve barrier function and to decrease skin sensitivity.

• Choose products that are hypoallergenic, water-based and free of fragrances and additives.

• Avoid products that contain sodium lauryl sulphate (irritating anionic surfactant).

• Avoid waterproof cosmetics and heavy foundations that are harder to apply and remove without irritating solvents.

• Avoid scrubs, exfoliants and alcohol-base products.

Does people with rosacea follow a particular diet?

Dietary modulation should aim at avoidance of triggers:

• hot drinks

• caffeine

• spicy foods

• alcohol