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Rosacea is a chronic inflammatory disease that most commonly affects the skin (central face) and is characterized by periodic eruptions and remissions. It has a poorly understood etiology (cause) and pathophysiology (disease process).
However, both genetic and environmental factors are currently thought to be key players in the disruption of the immune system, which eventually leads to the initiation and exacerbation of rosacea. (1)
Worldwide, the prevalence of rosacea is about 5%, which may go as high as 18% in countries with a predominant “Celtic” heritage. (2)
What are the common causes and triggers of rosacea?
The disease process of rosacea remains unclear. However, dysregulation of both the innate (i.e., keratinocytes, macrophages) and adaptive (T cells) immune systems is thought to be involved.
This dysregulation leads to increased levels of potentially disruptive compounds, such as nitric oxide radical species, cytokines, and chemokines.
Demodex (microscopic mites) and UV radiation appear to incite this process, but further studies need to be performed for a clear molecular mechanism. (5)
An antimicrobial peptide called cathelicidin (also known as LL-37) has recently attracted a lot of scientific scrutinies as it has been found at increased levels in patients. These increased levels play a role in stimulating the immune system, producing skin inflammation, and creating new blood vessels, perpetuating the symptoms of rosacea. (1)
Certain factors have been identified for causing disruption within the immune system and triggering rosacea, such as:
- Sun exposure
- Wind exposure
- Heavy exercise
- Certain skincare products
- Spicy foods
Avoidance or modification of these triggers can aid in symptom reduction and can guide possible treatment regimens. (1)
Alcohol (especially red wine) and caffeine have also been noted to trigger rosacea flares.
The National Rosacea Society (NRS) recommends keeping a diary log to record and thereby pinpoint potential triggers as they can differ from person to person. (6)
Is rosacea contagious?
No, there is no evidence to suggest that rosacea can be passed from one person to another through skin-to-skin contact or airborne transmission of respiratory droplets.
Because antibiotics are used for treating this skin condition, some people mistakenly assume that rosacea is a bacterial infection. However, the real purpose of these antibiotics is to alleviate the symptoms of rosacea by curbing the underlying inflammation, not fighting bacteria.
What are the different kinds of rosacea?
Rosacea can present in several ways, but the four common presentations have been grouped into the following subtypes:
- Inflammatory papulopustular
- Ocular rosacea (7)
While these are the primary subtypes, there has been a more recent shift in classification to analyze the particular patient who is presenting the symptoms.
The NRS has developed diagnostic signs (persistent facial reddening and skin thickening), major signs (flushing, pimples, eye irritation), and minor signs and symptoms (stinging, dryness, swelling) to aid in the diagnosis and treatment of rosacea. (7)
What are the possible treatment plans for rosacea?
The first step in the treatment of rosacea is identifying and avoiding/modifying known triggers. As mentioned, keeping a diary can aid with this step. Generalized advice primarily consists of using a sunscreen of at least SPF 30 (with the mineral zinc oxide), gentle cleansers (preferably not soaps), and moisturizing ointments as individuals with rosacea suffer from epidermal water loss and dry skin. (1)(7)
For flushing symptoms, the generally prescribed oral medications include beta-blockers and alpha-2 adrenergic agonists.
For symptoms of redness, prescribed topical medications include brimonidine and oxymetazoline hydrochloride. Intense pulsed light (IPL) therapy or KTP laser is also used.
For mild inflammatory papules and pustules, prescribed topical medications include ivermectin, azelaic acid, metronidazole, and sodium sulfacetamide (most commonly 5% sulfur lotion and 10% sodium sulfacetamide).
For more moderate to severe papules and pustules, doxycycline and isotretinoin can be prescribed.
For phyma (thickened skin), oral doxycycline can be used if the skin is inflamed, and surgical/laser options are available if the skin is not inflamed. (8)
Each of these medications and treatments has side effects that should be discussed with the prescribing doctor before use.
The use of oil-free foundation/concealer, especially one with a green tint, is recommended to conceal the redness better.
The following skin care products are not advised:
- Waterproof makeup
- Cosmetics with strong fragrances
- Fruit acids
- Glycolic acids
- Witch hazel
- Exfoliating scrubs (8)
What are the best complementary and alternative medicines for the treatment of rosacea?
Here are some additional or non-traditional treatment options for rosacea that may be used in conjunction with the standard medication and self-care:
- Topical vitamin C has more anecdotal evidence of treating rosacea and literature review of treating acne vulgaris. It is an antioxidant and anti-inflammatory agent commonly formulated with sodium ascorbyl phosphate (SAP) to improve stability. Some studies have shown that SAP alone can improve acne. (9)
- Niacinamide can improve rosacea by lessening the inflammatory response and increasing epidermal barrier performance. This product is found in commercially available OTC moisturizers.
- Skin-healing botanicals such as feverfew, licorice, chamomile, and green tea have been formulated in topical forms and shown to improve rosacea by decreasing the inflammatory response, decreasing the formation of blood vessels, or both.
- Researchers have recently discovered connections between rosacea and small intestinal bacterial overgrowth (SIBO). Moreover, the elimination of SIBO has shown to decrease many symptoms of rosacea. Researchers surmise that translocation of gut bacteria may lead to increased bloodstream levels of pro-inflammatory cytokines. (10)
Adjusting the diet to decrease fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (otherwise known as FODMAPs to include wheat, soft cheeses, and sweetners) can favorably alter the gut microbiota. (15)
What are the side effects of leaving rosacea untreated?
Studies have shown that if rosacea is left untreated, the redness will persist, and the blood vessels will become more prominent from underneath the skin. This redness can then progress to papules and pustules, eventually leading to skin thickening and an enlarged (rhinophymatous) nose, particularly in men.
Moreover, several studies have documented the decreased quality of life and decreased psychological well-being of individuals with rosacea. (8)(11)(12) Proper and timely treatment, on the other hand, can be a “game-changer” for most of these individuals.
What are rosacea comorbidities?
As rosacea is known to have an inflammatory reaction, which manifests as skin symptoms, recent studies suggest that this condition may be connected to other systemic inflammatory conditions.
A study in Denmark (then repeated in the USA with similar findings) showed that people with rosacea have a significantly greater risk of developing Parkinson’s disease.
An association between female rosacea patients and autoimmune diseases such as multiple sclerosis, rheumatoid arthritis, celiac disease, type 1 diabetes, and migraines has been documented. However, further studies need to be conducted to establish these findings conclusively. (13)(14)