Family doctor

What is rosacea and what causes it?

Rosacea is a long-term disorder that affects the skin of the face and the eyes. The exact cause of rosacea remains unknown, although there seems to be an inherited component to it. It can be described as a vascular and inflammatory disorder affecting the tiny blood vessels and connective tissue in diseased areas.

Many theories exist as to the exact cause of rosacea, including infection, mites, autoimmune disorders, and psychological causes (amongst others). None has as yet been proven.

What are the characteristic features of rosacea?

Rosacea typically causes reddened coarse skin with the following traits:

• pimples with or without pus (papules and pustules)
• broken veins (telangiectasia)
• swelling (hypertrophy)
• oiliness of skin.

Rosacea usually affects sun-exposed skin of the face and chest. In men, the nose is primarily affected, whereas women are more likely to get rosacea of the cheeks and chin. Eventually, the cheeks may become baggy, and the nose may become large and disfigured (known as 'rhinophyma').

The condition is characterised by episodes of flushing of the affected areas and flare-ups, in association with certain factors that sufferers learn to recognise.

Rosacea also affects the eyes in most sufferers (almost 60% of rosacea patients in one study). Eye involvement ranges from minor complications (common) to blindness (rarely). Rosacea is a common cause of 'red eye' and 'dry eye'.

Who gets rosacea?

Rosacea is most common in fair-skinned people, especially those of Celtic or Scandinavian origin. It typically occurs in those aged between 30 and 60, although it very occasionally affects children. Women are probably affected more than men, but it is usually more severe in the latter. Rosacea can run in families, with 40% of sufferers having a family member who also has the condition. It is not uncommon: in America, around 13 million people have rosacea.

Is it painful?

In its early stages, there may be complaints of burning, redness or stinging of the skin when skin care products or sunscreens are applied. However, the skin features described above are generally not painful; however, in some patients skin nodules eventually become painful.

The initial symptoms of rosacea of the eyes are usually pain, burning, grittiness and a foreign body sensation.

Although the physical symptoms of rosacea are typically not painful, they cause considerable psychological stress and discomfort. While many sufferers are embarrassed by their condition, three-quarters report they have low self-esteem, and over half feel they have been robbed of pleasure and happiness. Moreover, the majority of patients with rosacea feel that it negatively affects both their professional and social life.

How is rosacea diagnosed?

There is no diagnostic test for rosacea; it is diagnosed from the typical appearance of the facial skin. In about 20% of patients, rosacea affects the eyes before the skin changes occur; in such cases, the diagnosis may be more difficult to make, as primary eye conditions are suspected initially.

There are various other conditions that may resemble rosacea, although each has features to distinguish them from it. Examples (with distinguishing features shown in brackets) include:

• acne (blackheads are a feature, also affects the skin of the chest and back)
• seborrheic dermatitis (no flushing/blushing/broken veins)
• systemic lupus erythematosus [SLE] (no papules or pustules)
• sarcoidosis (no pustules)
• steroid-induced acne (associated with a history of use of steroid cream/lotion on the face).

What causes flare-ups?

Many factors are associated with flare-ups of rosacea. The idea that rosacea sufferers drink too much alcohol is ill founded, as the condition can occur even in those who don't drink. Sufferers are encouraged to learn to recognise factors that cause flare-ups and to take measures to avoid them (see Table). The most common 'triggers' are sun exposure and stress (causing flare-ups in around 60% of sufferers); alcohol consumption is a trigger in 45%.

Table: Common causes of rosacea flare-ups and methods to deal with them

How is it treated?

As noted, rosacea is a long-term condition characterised by flare-ups, which can become disfiguring with time if left untreated. Although it cannot be cured, it can be effectively managed. In addition to avoidance of triggers, various therapies are used to treat it, including both prescription medicines and surgical techniques. A skin specialist (dermatologist) is most qualified to treat rosacea, although an ophthalmologist's opinion may be required for any eye involvement.

The mainstay of treatment is oral antibiotic therapy; drugs from the tetracycline group are used most commonly (tetracycline, minocycline, doxycycline). Various other antibiotics have also demonstrated benefits, including erythromycin, clarithromycin, ampicillin, clindamycin and metronidazole. Oral antibiotics treat the pimples (papules and pustules) more effectively than the red skin and broken veins.

Isotretinoin is a capsule usually used to treat severe acne. It has been shown to improve inflammation, redness, broken veins and even rhinophyma. It can be toxic, so its use must be carefully monitored.

There are also some topical creams and gels available to treat rosacea, but their availability in different countries varies. These include metronidazole gel and cream (recently available in the United States in a slightly stronger, once-daily cream), and sulfacetamide/sulfur lotion. Occasionally 1% hydrocortisone cream is also used for rosacea, although its use may cause acne or dermatitis.

As with rosacea of the facial skin, rosacea of the eye is managed with oral antibiotics. In addition, it is very important to keep the eyelids clean, using warm soaks, dilute baby shampoos, or eye scrubs.

Occasionally non-medical management of rosacea is required. Broken veins may be treated with laser therapy or electrocautery, while rhinophyma treatments include cryosurgery (cold), laser therapy, dermabrasion (electrosurgical 'shaving'), or excision and skin grafting. Rosacea of the eyes may also require specialist surgery by an ophthalmologist.

Bibliography:

• Macsai MS, Mannis MJ, Huntley AC. Acne rosacea. In: Mannis MJ, Macsai MS, Huntley AC, eds. Eye and Skin Disease. 1st ed. PhilaLippincott-Raven, 1996: 335-45
• Thiboutot DM. Acne and rosacea. New and Emerging Therapies. Dermatologic Clinics 2000;18(1):63-71
• Zuber TJ. Rosacea. Primary Care; Clinics in Office Practice 2000;27(2):309-18