Rosacea – Types Causes and Treatment

About Rosacea

It is an immedicable skin condition, which particularly affects the facial skin. It causes redness and inflammation, giving the skin a blood-shot/blushed appearance like that of a ‘sunburn’. It most commonly appears on the Cheeks, Chin, Nose and Forehead. Though in rare cases, it can also be seen on the Eyes, Neck, Back or Chest. Women being the larger victims to the condition, though, men on getting affected can have severe symptoms. It is prevalent in the age groups of 40 to 60. It often gives a disguised exterior of an allergic skin, acne or eczema. Rosacea leads to the development of pustules, pimples or red bumps.

It is more common amongst the white-skinned people, though it can also occur in coloured skin. The symptoms of Rosacea tend to be intermittent during the start, however, can get persistent and severe as the condition progresses. It has no cure; though, various medical therapies or treatments can help to alleviate the symptoms. There are 6 types of Rosacea and an individual could suffer from more than one type. Also, the severity of symptomatic conditions could vary in different individuals.

6 types of Rosacea

Erytematotelangiectatic (ETR) / Vascular Rosacea:

ETR typically targets the face, giving a blushed appearance due to persistent and prolonged redness. The resulting phenomenon (termed as telangiectasias) is caused due to inflamed and ruptured blood vessels, that are reflected on the skin. Patients with severe ETR can experience burning sensation and scaling of the skin. Triggers such as warm showers, strenuous workouts, hot climatic conditions, stress and alcohol can further worsen the condition.

Papulopustular Rosacea/ Inflammatory Rosacea:

This type of Rosacea is characterized by swollen pus-filled reddish bumps, mostly on the chin, cheeks and forehead. It causes raised and swollen red patches resembling acne break-outs and in severe conditions can cause more than 40 blemishes. The scarring can take long time to heal, making the skin sensitive and oily. Often, this type is misdiagnosed as Acne due to similar symptoms such as redness, pustules and swelling.

Some practioners consider Papulopustular Rosacea as Acne Rosacea. While, some practioners are of the opinion that patients can suffer from both (Acne and Rosacea at the same time) which is termed as ‘Acne Rosacea’. However, taking acne treatments/medications for Rosacea can further worsen the condition. The distinguishing factor between Acne Vulgaris and Papulopustular Rosacea is that patients having the latter condition experience prolonged redness and hot flushes.

Phymatous Rosacea:

Also, known as ‘Rhinophyma’ this condition is more prevalent in men than women. It causes thickened skin (particularly on the nose), but can also affect other areas of the face due to excess tissue. Thus, giving a bumpy and swollen appearance (bulgy unshaped nose) due to enlargement of the sebaceous glands.

Ocular Rosacea:

This type of Rosacea pre-dominantly affects the eyes, giving them a moist and bloodshot appearance. It causes irritation and tingling sensation in the eyes, making them dry and sensitive, often causing cysts on the eyelids. It can also result into increased sensitivity to light and blurred eyesight.

Granulomatous Rosacea:

It is a rare chronic condition that involves swelling and inflammation of the facial skin. It tends to be more severe than other Rosacea types and the symptoms include thickened skin, yellowish-brown to pinkish papules/bumps and red patches. Apart from adults, middle-aged women are more likely to be affected by this condition. Due to its similarity with other dermatological ailments, it is often misleading to diagnose this rare condition of Rosacea and requires a skin biopsy.

Steroidal Rosacea:

As the name indicates, Steroidal Rosacea is induced by persistent use or discontinuation of oral or topical corticosteroids. Creams and lotions containing fluorine are more likely to induce this type of Rosacea. The symptoms include small scaly papules/pustules on the facial skin, causing redness and itchiness. If left undiagnosed and untreated for a long time, it can cause enlargement of blood vessels due to swelling (telangiectasia).

Causes

Although, exact factors on what causes Rosacea are yet not known, potential contributors of the same have been propounded. This set of probable inducers include defective immune system, nervous system, problems with the facial blood vessels, presence of certain microbes and Demodex mites. Based on some anecdotal evidence, Rosacea could also be as a result of inherited factors, and genetic research about the same is in progression.

The ‘indirect triggers’ that worsen the symptoms of Rosacea include:

• Sun Exposure (Ultra-violet radiations)
• Stressful conditions/Strong emotions
• Extreme climatic conditions
• Strenuous work-outs
• Alcohol consumption
• Hot showers
• Certain drinks (Tea/Coffee/Cola)
• Hot Beverages
• Menopausal conditions in women
• Milk products
• Other Medical ailments
• Certain Medications/Drugs

Many factors together in combination can also be responsible for the condition, however, sufficient evidence is not available to validate the claim. Several research studies facilitated by the National Rosacea Society (NRS) is identifying logical and empirical conclusions to the existing theories, so as to understand the phenomenon of the disease. As simplification of the accurate cause will enable to determine advanced preventive measures and treatments for Rosacea.

Apart from the indirect triggers, potential key factors responsible for the condition are outlined as below:

Mal-functioning of the Immune System:

According to the current scientific findings, immune system in Rosacea patients does not function properly. The immune system of the body consists of ‘Cathelicidins’, an anti-microbial molecule type that helps the body to defend against any illness. These molecules eliminate the harmful microbes and activate complex immune reaction, therefore any factors causing infection or irritation can induce the production of these substances.

Cathelicidins tend to cause inflammations, papules/bumps, acne-like break-outs, enlarged and dilated blood vessels (telangiectasia), which are all the symptoms observed in Rosacea patients. These substances were found in abundance and in different forms in the patients as per the research findings funded by the NRC. The indirect triggers are also associated to the production of Cathelicidins, which have further established its link to Rosacea.

Vascular Abnormalities:

According to the NRS-funded research, exposure to Ultra-violet (UV) radiations induce the production of VEGF (Vascular Endothelial Growth Factor), a substance that has been linked to telangiectasia. As pigmentation is more in dark-coloured individuals, UV radiations do not penetrate deeper into the skin. Thus, VEGF is produced only in the upper dermis without affecting the blood vessels. Contrastingly, in fair-skinned people, less pigmentation enables the UV rays to penetrate deeper into the skin. Thus, potentially causing the blood vessels to become visible. These findings also align with the fact that Rosacea tends to be more common in fair-skins.

Increased level of skin peptides:

As per the research studies, indirect triggers activate the skin peptides. Peptides are the molecules in the skin that facilitate the production of collagen, by sending signals to the skin cells. The level of peptides rises as a result of indirect triggers, causing adverse effects on the immune system and the neurovascular system of the dermis. This leads to enlarged, inflamed blood vessels and facial redness.

Certain Microbes/Bacteria:

Demodex mites, a natural microbiome, that dwell on all the human skins are found to be in larger numbers in Rosacea patients. As per the research findings, these mites tend to be in huge quantities on the same facial regions (such as forehead, cheeks, chin and nose) usually affected by Rosacea. This has been concluded based on the biopsies of Rosacea pustules/bumps. However, there has been no conclusive research yet, on whether the mites are the cause or effect of Rosacea.

Bacteria Helicobacter pylori related to the digestive system and gastric disorders is also suggested to be a probable factor to cause Rosacea. The bacterium chemically reacts with gastrin and induces symptomatic conditions of Rosacea such as redness/hot flushes. As per research studies, this phenomenon was found to be similar in Rosacea patients and non-existent in those without this condition. However, there is still more research to be conducted on the same for further conclusion.

Genetic Inducers:

Rosacea is found to run in families; however, enough empirical data is not available on how or which genes tend to inherit the condition. As per the research studies, Rosacea occurs mostly in identical twins than in non-identical/fraternal twins. Further research revealed that genetic contribution to the occurrence of Rosacea is half, while the rest is attributed to environmental factors.

Treatment

Although, there is no cure for Rosacea, various treatments combined with changes in lifestyle and skin-care routine can help to relieve the symptomatic conditions.

Medicinal Treatment (Topical/Oral):

There are various medicinal treatments, either in the form of topical application or oral dosage or both to treat the symptoms of Rosacea.

• Topical application of medicines help in minimising the facial inflammation/redness and can be applied to the skin once/twice daily. For maximum results, they are usually prescribed with other oral drugs.

Commonly prescribed topical applications (gel/cream base) include Azelaic acid, Tretinoin, Metronidazole and Benzoyl Peroxide.

• Facial flushing is usually difficult to treat than the pustules or bumps caused due to the condition. Brimonidine tartrate gel, relatively a new addition, can work effectively in reducing facial redness and starts acting within 30 minutes upon application. The effect lasts up to 12 hours, though the drug can have certain side-effects as well.
• Ivermectin cream, comparatively, a new drug prescribed to treat Rosacea-related symptoms is found to be less irritating to the skin than Metronidazole. Although, it is only advised, if the other drugs are not giving any results. The side-effects of these topical drugs can result into stinging sensation or dry to itchy skin.
• Oral drugs tend to work faster than topical applications and provide relief against inflammation. Some of the oral anti-biotics advised for Rosacea patients are Tetracycline, Minocycline, Erythromycin, Oxytetracycline, Doxycycline and Minocycline. There could be contra-effects to these medicines and are required to be taken under expert guidance.
• Oral Accutane/Isotretinoin often used to treat chronic acne, is occasionally advised to treat severe symptoms of Rosacea, if the other medicines have failed to work. Isotretinoin is a powerful drug, that prevents oil production by targeting the sebaceous glands. As this drug has severe side-effects, it has to be administered under the supervision and close monitoring of a skin expert.

Oral dosages such as Clonidine, Anxiety medicines/Beta-adrenergic drugs are also prescribed by the skin experts to treat redness/flushing of the facial skin, though their role in treating in Rosacea is yet not precisely clear.

• Blephamide, a steroidal ocular drop, is advised by the dermatologist for patients with eye symptoms or ocular rosacea. Tetracycline/Doxycycline drugs are also recommended for patients with symptoms of Ocular Rosacea.

Laser Treatment/IPL (Intense Pulsed Light) treatment:

The symptomatic conditions of Rosacea that causes dilated/inflamed blood vessels (telangiectasia) can be treated through vascular laser or IPL treatments. These treatments use narrow beams of light that generate heat and target the damaged blood vessels causing them to shrink. Thus, it reduces their visibility with minimal scarring/bruising in the peripheral area.

Laser treatments can be a bit painful, but are mostly bearable without the need of an anaesthesia. The side-effects of laser therapy are generally minor and can at times cause tenderness, swelling, bruising and crusting. However, they tend to be temporary and disappear within few days. In very rare cases, it can cause blisters or infections, which might require any further medical attention.

Surgical Treatments

For Rosacea patients with thickened skin that cause enlarged, bulbous nose (Rhinophyma) or puffy cheeks can be improved by removing excess tissue either through scalpel or laser treatments. The Carbon-dioxide laser treatment, which uses beam of Carbon-dioxide also helps to remove the layers of extra tissue. Other methods such as ‘Dermabrasion’ are also effective in minimising and scaling out the thickened skin.

Apart from the medical and surgical treatments, avoiding the ‘indirect triggers’ that can induce the symptoms of Rosacea, along with a good skin-care regimen are key to prevent the condition. Use of Sunscreens and gentle skincare products are must to stop it from worsening. Recommendations by dermatologists should be essentially followed.

Medical help at the right time and self-care can make living with Rosacea easier!

References

1. https://f1000research.com/articles/7-1885/v1
2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6624012/
3. https://www.nps.org.au/australian-prescriber/articles/an-update-on-the-treatment-of-rosacea