Over 14 million Americans live with rosacea, a skincare that has no cure and no definitive cause. While people may think that rosacea just causes more frequent blushing, this is actually a complex skin condition that can worsen over time. While rosacea can’t be completely eliminated, researchers and doctors have found several factors that worsen or trigger it, as well as treatments to minimize symptoms.
What is rosacea?
Rosacea is a skin condition that impacts roughly four to five percent of the American population. It is chronic, and occurs in cycles where it can be present for weeks or even months before disappearing for a period of time, and then returning. The most common symptom of rosacea include flushing and persistent facial redness, also known as erythema. And erythema doesn’t appear red on everyone: rosacea occurs on all skin tones and is often misdiagnosed in skin of color.
Often, rosacea appears as small, pus-filled bumps or swelling, flushing, and erythema across the center of the face. Small blood vessels on the nose and cheeks often swell and can become visible during on lighter skin. Rosacea can be easily misidentified as other skin conditions such as acne or eczema, partially due to the different subcategories of the disease.
Types of rosacea
The four main forms of rosacea are erythematotelangiectatic rosacea, which is the most common and what most people think of when they think of rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea. All four have slightly different symptoms and treatments, but a person can also be diagnosed with multiple types of rosacea, further complicating diagnosis and treatment.
Erythematotelangiectatic Rosacea (ETR)
ETR is the form of rosacea that most people are familiar with. This type causes flushing or redness across the nose and cheeks, but it can also appear on the forehead, scalp, chin, and neck if allowed to worsen without treatment. Less common symptoms of ETR include warmth or tingling in the affected areas or the skin getting dry and scaly. By not treating it, not only will symptoms escalate, but time between cycles will decrease and length of flare-ups will increase.
Papulopustular Rosacea
Also called “acne rosacea,” this type not only causes flushing, erythema, and visible blood vessels, but also brings pimples and acne-like symptoms, hence its name. It won’t cause blackheads and whiteheads (common indications of regular acne), but it usually results in large, painful blemishes called papules and pustules. These develop deep in the skin and are difficult to get rid of. The papules can also be accompanied by abnormally oily or abnormally dry patches of skin.
Phymatous Rosacea
Usually occurring on and around the nose, this also starts with redness and visible blood vessels, but additionally causes a buildup and thickening of skin, starting with small plaques. As it progresses, the skin can resemble scar tissue and is bumpy and tough. With cases that are left untreated, the skin can build up to the point where the nose is noticeably bulbous and protruding. This is the least common form of rosacea but unlike papulopustular rosacea, this condition is more common in men than women.
Ocular Rosacea
Ocular rosacea, meaning related to the eyes, primarily causes inflammation and redness around the eyes and eyelids. This can lead to additional bumps, swelling, and redness of the eyes, which will cause burning and watering. In certain cases, symptoms may also include photosensitivity and blurred vision. Due to these broad characteristics that are shared by other issues (including hay fever), it can be difficult to diagnose properly, even by a dermatologist. If someone has these symptoms in addition to other rosacea symptoms such as the redness and visible blood vessels, it is more likely that this is ocular rosacea rather than allergies or dry eyes. It may be treated by an ophthalmologist.
Rosacea triggers & causes
Now that we know what to look for, let's discuss rosacea triggers. While it’s true that there isn't a single cause of rosacea, there are numerous factors that trigger a cycle or worsen flare-ups.
Unbalanced skin microbiome
The first key to healthy skin, whether in controlling rosacea or other skin conditions such as eczema, is a balanced skin microbiome. It’s a complex topic, but the basics are that the surface of your skin is home to bacteria, some that are good and helpful and some that are bad and can be harmful if not kept in check.
If your skin microbiome becomes unbalanced, it creates an environment for bad bacteria to take over, which can make rosacea and other inflammatory skin conditions worse. When the microbiome is balanced, skin is healthy.
Environmental factors
Skin health is also impacted by environmental components. These can be external factors like sun exposure and heat, or internal factors like stress, or foods that you eat. Foods and drinks that can make facial redness worse include spicy food, dairy, alcohol, chocolate, citrus, and cinnamaldehyde, which is in cinnamon.
These external factors all impact how your skin reacts to perceived threats and can also disrupt your skin microbiome’s bacteria. Talk to your doctor about how to identify and reduce exposures to these rosacea triggers.
Harsh skincare products
Similar to several environmental factors like heat and sun exposure, harsh skincare products contain ingredients that dry out and irritate your skin. By looking through the products you use and eliminating those that have irritating ingredients, you might be surprised by the improvements you see over time. Harsh products often “overclean” and strip the skin of its microbiome and its natural barriers that help fend off redness and environmental pathogens. Fragrances and other ingredients can be harmful, so using products without them can be beneficial to your skin, whether you have rosacea or not.
Skin mites
The term skin mites can sound scary and make your skin crawl, but everyone has them on their skin and they’re totally normal. In particular, Demodex folliculorum are the types of mites connected to rosacea. Usually these mites are completely harmless and don’t cause any issues as they live in hair follicles, especially around the face.
However, people with rosacea have been found to have higher concentrations of this microorganism. Unfortunately, researchers aren’t sure whether they are a cause of the inflammation, or an effect of it. Either way, this is another reason to balance your skin microbiome and not let them get out of hand.
Genetics
Genetics almost certainly play a role in why rosacea appears in some but not others. Someone in a family that has a history of roscea is more likely to develop it themselves, and researchers at Stanford found two particular areas of the genome that can be linked to rosacea. Certain demographic groups are more susceptible to the disease, including females, those with fair skin, hair, and eyes, and those between 30 and 50 years old.
Rosacea treatment options
While rosacea doesn’t have a cure, it can be treated in various ways. Below we will talk through treatment options, both those that are stronger and usually reserved for more extreme cases, as well as those that are simpler and don’t require prescriptions. Certain forms of rosacea are treated differently (especially ocular rosacea), but usually through use of antibiotics or other prescriptions.
Avoid triggers
With rosacea, it's important to avoid triggers that cause flare-ups or worsen existing redness. With so many factors capable of influencing our skin and everyone’s skin being different, it can be hard to know where to start. A medical professional can help you identify triggers in your diet, skincare routine, daily schedule, and more.
Eye drops
Ocular rosacea is different from the other forms due to its proximity to the eyes and how sensitive they are. Eye drops are often prescribed to treat the redness and irritation. While dermatologists usually are the experts on rosacea, an eye specialist might have to be consulted for treatments like eye drops, and may prescribe blephamide, a steroid and antibiotic eye drop. Warm compresses also help soothe the effects of ocular rosacea, and are commonly paired with eye drops.
Prescription rosacea cream
For the other forms of rosacea, creams with azelaic acid or other ingredients may be prescribed by a doctor, who will provide specific usage instructions. It can take 3 to 6 weeks to see improvement. If using a topical steroid cream, talk to your doctor about the risk of topical steroid withdrawal.
Vasoconstrictors, which reduce blood flow by constricting blood vessels in the cheeks and the face, are also commonly prescribed for rosacea. Ask your doctor about the possibility of a reaction if you discontinue use.
Antibiotics
Antibiotic treatment of rosacea can fall under either topical or oral, with some overlap between topical antibiotics and prescription creams discussed in the previous section. Oral treatments include tetracycline, minocycline, and erythromycin and may produce results faster than topical options. These are also used commonly with ocular rosacea because of the limitations of creams around the eyes.
Antibiotics are powerful but can also lead to side effects and should be carefully considered only after topical treatment and trigger avoidance options haven’t worked. Side effects may include rashes, vomiting, abdominal pain, light sensitivity, aches and pains, and more.
Isotretinoin (Accutane)
This is another oral medication but is not an antibiotic. It’s a powerful drug that’s used to treat severe or resistant outbreaks of acne or rosacea by essentially preventing the skin from producing oil.
This is an option that should only be considered if everything else doesn’t work. Talk to your doctor about possible side effects, including behavioral changes, depression, vomiting, and joint pain. Isotretinoin can cause serious birth defects in children and is not recommended for use during pregnancy.
Laser treatment
Light or laser treatment is an option for rosacea treatment that would follow if any topical or oral medications are not not reducing symptoms. This therapy uses intense pulses of light to shrink the size of blood vessels in your face to bring inflammation, itchiness, and irritation back to manageable levels.
Laser therapy will usually not permanently reduce symptoms however, and can be needed on a recurring basis to not only reduce blood vessel size, but to remove buildup of skin from phymatous rosacea as well.
Surgical treatment
Similar to laser therapy to reduce skin buildup or thickness from phymatous rosacea, surgery may also be a consideration to get this done. A cosmetic surgeon would be required for this procedure rather than a dermatologist and the procedure usually involves removing excess skin and reshaping the surface of it.
With surgery, other treatment options may be used in conjunction so that the progress made doesn’t reverse, letting the rosacea worsen again. Often, the patient will be given medication that is more for maintenance and upkeep of the skin rather than the purpose of clearing it.
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Balancing your skin’s microbiome creates a healthier environment where good bacteria can keep bad ones in check.
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Once you've restored balance to your skin microbiome, upkeep is necessary. This is where both avoiding harsh skincare products that strip the skin microbiome and using gentle products that maintain it are essential.
Rosacea can be kept in check
Rosacea is a skin condition that can vary wildly in terms of how manageable it is and how much impact it can have on your life. With a better understanding of it and your treatment options, you should now be able to decide whether it’s something mild enough where more basic and accessible treatments will do or whether you need to visit a specialist. No matter what your situation with rosacea is, help is out there and rosacea can be managed so you can be comfortable in your skin.