Rosacea is a common skin condition characterized by central facial flushing and erythema (redness), telangiectasias (spider veins), papules (small bumps), pustules (pus-filled bumps), and phymatous changes (tissue thickening and nodularity). (Rosacea in The Merck Manual, 18th Edition. 2006:946-47)
Rosacea occurs more commonly in white persons, but it can occur in individuals of any ethnicity. It is more common in women and typically begins in the third or fourth decades of life.
Rosacea is often misdiagnosed for weeks or months due to its variable appearance and its similarity to other conditions, such as systemic lupus erythematosus, acne vulgaris (common acne), drug allergy, or other autoimmune, malignant, or inflammatory conditions.
Classification of Rosacea
Until recently, rosacea was classified according to four phases:
- “Pre-rosacea:” evanescent flushing and blushing on the cheeks, forehead, and/or chin, sometimes accompanied by a stinging sensation.
- Vascular phase: persistent erythema and swelling associated with multiple telangiectasias.
- Inflammatory phase: papules and pustules develop in areas that were previously only reddened (these lesions led to the designation of rosacea as “adult acne”).
- Phymatous phase: thickening, coarsening, and overgrowth of inflamed tissues (W.C. Fields and J.P. Morgan both had the classic rhinophyma associated with advanced rosacea).
- Ocular rosacea, a variable degree of reddening of the eye, could accompany any of these phases.
The National Rosacea Society has recently divided rosacea into four distinct subtypes, which are further classified according to their severity (i.e., mild, moderate, and severe). This classification regime is helpful for stratifying treatment for rosacea:
- Erythematotelangiectatic: characterized by redness and/or telangiectasias
- Papulopustular: papules and/or pustules are the predominant feature, usually combined with persistent redness
- Phymatous: tissues of the face (the nose, cheeks and chin are most commonly involved)
- Ocular: redness of the eye or lids, or symptoms of eye involvement (light sensitivity, sensation of irritation or foreign body, etc.). 60% of persons with rosacea have ocular involvement, which may occur before the skin becomes involved. (Goldgar C, et al. Treatment options for acne rosacea. Am Fam Phys. 2009;80[5]:461-68)
What Causes Rosacea?
The underlying cause of rosacea is unknown, but associations with impaired facial venous drainage, mite overgrowth (from Demodex folliculorum), or infection with Helicobacter pylori have been hypothesized.
Several aggravating factors, or triggers, for rosacea have been described. Sun exposure is listed as an inciting factor for over 80% of patients. Other triggers include:
- Emotional stress
- Heat (hot baths or showers, scarves, steam, etc.)
- Wind
- Strenuous exercise
- Alcohol consumption
- Spicy foods
- High humidity
- Cosmetics or other skin-care products
- Hot beverages
- Medications
How is Rosacea Treated?
A 2005 Cochrane review demonstrated that the quality of studies evaluating treatment for rosacea is generally poor. (van Zuurën E, et al. Interventions for rosacea. Cochrane Database Syst Rev. 2005;[3]:CD003262)
Nevertheless, an algorithmic approach to rosacea treatment—based on disease severity—has become popular among physicians who manage this condition.
Non-pharmacologic Treatment of Rosacea
- Avoidance of known triggers is of paramount importance in preventing rosacea and controlling its progression.
- The use of sunscreens and hats, limiting consumption of alcohol and hot beverages, avoidance of known irritants (e.g., sodium lauryl sulfate, astringents, menthol, eucalyptus, or cinnamon, clove, or peppermint oils), and the use of emollient, non-comedogenic cosmetics are recommended measures.
- Vascular lasers: the mainstay of non-pharmacologic therapy for many stages, including persistent erythema and telangiectasias and resistant rosacea.
- Mechanical dermabrasion, cold steel excision, laser peels, surgical shaving, and electrosurgery may all confer cosmetic improvement of rhinophyma, but these treatments have not been well-studied.
Pharmacologic Treatment of Rosacea
Topical Therapy
- Metronidazole (Metrogel) is one of two FDA-approved agents used for rosacea, so its effectiveness has been thoroughly evaluated. It is well-tolerated by most people and is generally used as first-line therapy for erythematotelangiectatic and papulopustular types.
- Azelaic acid (Azelex) has also been approved by the FDA for rosacea treatment. It is used as primary therapy or in combination with Metrogel or other agents.
- Sulfacetamide/sulfur cream, benzoyl peroxide/erythromycin (Benzamycin) gel, and benzoyl peroxide/clindamycin (Benzaclin) gel have shown some benefit in managing the inflammatory manifestations of rosacea.
- Retinoic acid agents (e.g., adapalene), the antiparasitic agent permethrin, and silymarin combined with methylsulfonylmethane have also been used to treat earlier rosacea stages, but the data supporting the use of these modalities are incomplete.
Systemic (Oral) Therapy
The evidence supporting the use of oral agents for rosacea is limited, but the following medications have found widespread use for treatment of various stages of rosacea:
- Tetracycline
- Doxycycline
- Minocycline (Minocin)
- Metronidazole (Flagyl)
- Azithromycin (Zithromax)
- Isotretinoin (Accutane)
Although many of the approaches used to treat rosacea mirror those used for acne vulgaris (adolescent acne), the two conditions are distinct. Rosacea can be controlled by avoidance of known triggers and tailoring therapy to the specific subtype that affects each individual.
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