Rosacea (pronounced roh-ZAY-sha) is a common but poorly understood disorder of the facial skin that is estimated to affect well over 16 million Americans and as many as 415 million worldwide — and most of them don't know it. In fact, a National Rosacea Society survey found that 95 percent of rosacea patients had known little or nothing about its signs and symptoms prior to their diagnosis. Because of its red-faced, acne-like effects on personal appearance, however, it can cause significant psychological, social and occupational problems if left untreated.

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While the cause of rosacea is unknown and there is no cure, today medical help is available that can control the signs and symptoms of this potentially life-disruptive disorder. Any one of the following warning signs is a signal to see a dermatologist or other knowledgeable physician for diagnosis and appropriate treatment before the disorder becomes increasingly severe:

• Redness on the cheeks, nose, chin or forehead.

• Small visible blood vessels on the face.

• Bumps or pimples on the face.

• Watery or irritated eyes.

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Rosacea can vary substantially from one individual to another, and in most cases some rather than all of the potential signs and symptoms appear. According to a consensus committee and review panel of 28 medical experts worldwide, diagnosis requires at least one diagnostic sign or two major signs of rosacea.1 Various secondary signs and symptoms may also develop but are not diagnostic.

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Diagnostic Signs of Rosacea

The presence of either of these signs is diagnostic of rosacea.

• Persistent Redness - Persistent facial redness is the most common individual sign of rosacea, and may resemble a blush or sunburn that does not go away.

• Skin Thickening - The skin may thicken and enlarge from excess tissue, most commonly on the nose (known as rhinophyma, pronounced “rye-no-FY-muh”). This condition is less common, but can lead to facial disfigurement and inadequate nasal airflow if severe.

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Major Signs of Rosacea

The presence of at least two of these signs is diagnostic of rosacea.

• Flushing: Many people with rosacea have a history of frequent blushing or flushing. This facial redness may be accompanied by a sense of heat, warmth or burning comes and goes, and is often an early feature of the disorder.

• Bumps and Pimples: Small red solid bumps or pus-filled pimples often develop. While these may resemble acne, blackheads are absent and burning or stinging may occur.

• Visible Blood Vessels: In many people with rosacea, prominent and visible small blood vessels called telangiectasia (pronounced “tell-ANN-jeck-TAY-zha”) become on the cheeks, nasal bridge, and other areas of the central face.

• Eye Irritation: In many rosacea patients, the eyes may be irritated and appear watery or bloodshot, a condition commonly known as ocular rosacea. The eyelids also may become red and swollen, and styes are common. Crusts and scale may accumulate around the eyelids or eyelashes, and patients may notice visible blood vessels around the lid margins. Severe cases can result in corneal damage and loss of visual acuity without medical help.

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Secondary Signs and Symptoms

These may appear with one or more of the diagnostic or major signs.

• Burning or Stinging - Burning or stinging sensations may often occur on the face. Itching or a feeling of tightness may also develop.

• Swelling - Facial swelling, known as oedema, may accompany other signs of rosacea or occur independently. Raised red patches, known as plaques, may develop without changes in the surrounding skin.

• Dryness - The central facial skin may be rough, and appear scaly despite some patients complaining of oily skin.

• In rare cases, rosacea signs and symptoms may also develop beyond the face, most commonly on the neck, chest, scalp or ears

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What Causes Rosacea?

• Although the cause of rosacea remains unknown, researchers have now identified major elements of the disease process that may lead to significant advances in its treatment. Recent studies have shown that the facial redness is likely to be the start of an inflammatory continuum initiated by a combination of neurovascular disregulation and the innate immune system. The role of the innate immune system in rosacea has been the focus of groundbreaking studies. Further research has now demonstrated that a marked increase in mast cells, located at the interface between the nervous system and vascular system, is a common link in all major presentations of the disorder.

• Beyond neurovascular and immune system factors, the presence of a microscopic mite called Demodex folliculorum has been considered as a potential contributor to rosacea. This mite is a normal inhabitant of human skin, but has been found to be substantially more abundant in the facial skin of rosacea patients. Researchers have also discovered that two genetic variants of the human genome may be associated with the disorder.

• Other recent studies that have found associations between rosacea and increased risk for a growing number of potentially serious systemic diseases, suggesting that rosacea may be an outcome of systemic inflammation. Although causal relationships have not been determined, these have included cardiovascular disease, gastrointestinal disease, neurological and autoimmune diseases and certain cancers.

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How is Rosacea Treated?

• Because the signs and symptoms of rosacea vary from one patient to another, treatment must be tailored to each individual case.

• A range of oral and topical medications for example topical metronidazole gel or azelaic acid may be used to treat the various signs and symptoms associated with the disorder. Prescribers may prescribe medical therapy specifically to control the redness. Bumps and pimples often receive initial treatment with oral and topical therapy to bring the condition under immediate control, followed by long-term use of an anti-inflammatory therapy alone to maintain remission. Therapies specific for rosacea are now available in various formulations that can be selected for each patient.

• When appropriate, lasers, intense pulsed light (IPL) sources or other medical and surgical devices may be used to remove visible blood vessels or correct disfigurement of the nose. Ocular rosacea may be treated with anti-inflammatory medications and other therapy, and referral to an eye specialist may be needed.

• Diathermy, a tiny needle the size of an eyelash is an excellent treatment for visible facial veins associated with rosacea.  Maintenance treatments will be required to keep veins at bay.

• There is a growing library of research for the use of toxin for rosacea too. Most uses of toxin are "off label" use, however the results can be rewarding.

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Skin Care

• Rosacea sufferers should check and ensure their skin-care routine is compatible with their rosacea. A gentle skin-care routine can also help control rosacea. Patients are advised to clean their face with a mild and non-abrasive cleanser, then rinse with lukewarm water and blot the face dry with a thick cotton towel. Never pull, tug or use a rough washcloth.

• Patients may apply non-irritating skin-care products as needed, and are advised to protect the skin from sun exposure using a mineral sunscreen that delivers UVA/UVB protection with an SPF of 30 or higher. Mild or paediatric formulations are available for sensitive skin, and look for non-chemical (mineral) sunscreens that contain zinc or titanium dioxide. Rosacea patients should avoid any skin-care products that sting, burn or cause additional redness.

• Cosmetics may be used to conceal the effects of rosacea. Green makeup or green-tinted foundations can be used to counter redness. This can be followed by a skin-tone foundation with natural yellow tones, avoiding those with pink or orange hues.

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Lifestyle Management

• Rosacea is benign in nature of acne rosacea and that progression to severe disease, such as rhinophyma, is uncommon (especially in women).

• Rosacea is not related to poor hygiene.

• Rosacea is a chronic condition that can be improved with treatment, but intermittent flare-ups may occur and no known permanent cure exists to date.

• Check out more sources of information and support, such as the British Association of Dermatologists (BAD) Patient Information Leaflet (PIL) for Acne rosacea, available on the quick links.

• The frequent application of high-factor mineral sunscreen (minimum sun-protection factor 30) to the face whenever the skin is exposed to daylight and sunlight.

• If flushing is problematic, the avoidance of trigger factors (where practical), such as extremes of temperature, sunlight, strenuous exercise, stress, spicy foods, caffeine, cheese, alcohol, and hot drinks can help.

• If the skin is dry, the use of hypoallergenic emollients can ease the symptoms.

• In addition to long-term medical therapy, rosacea sufferers can improve their chances of maintaining remission by identifying and avoiding lifestyle and environmental factors — often related to flushing — that may trigger flare-ups or aggravate individual conditions. Identifying these factors is an individual process, however, because what causes a flare-up in one person may have no effect on another.

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