Rosacea: Is that acne or rosacea on your skin?

What is rosacea?

Rosacea is a chronic (long-term) skin condition that typically affects the face, including the forehead, cheeks, nose and chin. Although rosacea is more common in women after 30 years of age, it can affect both genders at any age. When rosacea causes red bumps on the face, it may look similar to acne vulgaris (more commonly known as acne). Although they can coexist in some people, distinguishing between the two is important as treatment of each condition can be quite different. We hope this article will help you learn more about rosacea.

Causes of rosacea: what are the triggers?

The exact mechanism of rosacea is poorly understood. In the past, the symptoms of rosacea were perceived by the general public to be a consequence of heavy alcohol consumption, although definitive evidence to support this direct causal association is lacking.

Recent studies suggest a complex interplay between genetic, immunologic and environmental factors that trigger an abnormal response to microscopic organisms (Demodex mites) that are a normal inhabitant of the human skin, leading to inflammation and dilatation of blood vessels in the face.

Dietary triggers

• Alcohol
• Caffeine-containing beverages (e.g. tea or coffee)
• Spicy food, chocolate and cheese

Other triggers

• Exposure to sunlight/ ultraviolet radiation
• Heat
• Exercise
• Stress
• Exposure to chemicals in cosmetics, household cleaners (e.g. ammonia)
• Use of topical steroids on the face

Those with underlying chronic skin conditions (e.g. atopic dermatitis or contact dermatitis) or on long-term topical steroids are also more prone to develop rosacea.

Symptoms of rosacea

Symptoms of rosacea depend on its severity, and may present as::

1. Intermittent facial flushing (especially on cheeks or the nose) - with burning or stinging sensations;
2. Persistent redness - due to dilated blood vessels under the skin, and may show up as prominent blood vessels on the cheeks (telangiectasia) or around the nose;
3. Red papules (bumps) and pustules (pus-filled bumps);
4. Rhinophyma (swelling and soft tissue overgrowth of the nose) - due to persistent inflammation and thickening of the skin

Occasionally rosacea may affect the eyes, causing redness, burning and itching, known as ocular rosacea.

Diagnosis of rosacea

In most cases, the diagnosis of rosacea is made clinically by professionals, and no investigations are required. Doctors will examine your skin and eyes, and ask questions about your symptoms. 

You may have tests to rule out other conditions (e.g. autoimmune conditions) if there are atypical features observed, or be referred to an eye specialist (ophthalmologist) for further evaluation if your symptoms involve your eyes.

Skin biopsies are very rarely indicated, but can be helpful in case another condition is suspected.

Management and treatment of rosacea 

Rosacea is a “relapsing-remitting” condition, meaning that you may have periods where it flares (relapsing) and times when it settles (remitting). Frustratingly, the frequency and duration of both these phases are unpredictable. However, there are some general lifestyle changes you can do and try to manage your rosacea:

• Identify your personal triggers and avoid these (e.g. alcohol, heat or spicy food)
• Avoiding heat (steam treatments, saunas, washing the face with hot water)
• Protect your face from the sun, use light oil-free facial sunscreens
• Avoid scrubbing or rubbing your face, be gentle with your skin
• Use gentle cleansers and bland, hypoallergenic moisturisers
• Avoid or minimise the use of unnecessary skin care products/cosmetics
• Avoid irritating products such as toners, alcohol-based or strong chemical exfoliating agents 

Treatment for rosacea focuses on controlling symptoms. This often requires a combination of avoiding triggers, a simple skin care routine,  and prescription medications depending on the nature and severity of your symptoms.

Topical treatment of rosacea

• Metronidazole cream or gel - a topical antimicrobial with anti-inflammatory properties to be used long-term or in combination with oral medications for more severe cases
• Azelaic acid cream - a topical anti-inflammatory cream that reduces redness and inflammation in rosacea. It also has mild comedolytic properties (helps to dissolve clogged pores) that also is helpful in treating acne
• Ivermectin cream - targets the microorganisms (Demodex mites) that contribute to inflammation.
• Tacrolimus ointment/Pimecrolimus cream -  immunosuppressant inhibiting calcineurin

Oral medication for rosacea

• Antibiotics - e.g. doxycycline, minocycline, tetracycline. These are prescribed not because of bacteria causing rosacea, but because of their anti-inflammatory effects.
• Low-dose isotretinoin - a powerful drug used to treat severe, resistant acne, but can be helpful to treat rosacea that is resistant to standard therapies.
  • This medication can cause serious birth defects and must not be taken in those who are pregnant, intend to be pregnant soon, or breastfeeding women.

Other therapies 

• Vascular laser therapy - is advised for those with persistent facial redness or abnormal dilation of blood vessels
• Intense Pulsed Light treatment - uses high-intensity pulses of visible light targeted at redness

Your dermatologist will conduct a detailed assessment before laser or intense pulsed light therapies. You should be informed about the risk and complications and how these treatments work.

Sources: 

https://dermnetnz.org/topics/rosacea

https://www.hksh-healthcare.com/en/clinical-services/dermatology-centre/rosacea.php

https://www.hkcfp.org.hk/Upload/HK_Practitioner/2019/hkp2019vol41Sep/update_article.html

https://www.careoncall.ie/services/rosacea