Rosacea is a chronic inflammatory skin condition with symptoms of redness, flushing, inflamed bumps, visible blood vessels, eye irritation, and skin thickening in the central regions of the face. Symptoms of rosacea naturally go through periods of improvement and intensification, and may be triggered by lifestyle factors including sunlight, alcohol, emotional stress, and spicy foods.
Rosacea falls under theSkin, Hair, & Nailscategory.
Rosacea is a chronic inflammatory skin condition affecting primarily the cheeks, nose, chin, and forehead. It results in erythema (redness), flushing, telangiectasia (spider veins), and inflamed bumps. Rosacea can also affect the eyes (ocular rosacea) or cause thickening of the skin (phymatous changes). People with rosacea often experience episodes of remission and flare-ups, and some experience worsening of symptoms over time.
Unmanaged rosacea symptoms can negatively impact quality of life and psychological well-being, leading to low self-esteem, embarrassment, and an increased risk of anxiety and depression. A 2018 meta-analysis estimated the global prevalence of rosacea to be 5.5%, with nearly all cases occurring in adults over 30. Historically it has been thought that women are more frequently affected, but this meta-analysis found no difference in rates between men and women.
Common symptoms of rosacea include redness, flushing, visible blood vessels, and inflamed bumps (papules and pustules) on the skin of the face which may be accompanied by a burning or stinging sensation. These symptoms primarily affect skin on the cheeks, nose, chin, and forehead, and may be persistent or transient in nature. Flare-ups of flushing and/or erythema are common, and may occur following exposure to a trigger (e.g., heat, sun exposure, alcohol). Some people experience thickening of the skin, usually on the nose — a phenomenon called rhinophyma — which appears as nodular growths and bulbous enlargement of the nose.
More than half of people with rosacea experience symptoms in and around the eyes, including dryness, burning, itching, redness, sensitivity to light, inflammation of the eyes or eyelids, and rarely, inflammation of the cornea; the latter can lead to vision loss.
A qualified healthcare professional diagnoses rosacea based on clinical observations and patient reporting of signs and symptoms. The global ROSacea COnsensus (ROSCO) panel and the National Rosacea Society have recently updated the classification and diagnosis of rosacea:
Having one of the following features is considered diagnostic of rosacea:
- Persistent redness affecting the center of the face with periodic intensification
- Phymatous changes (thickening of the skin with irregular nodules and enlarged pores). In the absence of one of the above features, having at least two of the following features is considered diagnostic:
- Inflammatory papules/pustules
- Telangiectasia (small visible blood vessels)
- Ocular manifestations (symptoms affecting the eyes/eyelids)
Rosacea is a chronic condition, meaning that treatments are not curative but rather help to manage symptoms. Treatment should be managed by a health care practitioner, and tailored to the individual’s current symptoms. Given that symptoms of rosacea can vary between people and even within the same person over time, practitioners will generally focus on addressing the symptoms most bothersome to the individual at that time. Management options include both oral and topical (applied to the skin) medications and laser and light-based therapies.
For managing erythema (facial redness), health care practitioners may prescribe topical medications that constrict superficial blood vessels, such as brimonidine and oxymetazoline. These medications work quickly, often within 30 minutes, with effects lasting for up to 12 hours.
For reducing papules and pustules, health care practitioners may turn to medications with anti-inflammatory and anti-microbial properties. Topical medications like ivermectin, azelaic acid, metronidazole, and minocycline are often tried first. If topical medications fail to control symptoms, health care practitioners may prescribe oral medications such as tetracycline antibiotics or isotretinoin. All of these medications work slowly over time when used consistently.
For eye irritation, health care practitioners may prescribe eye ointments containing cyclosporine or antibiotics, lubricating eye drops, as well as some of the oral therapies previously mentioned.
Finally, health care practitioners may recommend lasers and intense pulsed light therapy to help reduce visible blood vessels, redness, and skin thickening (phyma), although skin thickening may sometimes require surgical correction.
A trial including 130 people with ocular rosacea found supplementation with omega-3 fatty acids (720 mg EPA + 480 mg DHA daily) was effective in reducing symptoms of dry eye (itching, burning, blurred vision, gritty sensation) compared to an olive oil placebo. The effects were notable after 3 to 6 months of supplementation. Further research is needed to strengthen these findings.
Two small trials have assessed the effectiveness of zinc supplementation in rosacea. While one trial found symptom improvements over three months of supplementation, another trial found no improvements compared to placebo. Currently, more evidence is needed to support the use of zinc for rosacea.
Well-designed trials assessing the impacts of diet on rosacea are lacking. However, certain foods are frequently reported to trigger flares of rosacea symptoms. Common trigger foods include spicy foods, marinated meats, certain fruits and vegetables (e.g., avocado, banana, tomatoes, citrus fruits), and cheese. Some researchers propose these effects may be due to certain compounds in these foods, such as histamine, capsaicin, and cinnamaldehyde.
A prospective cohort study in China found that higher adherence to dietary patterns similar to the Mediterranean diet (in this study, higher intake of plants, fish, and monounsaturated fats, and lower intake of animal products and saturated fats) was associated with a reduced incidence of rosacea in non-overweight people (BMI <24.5 kg/m2). Otherwise, the potentially protective effect of diet on rosacea is largely unexplored.
A daily skincare routine alongside medical treatment can help to improve rosacea symptoms by maintaining skin hydration and barrier integrity. This should include a gentle cleanser, an unscented moisturizer containing humectants and barrier lipids (e.g., ceramides, hyaluronic acid), and sunscreen. Skincare products that cause a burning sensation, or trigger symptoms, should be avoided.
Some alternative treatments with a less substantial evidence base are being explored. Hydroxychloroquine is a common treatment for some autoimmune diseases, due to its ability to reduce inflammation through immune system modulation. One small trial found that people with rosacea who took oral hydroxychloroquine saw similar improvements in their rosacea symptoms as those who took doxycycline. This effect is supported by mechanistic studies in mice, but more human studies are needed to determine the role of this medication.
Topical benzoyl peroxide, an established medication for acne, may also have a role in rosacea. More specifically, preliminary research has found that microencapsulated benzoyl peroxide — a less irritating formulation — may be beneficial for reducing the number of lesions and overall rosacea symptom severity. However, studies using regular topical benzoyl peroxide have shown contradictory results.
Current evidence suggests that rosacea occurs due to some combination of genetic predisposition and environmental influences. People with rosacea are four times as likely to have a relative with rosacea, and a genome-wide association study identified two gene variants strongly associated with rosacea.
The symptoms of rosacea are thought to be caused by immune and neurovascular mechanisms that become dysregulated and overactive, leading to inflammation, redness, and blood vessel remodeling. The factors driving this dysregulation are less clear and likely multifactorial.
Disruptions to the skin microbiome have been observed, and certain skin microbes have been identified as possible triggers for immune activation including Demodex mites, Bacillus oleronius, and Staphylococcus epidermidis. A 2017 meta-analysis found that people with rosacea were over 800% more likely to be infested by Demodex mites, and had a greater density of these mites on their facial skin. However, a causal relationship could not be established due to study design.
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