In later stages of the disease, the face may swell and the nose may take on a bulbous appearance, a condition called rhinophyma.
Rosacea produces redness and flushing of the skin, as well as pustules and papules. Areas of the face, including the nose, cheeks, forehead, and chin, are the primary sites, but some persons experience symptoms on their necks, backs, scalp, arms, and legs. It is a common disease that afflicts one out of every 20 Americans.
The similarity in appearance of rosacea to acne led people in the past to erroneously call the disease acne rosacea or adult acne. Like acne, the skin can have pimples and papules. Unlike acne, however, persons with rosacea do not have blackheads.
Causes and symptoms
There is no known specific cause of rosacea. A history of redness and flushing precedes the disease in most patients. The consensus among many experts is that multiple factors may lead to an overreaction of the facial blood vessels, which triggers flushing. Over time, persistent episodes of redness and flushing leave the face continually inflamed. Pimples and blood-vessel changes follow.
Unidentified genetic factors may also come into play because 40% of rosacea sufferers have a family member who has rosacea.
The disease is more common in women and in persons with light skin and fair hair. It may be more common in persons with a Celtic, English, Scandinavian, Swedish, Welsh, Polish, Lithuanian, or Balkan background.
Because certain antibiotics are useful in the treatment of rosacea, some researchers suspect a bacterium or other infectious agent may be the cause.
One of the newest suspects is a bacterium called Helicobacter pylori, which has been implicated in causing stomach ulcers. The evidence supporting this suspicion is mixed.
Other investigators have observed that a particular parasite, the microscopic mite Demodex folliculorum, can be found on areas of the skin affected by rosacea. However, this mite can also be detected in the skin of persons who do not have the disease. It is likely that this mite does not cause rosacea, but merely aggravates it.
Rosacea may be caused by factors such as a deficiency of B-complex vitamins or hydrochloric acid (HCl) in the stomach. Some researchers suspect that yeast may cause rosacea.
In early stages of rosacea, patients typically experience repeated episodes of flushing. Later, areas of the face are persistently red and telangiectasia, as well as inflamed papules and pustules, appear on the nose and cheeks. Over time, the skin may take on a roughened, orange-peel texture.
Very late in the disorder, a small group of patients with rosacea will develop rhinophyma, which can give the nose a reddened, bulbous appearance. The late actor W.C. Fields was affected with this condition. Men are three times more likely than women to develop rhinophyma.
Up to one-half of patients with rosacea may experience symptoms related to their eyes. Ocular rosacea, as it is called, frequently precedes the other manifestations on the skin.
Telangiectasia may appear around the borders of the eyelid, the eyelids may be chronically inflamed, and small lumps called chalazions may develop. The cornea of the eye (the transparent covering over the lens) can also be affected, and in some cases vision will be affected. Most of these eye symptoms do not threaten sight, however.
Diagnosis
Diagnosis of rosacea is made by the presence of clinical symptoms. There is no specific test for the disease. Episodes of persistent flushing, redness (erythema) of the nose, cheeks, chin, and forehead, accompanied by pustules and papules are hallmarks of the disease.
A dermatologist (skin disease specialist) will attempt to rule out a number of other diseases that have similar symptoms. Acne vulgaris is perhaps the disorder most commonly mistaken for rosacea, but acne patients do not have redness and spider-like veins. Blackheads and cysts are seen in acne patients, but not in those with rosacea.
Other diseases that produce some of the same symptoms as rosacea include perioral dermatitis, seborrheic dermatitis, and systemic lupus erythematosus.
Treatment
There is no cure for rosacea, but alternative and complementary treatments can be helpful in reducing the skin irritation and number of outbreaks associated with the disease.
Green-tinted makeup can mask the redness associated with rosacea. Because rosacea may cause psychological distress, psychotherapy or support groups can be an important component of treatment.
Patients should avoid using skin care products that contain alcohol, witch hazel, peppermint, menthol, eucalyptus oil, or clove oil. Skin care products should be fragrance-free and have a smooth, non-grainy consistency. Men can shave with an electric razor to lessen skin irritation on the face.
Persons who are treated for rosacea with antibiotics over a long period are more prone to yeast infections. Long-term antibiotic use can decrease normal bacteria populations and increase the number of yeast. Eating a yeast-free diet (eliminating breads and other yeast products and sugars) can help to restore normal bacteria to the body.
Identifying food triggers
Certain foods are known to trigger an outbreak of rosacea. Although individual triggers vary, the following foods may aggravate rosacea: hot spices (pepper, paprika, and cayenne), marinated meat, soy sauce, vanilla, vinegar, red plums, peas, lima and navy beans, sharp cheeses, cider, Asian food dishes, canned fish products, processed beef and pork, chocolate, tomatoes, citrus fruit, alcohol, and hot beverages.
Nitrates, sulfites, and certain drugs can also trigger outbreaks. Food allergies can also cause rosacea. The three foods that most often cause food allergies are wheat products, sugar, and dairy products.
Rosacea patients should keep a food diary to identify the specific foods that trigger rosacea outbreaks. Outbreaks can occur hours—or as long as a day—after the offending food has been eaten. The patient should stop eating a suspect food for a few months to observe the severity of the rosacea symptoms.
If the rosacea improves, the patient can then eat a small amount of the offending food to confirm whether it triggers an outbreak. Once a rosacea trigger food is identified, it can be eliminated from the patient’s diet.
Other treatments
Applying liquid-filled cold packs, a washcloth soaked in ice-cold water, or a compress of cold milk and ice-cold water to the neck and face can relieve flushing.
Sucking on ice chips can also help relieve flushing. A cold compress of chamomile tea can soothe irritated skin. Applying ice to the face may feel good but it can cause frostbite, which would worsen the reddening.
Some practitioners advocate gentle circular massage for several minutes daily to the nose, cheeks, and forehead. However, controlled studies on the effectiveness of this technique are lacking.
A deficiency of hydrochloric acid (HCl) in the stomach may be a cause of rosacea, and supplementation with HCl capsules (taken after meals) may bring relief in some cases.
Hypnosis may reduce stress, promote healthful behavior, and control bad habits. Hypnotherapy is especially useful in treating skin disease that can be triggered by emotions, including rosacea. As a complementary therapy, hypnosis has been shown to improve rosacea, especially the flushing component.
Nutritionists recommend eating more dark green vegetables such as kale, broccoli, asparagus, and spinach. These foods, and others that contain high levels of vitamins A and C, bioflavonoids, and beta-carotene, can improve rosacea by increasing capillary strength and boosting the immune system. Apple juice and dark grape juice drunk at room temperature between meals can help persons with rosacea.
A deficiency of B-complex vitamins can lead to rosacea. Vitamin E’s antioxidant properties can help prevent skin damage. Zinc can speed wound healing. Omega-3 and omega-6 fatty acid deficiencies can lead to dry, irritated skin, which can worsen rosacea.
Omega-3 fatty acids can be found in flaxseed oil, cod liver oil, salmon, mackerel, and herring. Omega-6 fatty acid is found in evening primrose oil.
Allopathic treatment
The mainstay of treatment for rosacea is oral antibiotics. These appear to work by reducing inflammation in the small blood vessels and structure of the skin, not by destroying bacteria that are present.
One of the more widely used oral antibiotics is tetracycline. In many patients, antibiotics are effective against the papules and pustules that can appear on the face. But antibiotics appear to be less effective against the background redness, and they have no effect on telangiectasia.
Patients frequently take a relatively high dose of antibiotics until their symptoms are controlled, and then they slowly reduce their daily dose to a level that just keeps their symptoms in check. Other oral antibiotics used include erythromycin and minocycline.
Some patients are concerned about long-term use of oral antibiotics. For them, a topical agent applied directly to the face may be tried in addition to an oral antibiotic or in its place.
Topical antibiotics are also useful for controlling the papules and pustules of rosacea, but do not control the redness, flushing, and telangiectasias. The newest of these topical agents is metronidazole gel, which can be applied twice daily.
Vitamin A derivatives called retinoids also appear useful in the treatment of rosacea. An oral retinoid called isotretinoin, which is used in severe cases of acne, reduces the pustules and papules in severe cases of rosacea that do not respond to antibiotics. Isotretinoin must be taken with care, particularly in women of childbearing age, because the drug is known to cause birth defects.
Topical vitamin A compounds may have a role in the treatment of rosacea. Accumulating evidence suggests that topical isotretinoin and topical azelaic acid can reduce the redness and pimples.
For later stages of the disorder, a surgical procedure may be needed to improve the appearance of the skin. To remove the telangiectasias, a dermatologist may use an electrocautery device to apply an electrical current to the blood vessel.
This procedure cuts off the blood to the blood vessel, effectively destroying it and eliminating its appearance as a red line. Special lasers, called tunable dye lasers, can selectively destroy these tiny blood vessels.
A variety of surgical techniques can be used to improve the shape and appearance of a bulbous nose. Surgeons may use a scalpel or laser to remove excess tissue from the nose and restore a more natural appearance.
Expected results
The prognosis is good for controlling symptoms of rosacea and improving the appearance of the face. Many people require lifelong treatment and achieve good results. There is no known cure for the disorder.
Prevention
Rosacea cannot be prevented, but once its is correctly diagnosed, outbreaks can be treated and repeated episodes can be limited. Patients can reduce outbreaks of rosacea by following this advice:
- Use mild soaps and cleansers. Avoiding anything that irritates the skin is a good preventive measure for persons with rosacea. Astringents and alcohol should be avoided.
- Learn what triggers flushing. Reducing factors in the diet and environment that cause flushing of the face is another good preventive strategy. The specific things that provoke flushing vary considerably from person to person and it usually takes some trial and error to figure these out.
- Cover the face. Limiting exposure of the face to excesses of heat and cold can also help. A sunscreen with a skin protection factor (SPF) of 15 or greater, used daily, can reduce rosacea outbreaks and limit the damage the sun causes to the skin and small blood vessels. Protective clothing (hats in the summer and scarves or ski masks in the winter) can reduce the skin’s exposure to sun and cold temperatures.
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