Rosacea

Overview

Rosacea is a chronic inflammatory skin condition that primarily affects the central area of the face, commonly occurring between the ages of 30 and 60. It is characterised by persistent redness on the face and tends to have periods of flare-ups and improvement. Management of symptoms involves a combination of lifestyle adjustments, general skincare, medications, and procedural treatments.

Rosacea is estimated to affect approximately 5% of adults globally. While it is often believed to affect women more than men, research has shown that the distribution between genders is nearly equal.

Typically, rosacea appears after the age of 30 and becomes more prevalent as individuals age. However, it can develop at any age and occasionally appears in children. Although rosacea can affect individuals of any background, it is more commonly observed in those with fair skin, blue eyes, and of Celtic or North European ancestry. Recognising and diagnosing rosacea may be more challenging in individuals with darker skin tones.

Rosacea has been linked to various health conditions, including depression, hypertension, cardiovascular diseases, anxiety disorders, dyslipidemia, diabetes mellitus, migraines, rheumatoid arthritis, Helicobacter pylori infection, ulcerative colitis, and dementia.

Causes and Risk Factors

Multiple factors are known to contribute to rosacea. Genetic, environmental, vascular, and inflammatory agents are the principal drivers of rosacea's onset. Chronic exposure to ultraviolet (UV) radiation is also associated with skin damage that may contribute to the condition.

The skin's innate immune response is directly linked with rosacea due to the presence of antimicrobial peptides, especially cathelicidins, in high concentrations. Cathelicidins play an important role in the skin's normal defence against microbes and are essential in promoting the infiltration of neutrophils in the dermis as well as dilating blood vessels. Neutrophils release nitric oxide, which also promotes vasodilation. When fluid leaks from these dilated blood vessels, swelling occurs. As a result, pro-inflammatory cytokines leak into the dermis, which increases inflammation.

Matrix metalloproteinases (MMPs) such as elastase and collagenase are also closely linked with rosacea. These enzymes are essential in remodelling normal tissue, aiding the healing process in wounds, and promoting the production of blood vessels. In patients with rosacea, these enzymes are found in high concentrations, which leads to cutaneous inflammation and causes the skin to thicken and harden. MMPs can also activate cathelicidins, which further promotes inflammation.

Hair follicle mites (Demodex folliculorum) are also closely associated with rosacea; however, the precise causal mechanism has not yet been determined.

In addition to the factors described above, rosacea can be triggered by certain facial creams and oils as well as topical steroids.

Signs and Symptoms

Rosacea typically appears in the form of red spots (papules) and pustules, which are a common presentation in papulopustular rosacea. These spots have a dome-shaped form. Unlike acne, rosacea does not present with nodules, whiteheads, or blackheads. Depending on the subtype, rosacea can manifest as red areas (erythemato-telangiectatic rosacea), swelling (phymatous rosacea), or scaling (rosacea dermatitis).

Patients diagnosed with rosacea experience frequent blushing or flushing. A red face may result from constant redness or prominent blood vessels. Red papules and pustules tend to appear mostly on the forehead, nose, cheeks, and chin. In rare cases, the trunk and upper limbs can also be affected. The facial skin may feel dry and flaky. Sun exposure and hot or spicy food and drinks can trigger increased redness. Individuals with sensitive skin may experience burning and stinging sensations as a reaction to makeup, facial creams, or sunscreens. Ocular rosacea may also be diagnosed when the eye area is affected; it is usually characterised by red, sore, and gritty eyelid margins with papules and styes.

Diagnosis

Rosacea is typically diagnosed through a regular clinical assessment performed by a dermatologist. A skin biopsy may be performed to evaluate any additional chronic inflammation and vascular changes. The Global ROSacea COnsensus (ROSCO) Panel recommends assessing rosacea based on diagnostic, major, and minor phenotypes. The diagnostic phenotype includes evaluating fixed centrofacial erythema in a characteristic pattern and phymatous changes. The major phenotypes include assessing papules and pustules, flushing, and ocular rosacea. The minor phenotypes include assessing burning or stinging sensations, oedema (swelling), and dry appearance.

Treatment Options

Numerous treatment methods are available for rosacea, and these are tailored to each individual patient. Different variations of oral antibiotics or topical treatments may be prescribed as part of a course of treatment. Persistent blood vessels that contribute to rosacea can be successfully reduced with the non-invasive and non-ablative treatment method of Intense Pulsed Light (IPL) therapy.