Rosacea: Clinic, diagnosis and treatment

Medical editor: Dr Pierre SCHNEIDER, Dermatologist, Saint-Louis Hospital, France.

Dr. Pierre Schneider

Key messages:

Rosacea is a skin disease that causes redness (dilated vessels) and pimples (papules and pustules) on the face.
The exact cause of rosacea is unknown, but it is most likely a combination of genetic and environmental factors.
Risk factors include family history, sensitive skin, hormonal changes and repeated exposure to hot or cold temperatures.
Differential diagnoses for rosacea include acne, atopic dermatitis, contact dermatitis, systemic lupus erythematosus and couperose.
There is no definitive treatment for rosacea, but there are treatments to relieve symptoms.
Treatments include topical medications such as antibacterial or antiparasitic creams, azelaic acid creams, oral antibiotics, as well as laser and pulsed light treatments.
It is important to protect your skin from UV rays to avoid worsening symptoms.
It is also important to maintain a good skin care routine to avoid irritation and inflammation.

Rosacea is a skin condition that causes redness and lesions to appear on the face, especially on the cheeks, nose, forehead and chin.
Symptoms may include dilated blood vessels, papules (red pimples) that may develop into pustules.
Rosacea can also cause thickening of the skin (especially of the nose, a phenomenon called rhinophyma), redness and irritation of the eyes (blepharitis, keratitis and conjunctivitis).
The disease is more common in fair-skinned people and can be aggravated by factors such as stress, heat, sun exposure and alcohol consumption.
There is no definitive treatment for rosacea, but there are treatments to relieve symptoms^2,3,5.
In France, rosacea is a common skin condition, affecting approximately 3 million people, according to the French National Academy of Medicine. It is more common in women but can also affect men.
The disease is usually diagnosed between the ages of 30 and 50, but it can also occur in young adults and the elderly.
It is important to note that although rosacea is not serious, it can have a significant impact on the quality of life of those affected, due to the redness and itching it can cause, as well as negative self-awareness^2,3,5.

The precise etiology of rosacea remains unknown; however, several factors are thought to be involved in its development:

Genetic factors play an important role in the etiology of the disease, as it is more common in people with a family history of rosacea.
Hormonal factors are also considered to be involved in its development, as it is more common in women and can worsen during menopause.
Environmental factors such as exposure to the sun, the wind and extreme temperatures can also contribute to the development of rosacea^3,6.

The physiopathology of rosacea is complex and multifactorial.

It is generally accepted that the disease is related to vascular hyperreactivity, which leads to redness and dilated blood vessels in the affected areas.
In patients with rosacea, Demodex folliculorum, a saprophytic parasite, is involved in the inflammatory phenomena.
Lesions are thought to be promoted by immunization against Demodex proteins or the bacteria it contains (Bacillus oleronius).
The frequency of Demodex carriage is higher in affected patients than in unaffected patients and its density is higher in affected skin areas than in healthy skin areas in the same subject^2,3,6,8.

In short:

Rosacea is a complex disease that is caused by a mixture of genetic, hormonal and environmental factors.
The physiopathology of the disease is related to vascular hyperreactivity and parasitic overgrowth, which can lead to redness, pimples, and dilated blood vessels in the affected areas^2,3,6.

The diagnosis of rosacea is mainly based on the clinical examination of the skin. It is usually carried out by a dermatologist or a general practitioner. Diagnosis criteria include the appearance of redness and pimples on the face, as well as dilated blood vessels (telangiectasias) and changes in the nose (rhinophyma) in severe cases.

There are different subtypes of rosacea, each with specific symptoms^1,2:

Erythematous rosacea

It is characterized by redness on the face, often accompanied by pimples and dilated blood vessels.
Most of the time, it affects the cheeks but can spread to the whole face.
The duration is more than 10 minutes. It is accompanied by superficial burning sensations^1,2.

Papulopustular rosacea

It is characterized by redness and spots on the face, similar to acne.
These are red papules of 2 to 5 mm in diameter, surmounted by white spots (papulopustules) located on the central facial regions (nose, cheekbones), then affecting the chin and forehead in more severe forms.
The lesions evolve in successive flare-ups, becoming more and more extensive and unsightly, interfering with social relations (people tend to associate rosacea with alcoholism)^1,2.

Phymatous rosacea

It is characterized by a thickening of the skin and dilated blood vessels on the nose.
It mostly affects men over the age of 50. The nose is affected (rhinophymas) with a budding aspect of the nasal pyramid that can be monstrous-like^1,2.

Ocular rosacea

The average age of onset for this form of rosacea is 50 years old.
It affects a predominantly female population.
There is no simultaneous evolution, as ocular rosacea may precede cutaneous rosacea by several months.
Functional signs are related to dry eyes and triggered by irritation: lacrimation, conjunctival burning.
Ophthalmological examination reveals conjunctivitis or keratitis, often associated with palpebral inflammation (blepharitis)^1,2.

Pediatric rosacea

It is rarer in children and teenagers.
The evolution and the subtypes are the same as in adults.
It mostly affects children from families with a history of rosacea⁷.

Good to know:

In order to reach a diagnosis, a physician may perform additional tests such as a skin test to assess vascular reactivity; he may test for Demodex or use imaging technology such as ultrasounds to assess skin thickening^1,2.
It is important to note that rosacea can be confused with other skin conditions such as eczema, acne or seborrheic dermatitis, so an accurate diagnosis is key to establishing an effective treatment plan¹.

Differential diagnoses for rosacea¹ include:

Eczema

Eczema is a skin disease characterized by redness, itching and flaking, which may resemble rosacea on the face.

Acne

Acne is a common skin condition characterized by pimples, blackheads and cysts, which may resemble the papulopustular form of rosacea.

Seborrheic dermatitis

Seborrheic dermatitis is a skin disease characterized by redness and flaking, which can resemble rosacea on the face.

Systemic Lupus Erythematosus (SLE)

It is an autoimmune disease that can cause redness and skin lesions similar to rosacea.

Steroid induced rosacea

Some medications (mainly corticosteroid creams) can cause redness and skin lesions similar to rosacea, which is why it is important to take the patient's medication history in consideration.

In conclusion:

The differential diagnosis of rosacea is important so that an effective treatment plan is established.
This requires a careful evaluation of the patient's symptoms and medical history to rule out other possible diagnoses.

Topical treatments

There are different types of topical treatments for rosacea. The main active ingredients used in these treatments are erythromycin, metronidazole, azithromycin, vitamin A, benzoyl peroxide and retinoids^1-6.

Erythromycin and metronidazole are topical antibiotics that have anti-inflammatory and antibacterial effects. They can help reduce the redness and pimples associated with rosacea. Azithromycin is an oral antibiotic that can also be used topically.
Vitamin A is used in the form of topical retinoids such as adapalene or tretinoin, these drugs have anti-inflammatory properties and can help reduce the redness and pimples associated with rosacea.
Azelaic acid 15% has an anti-inflammatory effect and modifies keratinization. It is used to treat papulopustular forms of rosacea.

Oral treatments

With respect to oral treatments, antibiotics such as doxycycline and minocycline have anti-inflammatory and antibacterial properties and can help reduce symptoms by reducing bacterial growth on the skin.
Leukotriene receptor antagonists (montelukast) are also used to improve rosacea symptoms^1-6.

Laser treatments

Laser treatments such as vascular laser therapy and intense pulsed light can help reduce the redness and dilated blood vessels associated with rosacea.
These treatments work by targeting the dilated blood vessels to reduce or eliminate them^1-6.

Good to know:

It is noteworthy that rosacea treatments of any kind can cause side effects such as pain, redness and temporary skin peeling, and should therefore be tailored to the severity of the disease and the patient's tolerance to the various treatments.
It may be necessary to combine several types of treatments to achieve the best results.
It is also important to continue treatments over a long period of time to maintain the benefits obtained.
A physician should be consulted regularly to evaluate the effectiveness of the treatments, so that s/he can adapt them in accordance with the evolution of the disease^1-6.

Hygienic and dietary measures

It is also crucial to emphasize the importance of adopting hygienic and dietary measures to prevent rosacea recurrence.
It is key to avoid triggers such as the sun, the wind, extreme temperatures as well as irritating cosmetics.
Patients should use sunscreen, adopt a balanced diet and follow a healthy lifestyle^1-6.

Should I avoid the sun and the cold?

It is important to highlight that exposure to the sun is a notoriously aggravating factor, so a very high level of photoprotection should be used as a matter of course. Cold is also an aggravating factor. It is best to avoid going from a warm room to the cold outside, which will trigger flushes^2,3,5.

Should the sun be avoided as a preventative measure? What are the seasons for which less photoprotection can be used?

Avoiding the sun is part of rosacea prevention. You can use less protection during the months with the least amount of sun (October to March)^2,3,5.

From what age can laser therapy be used?

The minimum age to use laser treatment is when the patient is able to remain calm despite the pain inflicted by the laser.

Are there any contraindications to accessing hot baths or swimming pools?

Hot baths aggravate erythrosis by vasodilatation, but there is no contraindication to swimming^2,3,5.

Is there a genetic component involved in rosacea (a mother who is very embarrassed by her rosacea may fear that her child may be affected)? If yes, what preventative measures should be taken to limit the pathology from an early age?

Yes, there is a genetic component. As a preventative measure, one should therefore favour photoprotection, and at an older age, avoid rich, spicy meals, as well as alcohol^2,3,6.

Can a pregnancy mask hide the appearance of rosacea?

A pregnancy mask and rosacea are completely unrelated.

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Rosacea: Clinic, diagnosis and treatment

Digest

Definition

Etiology and physiopathology

Diagnosis and clinic

Differential diagnosis

Treatments

Questions your patients may have

References