Rosacea In Depth
Between the ages of thirty and fifty, millions of adults, many with English or Irish ancestry, notice increasing redness across their nose and cheeks. The redness may start as a tendency to flush easily, and it often persists as continual redness. This is most likely rosacea.
Some people call rosacea adult-onset acne, and it can look similar. Redness, bumps, and even some swelling appear well after adolescence. Some rosacea sufferers are even labeled as alcoholics because of their redness.
WHAT IS ROSACEA AND WHAT TRIGGERS IT?
Please remember that you may have one or more causes for rosacea including some that may not be listed here.
WHAT ARE THE POSSIBLE TREATMENTS?
We’re all individuals, so there may be variations in treatment depending on your particular needs and your doctor’s style of practice. Here are some of the most common:
WHAT YOU NEED TO KNOW
What is Rosacea?
"My doctor tells me I have rosacea. What exactly is this?"
Rosacea is often referred to as "adult acne." It may begin as a tendency to flush or blush easily and gradually progresses to persistent redness and occasionally swelling across the bridge of the nose and into the cheeks, forehead, and chin. As it progresses, small blood vessels, red bumps, pimples, and sometimes even larger cysts appear in the area. Unlike acne, there are no blackheads.
Initially, the redness of rosacea may come and go; you may not realize you need treatment. Sometimes rosacea appears as redness that doesn't go away. If the skin doesn’t return to its normal color and enlarged blood vessels and pimples appear, you should see a dermatologist. Rosacea usually becomes worse without treatment and seldom goes away on its own. There are many good ways to treat rosacea now, so it really is worthwhile to see your dermatologist about it.
In more advanced cases of rosacea, a condition called rhinophyma may develop. The oil glands and the blood vessels on the nose enlarge so much that the nose becomes very bulbous in appearance. Thick bumps can develop on the nose and may require surgery to treat.
About half of the patients with rosacea have eye symptoms. Many experience some burning and grittiness of the eye (conjunctivitis) or inflammation and swelling of the eyelid areas.
Family history. The most likely people to develop rosacea have an English or Irish background. You may get it though even if your family genes are not Celtic or Northern European. Many rosacea sufferers are fair skinned, particularly women between the ages of 30 and 50, although rosacea also affects men and occasionally even teens. Researchers do not know why women get rosacea more often than men, and some cases have been associated with menopause.
The key to successful management of rosacea is early diagnosis and treatment. It is important to consult your dermatologist and follow his or her instructions.
Rosacea Trigger Factors
"I have heard of triggers for rosacea. Can I lessen my redness without medical treatment?"
Rosacea can be triggered by a number of factors, and many patients can reduce their redness by doing some detective work to figure out their own triggers for their redness. Two common triggers are alcohol and heat, but triggers range from soy to aged cheese and many more. Rosacea may cause redness in a non-drinker, and some of those who suffer from rosacea have been falsely assumed by others to be alcoholics.
Triggers to consider for your rosacea may include alcohol (especially red wine, beer, bourbon, gin, vodka, or champagne), heat (saunas or hot tubs), sun, strong winds, exercise, coffee or other hot drinks, foods (liver, dairy products, chocolate, soy products, vegetables especially eggplants, tomatoes and beans, fruits including avocados, bananas and citrus fruits, hot and spicy foods), skin care products (particularly sprays containing alcohol fragrances or witch hazel), and overuse of prescription topical steroid creams. Triggers can be very individual.
Remember that rosacea is a disease that often starts in mid-life and can continue for 10 to 30 years. The little things that you do every day really do make a difference over that many years in the progression and treatment of this problem.
Do some detective work on your alcohol use. Some patients with rosacea find that they tolerate white wine or certain spirits easily, but that red wine, bourbon, gin, or vodka gives them a flushed look. If you enjoy an occasional drink or glass of wine, you might want to experiment with different types. For some people the sulfites used to preserve wine are the problem rather than the wine itself; try a sulfite-free wine. Inexpensive wines have more additives in general.
Decrease your alcohol use. A glass of wine a day, particularly with a meal, may have beneficial effects on blood fat levels. But there can be problems with drinking more, beyond just causing your rosacea to flare. Alcohol increases estrogens circulating in the blood, which may increase a women’s risk of breast cancer. Women, for reasons that are not entirely understood, are more susceptible to liver damage from alcohol then men. Alcohol also contributes to thinning of the bones also called osteoporosis. And as we all know, alcohol and pregnancy don’t mix.
Exercise. Exercise in a cool environment, if possible, and try not to overheat more than necessary.
Foods. Food triggers are very individual, and you might want to keep a food diary for several weeks to see if any foods aggravate your redness.
Beverages. Try avoiding hot drinks and caffeine. Keep a log for a few weeks of when you’re flushing and if it’s associated with certain drinks. If there is no association, great, there’s no need to stop that beverage. If there is a beverage that’s causing problems, you may be able to find a substitute.
Weather. Practice good sun protection and avoid the extremes of hot and cold temperatures that aggravate symptoms of rosacea. Limit exposure to sunlight, wear a hat, and use broad-spectrum sunscreens with an SPF of 15 or higher in the winter and 30 or higher in the summer.
Facial scrubs. Rubbing will tend to irritate reddened skin. Avoid rubbing, scrubbing, or massaging the face.
Skin and hair care products. Try to avoid any type of hair spray product – use gels or creams instead. Avoid irritating cosmetics and facial products. Many rosacea patients don’t tolerate Renova/Retin-A/tretinoin very well. Creams with alpha hydroxy acids in high percentages may also be very irritating.
Emotional influences. Stress and anxiety have been reported to aggravate rosacea in some. There are many good stress reduction programs and gentle forms of exercise that may be beneficial, like some types of yoga or Pilates. Just don’t do the yoga in a hot room.
Do I Have Rosacea if I Flush and Blush Easily? Almost everyone who goes on to get rosacea has a history of flushing and blushing. But just because you flush, it doesn’t mean you have rosacea. Many of us flush and blush, especially with exercise, heat, and stressful situations. The difference is that with early rosacea you might start to flush more and more frequently and with more triggers. The redness doesn’t seem to go away as easily and is a more permanent flush. If you’re not sure, make an appointment with your dermatologist to discuss it.
"Would lifestyle changes help my redness?"
The following list gives you some of the lifestyle changes that may help your redness, flushing and blushing, and rosacea. Not all of these changes will work for everyone. Try these various changes one at a time. You’ll want to try the change for at least several weeks before you decide if it’s helping or not. Redness will often wax and wane over a period of weeks or months. If you try something only for a couple of days, you really can’t be sure if the change has made a difference or not. Some of the changes you might like to try are:
"My dermatologist told me that I need to cut down on my alcohol and coffee use and be more careful about the sun if I want my rosacea to get better. Is this true?"
Lifestyle changes really are one of the mainstays of rosacea treatment. The more effective you are at eliminating the things that trigger flushing, blushing, and rosacea breakouts, the more successful your dermatologist will be with her prescription treatments for your rosacea.
And if your rosacea is affected by your occupation, working closely with your dermatologist is even more important. Consider the case of the chef with severe rosacea. Her job required her to work in an overheated kitchen and to go to frequent wine tastings. Her rosacea can still be brought under control, but it takes more work.
Also, if you are a woman anywhere between mid-40s and mid-50s and having early symptoms of menopause, please consult your dermatologist. Menopausal hot flashes can aggravate your rosacea and make it more difficult to control.
"If I have rosacea, what should I be using to cleanse my skin?"
Mainly, it is important not to use cleansers that irritate rosacea. If you stick to something like Dove for sensitive skin or Cetaphil Lotion Cleanser you’ll be fine, but any gentle cleanser that doesn’t irritate you is okay. Your dermatologist may carry products that include nonirritating, non-drying cleansers for patients with rosacea or other skin conditions. There is also a prescription cleanser called Plexion (contains sulfacetamide and sulfur) that may be helpful as well.
Wash your face twice a day with warm but not hot water. Hot water will aggravate the redness that goes with rosacea. Also avoid washing your face in a hot shower and avoid aiming the spray of your high-pressure showerhead at your face.
After you wash your face with a non-irritating cleanser, pat it gently dry. When it is dry, apply any rosacea medications. Then if you still feel dry, you can add a gentle non-irritating moisturizer and sunscreen in the morning.
Avoid scrubs; they are too harsh for skin with active rosacea. Also, you may not tolerate the vitamin A derivatives like Renova/Retin-A/tretinoin or most alpha hydroxy acid or Vitamin C lotions or creams unless they are specifically formulated for sensitive skin.
"Are there any non-prescription medicines to use for redness?"
A newer non-prescription cream is Eucerin Red Reducer. Some patients have had good results with that.
Another non-prescription cream that is used for redness or rosacea is hydrocortisone, which comes in either 0.5% or 1.0% cream. This cream is a very mild anti-inflammatory cream in the steroid category. It does reduce redness somewhat. However, it really does not address the root causes of rosacea at all. While hydrocortisone cream may make the redness or rosacea look temporarily a bit less red, isn’t nearly as good as the treatments that are available by prescription.
Using a little hydrocortisone cream while you are waiting to get in to see your doctor is probably fine. But don’t use it over long periods of time or in lieu of the better prescription treatments that are available. Almost all steroid creams if used incorrectly can thin the skin and cause permanent dilation of blood vessels in the skin. Generally, hydrocortisone .5% and 1% are not strong enough to do that unless you use them many times a day over a long period of time. Don’t use them for long around the eye area under any circumstance without discussing it with your dermatologist.
Prescription Creams for Rosacea
"I am confused about all the different prescription creams available to treat rosacea.
Metronidazole is available in three forms: a cream, a lotion, and a gel also known respectively as Metrocream, Metrolotion, and Metrogel. These have been a staple for treatment of rosacea for many years. They are generally prescribed for use twice a day, although if your rosacea has been stable and inactive several months, cutting down to once a day might be fine. A relatively new cream called Noritate is also a metronidazole cream in a different strength and is used once a day. Sulfacetamide cream is another antibiotic cream used for treatment of rosacea. Other antibiotic creams may be prescribed according to your dermatologist’s preference.
The azelaic acids are also being used with some good results for rosacea. Azelex comes in a gel form and Finacea in a cream form. Your doctor will go over with you the various options among these prescription topicals.
If you are quite red or have permanently dilated small blood vessels, the creams alone may not take the redness away. The topical medicines are excellent at helping to get the rosacea under control and helping to prevent recurrences particularly over the long haul. Unfortunately, you may be disappointed if you expect the topical medications to get rid of all the redness, particularly if it has been going on for a long time. If you have been red for a while you will probably need other treatment in addition
"Does it make any difference if my rosacea medication is a gel, lotion or a cream?"
Whether you prefer a gel, lotion, or cream for your medication depends more on your underlying skin type than the fact that you have rosacea.
If you have oily or acne-prone skin, you will probably prefer a gel, like Metrogel or Azalex. Many male patients seem to prefer the gel. If your skin is more normal or combination, the lotion will probably be most compatible. If you are dry or over forty, the creams would be good choices for you. There is another topical antibiotic that works well called sulfacetamide. It also comes in lotion and creams forms.
Oral Antibiotics for Rosacea
"Why did my doctor prescribe oral antibiotics for my rosacea instead of a cream?"
As part of your rosacea treatment, your doctor may have prescribed an oral antibiotic either continuously or intermittently during the course of the disease. Oral antibiotics help to decrease the acne-like pustules and pimples and decrease the inflammation that can cause swelling and redness.
A common treatment approach with new active rosacea is to start metronidizole cream twice a day in addition to an oral antibiotic for 60 days. It takes the antibiotic creams about 8 to 10 weeks to really work. The oral antibiotics take effect faster and then may be stopped once the cream has started to take effect. Don’t discontinue your oral antibiotic without discussing it with your dermatologist. You may have the type of rosacea that needs an oral antibiotic for good control. Tetracycline, doxycycline, and minocycline are prescribed most commonly but other antibiotics may be used as well.
You should begin to see some improvement in one to three weeks with continued improvement slowly over several months. Antibiotics in the tetracycline (like doxycycline) family should not be taken by pregnant women or by women who are actively trying to get pregnant. They can also cause increased sensitivity to the sun, so ask your doctor about continuing their use if you plan to go on vacation in a sunny place or if you live in a very sunny climate.
Amoxicillin is an alternative in a woman who is past her third month of pregnancy and develops rosacea or in a woman who is trying to get pregnant. It is safe during pregnancy and has been used for many years. It is in the penicillin family and cannot be used by anyone who is penicillin allergic. Check with your obstetrician first.
"My dermatologist gave me Metrocream to use for my rosacea and also an oral antibiotic medicine. Why do I need both?"
Many dermatologists will use both oral and topical antibiotics at the beginning of treatment. The main reason for this is that it takes the topical antibiotic eight to twelve weeks to start working well. This is a long time to wait for many people who are anxious to get their rosacea under good control as quickly as possible. The oral antibiotics work much faster, and generally you should start to see results within a week or two.
One approach is to start both oral and topical medications and then stop the oral antibiotics after two to three months. It is often possible to maintain good control just with the Metrocream then. Another approach is to start with a metronidazole cream and if it isn’t working well after eight to ten weeks, then add an oral antibiotic. The most common oral antibiotics used for rosacea are tetracycline, doxycycline, and minocycline. Others may be used with good success, especially if you are allergic to tetracycline and its relatives.
Since the medicated creams and lotions may not control the rosacea one hundred percent of the time, it is often wise to keep some of the oral antibiotic on hand in case of a sudden flare-up of the rosacea. This seems to be most common around holiday times when perhaps more alcohol is consumed or dietary patterns interrupted. Another frequent time for flare-ups seems to be vacations, so be sure you take your medication when you go. Often a week or two of the antibiotic will suffice if the rosacea flare-up is caught early.
"My sister was prescribed Accutane for her acne. Would this help for my rosacea?"
Regular acne and acne rosacea are two very different diseases. In treating regular acne, Accutane should be reserved for patients who have severe cystic scarring acne or who have moderately severe acne that has not responded to reasonable trials of other types of therapy. Rosacea is a completely different story. It rarely is cystic, and it rarely scars. It does, however, work well in that occasional situation where rosacea has become cystic and is not responding to other treatment.
Accutane is a potent medication with many side effects and is discussed in more detail in my In Depth Article on Acne. Women who are pregnant or thinking about becoming pregnant or who are not actively preventing pregnancy with birth control should never be using Accutane. It does cause birth defects if you were to become pregnant while you are on it. It is safe to become pregnant two after Accutane is discontinued.
When Should I Consider Getting Laser Treatments?
Since being red doesn’t hurt you, the answer could be never if the redness doesn’t bother you. Laser treatments for redness or dilated blood vessels are really a cosmetic issue. But it might be time to consider them if:
1 Your flushing is bad enough that it is interfering with your work or social life. For example, you’re avoiding speaking in public because you’re afraid you might flush or blush.
2 You’ve had people assume that you’re a heavy drinker because your nose and cheeks are red. You can also try just educating your friends and coworkers about rosacea.
3 You’re having to pile on the make-up in the morning just to feel presentable for work or play.
4 You have a strong family history of rosacea, and you know you’re probably going to get worse over the next several years.
"My rosacea is under good control with prescription medications, but I still seem to be red. Why isn’t this going away?"
There are a lot of causes for redness, rosacea being one of the main ones. Once the active rosacea is under good control, the baseline redness and dilated blood vessels may not go away with prescription medications alone. It is still important to keep using them though to keep the rosacea under control and prevent further progression of the disease.
In your situation, the best way to remove the redness and dilated blood vessels and bring your skin back to its baseline color is to use the gentle lasers that are now available to take the red out. Don’t undertake laser treatments though until your rosacea has been treated for at least two to four months. You don’t want to waste your money.
It is also important to know that, after you have finished your laser treatment for the redness and dilated blood vessels, that you will probably need periodic maintenance treatments to maintain your baseline color. The more you flush and blush or do other things that aggravate redness, like drinking wine or spending time in the heat or sun, the more often maintenance treatments will probably be needed. Ask your dermatologist for a reasonable estimate of what you can expect, and see my guide to the average costs of cosmetic dermatology treatments.
SUMMARY OF ROSACEA: WHAT TO DO
Rosacea is a disease that often gets worse if you don’t do anything about it. To prevent progression, see your dermatologist for advice on your particular situation.
In general, you should get the rosacea under control if you:
Use gentle cleansers, sunscreens and moisturizers;
Have a lifestyle that avoids or minimizes your own triggers for rosacea;
And use prescription creams or antibiotics prescribed by your doctor if she thinks they are appropriate. Once your rosacea is treated and under control, you may want to consider having one of the gentle laser treatments to reduce the remaining redness and/or dilated blood vessels.
Next, see Dr. Irwin's Guide to IPL/Photorejuvenation Lasers.
See Dr. Irwin's expert answers to other reader's questions on rosacea:
Is sunscreen really needed if I'm at home? Problems with pigment increase after peels. Can Thermage, Exilis and Ultherapy be used for prevention? Are Dysport/Botox and Sculptra compatible? A problem! Which retinol is best for use on the delicate eye area? How does radiofrequency (Thermage & Exilis) compare with Ultherapy? All these different forms of Retin A (Renova, Atralin, tretinoin) -- arghhhh!
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