Rosacea

According to rosacea.org:

Rosacea is a chronic skin disorder of the central face (cheeks, nose, chin, forehead) that affects over 16 million Americans.

It presents with flushing, red-faced, acne-like inflammatory bumps and pimples, pustules, or visible blood vessels (telangiectasia or "spider-veins"). The nose may grow swollen and bumpy (rhinophyma). Rosacia may also affect the eyes (ocular rosacea), causing irritation, watering, or bloodshot appearance.

In rare cases, rosacea signs and symptoms may also develop beyond the face, most commonly on the neck, chest, scalp or ears.

This disorder tends to come and go, and tends to progress in severity over time.

The cause of rosacea is unknown [and probably multifactorial]. Although there is no cure, its signs and symptoms can be controlled by [individualized] medical interventions and lifestyle changes.

Please see conventional, complementary, and alternative medical treatments for important background information regarding the different types of medical treatments discussed on this page. Naturopathic, Complementary, and Alternative treatments that may be considered include:

Rosacea affects about 16 million individuals in the United States. The prevalance in women is greater than in men, but may be more severe in men. The incidence increases with age [Raedler2015  🕮 ].

Ocular rosacea, which affects the eyes, may be a component of about 58% of all cases Medscape

According to Medscape, rosacea is sometimes called the "curse of the Celts" because it most commonly associated with fair haired/skinned people of Celtic descent.

Etiology

According to rosacea.org:

Rosacea can vary substantially from one individual to another, and in most cases some rather than all of the potential signs and symptoms appear. Diagnosis requires at least one diagnostic sign or two major signs of rosacea [Gallo2018  🕮 ]. Various secondary signs and symptoms may also develop but are not diagnostic.

Diagnostic Signs of Rosacea

The presence of either of these signs is diagnostic of rosacea:

•     Persistent Facial Redness: may resemble a blush or sunburn that does not go away. [Photo courtesy of National Rosacea Society; click to expand, back to shrink.]
  


•     Skin Thickening: The skin may thicken and enlarge from excess tissue, most commonly on the nose (rhinophyma), which in severe cases can lead to inadequate nasal airflow. [Photo courtesy of National Rosacea Society; click to expand, back to shrink.]
  

Major Signs of Rosacea

The presence of at least two of these signs is diagnostic of rosacea:

• Flushing: Frequent blushing or flushing, which may be accompanied by a sense of heat, warmth or burning that comes and goes.
  
•     Bumps and Pimples: Small red solid bumps (papules) or pus-filled pimples often develop, but unlike acne, blackheads are absent. [Photo courtesy of National Rosacea Society; click to expand, back to shrink.]
  


• Visible Blood Vessels: prominent and visible small blood vessels called telangiectasia occur on the cheeks, nasal bridge, and other areas of the central face.
  
• Eye Irritation: The eyes may be irritated and appear watery or bloodshot (ocular rosacea). The eyelids may become red and swollen, and styes are common. Crusts and scale may accumulate around the eyelids or eyelashes. Severe cases can result in corneal damage and loss of visual acuity.

Secondary Signs and Symptoms

These may appear with one or more of the diagnostic or major signs:

• Burning, Stinging, Itching, or a Feeling of Tightness: may accompany other signs of rosacea or occur independently.
  
• Facial swelling: (Edema) or raised red patches (plaques) may accompany other signs of rosacea or occur independently.
  
•     Dryness: The central facial skin may be rough, and appear scaly despite otherwise complaints of oily skin. [Photo courtesy of National Rosacea Society; click to expand, back to shrink.]
  

According to Medscape, in February 2002, the National Rosacea Society further identified several clusters of symptoms that commonly occur together:

Erythematotelangiectatic rosacea (ETR)

The main features of ETR are flushing and [transient] central facial erythema. Secondary features are telangiectasia, stinging, burning, roughness, and scaling.

Papulopustular rosacea (PPR)

The main features of PPR are persistent central facial erythema with sporadic transient papules or pustules. Secondary features may include the features of ETR, but telangiectases may be obscured by persistent facial erythema.

Phymatous rosacea (PR)

The main features of PR are thickened, coarse, irregular skin, enlarged pores, tissue hyperplasia, and nodules. Secondary features may include the features of ETR and PPR.

In partcular, PR that affects the nose is called rhinophyma, which mostly affects men.

Ocular rosacea (OR)

Features of OR include a sensation of a foreign-body in the eye, burning or stinging, dryness, itching, photosensitivity, telangiectases of the conjunctiva, and periocular erythema.

Medscape notes that:

• Persistent redness of the central face is the most common sign of rosacea;
• The papules and pustules often appear in clusters;
• The burning or stinging often occurs upon application of sunscreens, moisturizers, or topical medications;
• The dry, scaly skin (xerosis) may be itchy.
• "Peripheral location, including the chest, neck, scalp, or back." Dr. Weyrich notes that other sources stipulate that this is a characteristic of acne vulgare and part of the ddx distinguishing against rosacea.

Differential Diagnosis

Red Flag Referrals

First Line of Treatment for Conventional, Naturopathic, Complementary, and Alternative Medical Approaches

Hygine

• Wash your face, eyelids, and eyebrow area with a MILD cleanser to exfoliate debris. Washing more that once a day may be beneficial or may disrupt sensitive skin. Dr. Dray.
• Wash bedlinnens at least once a week Dr. Dray.

Avoidance of Triggers

Various authors have proposed many different triggers, including the following:

Dr. Ghongde Sanjivani

Trigger (% of cases)	Representative Author
Sun exposure (81%)	Medscape
Emotional stress (79%)	Medscape
Hot weather (75%)	Medscape
Wind exposure (67%)	Medscape
Exercise (56%)	Medscape
Alcohol (52%)	Medscape
Hot baths (51%)	Medscape
Cold weather (46%)	Medscape
Spicy foods (41%)	Medscape
Humidity (44%)	Medscape
Indoor heat (41%)	Medscape
Skin care products (41%)	Medscape
Hot beverages (36%)	Medscape
Caffeinated beverages	Dr. Vikas Sharma MD
Chocolates	Dr. Vikas Sharma MD
Tomatoes	Dr. Vikas Sharma MD
Cinnamon	Dr. Vikas Sharma MD
Topical steroids	Dr. Vikas Sharma MD
Isotretinoin	Dr. Vikas Sharma MD
Chemical peels	Dr. Vikas Sharma MD
Microdermabrasion	Dr. Vikas Sharma MD
Benzoyl peroxide	Dr. Vikas Sharma MD
Excessive cosmetic use	Dr. Vikas Sharma MD
Red wine containing sulfites
Drugs that dilate blood vessels, including some blood pressure medications	Dr. Ghongde Sanjivani
Citrus	Dr. Ghongde Sanjivani
Cold beverages	Dr. Manisha Lakhekar
Perspiration	Dr. Manisha Lakhekar
Poor sleep	Dr. Manisha Lakhekar
Foods high in histamine like yoghurt, cheese, red wine	Dr. Manisha Lakhekar

Conventional Treatments

Topical Ivermectin

A 1% topical application of ivermectin has shown some benefit in treating rosacea [Raedler2015  🕮 ] RxList. This reference states that "The mechanism of action of SOOLANTRA™ cream in treating rosacea lesions is unknown." However, other sources suggest that the mechanism of action is to paralyze Demodex parasites living in facial skin pores Dr. Dray. However, Dr. Dray states that ivermectin can be very drying and irritating to the skin and is not recommended for rosacea.

Can be very drying and irritating to the skin. Not recommended for rosacea Clinical benefit in randomized, double-blind, vehicle-controlled clinical trials is reported to be about 40% versus about 13% for the carrier cream only (placebo) RxList.

This product is marketed as SOOLANTRA™ and is also available as a generic.

Topical Metronidazole

According to Medscape, mechanism of action by which Metronidazole reduces the symptoms of rosacea is unknown, but may be related to its anti-inflammatory and immunosuppressive actions.

Clinical benefit in randomized, split-face, double-blind, vehicle-controlled, paired-comparison clinical trial is reported to be about 65% to 75% versus about 15% for the carrier gel only (placebo). Benefits included reduction in total papules, pustules, and erythema. Treatment did not alter telangiectasia.

Topical Minocycline

Dr. Dray

Topical Azelaic Acid

Clinical benefit in a randomized, double-blind, split-face comparison in patients with papulopustular rosacea, topical azelaic acid 20% cream versus topical metronidazole 0.75% cream demonstrated both agents achieved significant and equal reductions in papules and pustules.

Azelaic Acid is also used in the treatment of acne vulgaris Medscape.

Topical Sodium Sulfacetamide

Lotions available include Klaron, Novacet, and Sulfacet R; A wash is also available (Plexion).

This antibiotic is not suitable for use with patients that are sensitive to sulfa drugs Medscape.

Topical Clindamycin

This product has been used off-label to treat rosacea Medscape.

Topical De La Cruz Acne treatment with 10% sulfur

Dr. Dray states that this OTC product reduces Demodex and is antiinflammatory, and is great for rosacea, sebohhraic dermatitis, perioral dermatitis, acne, and pityrosporum folliculitis. Also can be a bit drying too.

Topical Exfolient Salyicitc Acid

Dr. Dray states that OTC topical salyicitc acid products such as CeraVe Acne Control Cleanse can be used, but notes that it may be irritating for rosacea, and may be more helpful for sebohhraic dermatitis.

Topical Exfolient Adapalene Gel 0.1%

According to Dr. Dray, this is a retinoid that is used once a day. Also available as an OTC poduce "Differin Gel". Helps compaction of the stratem cornea, thus reducing food for Demodex. Also has anti-inflammatory properties, but cam be irratating for rosacea. Especially helpful for removing "lots of little bumps."

Topical Exfolient Benzoil Peroxide

According to Dr. Dray, benzoil peroxide may have antibacterial and antiinflammatory properties. It is available OTC as Neutrogena Stubborn acne AM treatment 2.5% Micronized Benzoil Peroxide, as well as a FDA-approved for rosacea. Since this product may irritate rosacea, lower strength is preferable. Dr. Weyrich notes (personal experience) that this product is a powerful oxidizer and may bleach clothing, bedding, carpeting, etc. that it comes in contact with.

Topical Tea Tree Oil

According to Dr. Dray, tea tree oil suppresses Demodex's ability to emerge from the follicle. Caution - essential oils like tea tree oil are too powerful to apply directly to the skin. She recommends using a commercial product formulated for topical use, such as Head and shoulders with tea tree oil. This product also contains also contains zinc pyrithione, which has anti-microbial, anti-fungal, and anti-seborrheic properties.

However, this product also contains surfactants such as sodium lauryl sulfate that are too harsh for routine facial use, and can strip the skin of its natural oils. This drying action may cause the skin to secrete more sebum as a compensatory mechanism, which is counterproductive when treating Demodex India Today.

Consider applying a moisturizer after use of this product.

Topical Selenium Sulphide

Products such as Selsun Blue contain selenium sulphide, which is effective in treating Malassezia infections (pityrosporum folliculitis). However, this product also contains harsh surfactants that may be too drying for routine facial use India Today.

Consider applying a moisturizer after use of this product.

Oral Doxycycline

More serious cases of rosacea can be treated with doxycycline (50-100 mg twice a day Medscape. Doxycycline may have anti-inflammatory effects in addition to being anti-bacterial Dr. Dray.

Oral Tetracycline

More serious cases of rosacea can be treated with tetracycline (250-500 mg twice a day) Medscape.

Oral Minocycline

More serious cases of rosacea can be treated with minocycline (50-100 mg twice a day) Medscape.

Oral Isotretinoin

More serious cases of rosacea that have not responded to oral antibiotic treatments can be treated off-label with oral isotretinoin. This product has serious side-effects, indluding teratogenicity, and special training is required to prescribe this product Medscape.

Electrosurgery

Telangiectasia and phymatous changes often do not respond to topical or systemic therapies; in this case, electrosurgery may be helpful. Medscape

Laser surgery

Telangiectasia and phymatous changes often do not respond to topical or systemic therapies; in this case, laser surgery may be helpful. Medscape

Dermabrasion

Telangiectasia and phymatous changes often do not respond to topical or systemic therapies; in this case, dermabrasion may be helpful. Medscape

Please also see rosacea.org.

Naturopathic, Complementary, and Alternative Treatments

Low Dose Naltrexone (LDN)

Dr. Weyrich has found that LDN is helpful in treating rosacea.

The mechanism of action of LDN in treating rosacea most likely to be via Toll-like receptor 4 antagonismantagonism [Toljan2018  🕮 ].

Please see What is Low Dose Naltrexone? for more information.

Homeopathy

Herbal Medicine

Dr. Dray suggests the topical use of Maneuca honey may be effective in treating Demodex rosacea.

Quercetin has been shown to reduce inflammation, immune infiltration, and angiogenesis associated with rosacea https://www.sciencedirect.com/science/article/abs/pii/S0024320524002650 .

Red tea, (rooibos, Aspalathus linearis) is rich in antioxidants like aspalathin and quercetin Medical News Today.

"Eucerin’s Redness Relief products contain licorice extract, which calms redness" Prevention.

Green tea, Aloe, Castor oil - Dr. Weyrich

Ocular rosacea may progress to keratitis, corneal opacities, and blindness; monitoring by an ophthalmologist is recommended Medscape.