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How is rosacea treated?

Updated: May 19, 2023



 

Disclaimer: The information in this article is not meant as specific individual medical advice. Please consult your dermatologist or other medical professional about your skin or medical condition.

 

What is rosacea?


Rosacea is a chronic facial skin problem that usually affects a person’s nose, cheeks, chin, and sometimes the forehead and eyes.


The characteristic features of rosacea are redness and flushing of the face, visible blood vessels (also called telangiectasia), acne-like breakouts and sometimes thickening of the skin.


When rosacea affects the eyes (also called ocular rosacea), a person may experience eye dryness, burning, stinging, light sensitivity, blurring of vision or the feeling like there is something in the eye.



Who does rosacea affect?


Rosacea most commonly affects fair-skinned individuals between 30 and 50 years of age.


It occurs more often in women than men.


Sometimes rosacea can run in the family.



What causes rosacea?


The cause of rosacea is largely unclear.


There is likely a genetic factor as rosacea is known to run in families. This suggest that there are genes that are inherited that play a role in people who develop rosacea


There are also bacteria and Demodex mites that are thought to play a role in causing rosacea. However, their role in rosacea is unclear because these same bacteria and mites are also found in people who do not have rosacea.



What can cause rosacea to flare up?


A variety of lifestyle and environmental triggers can cause rosacea to flare up.


The triggers may also be different for different individuals.


Common triggers for flare ups are:

  • Sunlight exposure

  • Wind

  • Stress

  • Heat

  • Heavy exercise

  • Alcohol consumption

  • Spicy food

  • Certain skin care products or make up

  • Over-scrubbing the face


Sometimes, it can be difficult to identify a lifestyle or environmental trigger for rosacea. Keeping a food or activity diary may help identify triggers.


If there is a lifestyle or environmental factor (such as drinking red wine) that is causing your rosacea to flare up regularly, avoiding it can reduce the severity of rosacea.



Types of rosacea


There are 4 main types of rosacea.


Many people with rosacea have a mix of the 4 different types.


The type of rosacea a person has determines the type of treatment that is recommended



Type 1: Erythema (redness) / telangiectasia (visible blood vessels)


People with this type of rosacea tends to experience redness and flushing of the face (erythema).


There are also visible blood vessels (telangiectasia).


Some people may experience very stinging and burning sensation.


The skin may also feel rough and dry.



Type 2: Inflammatory


In this type of rosacea, people experience acne-type break outs that may come and go.


These breakouts consists of small red bumps or pus bumps that typically develop where there is also redness and visible blood vessels.



Type 3: Phyma (Thickening of the skin)


In this situation, the skin becomes thicker because oil glands (sebaceous glands) in the skin increase in size.


This causes the skin to feel bumpy, thick, hard and oily.


Pores can also appear larger.


This change tends to affect the nose and the skin around it, and is called rhinophyma.



Type 4: Ocular (eye involvement)


Usually, people with eye involvement, also have other types of rosacea.


When rosacea affects the eye, it can cause the eye to feel dry, burning, stinging or itching.


The eyes may also be sensitive to light, and vision can be blurred.


There may also be the sensation of a foreign body on the eye


Sometimes, it can cause chalazions to form on the eyelids.


When severe, ocular rosacea may cause inflammation and scarring of the cornea.




Treatment of redness (erythema) and prominent blood vessels (telangiectasia) in rosacea



Redness and flushing (erythema) in rosacea is a result of increased blood flow through the superficial blood vessels in the skin.


The visible blood vessels (telangiectasia) are due to increase in size of the capillaries in the skin.


Sun protection measures can reduce redness, flushing and damage to the blood vessels.


Sun protective measures include:

  • Avoid midday sun

  • Wearing a wide-brimmed hat when outdoors

  • Seeking shade

  • Apply a broad-spectrum sunscreen that is SPF 30 or higher every day.


There are currently two topical treatments for facial redness:

  • Topical brimonidine gel (Mirvaso®)

  • Topical oxymetazoline cream (Rhofade®)


Both of these treatments work by causing blood vessels to constrict temporarily, which reduces blood flow through them.


Both brimonidine gel[1] and oxymetazoline cream[2] are meant to be applied once a day.


The treatments may decrease facial redness by up to 12 hours.


The facial redness returns when the treatment wears off, which means these treatments do not cause the redness to decrease permanently.


Some people may experience skin irritation from applying these treatments



There are also two types of laser treatments that reduces redness and prominent capillaries.


These are the pulsed-dye laser (PDL)[3] and potassium titanyl phosphate (KTP) laser.


These lasers work by emitting light that is absorbed by the blood vessels. The light energy is converted to heat and damages the blood vessels, hence decreasing facial redness and capillaries.


It is common to experience increased redness and swelling immediately after the laser treatment. These symptoms tend to resolve after one to three days


Sometimes, bruising (purpura) may develop after laser treatment, and this can take up to 1 to 2 weeks to resolve.


Lastly, if these treatments are not feasible or effective, green tinted makeup can be used to cover up redness.



Treatment of inflammation in rosacea


Inflammation in rosacea causes red bumps and pus bumps to form on the face, that is similar looking to what we see in acne.

There are both topical and oral treatments for reducing inflammation in rosacea.


They can all work by reducing redness, swelling, burning and stinging sensation, red and pus bumps.


When the inflammation is mild, topical treatment is recommended.


The topical anti-inflammatory treatments for rosacea are:

  • Azelaic acid (Finacea®)

  • Metronidazole cream (Metrogel®)

  • Ivermectin cream (Soolantra®)

  • Sodium sulfacetamide



Azelaic acid (Finacea®)


Azelaic acid[4] decreases redness and swelling in rosacea. It also has an anti-bacterial effect.


It is also helpful for lightening skin discoloration caused by rosacea lesions.


Azelaic acid is a mild treatment and usually does not usually cause skin irritation, and is better tolerated by people with sensitive skin.


Azelaic acid is available as a prescription gel, foam and cream. It is usually applied about once to twice a day.


Some people may experience skin irritation or tingling after using topical azelaic acid.



Metronidazole (Metrogel®)


Topical metronidazole has been used for rosacea to reduce redness and decrease acne-like lesions for years.


While metronidazole is an antibiotic, it is used in rosacea for its anti-inflammatory properties.


Metronidazole is available in two concentrations 0.75% and 1%, as a gel and cream.


It is usually applied once to twice a day to the affected areas on the face.


Some people may experience skin irritation or stinging with metronidazole use.



Ivermectin 1% cream (Soolantra®)


Ivermectin cream is also used as a prescription treatment to reduce break outs associated with rosacea.


While ivermectin has anti-parasitic effect, it is not clear how it treats rosacea. It is thought that it has an anti-inflammatory role by decreasing Demodex mites in the skin.


Topical ivermectin is usually applied on the skin once a day.


Topical ivermectin use may sometimes cause skin irritation and burning sensation.



Sodium sulfacetamide 10% (Klaron®, Ovace®)


Sodium sulfacetamide is also commonly used to reduce redness and acne-like lesions in rosacea.


Sulfacetamide is an antibiotic. and works by decreasing bacterial growth on the skin.


It is sometimes used in combination with topical sulfur which helps remove debris and dead skin.


Sulfacetamide is available as a solution, cream, foam, wash, gel and lotion.


Sodium sulfacetamide is also used for other facial inflammatory skin conditions including acne and seborrheic dermatitis.


Some people may experience skin irritation with topical sulfacetamide.


This treatment is best avoided if you are allergic to sulfa drugs, as potentially severe allergic reaction may happen.



Oral antibiotics (Doxycycline)


Oral antibiotics are used when inflammatory rosacea is severe, or if the inflammation is not responsive to topical treatments.


Tetracyclines (doxycycline and minocycline) are the first line oral medication for treating rosacea that is more severe.


In addition to have having anti-bacterial effect, tetracyclines also have direct anti-inflammatory effect in rosacea.


The main tetracycline used in rosacea is doxycycline.


Doxycycline is available in a sub-antibiotic dose (40mg) and is FDA approved as a once daily dose for treating rosacea in the United States.


Doxycycline can cause sun sensitivity and stomach upset.


Oral doxycycline is not recommended for use during pregnancy or nursing.


Other antibiotics, such as minocycline and sulfamethoxazole/trimethoprim (Bactrim), may also be used to treat inflammatory rosacea if oral doxycycline is not effective or well-tolerated.


Oral antibiotics are typically used for one to three months.


Some people with severe rosacea may need to use oral antibiotics for the long term for keeping their skin clear.



Oral isotretinoin (commonly known as Accutane®)


While it is mainly used to treat severe acne, oral isotretinoin has also been found to be effective to reducing inflammation in rosacea.[5]


Oral isotretinoin is a derivative of vitamin A.


It is only used when the degres of inflammation is severe.


Isotretinoin may also be used to treat inflammatory rosacea that is not responding to other treatments.


Most of the knowledge about the side effects of isotretinoin come from its use in the treatment of acne.


The main risk of using oral isotretinoin is that it will cause birth defects in pregnancies.


As a result, in the United States, enrollment in iPledge is required by both men and women who take this medication.


iPledge is a program that is mandated by the FDA to decrease fetal exposure to isotretinoin. It requires all women to abstain from sex or use 2 contraceptive methods during and until 30 days after completing isotretinoin treatment.


When taking oral isotretinoin, severe dryness of the skin, lips, eyes and nasal mucosa can be expected.


Occasionally, people may experience joint pain, muscle ache, headache or blurred night vision.


Blood tests are usually performed regularly during the treatment period to monitor for raised cholesterol and fat (triglyceride) levels and raised liver enzymes.


There have been situations where people taking isotretinoin experience delayed wound healing and keloid scar formation. As a result, it is recommended that procedures including laser treatments are delayed for 6 to 12 months after completing isotretinoin treatment.


Changes in mood, including depression, have been reported in people taking oral isotretinoin in acne. According to the American Academy of Dermatology, acne treatment guidelines, “many studies have shown no evidence of depression from isotretinoin”. However, given the prevalence of depression and anxiety in the general population, people who are taking isotretinoin should monitor for these symptoms closely, and inform their prescribing provider if they develop.


There are has been various studies to determine if oral isotretinoin use is associated with or causes inflammatory bowel disease such as Crohn’s disease or ulcerative colitis in people with acne. The American Academy of Dermatology states that the ‘current evidence is insufficient to provide either an association or causal relationship between isotretinoin use and inflammatory bowel disease.’[6]



Treatment of thickened skin (phyma) in rosacea


Thickening of the skin may occur around the nose, cheeks, and sometimes the forehead and chin. It most commonly affects the nose, and is termed rhinophyma.


This is the most difficult type of rosacea to treat, because it is difficult to remove thickened skin after it has developed.


Removing thickened skin usually requires a surgical procedure.


Ablative lasers, such as carbon dioxide laser and erbium laser[7], and electro loop cautery can be helpful in removing tissue and re-sculpting the skin.



Treatment of eye involvement in rosacea (ocular rosacea)


Ocular rosacea can cause dry eyes and inflammation of the eyelids. When severe, ocular rosacea can cause inflammation of the cornea and ulceration.


Eyelid hygiene can help reduce inflammation. Eyelid hygiene involves applying a warm compress with a wet washcloth on the eyelids twice a day. This removes debris from the eyelids and eyelashes.


A mild shampoo may be used on the eyelashes can be helpful for removing debris. However, take care not to irritate the eye when using a shampoo around the eyes.


Topical azithromycin[8], which is an antibiotic, has been useful in decreasing inflammation of the eyelids (blepharitis). It is usually applied as an eye solution once to twice a day.


Omega-3 fatty acid supplements have also been found to be useful in reducing dry eyes in people with rosacea.[9]


Finally, oral doxycycline, the same oral antibiotic that is used to treat inflammatory rosacea, is also helpful in reducing inflammation in ocular rosacea.


If you have having eye symptoms, it is important to consult with an ophthalmologist (eye specialist).




I hope you have found the information in this article useful in learning about the different types of rosacea and their treatment options. I also hope this will empower you when you make your medical decisions with your dermatologist.






[1] Fowler Jr., J. Jackson M. Moore A. et al. Efficacy and safety of once-daily topical brimonidine tartrate gel 0.5% for the treatment of moderate to severe facial erythema of rosacea: results of two randomized, double-blind, and vehicle-controlled pivotal studies. J Drugs Dermatol. 2013; 12: 650-656 [2] Rhofade cream prescribing information. Allergan, Irvine, CA2017 https://www.allergan.com/assets/pdf/rhofade_pi.pdf [3] Tan S.R. Tope W.D. Pulsed dye laser treatment of rosacea improves erythema, symptomatology, and quality of life. J Am Acad Dermatol. 2004; 51: 592-599 [4] Elewski B. Staedtler G.et al. Azelaic acid foam 15% in the treatment of papulopustular rosacea: a randomized, double-blind, vehicle-controlled study. Cutis. 2013; 92: 306-317 [5] Sbidian E. Vicaut É. Chidiack H. et al. A randomized-controlled trial of oral low-dose isotretinoin for difficult-to-treat papulopustular rosacea. J Invest Dermatol. 2016; 136: 1124-1129 [6] American Academy of Dermatology website. Position statement on isotretinoin. Available at: https://www.aad.org/Forms/Policies/Uploads/PS/PS-Isotretinoin.pdf. Accessed January 6, 2016. [7] van Zuuren E.J. Fedorowicz Z. Carter B. et al. Interventions for rosacea. Cochrane Database Syst Rev. 2015; : CD003262 [8] Opitz D.L. Tyler K.F. Efficacy of azithromycin 1% ophthalmic solution for treatment of ocular surface disease from posterior blepharitis. Clin Exp Optom. 2011; 94: 200-206 [9] Bhargava R. et al. A randomized controlled trial of omega 3 fatty acids in rosacea patients with dry eye symptoms. Curr Eye Res. 2016; 41(10):1274-1280

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