ROSACEA - THE RED FACE

Red face is a frequent complaint, in the young, and especially in the aging adult. Rosacea is the cause of facial redness in a large portion, but certainly there are a number of other unrelated factors or conditions that may be the cause as well.

Rosacea is a multi-faceted disease that includes persistent facial redness as one of its manifestations. Although Rosacea is not life threatening, the conspicuous facial redness, flushing, blemishes, and unsightly veins may deeply impact patients’ self esteem and inhibit potential. The enlarged knobby nose made famous by W.C.Fields is one example of a disfiguring variant of this disease. And approximately 50% of all Rosacea sufferers will develop concomitant eye symptoms, some associated with benign eye conditions, and others associated with more significant problems.

The impact of Rosacea on psychological measures is not to be understated, especially in view of the fact that long lasting remission is now an option. Surveys of Rosacea sufferers have revealed that 75% experience low self-esteem, 70% are frustrated, and 60% feel that social/career/happiness levels have been negatively impacted. Until recent years counseling was high on the list of conventional strategies for the Rosacea sufferer. Now fortunately, there are a few new treatment options that produce near normalization of appearance for sustained periods of time.

This disease is exceedingly common, with estimates ranging between 5-13% prevalence of rosacea symptoms in N.America and Europe. It affects typically fair skinned individuals such as those Eastern and Northern European decent, especially those of Celtic origin. Some darker complexioned individuals may be affected as well, including Native Americans, Afro-Americans, Asians, and Mediterraneans. The geographic prevalence may also reflect the geographic risk factors for Rosacea, such as exposure to extremes of heat and cold, e.g. the climate in Saskatchewan. The disease may present itself in adolescence, but this is the exception to the rule. Most individuals realize they have Rosacea sometime after their 30th birthday. Women are affected more often, but men tend to develop more severe disease, and are more likely to develop the bulbous nose variant known as rhinophyma.

The patient is gradually and progressively aware of the cosmetic conspicuousness of this condition, some reaching serious self-esteem and social performance issues as a result of the cosmetic stigmata of this disease. It is not unusual to hear patients describe their capability in camouflage make-up to “cover the red”. Other patients may be “the last to know” about their conspicuous facial redness and veins, presumably because the progression was insidious. They always relate that they have “always had a red face.” Others may be acutely aware of their redness by now. For some, the greatest issue is the intractable problem of blemishes. And others might cite “sensitive skin” as the greatest trial. Eventually most patients are apprised of the exceptional redness when well meaning others express concern about the “high blood pressure”. Others, however, will secretly assume that the one with a red face is “drinking”. In fact, most Rosacea patients won’t touch alcohol for fear of triggering a flushing episode!

Unfortunately, the disease remains incompletely understood as experts continue to debate the various hypotheses about the underlying aberrant physiology. There are some fundamental commonalities however, including the presence of highly reactive, small blood vessels in the skin. As the disease progresses the vessels become more dense and more reactive and associated with low-grade inflammation. The link between expansion of dysfunctional blood vessels and the growing inflammatory response remains the subject of continued debate. There are hypotheses involving infectious agents, but there is no clear answer at this time. And the pathology in the microscope is quite “pore oriented”, but the variants of rosacea are wide and sometimes involve overgrowth of the sebaceous glands (oil glands) and fibrosis (scarring). It is evident that ultraviolet light, (sun damage) plays a significant role. Genetic trends are strong. Thus the underlying mechanisms of Rosacea are apparently complicated and involve a variety of skin structures.

Patients are clear about the triggers of facial redness and flushing. For some the flushing is the most debilitating symptom, especially when in role on the job. It is impossible to keep your cool when emotional stress triggers a deep and intensely red flush that prickles with heat and completely embarrasses the patient. The cycle of embarrassment – flushing – embarrassment is obvious. There are lists of factors that might induce a flush, but the most commonly cited troublesome triggers are: exposure to heat or cold, ingestion of a small amount of alcohol, spicy foods, emotional experiences, and exertion. Flushing frequency varies from a couple of times per week to more than 20 per day. Historically, one of the strategies for controlling the disease was to eliminate exposure to the triggers. This remains a recommendation, but the effect of light therapy on vascular dysfunction is potent, stabilizing, and long lasting, such that lifestyle normalization might become a practical reality for affected individuals.

It is important to note that use of topical steroid creams or ointments on the “red, inflamed and itchy rash” will initially and transiently soothe, and then markedly exacerbate. The patient may persist with the topical, still impressed with the initial benefit. And so the rash worsens until it is discontinued.

Often the diagnosis of Rosacea is overlooked because the changes are insidious, and assumed to be due to “normal aging”. So these undiagnosed individuals are not relieved by therapy. And there are those that have been diagnosed on the basis of facial redness that may not be due to this disorder, and treated inappropriately. Rosacea classification systems help organize the protean manifestations of the disease into categories for diagnosis, monitoring, research, and communication.

Retrospectively, the patient may recall that flushing and blushing dated back to childhood. It appears that these individuals are at risk of progression to diagnosis. Family photos of the rosacea patient might reveal comparative facial redness years ago, worsening with time. The redness pattern is often focused on the convexities of the face, eg chin, nose, high cheeks, and perhaps center forehead. However, the redness may be sharply focal, for example, limited to the nose, or the chin. The threshold of “abnormal redness” for any given individual varies widely, and so some may be discrete at diagnosis while others will attract considerable attention before medical attention is sought.

The inflammatory manifestations are also quite variable, and generally there is a waxing and waning pattern. It is not unusual for the patient to confuse rosacea blemishes with those of acne. In fact, it is not unusual to see coexistence in one patient of both acne and rosacea. The red bumps associated with rosacea tend to be smaller, longer lasting, and there may be little pus. Blackheads are considered a sign of acne, and not rosacea. There may be patches of elevated red skin that “burn and sting”. Burning and stinging is a common complaint of rosacea patients. For some, this is the single worst symptom. Or there may be large zones, such as the convexities of the cheeks, swollen, deeply red, and pitted like an orange peel, reflecting water retention, inflammation, and possibly some fibrosis (scarring). The inflammatory process may involve the eyes in a benign or more serious manner. Eye symptoms in the setting of rosacea may warrant referral to an ophthalmologist.

The bulbous knobby change on the nose of some affected patients is known as rhinophyma. This unsightly variant of rosacea may even occur on the chin, or the forehead, or other sites. This represents an advanced stage of skin scarring and sebaceous gland aberration, and generally necessitates a surgical procedure to restore the appearance.

Another common observation in rosacea is the presence of dense and prominent skin veins, often referred to by patients as “broken capillaries”. These might reflect the underlying disease pattern of dysfunctional blood vessels, overgrown and superficial. However, there are other factors that lead to the appearance of such veins, unrelated to rosacea. Overlying facial redness might mask some of the veins, and with treatment they become more visible until they too resolve with light therapy, regardless of the underlying diagnosis.

The bad news: There is no cure for rosacea at the present time.
The good news: Long lasting remission is now a realistic goal.

There are several good reasons for early medical treatment. Antibiotics used to control the inflammatory aspects of the disease are much more likely to produce a response in early disease, and the converse is also true. Additionally, some of the changes of rosacea cannot be reversed, and therefore they are best prevented, e.g. fibrosis

The most obvious management intervention is prevention. Rosacea patients should maximize protection from ultraviolet light (in sunlight or sunbeds). Of course, topical corticosteroids are to be avoided. Although alcohol is itself not a cause, it will exacerbate the symptoms of rosacea. All skin products should be nonirritating, hypoallergenic, and noncomedogenic. The avoidance of exercise, and fear of a glass of wine, and consumption of non-spicy foods is not necessary in this day and age of improved therapy. The affected patient need not further stigmatize their life with a host of “avoidances”.

The usual “first line of therapy” has been antibiotic creams or ointments, and there are some newer suggestions amongst these. It is believed that the benefit is due to an anti-inflammatory effect, rather than specific killing of a microbial. Topical agents are helpful, and may produce complete remission in some, but addition of an oral antibiotic is often required to fully suppress or induce remission of the inflammation. It is believed that the mechanism of action of the topical, and subsequently oral antibiotics is anti-inflammatory, and not due to killing of bacteria. If a remission is induced then the patient may gradually withdraw from the medication. If the meds are simply suppressing the inflammation, then withdrawal will come with relapse, necessitating long term antibiotic use to maintain control. Long-term suppressive antibiotic use is associated with an increased risk of antibiotic resistance among skin bacteria.

In addition to the limitations described above, the use of antibiotics does not produce much improvement in the cosmetic disfigurement of facial redness, unsightly veins, and excessive flushing. The enlarged pores (fibrosis, scarring) will not significantly reverse with antibiotic use. It wasn’t more than a few years ago that the next management strategy was counseling! Fortunately, there are a few other options for treatment now, with a reasonable goal of long lasting remission and normalization of appearance in those who haven’t excessively scarred (rhinophyma, fibrosis).

Accutane is one additional therapeutic option with proven value, but of course, this is a medication with some potentially serious side effects requiring close monitoring. Now intense pulsed light is an evidence-based effective therapy for rosacea, with major benefits to facial redness, flushing, and telangiectasia. In addition, studies have confirmed that the inflammatory manifestations abate or remit. Anecdotally, it appears that the symptoms of burning and stinging improve. The technology has also proven itself in the improvement of pore size, and may reverse some of the orange peel enlarged pores seen in rosacea. In fact, recently the FDA has scrutinized this data and cleared the Vasculight device as effective in the treatment of rosacea. Intense pulsed light therapy by an accredited device has entered the realm as established, effective and safe for the treatment of rosacea.

Although Intense Pulsed Light has dramatically changed the outlook for rosacea patients, it should be emphasized that patients are not “cured”. Although it will reverse some of the disfigurement brought on by time, it will not stop the seemingly interminable progression of this disease, and it will not reverse the scarring of rhinophyma. Studies are forthcoming at a rapid rate yielding further information about the disease and the treatment, but thus far it is clear that patients typically enjoy months to years of relative reversal of the symptoms, including facial redness, veins, flushing, inflammation, and sensitive skin. And some will improve the texture of skin, especially pore size. The patient is relieved with the knowledge that remission and near normalization is an option, and may require an initial course of treatments (usually 1 – 6) followed by periodic maintenance, (variable). The outlook for the rosacea patient has improved.

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