Rosacea - Western SummaryWestern Medicine Summary

Western Medicine

Western Summary

Rosacea is a chronic skin condition mainly of the face that results in facial redness, flushing, bumps and skin thickening. Rosacea affects mainly the central parts of the face such as the cheeks, chin, nose and sometimes the eyes. Rosacea is a fairly common disease, especially among Caucasians of northern European decent.[1-3] In Europe and in the United States it is estimated that at least one to two adults out of a hundred have rosacea.[1,4] Although it is typically seen in Caucasians and those with lighter skin color, it can also be seen in those with darker skin color.[5] The western approach is to reduce the inflammation of rosacea through the use of anti-inflammatory topical agents and systemic medications such as antibiotics and isotretinoin (in severe cases).

Treatment Philosophy

Rosacea treatment combines lifestyle modifications and medications to prevent flares from developing. Lifestyle modifications include the avoidance of ultraviolet radiation, heat, known trigger foods, emotional stress and certain creams. Medications, both topical and oral, are used to target the underlying inflammation or blood flow to the skin of the face. Many patients will find what triggers their rosacea and can learn to avoid those triggers while using medications to limit the inflammation and too much blood flow to the face.

Symptoms

Rosacea often runs a chronic course with periods of intermittent flaring. It often begins in early adulthood but can occur at almost any adult age.[6] Notably, rosacea can be triggered by certain common day-to-day factors such as sun light, heat, alcohol, spicy foods and emotional stress, to name a few. One of the major barriers to understanding the cause of rosacea over the years has been the large variety of triggers and manifestations of the rash of rosacea.[7] While rosacea can look slightly different from one person to another, four main forms of the disease are well established.[6] This categorization helps when it comes to deciding on a treatment plan and also in designing research studies. It is important to recall that in many people more than one form can exist at the same time or at different times. The four forms of rosacea are:[1]

  • Type 1 (Erythematotelagiectatic Rosacea): In this form of rosacea, patients have persistent facial redness (erythema), many visible, fixed, dilated, small blood vessels (telangiectasia) and facial flushing. Symptoms include burning, stinging, dryness, and swelling.
  • Type 2 (Papulopustular Rosacea): This form of rosacea is characterized by facial bumps (papules) and pus filled bumps (pustules). Redness is also prominent.
  • Type 3 (Phymatous Rosacea): The name is derived from the Latin word phyma, meaning swelling. Phymatous rosacea refers to the form of rosacea that is characterized by thickening of the skin, most commonly the nose, but other areas of the face with sebaceous glands can be affected as well (e.g. forehead, chin, ears).
  • Type 4 (Ocular Rosacea): In this unique form, patients suffer from irritation in the eyes that is associated with a feeling of a foreign body and appearance of blood shot eyes. Some patients report feeling itchy or stinging pain in the eyes.

It is important to recall that these categories are slightly oversimplified and many patients have an overlap of several features of the different types. 

Causes

A clear cause for rosacea has not been established and there are likely multiple potential causes, but the basis of rosacea is inflammation. Although the exact cause of rosacea is not known, there are several associations that have been suggested:[8,9]

  • Heat
  • Ultraviolet light exposure
  • Spicy foods
  • Microbial overgrowth on the face and in the gut, including the presence of Demodex mites on the face

Over the last two decades research has demonstrated a strong role of the immune system in the development of rosacea. Specifically, the part of the immune system that helps fight non-specific microbes (known as the innate immune system) seems to be de-regulated in people with rosacea.[7] This results in over activation of the innate immune system and subsequent inflammation in the skin. Research has shown a role for sunlight and certain microbes in activation of the immune system resulting in rosacea.[10] In addition, some patients with rosacea have abnormal signaling of the nervous system in the skin that may lead to the dilatation of blood vessels and sensitivity to factors such as heat and spices.[11]

Risk Factors

Your body 

  • Age: Rosacea typically affects adults after the age of 30.[6] One theory for this is that adults have had more cumulative sun exposure over their lifetime than children.
  • Gender: There are some large scale studies showing higher rates of rosacea in females.[12] Other research suggests that rosacea occurs equally in males and females.[1] Females tend to be have more type I rosacea while males tend to have more type III rosacea.[13]
  • Genetics: A study in twins showed that there is a genetic link for rosacea.[14] The authors of this study estimated that genetics made of 46% of the risk for developing rosacea.

Lifestyle

  • Spicy food: The intake of spicy food is known to trigger rosacea flares in some people. The TRPV receptor(discussed above) is sensitive to molecules found in spicy food and is found in increased levels in patients with rosacea.[15]
  • Caffeine: The role of caffeine in rosacea has been unclear and may or may not affect rosacea. A study in 24 people with type 1 rosacea found that it was temperature and not caffeine that lead to flares of rosacea.[16]
  • Alcohol: There does not appear to be strong evidence for an association with rosacea and alcohol intake. Several previous studies did not find any association with rosacea[17,18] while one found a weak association.[14]
  • Hot drinks: Hot drinks like hot chocolate, coffee, or tea is likely to trigger a rosacea flare.
  • Smoking: The role of smoking cigarettes in the development and control of rosacea is unclear. Smoking has been associated with rosacea in some studies,[13,14,19] but other studies found that smoking did not have an association,[1] or was even associated with a decreased risk for rosacea.[12]
  • Stress: Emotional stress can play a role in worsening rosacea.[10]

Products

  • Any topical product: Some patients with rosacea develop exquisite sensitivity to application of nearly any topical product (such as creams and gels). Controlling rosacea in these patients may improve this sensitivity.[20]
  • Ingredients: People with type 1 and type 2 rosacea have an impaired skin barrier, an immune system that results in skin inflammation more easily, and skin blood vessels that become dilated more easily.[21] All of these factors lead to increased skin sensitivity. For this reason, skin products can easily irritate the skin in those with rosacea. A survey by the National Rosacea Society showed that patients reported many ingredients in skin products irritated their skin including alcohol (66%), fragrance (30%), and astringent products such as witch hazel (30%).[22]
  • Topical steroids: The prolonged use of topical steroids on the face can lead to the development of a form of rosacea known as steroid-induced rosacea, especially with use of a more potent topical steroid for more than 1 month.[23]

Environment 

  • Heat: Exposure to a hot environment, such as a kitchen or the gym, can be a trigger for a rosacea flare. Studies have shown that people with rosacea can be more sensitive to high temperatures and heat. One study in patients with rosacea showed that the skin has an increased biochemical cell receptor known as the “transient receptor potential ion channels of vanilloid type” (TRPV).[15] The TRPV receptor becomes activated when exposed to heat.
  • Sun and ultraviolet light exposure: Exposure to sunlight and ultraviolet has been associated with the development of rosacea.[14,19,24,25] {insert link to sunlight and rosacea piece}

Treatments

Medications

Topical medications

  • Antimicrobials: These compounds are not used for the antimicrobial effect but more due to their anti-inflammatory effects, although these medications do decrease Demodex mite numbers. Medications like topical metronidazole and ivermectin[26,27] have been used in the treatment of type II rosacea. Several studies have shown that topical permethrin may be helpful for type II rosacea.[28,29]
  • Topical agents that constrict blood vessels: An example medication is brimonidine.[30] These agents have been shown to be useful in reducing the redness associated with type I rosacea.[31,32] 
  • Azelaic acid[33,34]
  • Sodium sulfacetamide[35]

Oral Medications

  • Antibiotics: The most common oral medications used for the treatment of rosacea are antibiotics pills in the tetracycline family (ex: doxycycline, minocycline, tetracycline). Interestingly, these medications are used for their anti-inflammatory properties and may improve the skin barrier.[36] Studies on the use of low dose antibiotics have shown that the lower dose is anti-inflammatory and effective for rosacea[37] without inducing resistance in bacteria.[38]
  • Beta blocker medications: These medications work by inducing constriction of blood vessels in the skin.[39] This decreases blood flow in the skin which appears as reduced redness. [40,41]
  • Isotretinoin: Systemic isotretinoin is sometimes used by physicians to treat rosacea and has been used for type II and type III rosacea.[42] There are many risks associated with isotretinoin that should be carefully discussed with a licensed physician.

Procedures

  • Light therapy: reduces the redness and small blood vessels associated with type 1 rosacea. The best evidence exists for intense pulse light and the pulsed dye laser.[43]
  • Lasers: Ablative lasers such as carbon dioxide laser can be effective for reducing the thickening associated with phymatous (type 4) rosacea.[44]

Nutrition and diet

  • Diet: Although the role of diet and rosacea is not well studied, spicy foods are known to activate facial flushing and flares of rosacea. Minimizing spicy foods may help reduce these flares.

Lifestyle changes

  • Sunlight and ultraviolet light protection: Because sunlight and ultraviolet light can trigger flares of rosacea, it is important to have good sun protective habits. This includes the use of broad-spectrum sunscreens, sun protective clothing, avoidance of intense sunlight, and avoidance of ultraviolet light tanning booths.
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