Rosacea

Topic Overview

What is rosacea?

Rosacea (say 'roh-ZAY-sha') is a skin disease that causes redness and pimples on your nose, cheeks, chin, and forehead. The redness may come and go. People sometimes call rosacea "adult acne" because it can cause outbreaks that look like acne. It can also cause burning and soreness in the eyes and eyelids.

Rosacea can be embarrassing. And if it is untreated, it can get worse. If the symptoms bother you, see your doctor and learn ways to control rosacea.

What causes rosacea?

Experts are not sure what causes rosacea. It tends to affect people who have fair skin or blush easily, and it seems to run in families.

Rosacea is not caused by alcohol abuse, as people thought in the past. But in people who have rosacea, drinking alcohol may cause symptoms to get worse (flare).

Rosacea often flares when something causes the blood vessels in the face to expand, which causes redness. Things that cause a flare-up are called triggers. Common triggers are exercise, sun and wind exposure, hot weather, stress, spicy foods, alcohol, and hot baths. Swings in temperature from hot to cold or cold to hot can also cause a flare-up of rosacea.

What are the symptoms?

People with rosacea may have:

• A flushed face and pimples or bumps on or around the cheeks, nose, mouth, and forehead. Sometimes the flushing or redness can last for days.
• Tiny red veins on the face that look like spiderwebs.
• Burning or stinging facial skin, especially when they apply lotions or medicines. The face may feel increasingly dry, sensitive, or sunburned.
• Dry, red, irritated eyes. The eyelids may look red and swollen, and vision may be blurry. If it is not treated, rosacea can cause serious eye problems.

Without treatment, some cases of rosacea can cause knobby bumps on the nose and cheeks that can multiply. This is advanced rosacea, known as rhinophyma (say 'ry-no-FY-muh'). Over time, it can give the nose a swollen, waxy look. But most cases of rosacea don't progress this far.

How is it treated?

Doctors can prescribe medicines and other treatments for rosacea. There is no cure, but with treatment, most people can control their symptoms and keep the disease from getting worse.

• Antibiotic creams or pills may be used to treat redness and pimples. Antibiotic pills may also help treat eye problems. Women who are pregnant should not use some antibiotic creams or pills. If you use antibiotics, be patient-it can take a month or two before you start to see improvement.
• Stronger medicines may be tried if antibiotics don't control your rosacea. Examples include isotretinoin (Accutane) or tretinoin cream (Retin-A). You cannot use these if you are pregnant or might become pregnant.
• Surgery or other treatments may help your skin look better if you have advanced rosacea. Choices may include dermabrasion, cryosurgery, or laser surgery.

How can you prevent rosacea flare-ups?

There are some things you can do to reduce symptoms and keep rosacea from getting worse.

• Find your triggers. One of the most important things is to learn what triggers your flare-ups, and then avoid them. It can help to keep a diary of what you were eating, drinking, and doing on days that the rosacea appeared. Take the diary to your next doctor visit, and discuss what you can do to help control the disease.
• Use sunscreen every day. Pick a sunscreen rated SPF 15 or higher that blocks ultraviolet light (UVA and UVB) and infrared rays. During winter, use a moisturizer to prevent dryness caused by cold and wind.
• Be gentle with your skin. Use skin care products for sensitive skin, and avoid any products that scratch or irritate your skin. Try not to rub or scrub your skin.
• Take care of your eyes. Gently wash your eyelids with a product made for the eyes. Apply a warm, wet cloth several times a day. Use artificial tears if your eyes feel dry.

Frequently Asked Questions

Cause

The exact cause of rosacea is unknown. One theory is that it may result from oversensitive blood vessels in the face. Because rosacea causes increased warmth in the skin, bacteria may grow, causing the pimples and bumps.

Tiny mites (Demodex folliculorum) that normally live on our skin may also play a role: People who have rosacea have more of these mites on their faces than those who don't have the disease.

Flare-ups often start when certain triggers cause the blood vessels in the face to dilate, which causes redness. Common triggers are sun, exercise, hot weather, emotional stress, spicy foods, alcohol, and hot baths. Swings in temperature from hot to cold or cold to hot can also trigger a flare-up of rosacea.

Many people with this skin condition have a family history of rosacea.¹

There may be a link between rosacea and Helicobacter pylori bacteria, which causes an infection in the stomach, although studies are unclear.

Alcohol and poor hygiene do not cause rosacea, as was believed in the past. But drinking alcohol may trigger facial flushing and can cause symptoms to get worse.

Symptoms

Some people may notice that their skin has become very sensitive or that they blush easily before they notice other symptoms of rosacea. For example, facial products may burn their skin.

As rosacea develops, redness on the cheeks lingers, like a slight sunburn. This redness and other symptoms of rosacea come and go. The main symptoms include:

• Facial redness/flushing. Triggers, such as sun exposure or alcohol, stimulate increased blood flow, which causes blood vessels to expand and facial redness to appear. In women, the redness usually appears on the cheeks, nose, chin, and forehead. The redness may appear in a "butterfly" pattern across the cheeks and nose. Facial redness in men typically appears on the nose, although symptoms can appear on other areas of the face. In some cases, redness may also occur on the neck and upper chest.
• Pimples on the face. Small pimples may occur on the red areas of skin or on the edges. These pimples-red, round bumps in the skin-are different than acne pimples, which are blackheads or whiteheads.
• Red lines on the face (telangiectasia). These small, thin, red lines are tiny blood vessels that look like spiderwebs, and they usually appear on the cheeks.
• Swollen bumps on the nose. In severe cases, mostly in men, the nose appears enlarged, bulbous, and red, a condition called rhinophyma.
• Eye irritation. Symptoms include redness, dryness, burning, crusted mucus, tearing, a gritty feeling like that of sand in the eye, pinkeye (conjunctivitis), and swelling in the eyelid. The eyes may not tolerate contact lenses, and styes may develop. In some cases, vision may be blurry, but only in severe cases is vision damaged. About half of the people with rosacea have some eye irritation or symptoms.²

Rosacea may be mistaken for some other conditions with similar symptoms, such as acne or lupus.

Some research suggests a link between rosacea and migraine headaches.¹ Blood vessels may be the connection between these two conditions.

What Happens

Rosacea develops in phases. The first sign may be the tendency to blush often. Rosy cheeks or patches of red appear on the face. Facial skin may be more sensitive and may react to skin products, such as lotions or soaps. Some people notice eye irritation before they note any skin symptoms.

See a picture of rosacea.

As rosacea progresses, facial redness comes and goes on the cheeks, forehead, or chin. Facial flushing occurs when there is a sudden increase of blood flowing through the blood vessels under the skin. This causes the blood vessels to relax and get wider (dilate), which results in skin redness. In time, ongoing dilation may cause blood vessels to get larger and look like small red lines on the skin.

Tiny pimples may begin to appear on and around the area of redness. As flare-ups continue, the redness increases, and flare-ups occur more often. Later on, if rosacea is untreated, the redness and red lines may become permanent.

Along with the redness and pimples of the face, rosacea can also affect the eyes. Eye symptoms may develop before you notice facial symptoms, and they include redness, dryness, infection, and burning (conjunctivitis). If eye problems are not treated, they can lead to more serious complications. In some cases, vision may be blurry, but vision is damaged only in severe cases.

Treatment can help control rosacea symptoms and prevent the condition from getting worse. If untreated, rosacea may lead to a condition called rhinophyma, in which long-term (chronic) inflammation causes the nose to appear enlarged and bulbous, red, and with thick bumps. This is due to the oil-producing (sebaceous) glands and the tissues of the nose getting larger. Rhinophyma is more common in men than women. It often takes several years to develop. But most cases of rosacea do not progress this far.

What Increases Your Risk

There are no known risk factors for rosacea. But many people with this skin condition have family members with rosacea.¹

Certain triggers can cause flushing of the skin and a flare-up of rosacea symptoms. These triggers include sun, stress, hot weather, alcohol, caffeine, spicy food, exercise, hot baths, and cold weather. Triggers produce a sudden increase in blood flow through the blood vessels in the face. This causes the blood vessels to expand and the face to flush. A trigger that affects one person may not affect another.

When To Call a Doctor

Call your doctor if you notice symptoms that could be caused by rosacea, such as:

• Red patches on your face that come and go.
• Redness, pimples, and small, red lines on your face.
• Eye redness and frequent eye irritation.
• Bulbous, thick bumps and redness on your nose.

Watchful Waiting

If you notice any symptoms of rosacea, such as redness, redness with pimples, eye irritation, or large, swollen bumps on your nose, call your doctor. If you start treatment when you first notice symptoms, it is likely that your symptoms will improve and your condition will not get worse.

Who To See

The following health professionals can diagnose and treat rosacea:

• Family medicine physician
• Dermatologist
• Nurse practitioner
• Physician assistant
• Internist
• Ophthalmologist (for eye involvement in rosacea)

The following health professionals can treat moderate to severe cases of rosacea that may require surgery:

• Dermatologist
• A cosmetic or plastic surgeon

To prepare for your appointment, see the topic Making the Most of Your Appointment

Exams and Tests

Your doctor will diagnosis rosacea after a physical exam. You probably will not have medical tests unless the diagnosis is unclear. In that case, tests will rule out other conditions, such as lupus or a fungal infection.

During an exam, your doctor will check your eyes and the skin on your face, neck, and upper chest for any symptoms of rosacea. Tell your doctor when you first noticed symptoms and how often they occur. This information, along with your family history, is usually enough for a diagnosis.

Treatment Overview

There is no cure for rosacea. Treatment often helps keep symptoms under control and prevents the disease from getting worse. If left untreated, rosacea symptoms can get worse, can recur more often, and eventually may become permanent.

Treatment for the four main forms of rosacea vary depending on your symptoms:¹

• Erythematotelangiectatic. Symptoms include flushing and often thin, red lines (telangiectasias) on the face. Some people report stinging or burning of the face. Treatment may include oral antibiotics. Your skin may be too sensitive for you to use ointments on your face. In mild cases, you can apply a gentle anti-inflammatory product and sunscreen in the morning. If medication does not clear up the thin, red lines, which are tiny blood vessels, a form of laser surgery called pulsed dye laser therapy may help.
• Papulopustular. Symptoms include small pimples (pustules). You can also have facial flushing and tiny, red lines on your cheeks. Your doctor may prescribe ointments for your face or antibiotic medication. You may even use both at the same time. Skin tends to be less sensitive with this form of rosacea.
• Phymatous. Symptoms include thick, bumpy skin and large pores. The most common type affects the nose (rhinophyma). Other types affect the chin, forehead, ears, and eyelids. You may also have flushing, pimples, and visible blood veins. Your doctor may prescribe isotretinoin for phymatous rosacea in its early stages. Surgery or laser resurfacing can reshape the nose in severe cases of rhinophyma.
• Ocular. Symptoms include red, dry, and irritated eyes. You may feel like something is in your eye. Your eyelids may swell or feel dry and flaky. In severe cases you may feel pain or have blurred vision. You can try artificial tears for dry eyes. Ointments work well for mild cases. Your doctor may prescribe antibiotic pills.

With treatment, symptoms usually improve in 2 to 4 weeks. You'll see the best results in about 2 months.

Identifying and avoiding triggers that cause rosacea flare-ups is an important part of treatment. Keep a list or diary of triggers to help you avoid those foods, products, or activities that might cause flare-ups. Even people who are using medicine to control rosacea benefit from avoiding triggers.

Prevention

The cause of rosacea is unknown, and there is no way to prevent it.

But there are steps that you can take to prevent flare-ups of rosacea, and this can help stop the condition from getting worse. You can find out what triggers your flare-ups by making a list of what you were eating or doing around the time you had a breakout. Some triggers include sun and wind, hot and cold temperatures, stress, spicy foods, skin care products, and exercise.

Home Treatment

There are several things you can do to reduce symptoms of rosacea and prevent the condition from getting worse.

• Skin care. Use soaps, lotions, and cosmetics made for sensitive skin that do not contain alcohol, are not abrasive, and will not clog pores (noncomedogenic). Avoid rubbing or scrubbing your face. Cosmetics with a green-colored base may help mask the redness of a flare-up. Your doctor may be able to refer you to a clinic that specializes in the use of cosmetics for people with rosacea.
• Use sunscreen. It is important to protect your face from sun exposure. Every day, use a broad-spectrum sunscreen-one that blocks UVA, UVB, and infrared rays-that is rated SPF 15 or higher. It may be hard to find a sunscreen with the right ingredients that does not sting your face, but it's important to look for the right protection for your skin.
• Eye care. Apply warm compresses several times a day, and gently wash your eyelids with a product made for the eyes. Use artificial tears if your eyes feel dry.
• Identify triggers. Make a list or keep a diary of potential triggers when you have a flare-up. The National Rosacea Society has developed a rosacea diary checklist that you can use to keep track of the factors that may be causing symptoms of rosacea. Use the diary every day for several weeks. See the rosacea diary checklist(What is a PDF document?).
• Avoid triggers. After you have identified triggers that cause flare-ups, avoid these triggers to help reduce your symptoms.
  • Use sunscreen on your face every day. Avoid the midday sun, and wear a wide-brimmed hat.
  • Minimize stress in your life. Take care of yourself, eat a balanced diet, and exercise regularly.
  • Stay cool on hot, humid days.
  • Limit consumption of alcohol, spicy foods, and hot drinks.
  • Stay as cool as possible when you exercise. Try to exercise for shorter, more frequent intervals, and do low-intensity workouts. In the summer, exercise during the cool morning hours.
  • Use a moisturizer during the winter to protect your face from dryness. Wear a scarf over your cheeks and nose to help protect your skin from the cold and wind.
  • Avoid excessive hot water, hot tubs, and saunas.
  • Use skin care products for sensitive skin, and avoid any products that are abrasive or that irritate your skin.

Medications

You can use antibiotic creams to relieve the redness on your face and help eye symptoms that result from rosacea. Antibiotic pills may help clear the pimples, and can reduce the swelling or irritation in your eyes. Mild cases often respond to treatment with antibiotic creams. But symptoms usually improve faster with antibiotics you take as pills or capsules. Long-term use of oral antibiotics may cause side effects, such as stomach upset and vaginal yeast infections. Therefore, oral medication may be used first, then tapered off and followed by antibiotic cream.

With antibiotic treatment, symptoms usually improve in 3 to 4 weeks, with greater improvement in 2 months.

Swollen bumps on the nose (rhinophyma) do not respond well to antibiotic treatment.

Medication Choices

Medications used to treat rosacea include:

• Antibiotics. Used alone or with another medication, antibiotics are the most common medicines doctors prescribe to treat rosacea.
• Isotretinoin. Doctors usually prescribe isotretinoin only for severe rosacea or rosacea that does not respond to antibiotics.

  Note: Women who are pregnant or may become pregnant should not take isotretinoin, because of the risk of serious side effects such as miscarriage and birth defects.

• Tretinoin (Retin-A, Avita, Renova). Tretinoin is a topical medication most often used to treat acne. You may use it to treat the pimples that develop from rosacea. It is not useful for treating red lines (telangiectasia) or facial redness.

Doctors may prescribe other medications, including imidazoles or azelaic acid gel (such as Finacea).

What To Think About

Medications often work well to help improve the symptoms of rosacea.

You may need to keep taking medicine for rosacea if you have symptoms that are hard to control.

Surgery

Surgery may help for moderate to severe cases of rosacea to treat an enlarged nose (rhinophyma); small, red lines (telangiectasia); or lingering redness.

Some types of skin problems respond better to surgery than others. People with lighter skin who limit their time in the sun and use sunscreen after the procedure tend to have better results than people with sun-darkened skin and people who continue to spend lots of time in the sun.

Surgery Choices

Surgery options include:

• Laser resurfacing. Laser surgery removes layers of skin. This may help with an enlarged nose (rhinophyma); small, red lines; or lingering redness.
• Dermabrasion. This procedure may smooth the rough skin and bumps on the nose caused by rhinophyma.
• Cosmetic surgery. Reconstructive surgery and plastic surgery may reshape or remove bumps from a nose damaged by rhinophyma.

What To Think About

You may not be a good candidate for surgery if you are using isotretinoin or have used it within the last 6 to 12 months, because it may increase the risk of scarring after the procedure.

Other Treatment

Cosmetic counseling is often helpful for people with rosacea. Ask your dermatologist to recommend someone in your area.

Other Places To Get Help

Organizations

Related Information

• Acne Vulgaris

References

Citations

1. Powell FC (2005). Rosacea. New England Journal of Medicine, 352(8): 793-803.

2. Blount BW, Pelletier AL (2002). Rosacea: A common, yet commonly overlooked, condition. American Family Physician, 66(3): 435-440.

Other Works Consulted

• Habif TP, et al. (2005). Rosacea (acne rosacea). In Skin Disease Diagnosis and Treatment, pp. 98-101. St. Louis: Mosby.

• Van Zuuren EJ, et al. (2007). Systematic review of rosacea treatments. Journal of the American Academy of Dermatology, 56(1): 107-115.

Credits