Rosacea is a chronic inflammatory skin disease that usually occurs on the face. Read here what it can trigger, what stages, pre- and special forms there are and what medical therapy approaches and accompanying cosmetic treatments are possible. Christina Drusio also explains the differences between functional and constitutional facial flushing.
The chronic inflammatory disease rosacea occurs mainly in light skin types (skin types I and II according to Fitzpatrick) and was therefore often referred to as the "curse of the Celts" in the past.
Typically, the characteristic skin changes appear on the forehead, nose, chin and cheeks and the disease is initially recurring in episodes, later it tends to persist. Its causes have not yet been fully clarified, but knowledge about the disease has been significantly expanded in recent years. The results show that rosacea is based on a complex dysfunction of various regulatory systems. The innate immune system, neuroinflammation (inflammation of nerve tissue) and various mechanisms with changes in blood vessel and possibly lymph vessel regulation play an important role in this. In addition, external trigger factors such as UV light, temperature extremes, spicy or hot food and drinks, alcohol, hormonal changes, external cosmetics that are too greasy and stress, but also cutaneous microorganisms such as the colonization with skin mites, are of great importance. Not least because of the fact that rosacea takes place on the face, those affected feel a high level of suffering due to the visible reddening of the face and the changes in the skin.
Stimuli and trigger factors
Various factors play a role in the development of rosacea. The tendency to react to different stimuli and trigger factors with a flushed face is inherited and when rosacea occurs, the genes are about 50% responsible. This is due to a malfunction of the blood vessels in the skin of the face. Blood congestion occurs in the area of the smallest skin vessels and lymph congestion in the area of the lymphatic vessels on the face. As a result, small dilated blood vessels (so-called telangiectasias), but also tissue swelling (edema) can form due to fluid accumulation from the blood and lymphatic system. In addition, the body's own immune system plays a major role in rosacea. The human skin is in contact with the environment and therefore has several defense mechanisms. In addition to the physical skin barrier, there is also a "chemical defense system" of the skin. This consists, among other things, of special amino acid compounds (so-called peptides) that perform several tasks. A certain peptide with antimicrobial properties and influence on the immune defense is much more active in rosacea sufferers and releases inflammatory messenger substances (interleukins) and messenger substances for blood vessel growth (VEGFR factors). In addition, the skin is colonized by the hair follicle mite (Demodex folliculorum), which occurs on all of us and is part of the natural skin flora. In rosacea sufferers, however, the number of hair follicle mites on the skin is significantly increased. Via complex chemical processes, they lead to inflammatory reactions with the formation of small nodules (papules). However, it is important to note that rosacea is not an infectious disease, nor is it a contagious skin disease!
The three stages of rosacea
The first permanent reddening of the face (erythema) can occur before the age of 20. Most of the time, rosacea begins after the age of 30 and most often between the ages of 40 and 50. Men and women are equally affected, but women tend to get sick a little earlier than men.
The disease is divided into three stages depending on its appearance, although it is not linear and individual stages can also be skipped. The course of the disease is very individual and you can also define different special forms.
The precursor form of rosacea is characterized by a fleeting, seizure-like facial flushing, which can be triggered by the trigger factors described above. This so-called functional facial flushing can be accompanied by a feeling of heat due to an increase in blood flow to the face. In addition, abnormal sensations such as itching, burning or stinging can occur.
Stage I is also known as rosacea erythematosa, because here the redness of the face is no longer attack-like, but persists for hours to days. In addition, the first dilated blood vessels (telangiectasias) can appear, especially in the area of the cheeks and nasolabial. This stage is also often referred to as couperose.
If inflammatory, reddish nodules (papules) or nodules with pus tips (pustules) appear in addition to the ongoing redness of the face, then this is rosacea papulo-pustulosa and thus stage II of the disease
. The papules and pustules initially appear in episodes, later often recurring and are usually symmetrically distributed in the central face. They heal only with difficulty, but the healing usually takes place without scars - as long as there is no external manipulation! In stage III, rosacea hypertrophica, the persistent dysregulation of the blood vessels with consequent blood and lymph congestion leads to a long-term inflammatory thickening of the skin. The skin appears large-pored and swollen, and connective tissue and sebum gland overgrowth occurs. The enlargement and thickening of the sebum glands occurs particularly in the area of the nose and is also known colloquially as the bulbous nose (rhinophyma). For unexplained reasons, this almost exclusively affects men. In addition, deep-seated inflammatory lumps of the skin are often found.
Special forms of rosacea
An important special form of rosacea is ocular rosacea (Opthalmorosacea), in which the skin around the eyes, especially the edge of the eyelids, is affected. Eye rosacea can only occur in isolation in the eyes or it can be associated with the typical skin changes on the face. If only the eye area is affected and the rest of the skin is clear, this is often a harbinger that over time, rosacea will also develop in the rest of the facial skin! Those affected often complain of recurring eyelid inflammation, a foreign body sensation in the eye, increased sensitivity to light and dry eyes. In addition, enlarged blood vessels appear in the area of the eyelid skin and eyelid swelling can occur. Concomitant conjunctivitis, corneal inflammation and hailstones (inflammation of the sebum of the eyelid) can occur. If the outcome is unfavorable, even vision loss can occur, which is why the treatment of ocular rosacea always belongs in the hands of a dermatologist!
Medical measures
Rosacea in its various forms is incurable, but it can be well controlled with the right therapy. First of all, those affected can take general measures to avoid trigger factors. Proper skin care also plays an important role, for which the beautician can be the point of contact. Stages I to III as well as the special forms of rosacea are medically treated with topically applied topical therapeutic agents or internally with tablets. The respective therapy depends on the stage or the special form and the severity of the disease. In therapy, it is important to explain to those affected that the measures improve the symptoms, i.e. skin changes, but that it is a chronic disease that should be treated and checked for life. That is why the right care that is adapted to the condition of the skin is essential. The basics of the active ingredients are important not only in cosmetics, but also in local medical therapy, as bases that are too greasy can worsen rosacea. Four active ingredients are currently approved in European Union for topical treatment with topical therapeutic agents, in cream or gel bases: Brimonidine is used to treat facial redness, as the active ingredient ensures that the small blood vessels in the skin contract. If there are inflammatory nodules (papules) and nodules with pus tips (pustules) in addition to facial redness (stage II), the active ingredients metronidazole, azelaic acid and ivermectin are used. These substances have an anti-inflammatory effect, normalize the keratinization of the skin or also anti-parasitic in order to reduce the increased number of skin mites. It is important that cortisone should not be used externally, as this has a negative effect on the course of the disease! In the more severe forms of rosacea, supplementary internal system therapy with tablets is usually required, which is carried out with antibiotics from the group of tetracyclines, which include the active ingredients minocycline or doxycycline. The antibiotics are usually low-dose, so that they do not show an anti-bacterial effect, but an anti-inflammatory effect. They should be given long enough to improve, but still be used for a limited time. In the case of extensive facial flushing, IPL and laser therapy can be used, usually in several sessions. Dilated blood vessels (telangiectasias) can also be "obliterated" using a vascular laser.
The bulbous nose (rhinophyma) occurring in stage III can usually no longer be improved by drug therapy. Here, ablative lasers or, alternatively, surgical ablation by an operating room are used.
Differential diagnosis
But reddened skin is not always the same as rosacea. In addition to the functional flushing of the face of rosacea, there is also a constitutional flushing of the face that has nothing to do with rosacea. This is predisposed and often occurs in young adulthood. This facial flush is harmless, symmetrically arranged and can occur permanently or alternately. In the vernacular, one also speaks of apple cheeks. Affected people almost always also have a grater skin (keratosis pilaris)! Furthermore, rosacea with flat facial redness (rosacea erythematosa) should be distinguished from a sore rose (erysipelas) on the face. This acute clinical picture is a bacterial infection of the skin, there is almost always a portal of entry in the sense of a small wound or scratch area and is accompanied by unilateral reddening as well as a strong feeling of illness and fever. Papulo-pustular rosacea can often be mistaken for acne in the cabin due to the appearance of inflammatory nodules (papules) and nodules with pus tips (pustules)! For orientation, one can look out for the appearance of open or closed comedones: these only occur in acne!
Cosmetic measures
Cosmetic measures can be supportive and helpful, especially in the preliminary and early stages of rosacea. The skin shows an increased reactivity of the vessels as well as increased irritability and sensitivity. The treatment goals therefore include calming the skin, stabilizing the superficial blood vessels, possibly inhibiting inflammation and stabilizing the skin barrier. The skin should therefore be cleaned gently and must not irritate the skin or blood vessels, i.e. mild products and only lukewarm water (no temperature extremes!) Should be used. If at all, only exfoliate enzymatically and do not use mechanical abrasive particles that can irritate the skin too much. Furthermore, steaming should be avoided during the facial treatment in order to avoid temperature fluctuations or excessive heat. The cleansing of the skin depends on its sensitivity. If the sensitivity is very high, the veins widen immediately and a flush occurs. Therefore, the skin reaction can first be tested on a small area. Ideally, a classic massage should not be used for the facial treatment, manual lymphatic drainage can be carried out instead. Since lymphatic congestion with tissue swelling often occurs in rosacea, manual lymphatic drainage is not only ideally suited to decongesting the blood and lymphatic system of the skin, but also to strengthen it by ensuring an improved metabolic function. Extreme caution should be exercised with masks as they may exacerbate facial flushing. A mask with a strong occlusion effect should not be used, rather lighter gel masks should be used. Select balancing and calming daily skin care and use special products to cover redness. They have a calming, anti-inflammatory effect and hide the redness with brown or green pigments. A consistent daily sun protection should be part of every care for rosacea sufferers.
Christina Drusio , specialist in dermatology and venereology,
part of the Dr. Schrammek management
Very informative, especially the eye area information, thank you 🙏