Treatment Pales Rosacea's Red Face
by Margie Patlak
updated about 1 year ago
When she was a teenager and her friends were bemoaning the whiteheads and blackheads erupting on their faces, Marcia Meyer of Kensington, Md., had a clear, ruddy complexion. She was surprised, then, when her face broke out in pimples for the first time when she was in her 20s. Feeling she was "too old for this," Meyer says, and upset over her appearance, she went to see her dermatologist, who told her she had a skin disorder known as rosacea.
Although few people are familiar with the disease, rosacea is a common skin disorder that afflicts about 1 in 20 people in this country, estimates dermatologist and rosacea expert Jonathan Wilkin, M.D., of Ohio State University in Columbus. Despite its prevalence, many people with the condition go undiagnosed, he says.
Wilkin has seen patients who seek care for other skin disorders and don't realize they have rosacea until he points it out to them. "Most people with rosacea are surprised to hear it's something the medical field can help them with," he says, "because they think it's just a complexion problem that runs in their family."
The disorder can be effectively curbed with various drugs, laser treatments, and surgery, including products regulated by the Food and Drug Administration, as well as by preventive measures. Without proper care, in contrast, rosacea may progress to a more disfiguring condition.
Although it can occur among adults of any age and of any skin color, rosacea is more prevalent among fair-skinned people between the ages of 30 and 50. The disease is more common in women, but more severe when it strikes men. People who flush easily are more prone to rosacea, as are people with peaches-and-cream complexions, including many with Irish, English, or Eastern European ancestry, a survey by the National Rosacea Society suggests. The tendency towards rosacea appears to be inherited; often several people in a family have the condition.
Red Mask
Rosacea usually begins with frequent flushing of the face, particularly of the nose and cheeks, although sometimes the redness spreads to the chin and forehead as well. The flushing is caused by swelling of the blood vessels under the skin of the face and can last as little as a few minutes to as long as a few hours. In most cases, however, eventually the blood vessels stay dilated and a sunburn-like redness becomes a permanent feature on the central areas of the face.
This red mask can serve as a red flag for attention. Meyer notes that people tend to tease her about being out in the sun too much. "I'm probably the only person who uses makeup to tone down her face, rather than the reverse," she says.
Once the redness becomes permanent, it often is accompanied by pus-filled or solid red pimples. There are no blackheads or whiteheads with rosacea, and the pimples are usually limited to the central portion of the face. Thin red lines that resemble a road map also tend to surface. These lines are actually small blood vessels in the upper layers of the skin that have become enlarged. If rosacea is not treated, a condition called rhinophyma can develop in some people. Rhinophyma occurs much more frequently in males than in females. The hallmark of rhinophyma is a big bulbous red nose like the one sported by the late comedian W.C. Fields, who had rosacea with rhinophyma. The nose can also become thicker at the base.
This disfiguring condition "has never killed anyone," notes Wilkin, "but it has ruined a lot of lives."
Rosacea can also cause a persistent burning and grittiness of the eyes or inflamed and swollen eyelids. In severe cases, vision may become impaired.
Waxing and Waning
Rosacea is a chronic ailment that waxes and wanes. Between flare-ups, some people have no signs of the disorder. But other people still have facial redness or red lines, accompanied by pimples during flare-ups.
Dermatologists usually diagnose rosacea by its symptoms; no tests are available, but on rare occasions skin biopsies can pinpoint the condition. Few people with rosacea have all the symptoms of the disorder, which can make it tricky to diagnose at times, Wilkin admits. He strongly suspects rosacea in people with just a few symptoms of the disorder if other people in their family have the condition.
There is also a condition known as steroid-induced rosacea, which occurs in some people after applying corticosteroid ointments to their face for a long period to treat eczema or other rashes. The onset of this condition is sudden. The same telltale redness, pimples, and thin, wavy red lines appear on the face as in standard rosacea, but people with steroid-induced rosacea usually have these symptoms wherever the steroid ointment was applied--up to the hairline--and not just centrally located on the face, for example. People with steroid-induced rosacea also often have a distinctive shine to their facial skin.
Steroid-induced rosacea is treated first by stopping the steroid and then by taking the same medications as with standard rosacea. Although it can take several months of treatment before symptoms subside, steroid-induced rosacea is not likely to recur unless corticosteroids are applied again on the face. Less commonly, oral or inhaled corticosteroids can also induce rosacea.
Searching for a Cause
Although dermatologists have been speculating about causes for standard rosacea for more than a century, none have been definitively proven. Most experts think the condition can be provoked by several different factors, some of which may work together to cause rosacea.
One might be an underlying vascular disorder that causes blood vessels in the face to expand and fluid to build up in the skin. This fluid can trigger an inflammatory response that manifests as facial pimples or excess tissue growth on the nose.
Wilkin says several findings support this theory. One is that researchers detected structural abnormalities in the small blood vessels in the facial skin of patients with rosacea. Another is that rosacea worsened when people with the condition take drugs such as theophylline and nitroglycerin, which dilate blood vessels. Also, people with rosacea are more likely to suffer from migraines, which are also thought to be caused by a vascular disorder. A vascular cause for rosacea might also explain why the condition is more common in older women, who are more likely to have swelling of the facial blood vessels as part of the menopausal "hot flashes."
In addition to vascular disorders, another factor that might play a role in fostering rosacea is a microscopic mite by the name of Demodex folliculorum. This mite, a normal resident in human skin, lives in hair follicles, where it dines on cast-off skin cells. They have been retrieved from almost every area of human skin, but they have a taste for the face.
Two recent studies revealed that the mites were significantly more numerous in facial skin samples of people with rosacea than of people without the condition. In addition, the mite population peaked on the skin samples of these patients in the spring, when rosacea tends to flare up. The studies were done by Frank Powell, M.D., and colleagues at the Mater Misericordiae Hospital in Dublin, Ireland, and by F. Forton, M.D., and B. Seys, M.D., of the Saint Pierre University Hospital in Brussels, Belgium.
According to Powell, other studies show that patients with steroid-induced rosacea also had a boosted mite population on their faces. This population dropped when the rosacea subsided after treatment with an ointment that kills mites.
Although these findings do not prove that the skin mite causes rosacea, they do suggest that Demodex might play a role in fostering the disorder. The mites may provoke rosacea by clogging skin follicles, which in turn might trigger an inflammatory response. Rosacea may also be triggered by an allergic-like reaction to these skin mites or to the bacteria the mites harbor. Forton proposes that an underlying vascular disorder of the face that fosters flushing could create an environment particularly hospitable to Demodex mites. These mites could then multiply excessively or penetrate more deeply into the skin, triggering an inflammatory response in the form of pimples.
Other Flare-Up Triggers
Several other factors have been found to aggravate (but not necessarily cause) rosacea, mainly by triggering flushing. These factors include drinking hot beverages, smoking, certain emotions (such as worry and anxiety), spicy foods, large meals, exposure to temperature extremes, wind, excessive sunlight, and overindulgence in alcohol. (Although alcohol can worsen rosacea, a nondrinker can develop a case of rosacea just as severe as someone fond of alcohol.) Make-up, moisturizers, sunscreens, or other skin products used on the face that contain alcohol or other irritating ingredients can also foster a rosacea flare-up.
What worsens one person's rosacea may not have any effect on another person's symptoms--it's very individual. "Many patients can actually reduce or eliminate the need for medications to control their rosacea," said Wilkin, "by avoiding the factors that trigger it."
Treatment Effective
If preventive measures aren't effective, however, the pimples can often be effectively treated with certain drugs. FDA has approved Metrogel (metronidazole), a topical antiprotozoal and antibacterial, to treat rosacea. Doctors may also use several other approved drugs to treat rosacea-induced acne. Such drugs include oral and topical antibiotics, particularly those in the tetracycline family, and these are also often used to treat eye manifestations of rosacea. (Pregnant women should not take tetracycline because it can discolor the unborn child's teeth.)
Such therapy for acne is effective in about three-quarters of rosacea patients, usually within a few months, according to dermatologist Seymour Rand, M.D., of FDA.
Removing Unsightly Vessels
Wilkin says that some rosacea patients find antibiotic therapy not only relieves their acne, but also decreases facial redness, which had been hiding the spidery red lines of enlarged blood vessels. Dermatologists can usually rid the face of these enlarged blood vessels by destroying them with an electrical needle or a laser. Patients who have this treatment experience little or no discomfort. Their faces may look somewhat bruised for about a week after the procedure, and may scab, peel or crust.
To treat the more extensive facial redness, dermatologists can use lasers to destroy the expanded blood vessels in the skin that cause it. One recent study by San Diego dermatologist Nicholas Lowe, M.D., and associates found laser therapy effective in more than three-quarters of treated patients. In more than half of those, the therapy not only rid the face of the redness or red lines, but also stemmed the acne. This finding further supports a vascular cause for rosacea, according to Wilkin.
Lasers or electrical devices are also used to remove the excess tissue that accumulates on the nose in patients with rhinophyma. The tissue can also be removed with a scalpel or a rapidly rotating wire brush, which is often used by dermatologists to scrape away tissue in a procedure known as dermabrasion. Local anesthesia numbs patients' noses before treatment. The nose looks red for a year or so following tissue removal and then assumes a normal skin color, according to Wilkin. "I've seen people whose noses were the size of baseballs look great after treatment," he says.
One of the most difficult barriers to countering rosacea is convincing people with the disorder to seek care. Even after Meyer knew she had rosacea, for example, she delayed seeking medical treatment for a flare-up because she thought the emotional stress she was experiencing at the time was behind her "acne."
"Even though my personal problems hadn't gone away," she said, "within a week of treatment, my 'acne' did. My appearance improved so quickly, I wished I hadn't waited so long to see my dermatologist. I hope others won't be so slow to go to the doctor."
Many people don't see a doctor because they don't realize they have a condition that can be treated. But as Wilkin notes: "People with rosacea can be very hopeful, whatever stage they've got, because there's something that can be done for everyone."
Margie Patlak is a writer in Elkins Park, Pa.
U.S. Food and Drug Administration
FDA Consumer: April 1994
