by Dr Deborah Lee, Dr Fox Online Pharmacy
Photo by Noah Buscher on Unsplash
What is acne rosacea?
Acne rosacea is a chronic, inflammatory skin condition that occurs on the face. It’s very common, affecting around 1 in 10 of the population. This is a different medical condition to acne vulgaris – the most common type of acne that causes teenage spots.
Living with rosacea causes a great degree of distress and embarrassment. It frequently causes redness and flushing of the central part of the face. Many sufferers have low self-esteem and self-confidence. 77% say they have been suffered emotionally, 63% say it has affected their work, and 53% say it has affected their relationships.
What are the symptoms?
Rosacea is characterised by the following symptoms –
- facial flushing and redness,
- pimples and pustules,
- telangiectasia, which are small, dilated blood vessels
- micro-oedema (facial swelling).
It tends to affect the convex areas of the face such as the cheeks, the chin, the nose and the forehead. People with rosacea often have sensitive skin which feels like it’s stinging or bursting
What causes it?
The exact cause of rosacea is not known. However, various causative factors have been identified. These provide the basis for treatment.
- Familial – It may be familial. In one cross-sectional study, 50% of sufferers had an affected family member.
- Genes – Recently, HLA (human leukocyte antigen) genes have been linked to the development of rosacea.
- Demodex mites – Demodex mites, inhabit the sebaceous glands found in the convex areas of the face. Treating these mites in people with acne rosacea has been shown to reduce symptoms.
- Bacteria – Bacterial colonisation of the skin may also play a role – such as Bacillus oleronius, Staphylococcus epidermidis, Helicobacter pylori, and Bartonella Quintana.
- Cathelicidin – Levels of a protein called cathelicidin (LL-37) are abnormally elevated in the skin of people with rosacea. Cathelicidin is a protein that is important in the antimicrobial defence of the skin. It signals the inflammatory response in the skin and causes vascular changes and new blood vessel formation.
- Rosacea triggers – Rosacea is a lifelong condition that flares up intermittently. Flare-ups seem to be caused by a number of triggers such as – change in temperature, being too hot, or being too cold, exercise, U/V light, spicy foods and alcohol. These directly stimulate certain skin receptors and cause the skin to flush bright red.
- Stress also triggers rosacea – Stress activates the sympathetic nervous system. Rosacea sufferers may also have some underlying dysregulation of the parasympathetic nervous system.
Managing rosacea
Rosacea is something you were born with. Having rosacea has nothing to do with being unclean. It is a long term condition that will flare up from time to time. If you can understand what’s happening to your skin, and in particular, which triggers are causing flare-ups, you will learn how best to manage your own condition.
Everyone with rosacea is affected slightly differently. The condition may be mild, moderate or severe. In addition, some people will suffer more from redness and flushing, whereas others will have more papules, pustules or telangiectasia (broken blood vessels). Some people have sensitive and dry skin. This means everyone will find some treatments more effective than others. The treatments will not cure the condition – they can only help improve symptoms.
- Get an accurate diagnosis – See your GP or ask for a referral to a Consultant Dermatologist. There are several other similar conditions such as acne vulgaris, seborrheic dermatitis, perioral dermatitis, carcinoid syndrome or systemic lupus erythematosus (SLE).
- Manage your stress levels – Stress management – Effectively managing stress can result in significant skin improvements.
- Eat a healthy diet – Common triggers for flare-ups include hot coffee and hot tea, as well as peppers and spicy foods, tomatoes, citrus foods, cinnamon and chocolate.
Rosacea appears to be linked to an increased risk of gastrointestinal diseases including coeliac disease, Crohn’s disease, ulcerative colitis, H.pylori infection, small intestinal bacterial overgrowth (SIBO) and irritable bowel syndrome
Increase your dietary intake of prebiotics and probiotics. Prebiotics are fibre-rich foods that are not digested but stimulate healthy gut bacteria. Probiotics are live micro-organisms, which are ingested as dietary supplements, and confer overall health benefits. They include yoghurts, kefir, fermented cheeses (Cheddar, Gouda, and Parmesan, for example), and fermented vegetables such as sauerkraut and pickles.
- Avoid triggers – These are things that can set off a rosacea flare. They include
change in temperature, being too hot or too cold, hot drinks, alcohol, spicy foods, peppers, stress and anxiety, and exposure to sunlight (U/V A, and U/V B).
Some skin products can trigger rosacea. The American Academy of Dermatology recommends avoiding products that contain alcohol, fragrances, glycolic acid, lactic acid, menthol, sodium laurel sulphate and urea. Some types of makeup may also be triggers.
It may be difficult to assess what is causing your skin to flare up. The National Rosacea Society has an online booklet which you can fill in every day, over a 2-week period to help provide a picture.
- Always wear sunscreen – Protect your skin from both U/V-A and U/V-B light every day.
Exposure to sunlight is a trigger for 80% of rosacea sufferers. Using daily sunscreen reduces the production of cathelicidin and reduces skin inflammation.
The British Association of Dermatologists (BAD) recommends the use of sunscreen containing at least an SPF-30 anti-UVB rating – and also a minimum of 4 out of 5 stars for anti-UVA protection.
- Menopause – Acne rosacea may flare at menopause when it often triggered by hot flushes. No one knows what causes hot flushes, however, the frequent rise and fall of hormone levels as you go through the menopausal transition may trigger a hot flush.
You may want to discuss this further with your GP. If you take hormone replacement therapy (HRT) this stabilises your hormone levels. It may be an idea to choose a longer-acting HRT preparation, such as a weekly skin patch, rather than the daily administration of a tablet.
Medical Treatments for Rosacea
For mild or moderate papules and pustules – Topical 0.75% metronidazole gel applied thinly twice a day. 15% azelaic acid applied twice a day, is an alternative for people who do not have sensitive skin. (NICE 2018).
For moderate or severe papules and pustules – first-line antibiotics are oxytetracycline or tetracycline 500 mg twice daily 6-12 weeks, or doxycycline 100 mg once daily (unlicensed) as an alternative. Another option is lymecycline. Erythromycin is often used for pregnant women who cannot take tetracyclines.
If redness is a major problem, NICE also recommends brimonidine 0.5% gel. Brimonidine is an alpha-agonist that causes vasoconstriction and can prevent flushing for up to 12 hours after local application.
Other antibiotics taken by mouth are sometimes used, such as metronidazole, clarithromycin or azithromycin – although these are unlicensed for this purpose.
If treatment is successful, this can be continued long term, although treatment holidays are suggested after 6 months. Some people may need both systemic and topical treatment.
If symptoms are persistent and these measures are not helping, referral to a consultant dermatologist is suggested. Other oral treatments may be tried such as clonidine, or isotretinoin.
One additional option is the use of ivermectin 1% cream, or ivermectin tablets, which is effective against Demodex mites.
Sometimes laser treatment can be helpful.
Rosacea skincare
Rosacea is a life-long condition. Choosing a skincare regime may seem confusing when there are so many products to choose between. You will need to try different products to work out which ones seem to work best for your skin. Be patient, as you won’t see instant results.
It’s imperative to establish a good skincare regime as part of managing the condition.
Here are some tips –
- Choose simple, natural products. The best products for your skin are not necessarily the most expensive. Patients are often sensitive to the common ingredients in skincare products so these should be avoided e.g. alcohol, menthol, peppermint, eucalyptus, and clove oils.
- Wash your face twice a day with an oil-free product. Be gentle with your skin. Pat it dry – don’t rub.
- Apply a moisturiser every morning which contains an SPF-30 anti-U/V-B sunscreen. The British Association of Dermatology (BAD) also recommend sunscreen which has at least 4 out 5 stars for anti-U/V-A protection. Moisturising is especially important as many patients with rosacea have dry skin, which makes symptoms worse. Moisturisers repair the skin barrier function and help the skin retain water. They have been shown to support other skin treatments used to treat rosacea. Also, use a night-time moisturiser.
- Avoid products that contain harsh ingredients because many people suffering from rosacea have sensitive skin. For example –
- Avoid products containing certain types of alcohol – specifically – ethanol, isopropyl alcohol and alcohol These can be dehydrating and cause skin irritation. ‘Good’ alcohols, however, are ‘fatty alcohols,’ such as cetyl alcohol, Cetearyl alcohol, and stearyl alcohol, which have skin benefits.
- Avoid agents such as glycolic acid, salicylic acid and benzoyl peroxide which can irritate sensitive skin.
- Avoid using topical retinoids have been reported to cause flare-ups in people with rosacea.
It’s hard to recommend specific product brands as there are so many on the market and everyone will have a different response to treatment. Cerave, Cetaphil, Aveeno, or Vanicream products, for example, are all recommended, but there are many excellent products to choose from.
For more information –
- Rosacea – British Association of Dermatology
