Ask the expert: what is rosacea?

Around one in 20 people in the UK have rosacea, a long-term (chronic) skin condition that causes burning, stinging sensations and flushing (redness) of the skin. 

Here, we’ll explore what rosacea is and who is at risk, as well as its signs, symptoms, triggers and treatments. 

What is rosacea and what causes it?

Rosacea is a chronic inflammatory skin condition, which is not contagious. It is caused by an imbalance in the microbiome of your skin. The microbiome consists of microorganisms that live naturally in the skin. 

An overgrowth of bacteria and an overabundance of a mite called Demodex that lives in your hair follicles, combined with inflammation of blood vessels that supply your skin, leads to reddening of the skin (flushing). This includes red inflamed lumps and yellow heads. The redness may appear brown or black on darker skin.

In advanced stages of rosacea, the sebaceous glands — glands that release an oily substance called sebum to prevent your skin from drying out — are also affected. The glands increase in size and thicken.

What are the different types of rosacea?

Rosacea can be categorised according to the signs and symptoms that occur.

Erythematotelangiectatic rosacea (ETR) causes a burning, stinging sensation in the skin followed by flushing due to widened blood vessels. In the early stages, flushing is intermittent and dynamic ie it occurs in response to certain triggers, such as a temperature difference when outdoors versus indoors. In more advanced stages, the widening of the vessels is static so the skin is always red. 

Papulopustular rosacea causes breakouts of yellow-headed pimples and red inflamed lumps — this looks like acne but doesn’t produce black or white heads. 

Ocular (eye) rosacea can occur in isolation or alongside another type of rosacea and causes swelling of the eyelids, sticky margins of the eyelids, red, gritty eyes and inflamed corneas (transparent coverings over the front part of your eyes). Inflammation of the cornea can lead to impaired vision. 

Rhinophyma is an advanced type of rosacea that is more common as you get older and most commonly occurs in older men. Enlarged sebaceous glands cause thickening of the skin on the nose resulting in a misshapen and knobbly nose.

What areas of the body can rosacea affect?

Rosacea usually affects the face, specifically more central areas, namely the nose, cheeks and middle of the forehead. 

However, rosacea can also affect your genitals, where it can be more difficult to diagnose as the signs and symptoms (eg redness, itchiness, a burning sensation) are similar to those found in other genital problems.

Who is most at risk of rosacea?

The two biggest risk factors for rosacea are advancing age and light skin. Your risk is also higher if you’re taking topical steroids, that is, steroids applied directly to your skin.

What are common triggers of rosacea?

The most common triggers of rosacea are UV light (natural sunlight comprises UVA and UVB light), high temperatures and dietary triggers, such as spicy food, caffeine and alcohol, especially red wine. Exercise can also trigger a rosacea flare-up. 

However, not all people with rosacea notice any particular triggers. 

What health conditions appear similar to rosacea?

There are several skin conditions that appear similar to rosacea, most commonly acne. The main difference between acne and papulopustular rosacea is that acne causes black and white heads, while papulopustular rosacea only causes yellow heads. 

Other skin conditions that can be confused with rosacea include periorificial dermatitis and seborrheic dermatitis. A doctor who specialises in treating skin complaints (a dermatologist) will help reach a diagnosis. 

Conditions that mimic rosacea are light-sensitive skin problems, such as lupus and dermatomyositis, or a chronic inflammatory disease called sarcoidosis. However, these conditions may cause other health problems by affecting internal organs, whereas rosacea is limited to the skin alone. 

How is rosacea treated?

There are several prescription creams and gels that your doctor can prescribe, such as those containing ivermectin or the antibiotic metronidazole. It takes several months of daily use for these creams and gels to work. 

Other topical (applied on the skin) treatments include tacrolimus ointment and brimonidine gel. 

Brimonidine gel constricts your blood vessels to prevent a flare-up. However, after the effects of the gel wear off, usually after around six hours, you are at risk of a rebound effect where you may experience flushing and redness of your skin.

Tacrolimus ointment is an immunomodulator and dampens the immune system to reduce inflammation of your skin. 

For rosacea that is mainly vascular (blood vessel), causing redness and flushing, vascular laser treatment or intense pulse treatment can help relieve your symptoms. 

If your rosacea is predominantly inflammatory with red bumps and yellow-headed pimples, a six-month course of anti-inflammatory antibiotics can help, usually combined with a topical treatment such as ivermectin or tacrolimus.

In severe cases, your doctor may prescribe isotretinoin capsules (vitamin A), which are also used to treat acne. 

For rhinophyma, CO2 laser treatment can burn off excess skin and reshape the nose. This takes at least two to three weeks to heal and also requires a course of antibiotics.

What are the do’s and dont’s of living with rosacea?

It is important to avoid known triggers of your flare-ups, as well as to avoid heavy lotions and creams.

You should use an SPF50 or higher sunblock daily. Mineral sunscreens that contain zinc oxide or titanium dioxide and reflect UV light are more effective at protecting your skin and avoiding flares triggered by sun exposure.

You can also use an antimicrobial facial wash to reduce the microbial burden placed on your skin. There are over-the-counter options, but if you have advanced rosacea, your doctor may be able to prescribe an antimicrobial facial wash.

If you want to hide redness caused by rosacea, you can use green-tinted cosmetics and/or emollients.