Rosacea is a stubborn, chronic, and pervasive skin disorder that is not only frustrating but extremely tricky to treat. It is thought to afflict an estimated 14 million Americans alone, with women being affected at a slightly greater rate than men. Despite its prevalence, rosacea is often misdiagnosed by physicians and even dermatologists, and most people don’t even know the disorder exists. According to a survey commissioned by the National Rosacea Society, 78% of respondents did not know what rosacea was and, it follows, how to identify it.

In simple terms, rosacea is a very distinctive skin problem of the face identified at first by a characteristic pattern of redness which often appears in a butterfly pattern over the nose and cheeks. In the beginning this "blushing" can be intermittent, but eventually, it almost always increases in severity, sensitivity, and can be accompanied by rashes, enlarged pores, blemishes, and noticeable surfaced capillaries.

If you notice any extreme facial redness that comes on suddenly (and is not from overexposure to sun or wind) and does not dissipate within a short period of time you may want to consider consulting a dermatologist. Other warning signs include a constellation of broken capillaries (often in a webbed pattern on the cheeks) and bumps or blemishes on the skin that respond minimally, if at all, to standard acne treatments.

What causes Rosacea?

What causes rosacea? After much research and conjecture, we still don't know. It has long been suspected that some kind of microbe (likely Demodex folliculorum) under the skin is responsible for the symptoms but there are other theories about a generalized vascular inflammatory disorder. Regardless of the etiology, one of the classic and effective treatments is the topical drug metronidazole found in MetroGel, MetroLotion, and MetroCream. There are also studies showing adapalene (Differin), topical benzoyl peroxide with erythromycin gel, or azelaic acid are also good options to consider. What is most important is starting treatment as soon as the condition is identified to keep problems from getting worse, particularly the occurrence of surfaced capillaries (Sources: Cutis, March 2005, pages 27-32; International Journal of Dermatology, March 2005, pages 252-255; Dermatology, February 2005, pages 100-108; Expert Opinion on Pharmacotherapy, January 2004, pages 5-13; Journal of Dermatology, August 2004, pages 610-617; Archives of Dermatology, November 2003, pages 1444-1450).

Other possible causative factors that have seen their fair share of speculation, include hereditary links, environmental causes, vascular problems, miscellaneous inflammatory factors and the stomach ulcer-causing microorganism Helicobacter pylori (Sources: Dermatology, February 2005, pages 100-108 and Journal of the American Academy of Dermatology, September 2004, pages 327-341).

Skin Care for Rosacea

Whichever method of treatment or combination therapy you and your physician decide on, it is important to take steps in your regular skin-care routine to ensure it is as gentle as possible. For those with rosacea, reducing any risk of irritation or sensitizing reactions will help reduce the risk of flare-ups and exacerbations. Fragrance- and irritant-free products are paramount but avoiding topical scrubs, washcloths, at-home facial peels, products containing alcohol, hot water, or steam rooms can also be significant (Sources: Cutis, March 2005, pages 17-21 and March 2004, pages 183-187; and Dermatologic Therapy, 2004; 17 Supplemental 1, pages 26-34).

Generally speaking, it is best for those with rosacea to stick with the basics:

Gentle, non-drying water-soluble cleanser (absolutely no bar soap or bar cleansers)
Sunscreen with SPF 15 or higher containing the active ingredients of titanium dioxide and/or zinc oxide (other sunscreen agents can prove irritating). Those with rosacea and oily skin may find using a foundation and pressed powder with sunscreen is a great alternative.
Moisturizer formulated with antioxidants and barrier-protecting ingredients (to improve skin function).
Salicylic acid (BHA) exfoliant.**
Based on the above recommendations, you may wish to consider these products for your skin type:

Step-by-Step Skin Care for Rosacea
Rosacea with Normal to Dry Skin
Rosacea with Normal to Oily/Combination Skin
Until your rosacea is under control, you may want to avoid all sources of flare-ups, including strenuous exercise, cooking over a hot stove, spending too much time outdoors when the weather is summer-hot or winter-cold, alcohol consumption, or anything that causes your skin to feel hot and redden. Many patients find it helpful to keep a diary of their rosacea triggers, and that includes noting what causes their flare-ups or reactions to skin care and cosmetics used. As much as possible, try to minimize sources of stress; you may want to consider alternative methods of stress control, including meditation and controlled, focused breathing. Talk to your dermatologist about which over-the-counter, anti-inflammatory medications (aspirin, naproxen, ibuprofen) may be suitable for calming flare-ups.

Ingredients to Avoid

While it is almost impossible to list all of the ingredients that can potentially trigger reactions for those with rosacea, the following is a good general list to consider. Keep in mind that not everyone reacts the same to any of these elements:

Acetone
Alcohol or SD alcohol followed by a number (Ingredients like cetyl alcohol or stearyl alcohol are standard, benign, waxlike cosmetic thickening agents and are completely nonirritating.)
Ammonia
Arnica
Ascorbic acid
Balm mint
Balsam
Bentonite
Benzalkonium chloride
Bergamot
Camphor
Chamomile
Cinnamon
Citrus juices and oils (such as grapefruit or orange)
Clove
Clover blossom
Cocoa butter
Coriander
Cornstarch
Eucalyptus
Fennel
Fennel oil
Fir needle
Fragrances of any kind
Geranium
Horsetail
Lavender
Lemon
Lemongrass
Lime
Marjoram
Melissa
Menthol
Mint
Oak bark
Papaya
Peppermint
Phenol
Sandalwood oil
SD alcohol, ethanol alcohol or isopropyl alcohol
Sodium C14-16 olefin sulfate
Sodium lauryl sulfate
TEA-lauryl sulfate
Thyme
Wintergreen
Witch hazel
Ylang-ylang

The Rosacea Review, an online newsletter of the National Rosacea Society, at www.rosacea.org/rr/, is an excellent source for detailed and ongoing information concerning treatment and research for rosacea.

*As effective as an oral antibiotic can be when you begin taking it, after a period of time bacteria can become immune to the antibiotic, causing symptoms to return. Most of the research about antibiotic bacteria-resistance is based on research regarding other uses such as acne and infections. Whether or not this is a concern for rosacea should be discussed with your physician. (Sources: International Journal of Antimicrobial Agents, March 2004, pages 209-212; Dermatology, January 2003, pages 54-56; Expert Opinion on Pharmacotherapy, March 2005, pages 409-418; and American Journal of Clinical Dermatology, April 2003, pages 813-831).

**BHA is an interesting option for rosacea, not only does it exfoliate skin and improve pore function, it has anti-inflammatory action (due to its relationship to aspirin—acetyl salicylic acid), which may help reduce the facial redness caused by the papules and pustules that can accompany rosacea. BHA also has antimicrobial properties that can reduce the presence of the microbe thought to be causing the problem. Just like any other rosacea therapy, salicylic acid won't work for everyone (indeed, some rosacea patients find it intolerable) but it is comparably inexpensive and worth a try (Sources: Dermatology, January 1999, pages 50-53; Pain, September 1995, pages 339-347; and Archives of Dermatology, November 2000, pages 1390-1395).

Acne Rosacea

For years, this skin condition was simply referred to as "acne rosacea." Unfortunately, pustules (pimples) and papules (red, raised bumps) are often present, which makes rosacea look like acne. Rosacea is rarely, if ever, accompanied by blackheads and many sufferers deal with persistent dryness (flaking) over the affected areas. These polar opposite symptoms can be extremely confusing because the dry, flaky skin responds minimally to moisturizers and the bumps and whiteheads do not respond to typical acne treatments. Further complicating matters, when doctors misdiagnose rosacea, the medications prescribed usually make matters worse. Fortunately, due to a new classification system of four rosacea subtypes, more physicians are becoming familiar with how to recognize and properly diagnose rosacea (Source: www.rosacea.org).

Keep in mind that when rosacea first develops, it may appear, disappear, and then reappear a short time later. This series of visible problems and spontaneous remissions also make a precise diagnosis difficult. Despite its mysterious nature, the condition rarely reverses itself and almost always becomes worse without treatment. Rosacea most often starts with skin that stays persistently red and doesn't return to its normal color. Other symptoms, such as enlarged blood vessels, flaky patches, oily skin, skin sensitivity, and breakouts, become more and more visible. As rosacea progresses, pimples appear on the face in the form of small, solid red and pus-filled bumps. In more advanced cases of rosacea, a bulbous, enlarged red nose and puffy cheeks (rhinophyma) may develop. However, rhinophyma, for some reason, rarely occurs in women.

Rosacea Treatments

The treatments for rosacea are varied and all these options are to be considered because what works for you may not be the same as for someone else. But finding one that does work for you is critical to keeping this problem at bay and reducing (or potentially eliminating) all symptoms. Unfortunately, all of the topical treatments for controlling rosacea are only available by prescription. They include:

MetroGel, MetroCream, MetroLotion, and Noritate (active ingredient metronidazole)
Azelaic acid (Azelex, a cream, or Finacea, a gel)
Topical sulfur preparations (Klaron, Plexion)
Adapalene (Differin)
Benzoyl peroxide with erythromycin applied topically
Oral antibiotics (tetracycline) prescribed in combination with topical treatments.*
isotretinoin
Laser treatments
(Sources: Cutis, March 2005, 13-16; Journal of Drugs in Dermatology, May-June 2004, pages 251-266; and www.emedmag.com/html/pre/cov/covers/121503.asp).

It should be noted that some patients cannot tolerate metronidazole. If you cannot tolerate it, don’t despair: research has shown an alternate treatment consisting of the disinfectant benzoyl peroxide with topical antibiotic erythromycin can be a very effective alternative (Source: The Journal of Dermatology, August 2004, pages 610-617). Another study compared results of 0.75% topical metronidazole (MetroLotion) to 15% azelaic acid (Finacea) and the 251 patients who completed a 15-week treatment regimen found success with both options, though azelaic acid had a slight edge (Source: Archives of Dermatology, October 2004, pages 1282-1283).

If the inflammation and redness of rosacea is accompanied by numerous papules and pustules, there is research showing that the topical prescription Differin (active ingredient adapalene) can be of significant help. However, Differin doesn’t have an effect on facial redness, so for best results, it is used in combination with metronidazole (Source: International Journal of Dermatology, Volume 44, Issue 3, March 2005, pages 252-255). Some dermatologists may also prescribe tretinoin (Retin-A, Renova) though most rosacea patients find the side effects of this vitamin A medication intolerable (Source: www.drnase.com/Prescipt_ions.htm).

For extremely stubborn or unresponsive cases of rosacea, the powerful oral medication isotretinoin (isotretinoin, also available as a generic) may be worth considering. It has been shown in several studies to be effective for those with treatment-resistant rosacea, and it is effective in an extremely low dose. No one is quite sure how or why isotretinoin works for rosacea, but the success rate is positive, and after treatment, the swelling and distortion of the oil glands are often resolved (Source: Archives of Dermatology, July 1998, pages 884–885; and Total Skin, David J. Leffell, M.D., Hyperion, 2000, page 337).

In conjunction with topical and oral prescription medicines, non-ablative laser and Intense Pulsed Light (IPL) treatments have shown great promise in helping to restore rosacea-afflicted skin to its natural, non-reddened coloring and healthy appearance. Whereas prescriptions such as MetroCream or Azelex work to control the theoretical cause of rosacea and minimize symptoms, they are not all-encompassing solutions. For example, facial flushing and telangiectasias are typically not affected by topical rosacea treatments (Sources: Journal of Drugs in Dermatology, September-October 2004, pages 12-22; Journal of the American Academy of Dermatology, October 2004, pages 592-599; British Journal of Plastic Surgery, June 2004, pages 303-310; and Journal of Drugs in Dermatology, June 2003, pages 254-259). Although laser and light-emitting procedures hold much promise, keep your expectations realistic and remember that you will most likely see a reduction (not elimination) of bothersome facial redness. In addition, keep in mind that upwards of six treatments are generally required to produce satisfactory results.

If you have been diagnosed with rosacea, be aware of a serious complication called ocular rosacea. This condition refers to rosacea of the eye and, according to an item in the March 2001 issue of Cosmetic Dermatology, is significantly underdiagnosed and untreated. Those with ocular rosacea most commonly experience irritation of the lids and eye, as well as sties and chronically red eyes. In rare cases, ocular rosacea can also affect the cornea. This condition can be treated, usually with soothing eye drops (but not Visine) along with oral or topical antibiotics, but it requires a dermatologic or ophthalmologist evaluation before any action is taken.

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