Is Your Face on Fire? Cool it Down for Summer. Managing the Embarrassing Symptoms of Rosacea

By, Kimberly Moskowitz, MD

It begins as an innocent rosy flush to your face triggered by emotional stress or exertion.  You soon notice that hot beverages, spicy foods, tomatoes, certain cheeses, sun exposure, caffeine or alcohol (especially red wine) cause your face to erupt into a bright red flare.  With time, the flushing becomes more persistent as tiny blood vessels called telangiectasias, become a prominent feature of your cheeks, nose, and chin.  Many people complain of a “facial hot flash” or a stinging pain associated with these episodes.  People question why your face looks constantly sun burned.  These episodes can be socially embarrassing and can occur unpredictably or in response to the triggers described above.

The disease of “flushers and blushers”, Rosacea is the 3rd most common chronic skin disorder in the western world.  It affects over 14 million people in the United States alone.  It is more common in families and fair-skinned people of Celtic or Northern European heritage.   It is two to three times more common in women than men but tends to run a more aggressive and disfiguring course in males.  Symptoms usually begin in persons aged 30-50, progressively worsen over time, and can lead to permanent disfiguring skin changes.  Hallmarks of the disease include redness and visible blood vessels on the nose, cheeks, and chin.  Tiny bumps resembling pimples often appear resulting in misdiagnosis and confusing terms such as “acne rosacea”, or “adult acne”.  At least 50 percent of patients with rosacea will also develop ocular (eye) symptoms such as itching, burning, dryness, grittiness, and redness.  In late stages, usually in men, disfiguring swelling and nodules form on the nose – a condition called rhinophyma.

Despite its prevalence and social impact, its exact etiology remains elusive.  While the signs, symptoms, and demographics of rosacea are well-known, scientists still work to discover the underlying cause.  The current buzz words for rosacea are Demodex and inflammation.  Aside from the “triggers” already discussed, scientists have found possible associations with the common face mite known as Demodex folliculorum.  The most agreed upon theory is that rosacea is caused by factors that generate inflammatory changes in the skin.  Scientists have not yet proven if and how Demodex and inflammation are related; but we do know that current therapies, including oral antibiotics and creams exert their effects by reducing inflammation in the skin.

Despite inconclusive theories about the cause of rosacea, the main treatment options are generally agreed upon by clinicians.  The initial therapeutic step is avoidance of known precipitating factors such as alcoholic beverages, caffeine, and foods that commonly flare symptoms.  Because rosacea is worsened by sun exposure, it is crucial to apply broad spectrum sunscreen (Zinc oxide and Titanium dioxide are ingredients to look for).  Without it, the UV rays of the sun will increase facial flushing and tiny broken blood vessels.  Topical and oral antibiotics such as Metronidazole or Tetracyclines are common first-line choices, especially for papulopustular rosacea (the type that resembles acne).  These choices generally provide mild improvement but will not reverse long-term changes such as dilated facial veins, persistent redness, and rhinophyma.

To permanently improve the redness, flushing, and facial veins associated with rosacea, vascular specific laser light treatments such as intense pulsed light (IPL) or pulse dye laser provide great success.  The laser light energy targets abnormal blood vessels that cause flushing and seals them shut.  It generally requires two to six treatments scheduled four to six weeks apart to cause significant improvement.  IPL treatments have also been shown to reduce the “acne” bumps associated with rosacea and improve sun damage including age spots, fine lines, and blotchy pigmentation.

Patients with rosacea typically have “sensitive” skin and find that cleansers designed for “regular acne” worsen their symptoms.  Gentle, cleansers such as Cetaphil are commonly recommended.  Herbal remedies sometimes bring relief with ingredients such as green tea, calendula, chamomile (bisoprolol), licorice, feverfew, oatmeal, or lavender.  The utility of these herbs is based on their purported anti-inflammatory properties.

When flushing is difficult to control, especially in postmenopausal women, your physician can prescribe low-doses of certain blood pressure medications like beta blockers or clonidine.  This must be performed carefully in persons with normal or low blood pressure.

Rosacea, the “great pretender”, mimics many common disorders such as acne, postmenopausal symptoms, sunburn, and lupus.  It is a chronic disorder that inevitably worsens over time so early diagnosis and management is critical.  While there is no “cure” for this common disease, there is a vast armamentarium of choices from pills & creams to laser light technology that can rid you of your red.

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