Rosacea/What Is Rosacea?

Rosacea (IPA:ɹəʊ.ˈzeɪ.ʃə) is a common but often misunderstood condition that is estimated to affect over 45 million people worldwide. Most often, it begins as flushing and redness on the central face and across the cheeks, nose, or forehead but can also less commonly affect the neck, chest, scalp or ears. As rosacea progresses, other symptoms can develop such as permanent redness, red bumps (some with pus), red gritty eyes, burning and stinging sensations, small blood vessels visible near the surface of the skin, and in some advanced cases a bulbous nose. The disorder can be confused and co-exist with acne vulgaris and/or seborrheic dermatitis. People that are fair-skinned are disproportionately affected. Rosacea affects both men and women of all ages, but middle-aged women are more susceptible because of hot flushes caused by menopause.

Subtypes and symptoms

There are four identified rosacea subtypes and patients may have more than one subtype present.

1. Erythematotelangiectatic rosacea: Permanent redness (erythema) with a tendency to flush and blush easily. It is also common to have small blood vessels visible near the surface of the skin (telangiectasias) and possibly burning or itching sensations.
2. Papulopustular rosacea: Some permanent redness with red bumps (papules) with some pus filled (pustules) (which typically last 1-4 days but sometimes as long as a month or more); this subtype can be easily confused with acne.
3. Phymatous rosacea: This subtype is most commonly associated with rhinophyma, an enlargenent of the nose. Symptoms include thickening skin, irregular surface nodularities, and enlargement. Phymatous rosacea can appear on the nose, chin, forehead, cheeks, and ears. Small blood vessels visible near the surface of the skin (telangiectasias) may be present.
4. Ocular rosacea: Red, dry and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching and burning.

Rosacea sufferers often report periods of depression stemming from cosmetic disfigurement, painful burning sensations, and decreases in quality of life.

Causes

The precise pathogenesis of rosacea still remains unknown, but most experts believe that rosacea is a disorder where the blood vessels become damaged when repeatedly dilated by stimuli. The damage causes the vessels to dilate too easily and stay dilated for longer periods of time or remain permanently dilated, resulting in flushing and redness. Immune cells and inflammatory mediators can leak from the microvascular bed causing inflammatory pustules and papules, especially with those with papulopustular rosacea.

Rosacea has a hereditary component and those that are fair-skinned of European or Celtic ancestry have a higher genetic predisposition to developing it. Women are more commonly affected but when men develop rosacea it tends to be more severe. People of all ages can get rosacea but there is a higher instance in the 30-50 age group. The first signs of rosacea are said to be persisting redness due to exercise, changes in temperature, and cleansing.

Triggers that cause episodes of flushing and blushing play a part in the development of rosacea. Exposure to temperature extremes can cause the face to become flushed as well as strenuous exercise, heat from sunlight, severe sunburn, stress, cold wind, moving to a warm or hot environment from a cold one such as heated shops and offices during the winter. There are also some foods and drinks that can trigger flushing, these include alcohol, foods high in histamine and spicy food.

Certain medications and topical irritants can quickly progress rosacea. If redness persists after using a treatment then it should be stopped immediately. Some acne and wrinkle treatments that have been reported to cause rosacea include microdermabrasion, chemical peels, high dosages of isotretinoin, benzoyl peroxide and tretinoin. Steroid induced rosacea is the term given to rosacea caused by the use of topical or nasal steroids. These steroids are often prescribed for seborrheic dermatitis. Dosage should be slowly decreased and not immediately stopped to avoid a flare up.

Studies of rosacea and demodex mites have revealed that some people with rosacea have increased numbers of the mite, especially those with steroid induced rosacea. When large numbers are present they may play a role along with other triggers.

It has also been suggested that rosacea might be a neurological disorder resulting from hypersensitization of sensory neurons following activation of the plasma kakllikrein-kinin system by exposure to intestinal bacteria in the digestive tract.

Incidence

Age

There has never been a thorough study on the incidence of age and rosacea. The National Rosacea Society and their Canadian affiliate the Rosacea Awareness Program report in their 'Standard classification of rosacea' that "Rosacea occurs in both men and women and, although it may occur at any age, the onset typically begins at any time after age 30". This statement is believed to be based on a large mail in survey which the results are summerised in Figure 1. This can be compared to an Internet survey Figure 2 that reported different results. Both surveys are considered to be inaccurate as both methods used to survey have inherent flaws and large bias.

Figure 1: NRS mail survey with 2,000 respondents
###	0-29
#########	30-49
#########	50+

Figure 2: Rosacea-support online poll with 378 respondents
###	Teens
########	20-30
#####	31-40
##	41-50
#	51+

Sex

A 1989 study of 809 office employees found that 14% of the women and 5% of the men were diagnosed as having rosacea.