Rosacea: More than Red Cheeks

Dr. CHAN Chun Yin, Johnny

Director, Dermatology, Hong Kong Sanatorium & Hospital

Specialist in Dermatology & Venereology

Common in women, rosacea is a skin condition that causes persistent redness and a burning and stinging sensation in the face. It is often mistaken for eczema, acnes or even lupus erythematosus. Rosacea patients also tend blush easily, especially when they are nervous or under pressure. It can be a cause of social embarrassment, even psychological distress in their daily interactions.

Vasodilation and Facial Redness

Our skin is made of 3 layers, i.e. the epidermis, the dermis and the subcutaneous tissue. Rosacea is caused by abnormal nerve control of the facial blood vessels, which triggers excessive vasodilation. If untreated, papules or pustules may grow on the face, followed by skin fibrosis causing   thickened and bulbous skin, especially in the nose area, i.e. a brandy nose or rhinophyma.

Rosacea may also swell the blood vessels and affect the eyes. Common symptoms are red, burning eyes and chalazia on the eyelids.

Rosacea

• Red cheeks due to vasodilation, but no pimples, blackheads or scaling skin
• Bloodshot eyes
• A brandy nose due to skin fibrosis (if severe)

Acne

• Occurs in the form of pimples and blackhead as a result of plugged hair follicles
• Unrelated to facial vasodilation
• Common in people aged below 20

Eczema

• Red rash, scaling skin

Systemic Lupus Erythematosus (SLE)

• Red rash all over the cheeks (except the nasolabial folds)
• Hair loss

Facial Vasodilation: Congenital and Acquired Factors

Facial vasodilation can be caused by hereditary factors, i.e. a family history of rosacea, or acquired factors, i.e. hormone-related. As female sex hormones promotes facial vasodilation, nearly 90 % of rosacea patients are women.

Other acquired factors include a history of atopic dermatitis during childhood, chronic facial inflammation when grown up and the use of allergen-containing skincare or cosmetic products. Chronic inflammation occurs when blood vessels keep dilating, and in the end cause rosacea.

Caffeine-containing beverages, e.g. coffee, mike tea, etc. and spicy foods should be consumed less frequently. Foods like chocolates, cheese and alcohol-containing drinks can also induce vasodilation.

Other environmental triggers are the sun’s UV rays and high temperature. Certain emotions, e.g. nervousness, can also trigger flare-ups.

Severe Psychological Strain on Patients

Rosacea is common in people aged between 30 and 60, and mostly occurs at around 30 years old. While severe blushing can put patients under great pressure, persistent facial redness may also lead to skin fibrosis over time.  And the resulting red spots may stay for a long time.

The 4 Stages of Rosacea

1. Intermittent facial blushing

2. Persistent redness

3. Papules, pustules and inflammation (besides persistent redness)

4. A brandy nose due to skin fibrosis

Do not squeeze, pick or pinch the pustules, as it can cause infection and scar formation. If left untreated or poorly controlled, rosacea may lead to fibrosis in 5 to 10 years, causing rhinophyma or affecting the cheeks.

Treatment varies with stages of rosacea development. Non-pharmacological treatment is recommended for stage 1 and 2 rosacea with the following lifestyle changes:

• Avoid alcohol, caffeine-containing beverages, chocolate and cheese
• Use sunscreen regularly
• Stay away from hot areas
• Stay calm and relaxed

Generally speaking, mere lifestyle changes can cure or improve rosacea significantly in about one-third of stage 1 and 2 patients. Instead of receiving facial treatments at beauty salons, patients are advised to maintain simple makeups and use skincare products that contain minimal additives.  

The following medications are usually prescribed for stage 2 or above:

Medication: Topical Medication (Ointments)

Example:

Metronidazole

• First-line topical regimens with anti-inflammatory and immunosuppressive properties

Tacrolimus

Brimonidine

• Reduces redness by constricting facial blood vessels within 4 to 6 hours after application
• Vasodilation may recur but not worsen after use; recommended for people with severe blushing or for use on important occasions, e.g. business meetings
• May cause pimples due to its greasy nature; do not apply makeup until 30 minutes after use

In case of pimples or pustules, use Vitamin A ointment or antibiotic creams for acne

Medication: Systemic Medication (Anti-inflammatory Oral Antibiotics)

Example:

Tetracycline and Erythromycin

• Half of the dosage used for antiseptic purposes
• To be used for 1 to 3 months
• Remains effective for 2 to 3 months after treatment; can put rosacea under control for around 6 months
• Should not be used for more than 6 months; no repeated use within a year
• May lose effect after 4 months, and can be replaced by prescription of other antibiotics
• May affect liver and kidney function after use; blood test recommended when in use

Medication: Vasoconstrictors

Example:

Beta-blocker and Clonidine

• Can promote constriction of facial blood vessels; recommended for patients who tend to blush when nervous
• Prescription only
• Start at a low dose to maintain stable heartbeat and blood pressure

Energy treatment is considered to promote vasoconstriction if medications fail. Improvement is usually noticeable after 2 to 4 sessions within in 4 to 6 months. Each session is conducted every 4 to 6 weeks. Clinical data suggest significant outcome within 1 to 2 years after treatment, while recurrence occurs to a lesser extent in about 50% of cases and requires repeated treatment.    

Use Energy Treatment with Care

The energy level of laser is higher than that of intense pulsed light. While laser treatment is shorter in duration, patients may feel more comfortable during intense pulsed light treatment. Most people have no pain after treatment except mild facial redness the day after. Red rash may remain in the first week but will show improvement after 2 to 4 weeks.

Compared with medications or ointments, energy treatment may increase the risk of skin damage, bleeding, infection, black or white spots caused by activated melanocytes, and even scar formation. Intense pulsed light or laser treatment is recommended only after ointments and oral medications have been prescribed but failed to improve the condition.

For rosacea-induced rhinophyma, 1 to 4 sessions of CO2 laser treatment can be performed based on one’s request and skin thickness. As a CO2 laser beam is used to vaporise hyperplastic tissues and reshape nasal contours, the treatment must be performed with high precision by an experienced dermatologist. If the energy level is too high, patients may suffer burns and infection, causing hypertrophic or atrophic scars.

Energy treatment is also not recommended for pregnant women, SLE patients and those who are prone to scar formation, has had skin spots after treatment, are more likely to have wound problems.