The best and safest ways to treat rosacea

Who is likely to get rosacea?

People of all races can get afflicted by rosacea although the fair skinned individuals (especially with blue eyes and blond hair) are more prone to develop this disease. The prevalence of rosacea in this high-risk group ranges from 2-22%. Other risk factors include-

• North European lineage
• Female gender
• Family history of rosacea
• Skin damaged by sun
• Tendency to have lots of acne
• Smoking
• Age above 30 years

What are the triggers for Rosacea?

The factors that can trigger rosacea are-

• Extremes of temperature
• Exposure to sunlight
• Wind
• Consumption of alcohol
• Hot drinks
• Spicy food
• Menopause
• Vigorous exercise
• Strong emotions
• Medications- (steroids, excess of Vitamin B6 and B12, amiodarone, sildenafil)
• Cosmetics

What causes rosacea?

Rosacea often goes undiagnosed as its signs and symptoms are often confused with acne or sunburn. Around 14 million people in the United States suffer from this chronic skin ailment. Despite many victims, the exact etiopathogenesis of rosacea remains a mystery. A multifactorial etiology along with a predominant genetic susceptibility has been the most widely proposed theory. The other factors suspected to be involved are-

• Damaged blood vessels- Sun induced damage of the blood vessels of the face may lead to flushing and redness associated with rosacea.
• Hyperactive peptides- Peptides are short chain amino acids which are linked by peptide bonds. Activation of these molecules by the triggers (heat, cold, stress, spicy food, alcohol, etc.) can lead to derangement of the immune system leading to skin damage. The neurovascular system is proposed to be involved in this mechanism.
• Genetics- Those with a family history of rosacea are more prone to manifest this chronic skin disorder.
• Mites infestation- Skin infestation by a microscopic mite (demodex folliculorum) has been postulated to lead to rosacea in susceptible individuals. Though this mite is naturally found on the skin of all people, in patients of rosacea, the number of this mite is increased manifold.
• Helicobacter pylori infection-pylori is a bacterium found in the alimentary canal and is a causative factor for peptic ulcers. It has been postulated to release a chemical called as bradykinin which causes the blood vessels to dilate.

How is rosacea diagnosed?

There is no specific test to diagnose rosacea. A detailed medical history and thorough clinical examination by your physician can help him reach a diagnosis.

As rosacea resemble a multiple skin disorders, specific tests may be carried out in order to rule out conditions such as lupus erythematosus, eczema, psoriasis, acne vulgaris and carcinoid syndrome.

How is rosacea treated?

Rosacea is a chronic disorder with no known cure. However, interventions aimed at educating the patient regarding the relapsing nature of the disease and the likelihood of exacerbations forms the backbone of management. The patient is advised to avoid getting exposed to the triggering factors. As rosacea is essentially an inflammatory disease, intrusions at impeding the inhibitory pathways supported by symptomatic therapy is the aim of the physician.

The treatment modality at containing this skin ailment includes-

• Skin care- The mildest of cases can be managed by photoprotection and reducing skin irritability. A three-pronged approach to skin care including a gentle face cleanser, a mild moisturizer and a barrier product can be a standalone therapy in mild cases and an adjuvant in severe cases. Cosmetics (non-irritant types) can be used to cover up the lesions of rosacea, especially the erythema.
• Topical therapies- When rosacea is of mild to moderate severity, topical approach is the ideal therapeutic modality. The commonly prescribed drugs and their formulations are as follows:

Metronidazole (cream, lotion, gel)- The strength of the formulation varies from 0.75%-1%. The application schedule is twice daily for the lighter strength formulation and once daily for the stronger one.

Azelaic acid (gel)- With a strength of 15%, this gel is to be used twice daily for local application.

Ivermectin (cream)- The strength of this cream is 1% (once daily application).

Brimonidine tartrate (gel)- This medicine has the potential of constricting the dilated blood vessels, thus relieving the symptoms. A gel with the strength of 0.33$ is used once daily.

• Systemic therapies-

Doxycycline-The only systemic drug approved by FDA for the treatment of rosacea is oral doxycycline (40 mg, once daily). This medicine has good anti-inflammatory properties.

Azithromycin- Oral azithromycin can be used to treat inflammatory rosacea if a person cannot tolerate or is allergic to tetracyclines.

Isotretinoin- Oral Isotretinoin is reserved for severe or persistent cases of rosacea. Isotretinoin is contraindicated if a person is pregnant or is planning to conceive.

• Ocular treatment- Adequate ocular hygiene and lubrication of the dry eyes can alleviate the burning of the eyes, crusting of the lids and prevent formation of chalazion/hordeolum. Systemic treatment with antibiotics (topical or systemic) or cyclosporine is sometimes required.
• Physical intervention- Rhinophyma can lead to deformity of the facial features, and the modalities discussed above cannot reverse or treat this disfigurement. However, mild cases can be treated with systemic isotretinoin as this drug has the potential to shrink the sebaceous glands of the skin. A more definitive treatment involves destruction of the dilated blood vessels by laser therapy.
• Psychological counselling- Rosacea is a chronic disease with relapses and exacerbations being its natural course. It can be disfiguring in the severe forms. As face is the area most significantly affected by rosacea, it can lead to multiple psychological manifestations. These can vary from low self-esteem, embarrassment, anxiety and frustration to severe depression. Professional as well as personal interactions can suffer drastically therefore. Counselling with a psychologist regarding the cosmetic disfigurement is as important as the conventional treatment modalities discussed earlier.
• Alternative medicine-

Caffeine has been postulated to decrease the risk of developing rosacea. However, it should be kept in mind that hot beverages have the potential to trigger an attack of rosacea.

Gentle facial massage can reduce the swelling and the inflammation associated with the lesions of rosacea. Circular motions are advised during the process of massage.

Yoga, as a therapy to reduce stress has been advocated. Emotional stress, as mentioned earlier is a major trigger factor for rosacea.

Oils such as emu oil, oregano oil and laurelwood are supposed to alleviate the symptoms of rosacea.

Can rosacea be prevented?

The exact etiology of rosacea is still poorly understood. Therefore, it is not possible to prevent this chronic skin ailment. However, rosacea can be kept under remission by making certain life style changes and avoiding exposure to the known trigger factors.

Dos and Don’ts

Do-

• Keep a note of triggers (especially foods and drinks) which lead to exacerbation of rosacea in your case. These factors differ from one individual to another.
• Protect your skin from extremes of temperature.
• Protect your face from the wind and cold.
• Use sunscreen on your face and exposed skin. A broad-spectrum sunscreen with an SPF (sun protection factor) of 30 and above should be used.
• Keep your skin care simple with the use of minimum cosmetics.
• Take care of your ocular hygiene including the eyelids.

Don’t-

• Rub or massage your face vigorously.
• Allow your hair spray to meet your skin.
• Use oil-based cosmetics.
• Use a razor blade (in men). Instead, go for an electric shaver as it may cause lesser skin irritation.
• Use steroids for your lesions unless prescribed by your physician. Self-medication will do more harm than good.

What are the complications of rosacea?

Rosacea is a chronic disease with widespread features. Keratoconjunctivitis sicca, refractory conjunctivitis and blepharitis are its common ocular complications. Issue of low self-esteem and other psychological ramifications have already been discussed. According to a recent study, patients suffering from rosacea are more prone to suffer from a plethora of systemic disorders that include-

• Allergies
• Hypertension
• Hyperlipidemia
• Type 1 diabetes mellitus
• Cardiovascular disorders
• Gastrointestinal ailments

References
1. https://www.mayoclinic.org/diseases-conditions/rosacea/symptoms-causes/syc-20353815
2. https://my.clevelandclinic.org/health/diseases/12174-rosacea-adult-acne
3. https://accessmedicine.mhmedical.com/content.aspx?bookid=392&sectionid=41138786
4. https://med.stanford.edu/news/all-news/2015/03/genetic-basis-of-rosacea-identified-by-researchers.html
5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/

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