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Rosacea

One of the most common causes of a red face is a skin disorder called ‘rosacea’. Rosacea (pronounced ‘rose-ay sha’) is a skin disorder. It can affect people of any age, but usually starts in the 30s and 40s. The skin of the nose, cheeks, chin and forehead becomes red. Instead of being smooth, the skin in the red areas may also feel slightly lumpy with acne-like spots. Tiny, spidery thread veins are often visible. There may also be a burning sensation. The eyelids are often inflamed (blepharitis). The eyes may feel dry, gritty and irritable.

Symptoms of rosacea

Redness of nose, cheeks, chin and forehead
Small visible thread veins on the face
Bumps or pimples on the face
Irritated eyelids and dry, gritty eyes

People with rosacea often say that the problem started with flushing of the face, without sweating. The flushes may be triggered by hot or spicy food, alcohol, coffee, emotional upset, windy weather or exercise. Each flush lasts from a few minutes to an hour, and then goes away. This flushing stage can last for years, but then the face gradually becomes more permanently red, and the flushes lessen. (Of course this does not mean that if you have a tendency to blushing or flushing, you will develop a permanently red face – in most people blushing is not an early stage of rosacea.)

What causes rosacea? It is frustrating that the cause of rosacea has not been discovered. It is certainly not infectious, so you cannot catch it by skin contact with someone who has it. It may be partly genetic, because a rosacea-type red face seems to run in some families, and it is more common in fair-skinned individuals with Irish or Scottish ancestry.

Some researchers think that an allergy to a microscopic mite (Demodex folliculorum) that lives in the hair follicles may be the cause. Other researchers have suggested that a reaction to the bacterium Helicobacter pylori, which many people carry in their stomach, is involved. Stress may be a factor, but no one really knows. In the past, ‘lifestyle’ factors, such as too much alcohol, have been blamed, but there is no evidence for this at all.

Is it really rosacea? Your doctor is the best person to decide whether you really have rosacea. There is no laboratory test for it. Acne can sometimes look similar, but blackheads and big lumpy cysts do not occur in rosacea. Some types of dermatitis can also look similar, but the skin has tiny scales that are not seen in rosacea.

Does rosacea go away? Rosacea is a problem that you are likely to have for a long time, and it is unlikely to go away completely. Like other skin problems, there will be periods when it improves and is less troublesome. Fortunately, there are some effective treatments. After a few years, some people with rosacea develop thickening of the skin, especially on the nose, but this can now be dealt with by laser treatment.

What you can do

It is common sense to avoid hot drinks, spicy foods or alcohol if they make the flushing worse. The National Rosacea Society website has a Diary Checklist to help you identify situations or substances that may worsen your rosacea.
Some people find rosacea flares up in the summer in response to ultraviolet light; if so, use a sunscreen and keep out of the sun.
Avoid strong winds and sudden temperature changes.
Chlorinated water (for example, in swimming pools) can make rosacea worse.
Treat your skin kindly. Avoid perfumed soaps, alcohol-containing preparations (such as aftershave lotions) and exfoliating skin cleansers.
Do not put strong steroid creams on your face, because these usually worsen rosacea.
Special make-up to disguise the thread veins and redness is available - cosmetic camouflage. In the UK, some hospital dermatology departments provide advice about cosmetic camouflage from volunteers trained by the Red Cross, using products available on prescription. You will need a referral letter from your family doctor (see Useful contacts).
It is worth remembering that your skin is sure to look much worse to you than to anyone else. Specialists on rosacea always say that the distress it causes is out of proportion to the actual appearance. This is because we are the severest critics of our own faces.

What your doctor can do

For many years antibiotics (usually metronidazole or tetracycline), taken as tablets, have been the standard treatment for rosacea. No one knows why antibiotics work, because rosacea does not seem to be an infection. They are particularly helpful for the lumpiness of the skin. It may be more than 3 weeks before you notice any improvement, so be patient.
A gel or cream containing an antibiotic (usually metronidazole, sometimes erythromycin) is an alternative treatment, but takes even longer to work (often about 8 weeks). The gel needs to be applied twice a day, is difficult to cover with make-up and seems to leave a sticky film on the face, whereas the cream is used only once a day.
Azelaic acid gel is another effective treatment. It is applied twice daily. It may sting when you first start to use it (New England Journal of Medicine 2005;352:793 –803).

When the treatment has had an effect, it is usually continued for another month and then stopped. It is possible that the rosacea will come back again, in which case you can have another course of treatment.

If your rosacea is severe, and these treatments are ineffective, your doctor can refer you to a skin specialist (dermatologist) for other treatments such as isotretinoin. The specialist can also organize laser treatment if skin thickening or thread veins are very noticeable.

Private clinics. Some private clinics advertise costly treatments for rosacea, such as ‘intense pulsed light’. This uses light to destroy the tiny blood vessels in the skin that cause the redness. Several treatments may be needed. Some small studies suggest that this treatment reduces redness and flushing, and improves skin texture (Journal of Drugs and Dermatology 2003; 2:254 –9, Dermatological Surgery 2003; 29: 600 –4), but it has not yet been tested in large trials. Therefore we do not really know how effective it really is. Before going to any private clinic, think carefully, be cautious and discuss it with your doctor, and look at the section on cosmetic surgery.