Rosacea is a chronic, relapsing inflammatory skin condition that primarily affects the central face (cheeks, nose, chin, and forehead). It is characterized by flare-ups featuring facial redness, prominent, dilated blood vessels, stinging, flushing, and acne-like bumps (papules and pustules). In severe cases, it can cause the skin to thicken, particularly on the nose, or affect the eyes.
Unlike acne, rosacea skin is very sensitive often with an impaired skin barrier. While there is no permanent cure, current treatments are very effective and in almost all cases can achieve excellent control of the condition.
Rosacea is caused by a combination of a tendencgy for inflammatory (white blood) cells to collect in the skin, particular around hair follicles and a tendency for blood vessels to dilate causing flushing and increase in number causing fixed redness and prominent blood vessels. These different components affect individuals differently but usually both are present and must be addressed to fully control the disease.
1. Identifying and Managing Triggers
It is helpful to understant what causes blood vessels to dilate. Common triggers include excessive sun exposure, extreme temperatures, hot beverages, spicy foods, alcohol (particularly red wine), and emotional stress. Where possible exposure to these triggers should be minimized or avoided. Meticulous sun protection is essential for rosacea patients.
2. Topical Treatments
- Ivermectin: In my experience this is the most effective topical treatment for inflammatory rosacea. It is used to reduce Demodex mites within the skin and additionally has anti-inflammatory effects.
- Azelaic Acid: Azelaic acid reduces redness and clears pustules.
- Metronidazole: A well tolerated topical antibiotic, which is often a first line topical treatment in rosacea.
- Brimonidine: For patients whose primary concern is severe background redness (erythema), brimonidine can give a temporary improvement but it is often associated with rebound flares which limit usage.
3. Systemic Treatments
When topicals are not sufficient, oral medications are used.
- Oral Antibiotics: Low-dose tetracyclines, such as doxycycline, are frequently prescribed. At specific "sub-antimicrobial" doses, these medications do not kill bacteria but act purely as systemic anti-inflammatories, safely reducing red bumps over long periods without causing antibiotic resistance.
- Beta Blockers and Clonidine: For patients who suffer from intense facial flushing triggered by stress or exercise these medications can be helpful.
4. Laser and Light Devices
Creams or tablets cannot reverse permanent, broken blood vessels or diffuse background redness. For these issues, device-based treatments are the gold standard.
- Vascular Laser devices like the pulsed dye laser or Intense Pulsed Light (IPL) selectively target the haemoglobin in the skin improving fixed redness and removing broken capillaries.
- Ablative Lasers: For advanced phymatous rosacea, where the skin of the nose has become severely thickened and bumpy (rhinophyma), surgical lasers like the carbon dioxide laser are used to vaporize excess tissue and reshape the nose.