Montgomery Medicine No. 775

The comedian W.C. Fields once said,  “I never drink water; that’s the stuff that rusts pipes.” This was in response to a question about his penchant for alcohol. So what do alcohol and W.C. Fields have to do with this week’s topic of rosacea? Read on.

Rosacea is a common skin condition usually affecting the face, which can be very embarrassing. It is a disease with various clinical presentations. These can include redness, flushing, coarse skin, and bumps and pustules resembling acne. It may also present with visible spider-like superficial blood vessels called telangiectasias.

The condition is three times more common in women and usually begins between 30 and 60 years of age. It is also more common in fair-skinned people of European and Celtic origin, hence its nickname, “The Curse of the Celts.”

Rosacea is diagnosed on clinical grounds (i.e. signs and symptoms). There has to be a persistent rash on the central part of the face for at least three months to meet the diagnostic criteria. Classifying rosacea is important in determining the best treatment.

The exact cause of rosacea is not well understood, though there are numerous factors that likely play a role. The increased number of blood vessels close to the skin surface, as well as the increased sensitivity of the vessels to heat, are felt to cause flushing, a common sign. Sun exposure may play a role based on the location of the rash, though some studies refute this.

Skin inflammation is very common. Demodex, a species of skin mite, may also play a role in the development of an inflammatory reaction, though studies are somewhat conflicting. Free radicals in the skin produced by various biochemical reactions can also cause damage.

There are four subtypes of rosacea based on clinical findings, likely the result of how a particular patient responds to various biologic factors and triggers. The first is the erythematotelangiectatic type. Its main signs and symptoms are central facial flushing, often with burning or stinging sensations. The redness usually is not found around the eyes. The involved skin can be rough with some scaling.

The second subtype is termed papulopustular. This is the most common type, typically found in middle-aged women. It presents with redness of the central part of the face with small red bumps (papules) that have small pustules on top of them.

Phymatous is a third subtype. It presents with severe thickening and irregular contours of the skin of the nose, chin, forehead, ears and/or eyelids. W.C Fields suffered from phymatous rosacea that caused his distinctive enlarged nose, known as a rhinophyma.

The last subtype of rosacea is ocular. It can present with signs that may be present for years before the skin manifestations develop. Patients can develop inflammation of various structures of the eyelids and the conjunctiva that lines ,the inside of the lids. Symptoms can include burning eyes, dryness, light sensitivity and/or the sensation of a foreign body in the eye.

Various triggers can worsen skin flushing. These include stress, alcohol, spicy foods, hot drinks, wind, topical skin products, caffeine, exercise, hot or cold weather, and hot baths or showers.

The first goal of treatment is to identify a patient’s triggers so they can be avoided (alas, W.C. Fields could not). Daily use of broad-spectrum sunscreen (protection from UV-A and UV-B) is recommended for all patients. Sufferers should avoid astringents, toners, menthols, waterproof cosmetics that require solvents for removal, camphor, and products containing sodium lauryl sulfate.

Some types of rosacea respond to topical medications including antibiotics and acne agents. Oral antibiotics may also be used. Mild cases can be masked with creams containing green pigments. Laser surgery aimed at reducing the size and number of blood vessels are the mainstay of treatment. Surgery, dermabrasion or laser treatments may also be used to reduce excessive skin.