The comedian W.C. Fields once said, “I never drink water; that is the stuff that rusts pipes.” This referred to his penchant for drinking 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 found on the face, which can be a great source of consternation. It is a disease with various clinical signs. These can include redness, flushing, coarse skin, and bumps and pustules resembling acne. It may also present with visible tiny superficial blood vessels called telangiectasias.
The condition is found three times more often in women and usually presents between 30 and 60 years of age. It is also more common in fair-skinned people of European and Celtic origin. One of its nicknames is the “curse of the Celts.”
The diagnosis of rosacea is made 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 qualify as rosacea. 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 flushing associated with rosacea is thought to be due to the increased number of blood vessels that are close to the skin surface as well as the increased sensitivity of the vessels to heat. Sun exposure may play a role based on the location of the rash, though some studies refute this.
Skin inflammation is a major finding in rosacea. 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 different 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. The redness usually is not found around the eyes. The involved skin can be rough with some scaling.
The second type of rosacea is the papulopustular type. This is the most commonly seen 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.
The third type is the phymatous type. This presents with severe thickening and irregular contours of the skin of the nose, chin, forehead, ears and/or eyelids. This is the type suffered by the comedian W.C. Fields, resulting in his distinctive enlarged nose, known as a rhinophyma.
The last subtype of rosacea is the ocular type. 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 coverings of the insides of the lids. Symptoms can include burning eyes, dryness, light sensitivity or the sensation of a foreign body in the eye.
There are various triggers that can worsen flushing in rosacea. 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 that he or she can avoid them (alas, W.C. Fields could not). Daily use of broad-spectrum sunscreen (protection from UV-A and UV-B) is recommended for all patients. Patients should also 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 blood vessels are the mainstay of treatment. Surgery, dermabrasion or laser treatments may also be used to reduce excessive skin.