Rosacea, also known as acne rosacea, is a common chronic dermatological disorder characterized by erythema (redness) and pustules affecting the face, particularly the nose, forehead, chin, and cheeks. It is a multifactorial condition with a variety of triggers and an underlying genetic and environmental etiology. Rosacea affects approximately 16 million individuals in the United States alone, with the highest prevalence observed among fair-skinned women aged 30 to 60 years. While the disorder is more severe in men, it is primarily a condition affecting women. The condition is characterized by the exacerbation of facial redness and inflammatory lesions, which can worsen over time without intervention.

Pathophysiology

The exact etiology of rosacea remains incompletely understood, but several contributing factors have been identified. It is believed to result from an interplay between genetic predisposition, immune dysregulation, vascular abnormalities, and environmental triggers. One of the primary features of rosacea is the tendency of affected individuals to flush or blush easily. This phenomenon is thought to be linked to sun-induced damage to the small blood vessels beneath the skin, leading to their permanent dilation and leakage of fluids, which cause the characteristic erythema (redness) of rosacea. The inflammation and vascular dilation contribute to the development of telangiectasia (visible capillaries) and inflammatory pustules. The flushing response is often triggered by specific environmental factors, such as hot beverages, spicy foods, alcohol consumption, stress, and extreme weather conditions, which cause vasodilation and further exacerbate the condition. Additionally, long-term sun exposure and the use of topical steroids are associated with disease exacerbation.

Clinical Manifestations

The clinical presentation of rosacea is variable, ranging from mild erythema to more severe, persistent features, including telangiectasia, pustules, and rhinophyma.
The primary symptoms include:

• Erythema and Flushing
  The earliest and most characteristic sign of rosacea is persistent facial redness, often localized to the central face, including the cheeks, nose, forehead, and chin. This erythema is exacerbated by flushing, which is frequently triggered by heat, stress, or certain foods and beverages.
• Papules and Pustules
  Inflammatory lesions such as papules (red bumps) and pustules (pus-filled lesions) may develop, closely resembling acne. Unlike acne, however, rosacea typically does not involve comedones (blackheads), which helps distinguish it from acne vulgaris. These lesions may appear on the cheeks, nose, and forehead, leading to further skin irritation and discomfort.
• Telangiectasia
  The dilation of small blood vessels beneath the skin, known as telangiectasia, becomes visible as red or purple streaks on the face. These are most commonly seen around the nose and cheeks and are a hallmark of the disease in later stages.
• Rhinophyma
  In severe cases, particularly in men, rosacea can lead to rhinophyma, a condition characterized by the thickening of the skin on the nose, leading to a bulbous appearance. This occurs due to tissue hypertrophy, resulting in disfigurement.
• Ocular Rosacea
  About 50% of individuals with rosacea may develop ocular manifestations. These can range from mild dryness and grittiness to more severe conditions such as keratitis and corneal scarring, which can potentially lead to vision loss if untreated. Symptoms of ocular rosacea include redness, burning, stinging, photophobia, and chalazia (inflammatory bumps on the eyelids).

Diagnosis

The diagnosis of rosacea is primarily clinical and based on the characteristic appearance of the skin and a patient’s history. There are no specific laboratory tests for rosacea, but elevated serum levels of inflammatory markers such as C-reactive protein and pro-inflammatory cytokines may be noted in some cases. A diagnosis of ocular rosacea should prompt referral to an ophthalmologist, as untreated ocular complications can lead to significant morbidity, including vision loss.

Treatment Options

The treatment of rosacea aims to control symptoms, reduce inflammation, and manage triggers to prevent disease exacerbation. Management includes both pharmacological and non-pharmacological approaches, which should be individualized based on the severity of the condition.

• Topical Therapies
  Mild to moderate cases of rosacea can be managed with topical treatments that target inflammation and vasodilation. Commonly used agents include:
  • Topical Metronidazole: A first-line treatment for rosacea, it reduces inflammation and can decrease erythema and pustules. It is typically applied once or twice daily.
  • Topical Ivermectin: This antiparasitic agent is also effective in reducing inflammatory lesions and improving erythema.
  • Topical Azelaic Acid: Known for its anti-inflammatory properties, azelaic acid can be helpful in reducing erythema and pustules.
  • Topical Brimonidine: A selective α2-adrenergic agonist that reduces erythema by causing vasoconstriction of dilated blood vessels.
• Oral Therapies
  Oral medications are often used for moderate to severe rosacea or when topical treatments are ineffective. These include:
  • Oral Antibiotics: Tetracycline-class antibiotics, such as doxycycline and minocycline, are commonly prescribed for their anti-inflammatory properties. Low-dose doxycycline is often used for prolonged therapy .
  • Oral Isotretinoin: In severe or treatment-resistant cases, oral isotretinoin may be considered. This potent retinoid reduces sebaceous gland activity and has been shown to significantly reduce rosacea symptoms.
• Laser and Light Therapies
  For persistent telangiectasia and rhinophyma, procedural interventions may be necessary:
  • Laser Therapy: Intense pulsed light (IPL) and pulsed dye laser (PDL) can effectively target and reduce visible blood vessels, improving the appearance of erythema and telangiectasia.
  • Electrosurgery: For rhinophyma, electrosurgical techniques or laser therapy can be used to reduce excess tissue and reshape the nose.
• Management of Triggers
  Lifestyle modifications to avoid known triggers are an essential aspect of managing rosacea. These include:
  • Sun Protection: Using broad-spectrum sunscreen with SPF 30 or higher, avoiding direct sun exposure, and wearing hats.
  • Avoiding Flushing Triggers: Identifying and avoiding foods, beverages, and environmental factors that exacerbate symptoms, such as spicy foods, alcohol, hot drinks, and emotional stress.
• Ocular Rosacea Management
  For ocular rosacea, treatment involves both systemic and localized interventions:
  • Warm Compresses: To relieve symptoms of dryness and inflammation, patients are advised to apply warm compresses to the eyes twice daily.
  • Topical Lubricants and Antibiotics: In cases of blepharitis or chalazia, topical antibiotics such as erythromycin or doxycycline may be used.

Conclusion

Rosacea is a chronic and often progressive dermatological condition that can have a significant impact on quality of life. While its exact etiology remains complex, effective treatment strategies have been developed, including both pharmacological interventions and lifestyle modifications. Early diagnosis and treatment, particularly when ocular involvement is present, are essential for preventing complications. Although rosacea is not curable, with appropriate management, symptoms can often be controlled, and the progression of the disease can be halted or slowed.

References

1. Bosch, R., Galván, G., & Sánchez, J. (2022). Advances in the treatment of rosacea: A review of therapeutic options and new developments. Journal of Dermatological Treatment, 33(1), 1-9. https://doi.org/10.1080/09546634.2021.1887874
2. Del Rosso, J. Q., & Baldwin, H. E. (2020). Rosacea: An overview of clinical features, pathogenesis, and treatment. Journal of Clinical and Aesthetic Dermatology, 13(5), 24-30.
3. Fabbrocini, G., Nardone, B., & Annunziata, M. C. (2019). Rosacea: Pathogenesis, clinical features, and management. Journal of Clinical Medicine, 8(9), 1341. https://doi.org/10.3390/jcm8091341
4. Liu, Y., Zhang, L., & Li, Z. (2021). Mechanisms of rosacea and novel therapeutic strategies. Journal of Dermatological Science, 104(2), 89-95. https://doi.org/10.1016/j.jdermsci.2021.02.001