Rosacea

Rosacea is a long-term inflammatory condition of the facial skin. It produces flushing, lasting redness across the cheeks, nose, chin and forehead, visible small blood vessels, and in many people crops of inflamed spots that look very like acne.

It is common, it is harmless to physical health, and it does not shorten life. What it does do is sit in the middle of the face, which is why its effect on how people feel about themselves is out of all proportion to its medical seriousness. It is also treatable — not curable, but most of its features respond to the right treatment, and several of them respond well.

The difficulty is that rosacea is routinely mistaken for something else, and the treatments for those other things range from useless to actively harmful.

The patterns it comes in

Rosacea is not one presentation but several, and they are treated differently. Most people have more than one at once.

• Flushing and lasting redness. Episodes of going red that last longer than an ordinary blush, settling over time into a background redness that does not fade. Often the first feature to appear.
• Visible blood vessels — fine red threads, usually across the cheeks and around the nose. These frequently become more noticeable as the general redness is brought down, which can be mistaken for the treatment making things worse.
• Papules and pustules — raised red spots and pus-filled spots. This is the pattern most often confused with acne. The distinguishing feature is that rosacea does not produce blackheads, and acne does.
• Thickened skin, most often on the nose, where the skin coarsens and the nose enlarges. This is uncommon, develops slowly, and affects men far more than women.
• Eye involvement, which is dealt with separately below because it is both common and commonly missed.

Dryness, burning, stinging and a feeling of tightness are usual alongside any of these, and skin with rosacea tends to react badly to products that other skin tolerates.

What is known about the cause

The honest answer is that it is not fully understood. What is reasonably well established is that it involves the blood vessels of the face behaving abnormally, an overactive innate immune response in the skin, and in the spot-forming pattern a population of Demodex folliculorum — a microscopic mite that lives in human hair follicles and is present in far greater numbers in rosacea-affected skin. That last point is not a curiosity: it is why one of the most effective treatments is an anti-parasitic cream.

Two things it is not caused by, both of which attract a good deal of unearned blame:

It is not caused by poor hygiene, and washing more often makes it worse rather than better.

Thickening of the nose is not caused by drinking. The association is folklore. Alcohol can trigger flushing in someone who already has rosacea, as can a hot drink, but it does not cause the condition and it does not cause the nasal change. People with rhinophyma who do not drink are routinely assumed to, and the assumption is simply wrong.

Sun protection, which matters more than anything else bought over a counter

Ultraviolet light is the most consistently reported trigger and is thought to contribute to the underlying vessel damage over years. Daily sun protection on the face is therefore not cosmetic advice but the single most useful self-care measure available.

UK guidance is a minimum of SPF 30 on the face whenever sun exposure is likely, and no sunbeds. Mineral filters based on zinc oxide or titanium dioxide are often better tolerated than chemical ones on reactive skin. Where eye features are present, sunglasses with ultraviolet protection are worth having.

The rest of the routine is a matter of taking things away rather than adding them. Unperfumed, non-comedogenic emollients for dryness; no scrubs, exfoliants, astringents, alcohol-based toners or anything marketed as deep-cleansing; lukewarm rather than hot water. Green- or yellow-tinted make-up counteracts redness optically and is a legitimate measure, not a cop-out — camouflage services exist in the UK through the British Red Cross and through Changing Faces.

Triggers

Triggers vary so much between individuals that general lists are of limited use, which is the argument for keeping a short diary rather than pre-emptively giving things up. The common ones are sunlight, heat, cold wind, sudden temperature change, hot drinks, spicy food, alcohol, strenuous exercise and stress. Some prescribed medicines provoke flushing as well, calcium-channel blockers among them, and that is worth raising rather than acting on alone.

Exercise deserves a specific note, because giving it up is a poor trade. Exercising in a cooler environment, earlier or later in the day, in shorter intervals, and with a cold drink to hand usually makes it manageable.

What is actually prescribed

Treatment follows the pattern, and this is where the difference between rosacea and acne matters, since several standard acne treatments irritate rosacea.

For spots. Ivermectin cream is first choice in current UK primary care guidance, applied once daily over a course of eight to twelve weeks — the anti-mite treatment referred to above. Where it is unsuitable, azelaic acid gel or metronidazole cream or gel are the alternatives, applied twice daily, with improvement expected over four to nine weeks rather than days. For moderate or severe spots, a topical treatment is combined with a low-dose oral antibiotic: modified-release doxycycline at 40 mg once daily, a dose chosen because it acts on inflammation rather than as an antibacterial, which matters for antibiotic resistance. Erythromycin is used instead where tetracyclines cannot be, including in pregnancy.

For lasting redness. Brimonidine gel constricts the facial blood vessels and reduces redness for several hours at a time. It is used sparingly and built up gradually, because starting at full dose can provoke a worsening of redness in some people, and it is not applied to broken or irritated skin.

For visible blood vessels. Creams do not remove them. Laser and intense pulsed light treatments do, and are the reason for a dermatology referral where the vessels are the main complaint.

For thickened skin and an enlarged nose. This needs specialist assessment early rather than late, since treatment is easier before the change is established. Surgical and laser reshaping exist, though they are generally not funded by the NHS for appearance alone.

One general point about all of it: these treatments suppress rather than cure, and stopping usually means the features return. A maintenance regime is the normal end state, not a failure.

The eyes

Eye involvement affects a large minority of people with rosacea and is frequently not connected to the skin condition by either the person or whoever they see first. It produces gritty, dry, sore eyes, redness of the lid margins, recurrent styes, crusting and light sensitivity, and the eye symptoms can arrive before anything appears on the skin.

Most of it responds to warm compresses and lid hygiene — a clean flannel wrung out in hot water held against the closed lid for about a minute, then the lid margin cleaned — along with artificial tear drops, and treatment of the skin where that is also involved.

Two symptoms are not in that category. Eye pain, blurred vision, marked light sensitivity or a red eye need to be assessed urgently, because rosacea can affect the cornea and that can threaten sight.

Steroid creams, which make it worse

This is the most important practical warning in the subject. A topical steroid will often calm rosacea for a few days, which is exactly what makes it dangerous: the redness returns worse than before, the treatment gets repeated, and the result is a steroid-driven facial rash that can be considerably more difficult to deal with than what it was applied to. Current UK guidance is to avoid topical corticosteroids on the face in rosacea.

This happens most often where rosacea has been mistaken for facial eczema, which is treated with steroids, or where a steroid cream intended for somewhere else on the body is used on the face because it is in the cupboard. Anyone who has been using one on facial redness for weeks or months needs advice on coming off it rather than simply stopping, since the rebound can be severe.

Where the herbal remedies stand

A good deal of writing on rosacea recommends plant extracts and kitchen ingredients. What can honestly be said about them:

Niacinamide and liquorice extract appear in cosmetic products aimed at redness. The evidence is weak but they are not harmful and some people find them soothing. As an addition to sun protection and emollients they are reasonable; as a substitute for treatment they are not.

Green tea applied to the skin has no useful evidence behind it.

Riboflavin deficiency has not been shown to cause rosacea, and taking B vitamins does not treat it. High-dose niacin taken by mouth is in fact a well-known cause of flushing.

Apple cider vinegar should be mentioned specifically because it is so widely recommended and the recommendation is poor on three counts. Rosacea is not caused by a digestive disorder. Acidic and hot drinks are among the commonest flushing triggers. And drinking vinegar erodes tooth enamel.

Azelaic acid is not a herbal remedy, although it is often listed as one. It occurs naturally in grains, but the preparation used on rosacea is a prescription-strength topical medicine and one of the first-line treatments named above. It is a licensed drug that happens to have a natural origin, which is true of a great many drugs.

The broader point is the one the alternative therapies section makes generally. Something pleasant that soothes the skin is worth having. It is not the same as a treatment, and the gap between the two is where several months of avoidable redness tends to sit.

When to be seen

A first diagnosis is worth getting rather than assuming, because rosacea is treated differently from acne and from facial eczema, and because a few other conditions — including lupus and some drug reactions — produce facial redness and need excluding.

Beyond that: eye pain or visual change, urgently. Spots that have not improved after about twelve weeks of proper treatment. Thickening of the nose, early. Redness or visible vessels that treatment has not touched. And the one that is under-reported and perfectly good grounds for a referral on its own — when the appearance of it is affecting work, social life or mood.