This site is intended for health professionals only

Everything you need to know about... rosacea

Karina Jackson
RGN BA(Hons) MSc
Nurse Consultant
St John's Institute of Dermatology
London

Rosacea is a chronic inflammatory skin condition that symmetrically affects the face, most commonly the central cheeks, chin, end of nose and forehead. It presents with a combination or selection of common features, including:

  • Facial flushing.
  • Nontransient erythema.
  • Crops of papules and pustules.
  • lA telangiectatic background.

In severe cases there can be nodules. There are no comedones. It is not infectious, and the cause is unknown. It is more common in fair-skinned people of Celtic origin. It is also more common in women and often presents for the first time in the third to sixth decades. It can occur earlier in men and is often more severe.
Rosacea can be regarded as a spectrum of disease and is sometimes categorised by subtypes:

  • Erythematotelangiectatic.
  • Papulopustular.
  • Phymatous.
  • Ocular.

The subtypes or stages can sometimes be progressive or may be interdependent. Up to 50% of people with rosacea will have some ocular involvement, but it may go unnoticed if the symptoms are mild.

[[nip32_fig1_60]]

[[nip32_box2_60]]

*Images provided by St John's Institute of Dermatology

What causes rosacea?
There is no known cause, and little can be done to prevent the development of the condition. Certain aggravating factors have been identified and are attributed to a worsening of rosacea or cause the flushing symptom. This has led to the theory that the disease may relate to a vascular dysregulation in facial capillaries. Sun damage and an abnormal immune response in the skin are also suggested contributory factors.(1)

[[nip32_box1_62]]

[[nip32_box2_62]]

Managing the signs and symptoms of rosacea
One of the most problematic features of this disease is the prolonged facial flushing. This can cause embarrassment and discomfort for the patient. Certain common triggers have been reported, and the patient should be advised to avoid these as far as possible. The patient may also have identified individual triggers. Dietary triggers, such as alcohol, spicy foods and hot drinks, can be removed from the diet. Strenuous exercise should be avoided if found to cause problems and advice given on less demanding exercise. Where possible, extremes of temperature should be avoided and sun protection practised religiously, using a factor 15+ sunblock on the face at all times. Stress has also been associated with the exacerbation of the condition, and advice on stress management techniques may be helpful. Vasodilatory drugs may also cause problems and should be avoided where possible.
Rosacea can also cause the sensation of burning or stinging in the skin and may result in dryness and itching. General skincare advice can help these symptoms.

General skincare advice
People with rosacea are likely to have an increased sensitivity to the many additives found in routine skincare products. Advice should be given to avoid any treatments containing chemicals known to dry the skin, or those that are abrasive or perfumed. Washing with a soap substitute, such as aqueous cream, should avoid risk of further irritation of the skin.
The skin should be washed once to twice daily with a soap substitute and then gently dabbed dry. If the skin is dry, a light emollient cream can be applied once or twice daily. A list of emollient preparations is available in the BNF.(2) Abrasive agents, scrubbing and exfoliation should be avoided as they can cause further aggravation of the condition.

Clinical considerations
Rosacea is a chronic condition that may flare intermittently. There is no cure, and the treatment goal is to control the signs and symptoms. Rosacea should be treated actively to avoid disease progression and prevent complications. Rosacea can have a significant psychosocial impact on the individual, which should always be borne in mind when prescribing treatment.

Topical treatment
Mild rosacea with a small number of pustules or papules can be treated with a topical antibiotic. The first recommended choice is topical metronidazole cream used once or twice daily.(3) Cream is preferable to gel as it is less likely to irritate the skin. Topical azelaic acid has also been shown to be beneficial.(3) The therapy can continue intermittently, indefinitely, and should be used continuously for at least the first three months before proper assessment of efficacy can be made.

How to use topical treatments
The skin should be cleansed gently using a soap substitute and dabbed dry, and then the prescribed topical therapy should be applied to all affected areas, avoiding the eyes and mucous membranes.

Contraindications and cautions for topical treatments
Topical steroids should never be used to treat rosacea. They will worsen the condition in the long term. Always check for patient allergy to topical treatments, to avoid contact reactions. Topical treatments will also make the skin more sensitive to UV, so the need for sunblock is even greater.

Cosmetic advice
Treating the redness in the skin is difficult, and camouflage advice might be necessary if the patient is worried about their appearance. The Red Cross provides free access to camouflage clinics with a GP referral. Telangiectasia may respond to laser treatment, but this is unlikely to be available on the NHS. 

Moderate-severity rosacea
For more moderate disease (ie, pronounced and persistent redness and more extensive papules and pustules), systemic treatment will be required. This requires oral antibiotic therapy (see Box 3).
Antibiotic therapy is prescribed for a minimum of three months. A response to treatment may not be seen for the first six weeks, and in some people it takes up to three months to see an effect. After a response is seen, the drug dose can be reduced or stopped if the rosacea has cleared. There is, however, a high risk that the signs and symptoms will return, and a further course of topical or systemic treatment will be required.

[[nip32_box3_63]]

Contraindications and cautions for oral antibiotic therapy for acne
Tetracyclines can cause irreversible discoloration of teeth in children or the unborn child and are therefore contraindicated in children under 12 and pregnant and breastfeeding women.(2)
Tetracycline antibiotic therapy (with the exception of doxycycline) is contraindicated in kidney disease and should be used with caution in patients with hepatic impairment or receiving hepatotoxic drugs. Tetracyclines may reduce the contraceptive effect of oestrogens in the first few weeks of treatment, and additional contraceptive precautions may be advised
Photosensitivity has been associated with tetracylines, which is yet another reason for people with rosacea to take care not expose their skin to direct sunlight or ultraviolet light.(2)

Severe rosacea
Severe rosacea, resistant to oral antibiotics, will require referral to a dermatologist for secondary care management, which may include oral isotretinoin. Patients who develop a rhinophyma may also be referred to a dermatologist or plastic surgeon for surgical treatment.

Ocular rosacea
The eyes can be involved in rosacea. This can include mild symptoms of blepharitis and conjunctivitis that can be managed with careful eye hygiene and topical antibacterial eye ointment as required. Patients on oral tetracycline should not experience blepharitis. More serious eye involvement can result in keratitis (corneal involvement). Symptoms of keratitis include:

  • Severe eye pain.
  • Blurred vision.
  • Sensitivity to light.

An urgent referral to an ophthalmologist is recommended if there is any suspicion of keratitis.

Patient information
There are a number information leaflets about rosacea available for patients. Many can be downloaded from internet sites. The British Association of Dermatologists, Primary Care Dermatology Society and Prodigy all provide useful resources that serve to supplement the verbal advice and instructions that healthcare
professionals deliver.

References

  1. Cunliffe W, Gollnick H. Acne: diagnosis and management. London: Martin Dunitz; 2001.
  2. British Medical Association and Royal Pharmaceutical Society of Great Britain. British National Formulary 52. September 2006. Available from:
    http://bnf.org/bnf/bnf/current/104945.htm
  3. Prodigy Guidance - rosacea (last revised July 2005). Available from:
    http:// www.prodigy.nhs.uk/rosacea


Resources

British Association of Dermatologists
W: www.bad.org.uk

Primary Care Dermatology Society
W: www.pcds.org.uk

Dermnet NZ - the dermatology resource
W: www.dermnetnz.org

National Roseacea Society
W: www.rosacea.org

Prodigy guidance
W: www.prodigy.nhs.uk