Rosacea is a painful and embarrassing, chronic, vascular, inflammatory skin condition that affects the skin of the face and sometimes the eyes. Its symptoms can include persistent redness, acne-like lesions, skin thickening, and eye irritation. An important characteristic of this condition are its periods of “flare-ups” when symptoms worsen due to skin hyper-irritability, hyper-sensitivity, cosmetic intolerance, stress, or sensory irritation. Common environmental triggers that are known to cause flare-ups include sun, wind, cosmetics, spicy food, exercise, and alcohol.

Rosacea has no known cause and no proven cure. It is a lifelong condition that can worsen and potentially cause permanent damage with time if left untreated. However, through trial and error, many people with rosacea find the specific triggers and solutions, natural and/or medical, to manage and halt the progression of their condition in order to lead relatively normal lives without the discomfort and stigma of rosacea symptoms. Solutions can include hypoallergenic skin care, antibiotics, anti-fungals, laser treatment for broken capillaries and excess tissue, naturopathic/homeopathic remedies, avoidance of triggers, and stress management.

Rosacea has been classified into four main subtypes according to the symptoms that often occur together. The symptoms of each subtype can range from mild to severe in expression and typically worsen if left untreated. Rosacea is a very diverse condition that can manifest with the symptoms of only one subtype, more than one subtype, or all four. Redness, or erthema, is associated with just about every subtype of rosacea.

This subtype is characterised by flushing and persistent facial redness. It may include visible blood vessels (blood vessels that have burst, telangiectatic vessels, because of frequent flushing and are permanently visible) and can be accompanied by stinging, burning and swelling. Areas of redness are typically most prominent on the forehead, cheeks, nose and chin.

This subtype is characterised by persistent facial redness accompanied by acne-like bumps and pimples. It is often seen after or at the same time as the symptoms of subtype 1 and is commonly confused with acne. Papules are small raised and discoloured bubbles of skin, solid, and without visible fluid. Pustules are similar pin-point lesions, except they are filled with pus. This subtype is also commonly referred to as inflammatory rosacea. Papulopustular rosacea is distinguished from acne because rosacea does not present with blackheads that are seen with acne. Also rosacea typically presents as an adult and symptoms are generally restricted to the nose, cheeks, chin and forehead. Furthermore, in contrast with acne, rosacea bumps and pustules generally are not associated with the hair follicle, are surface lesions that do not penetrate the dermis, and do not involve the sebaceous glands (except in severe phymatous rosacea, subtype 3).

This subtype is characterised by an overgrowth of tissue and irregular surface of the skin, typically around the nose. This type of rosacea is often mistakenly identified as a “drinker’s nose”. It predominantly occurs in men, and can occur on the cheeks, chin, and ears as well.

This affects the eyes and eyelids and is characterised by watery or bloodshot eyes, tearing and burning or stinging, dryness, itching, white discharge, swollen eyelids, and recurrent styes. If left untreated, ocular rosacea can cause permanent damage to eyes and vision.

Rosacea is most common among Caucasians of Celtic or Northern European descent. It affects three times as many women than men and arises between the ages of 25 and 35 or during menopause.

Over 17 million people in North America and over 46 million people in the World are estimated to have rosacea. However, this disease is significantly under diagnosed as many sufferers attribute symptoms of redness, bumps, and pain to lifestyle, acne, or general skin sensitivity.

Dr. Mark Dahl, an expert dermatologist in the field of rosacea, states, “Many patients with rosacea have hyper-irritability of the skin; many creams, cosmetics, and ointments cause their skin to burn and sting. This ‘cosmetic intolerance syndrome’, or ‘sensory irritation’ hinders treatment, because even prescribed topical medications and their bases can produce unpleasant sensations.”

16 million in USA:
9.6% in all women, regardless of ethnic background;
16% in Caucasian women.
14% in Ireland
10% in Sweden: 14% in women and 6% in men

For most with rosacea (over 90%), the number of rosacea flare-ups can be reduced by avoiding the combination of environmental and lifestyle factors that trigger their symptoms. What causes a rosacea flare-up in one person may not affect another. Thus, understanding and avoiding your personal triggers is an important step in managing rosacea symptoms.

Sun Exposure (81%)
Emotional Stress (79%)
Hot weather (75%)
Wind (57%)
Intense Exercise (56%)
Alcohol (52%)
Spicy foods (45%).

One method of discovering your personal rosacea triggers is to keep a daily rosacea journal; keep track of environmental and lifestyle factors while observing your rosacea symptoms on a daily basis. Track and record weather conditions, foods and beverages consumed, exercise, stress level, products used on the face, medications, and anything that causes flushing (such as hot showers or baths). There are even tracking apps available for smartphones.

The underlying cause of rosacea is unknown. Part of the reason for this is the varied expression of the condition and multiple components that contribute to rosacea in any one person.

There are several popular theories including genetic factors, dermodex mites, overgrowth of intestinal bacteria, and cathelicidins.

There is increasing evidence of a genetic component to rosacea. Not only is rosacea more prevalent in certain ethnic populations including Irish, Scottish, English, German, Scandinavian, French, Polish, Russian, Lithuanian, Hungarian, and Czech, but it also appears to run in families. While specific genetic factors or “rosacea” genes have not been conclusively discovered, a majority of people with rosacea also have rosacea in their immediate family. In a survey of 600 rosacea patients by the National Rosacea Society, nearly 52% of respondents said someone else in their immediate family had rosacea, Additionally, new research is pointing to genetic changes in some cases of rosacea.

Demodex mites are microscopic inhabitants of normal skin. One possible cause or exacerbating factor in rosacea is related to these organisms. Demodex mites have been found in much greater numbers in rosacea patients. Furthermore, people with subtype 2 rosacea are found to have a greater immune system response to the bacterium found in Demodex, Bacillus oleronius. This points to a link between the increased number of mites in people with rosacea and rosacea symptoms that may arise by a combination of factors including reaction to the proteins produced by the bacteria associated with demodex mites, an allergic reaction to the mites themselves, and/or other microbes that might be associated with the mites. Furthermore, new evidence also points to infestations of demodex mites as a cause for ocular rosacea.

Intestinal bacteria may play a role in causing rosacea. Small intestinal bacterial overgrowth (SIBO) is more prevalent in people with rosacea than people that do not have the condition. SIBO has been detected in 47% of rosacea patients compared to 5% of controls using a hydrogen breath test. Hydrogen-positive patients (with SIBO) were then treated with an oral antibiotic, rifaximin, and 37 of 48 experienced a complete remission of rosacea symptoms which lasted at least 9 months. The rosacea symptoms of 13 of 16 patients that had negative breath tests (no SIBO) that were also treated with rifaximin remained unchanged. This points to a significant role of SIBO in the symptoms of a large percentage (almost half) of those with rosacea.

Cathelicidins serve a critical role in immune defence against invasive bacterial infection. A range of skin diseases with inflammation are linked to a shortage of cathelicidin. The opposite problem has been observed in rosacea. Patients with rosacea have been shown to have elevated levels and a different form of cathelicidin than people without the condition. Furthermore, patients with rosacea have been found to have significantly elevated levels of cathelicidin and stratum corneum tryptic enzymes (SCTEs) and the interaction of these proteins converts cathelicidin into inflammatory peptides that have been shown to cause rosacea symptoms. SCTEs are inhibited by some antibiotics, and researchers hypothesise this is why antibiotics have been shown to alleviate the symptoms of rosacea in some patients. This discovery may lead to new therapeutic approaches to treating rosacea, since bacteria may not be the right target.