Rosacea – redness of the face

Rosacea is a chronic inflammatory dermatosis that predominantly affects the skin of the central part of the face and most often appears between the ages of 30 and 60.

It is a relatively common dermatosis characterized by initial transient, then persistent redness of the face.

It usually has a relapsing course, with symptoms that are controlled by certain lifestyle habits, general skin care, medications and certain “in-office” treatments.

It is estimated that rosacea affects about 5% of the adult population in the world. Although rosacea is often thought to affect women more than men, studies have proven approximately the same occurrence in both sexes.

Rosacea usually appears after the age of 30 and becomes more common with age. However, it can occur at any age and occasionally occurs in children.

Although rosacea can occur in anyone, it is more common in people with fair skin, blue eyes, and those of Celtic or Northern European descent. The diagnosis of rosacea is often difficult to make or even overlooked in dark-skinned patients.

The pathogenesis of rosacea is considered to be multifactorial and includes:

• genetic predisposition
• altered skin and gut microbiome – excessive bacterial growth in the small intestine, Helicobacter pylori infection and increased density of Demodex folliculorum and Staphylococcus epidermidis on the skin may play a role in skin inflammation
• dysregulation of the immune response – can lead to excessive inflammation, vasodilation, lymphatic dilation and angiogenesis
• neurocutaneous mechanisms – triggers include ultraviolet (UV) light (the most important), temperature changes, exercise, spicy foods, alcohol, psychological stress, air pollution and smoking
• damaged skin barrier – the affected skin shows features that indicate damage to the skin barrier, which allows bacteria to colonize and inflammation
• disorder of innate immunity in the form of an exaggerated response to the initial trigger – in the skin of patients with rosacea there is an increased expression and activity of toll-like receptors 2, cathelicidin, kallikrein 5 and mast cells

Clinical features include:

• Transient recurrent erythema – flushing
• Peristentent erythema of the face
• telangiectasia – most commonly in the area of the skin of the face, nasal wings and along the edge of the eyelids (erythematotelangiectatic rosacea)
• inflammatory papules and pustules (papulopustulous rosacea)
• fimatous changes – thickening of the skin due to hyperplasia/fibrosis of the sebaceous glands of the face; The most commonly affected area is the nose (rhinophyma), which is more common in men

The main complications of untreated rosacea are:

• Phimatous rosacea
• inflammatory complications of the eye (e.g. blepharokeratoconjunctivitis, sclerokeratitis)
• negative psychosocial effect – increased anxiety, depressive disorder, low self-esteem and gradual social isolation
• statistically proven correlation with other systemic diseases such as hypertension, cardiovascular disease, anxiety disorders, dyslipidemia, diabetes mellitus, migraine, rheumatoid arthritis, Helicobacter pylori infection, ulcerative colitis and dementia

Rosacea is diagnosed in most cases based on clinical findings.

The diagnosis is made according to the diagnostic and main criteria recommended by the Global ROSacea COnsensus (ROSCO) panel in 2017. In cases where there is diagnostic uncertainty, it may be considered to do a skin biopsy – a skin sample that is sent to a pathologist for histopathological verification of a suspected diagnosis.

Other diseases that have a similar clinical presentation include:

• Acne vulgaris
• demodicosis (demodex folliculitis)
• dermatomyositis
• Perioral dermatitis
• sunburn
• Seborrheic dermatitis
• Systemic lupus erythematosus

Although there is no cure for rosacea, symptoms can be controlled by lifestyle changes, targeted local and systemic therapy, and certain “in-office” treatments.

All patients with rosacea should keep a symptom diary to help them identify the triggers responsible for worsening symptoms.

Common triggers include spicy foods, hot/cold temperatures (hot baths), exercise, sun exposure, cosmetics, medications (those that cause vasodilation), alcohol, fruits and vegetables, dairy products, and canned meat products.

In addition, it is necessary to carry out general skin care that is prone to redness, which includes the use of milder skin washing products and creams for adequate hydration and sun protection (minimum SPF 30).

Targeted treatment of rosacea is usually based on several treatment modalities at the same time. The treatment protocol itself is determined based on the clinical picture, i.e. symptoms.

Transient and persistent erythema (redness)

For transient redness of the face, the best carpet effect has the local application of alpha-adrenergic agonists in the form of a cream (oxymetazoline) or gel (brimonidine).

Although they significantly reduce redness, long-term use may result in recurrent redness after discontinuation of use.

In addition to the above-mentioned topical therapy, oral administration of beta-blockers (carvedilol) also has a good effect on facial redness. Intense pulsed light (IPL) or vascular laser therapy can also be performed.

Inflammatory papules/pustules

Azelaic acid or ivermectin in the form of a cream and metronidazole in the form of a cream or gel are applied topically. This is applied alone or in combination with the topical application of the antibiotic erythromycin.

In the event that there is no satisfactory therapeutic effect on the applied local therapy, the oral antibotic doxycycline is introduced into the therapy according to a certain scheme for the treatment of rosacea.

For a form of rosacea that is refractory to all treatment modalities, there is a possibility of treatment with oral retinoids (vitamin A derivatives) – isotretionin.

Retinoids are drugs that have numerous side effects and caution should be exercised when used and regularly checked by a competent doctor. In this case, too, “in-office” treatments such as intense pulsed light therapy (IPL) or vascular laser can be applied.

Fima

In patients with afhim, if inflammation is visible, oral antibiotic therapy with doxycycline or oral retinoid isotretionine is performed.

After the inflammation is subdued, “in-office” treatment methods are used, such as physical modalities for the removal of excess tissue and reshaping of structures (e.g. ablative CO2 laser, erbium laser, radiofrequency, surgical debulking).

Although rosacea is not a life-threatening disease, it is chronic and all acute exacerbations significantly affect the quality of life of the patient. That is why the goal of all the previously described treatment modalities is to prolong the remission phase with as few and milder exacerbations as possible.

For a consultation and examination with our expert team, you can contact us by phone at +3851 2444 646 or via our online form.

We will warmly welcome you at the premises of the Lohuis Filipović Polyclinic at Trg John Fitzgeralda Kennedya 6b, Zagreb. You can easily reach us by public transport, and parking is provided in front of the building with prior notice by phone.

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