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Acne Rosacea

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Acne rosacea is not true acne. Rather it is a related disease. Find out how rosacea is similar to and different from acne vulgaris and how it is treated.

Acne refers to a number of related skin diseases ranging from common acne, acne vulgaris, to severe forms of acne such as acne conglobata.

Acne produces a specific set of symptoms that distinguishes it from other skin diseases. Acne can produce both inflammatory and non-inflammatory lesions.

In mild acne, there are only a few acne bodies on the skin. These are mostly comedones such as whiteheads and blackheads. While there is only very little skin inflammation during mild acne, moderate acne includes inflammatory acne lesions along with whiteheads and blackheads.

There is more inflammation in moderate acne than mild acne. New inflammatory acne lesions observed during this stage of the skin disease are pustules and papules. In addition, both inflammatory and non-inflammatory lesions appear in greater numbers at this stage.

When moderate acne progresses to severe acne, it is called cystic acne.

Two new inflammatory bodies are seen during this stage. They are nodules and cysts. These appear as large, painful lumps under the skin surface.

Unlike comedones, pustules and papules which are superficial acne bodies, nodules and cysts are caused by deeper damage in the dermis and they can cause extensive and permanent scarring.

Acne affects the areas of the skin with the highest concentrations of sebaceous follicles. Therefore, it is mostly found on the face, neck, shoulders, back and upper parts of the chest.

In severe cases, acne may spread to other parts of the body such as upper arms, thighs and buttocks.

There are generally two root causes of acne. These are high levels of androgens such as testosterone and increased growth or skin sensitivity to acne-causing bacteria such as Propionibacterium acnes.

Acne generally first appears during puberty and it clears after a decade. However, in some people acne can last long into adulthood and develop into adult acne.

What is Acne Rosacea?

Acne rosacea is the other name given to a chronic skin condition called rosacea.

Although rosacea causes acne-like symptoms, it is not true acne. Rosacea is called acne rosacea because it also turns the face red and may cause swelling and sores on the skin.

Rosacea commonly affects white people of north western European descent. It usually starts between the ages of 30 and 60; and it is more common (3 times more common) in women than in men.

The first sign of rosacea is redness across the middle of the face including the forehead, nose and cheeks. When it spreads, it can also affect the scalp, ears, neck and chest.

The symptoms of rosacea are:

  • Redness of the face including a semi-permanent redness
  • Telangiectasia or the appearance of dilated, spider-like superficial blood vessels on the face
  • Red domed acne-like papules and pustules that ooze and crust
  • Burning and stinging sensations on the face
  • Irritated, reddened and watery eyes
  • Rhinophyma or red, bulbous nose

Rosacea affects a lot of people (more than 16 million Americans) and it can be just as psychologically distressing as acne. Most people with rosacea only have a mild form of the skin condition and they never treat or even diagnose the condition.

There is no specific diagnostic test for rosacea but visual examination by a dermatologist is sufficient to make the diagnosis.

Rosacea commonly occurs along with common skin diseases such as acne vulgaris and seborrheic dermatitis. Therefore, it is commonly confused with these other skin conditions.

Types of Rosacea

Rosacea is really a family of related skin diseases. There are 4 known subtypes of rosacea and it is possible for more than one of these to affect a single person.

  • Erythematotelangiectatic rosacea – this form of rosacea is differentiated by permanent redness on the face. It also causes frequent blushing and flushing as well as burning or itching sensation on the face. This type of rosacea also causes small blood vessels to appear close to the skin surface enough to be visible.
  • Papulopustular rosacea – This is the type of rosacea most commonly confused for acne. This is because it causes red bumps which can be papules or pus-filled pustules. It also produces some degree of permanent redness on the face.
  • Phymatous rosacea – This is the type of rosacea that causes rhinophyma, a condition whose main symptom is the enlargement of the nose. Besides the nose, this rosacea also causes the thickening of the skin around the ears, eyelids, chin, cheeks and forehead. It also produces scattered nodules on the skin and small blood vessels may be visible on the skin too.
  • Ocular rosacea – This type of rosacea mostly affects the eyes. It causes reddening, dryness and irritation of the eyes and eyelids. It also causes burning, itching and foreign body sensations.

Rhinophyma refers to the appearance of the nose as large and bulbous.

It occurs when rosacea is left untreated. Although, it was once wrongly attributed to chronic intake of alcohol, it can still be worsened by excessive alcohol consumption.

Rhinophyma occurs due to the slow but progressive enlargement of the sebaceous glands at the tip of the nose. It is mostly seen in middle-age men with long-standing, uncontrolled rosacea. It is treated by surgical removal of the excess tissue of the bulbous nose.

Severe forms of rosacea are also classified differently and along the same lines as severe forms of acne vulgaris.

The 3 common forms of severe rosacea are:

  • Rosacea conglobata – This is the form of severe rosacea that mostly resembles acne conglobata. It causes ulcerating and bleeding nodules  as well as plaques from healing and rupturing cysts
  • Rosacea fulminans – It also resembles acne fulminans. Like the severe form of acne, it has a sudden onset and similar sets of symptoms. It is also known as Pyoderma faciale
  • Phymatous rosacea – This is a cutaneous condition that is caused by the overgrowth of sebaceous glands. When it affects the nose, it is known as rhinophyma; ears (otophyma), eyelids (blepharophyma), chin (gnathophyma) and forehead (metophyma).

Causes of Rosacea

There are a number of theories regarding what could cause rosacea. These theories blame genetic, environmental, vascular and inflammatory factors. It is believed that rosacea is caused by any combination of these factors.

However, there are known triggers of rosacea. These triggers can be environmental, diets or drugs.

For example, besides alcohol, other drinks containing caffeine and histamine are known triggers of the skin disease.

The National Rosacea Society polled responses from over a thousand rosacea patients to determine what the major triggers are. The results are summarized in the table below:

Rosacea Triggers (% of sufferers) 

Sun exposure – 81%

Emotional stress – 79%

Heat Wave – 75%

Wind – 57%

Strenuous exercise -56%

Hot baths – 51%

Cold weather - 46%

Spicy food – 45%

Some skincare products – 41%

Hot beverages – 36%

Drugs especially stimulants – 15%

Marinated meat – 10%

Dairy products – 8%

Investigational studies have also identified evidence for specific causes of rosacea. These include:

Cathelicidins – In one study, patients with rosacea were observed to have elevated levels of the antibacterial peptides called cathelicidins. Also these patients do have high levels of SCTEs (stratum corneum tryptic enzymes). It is believed that one of the ways antibiotics work in rosacea therapy is through the inhibition of SCTEs.

Intestinal bacteria – The presence of SIBO (small intestinal bacterial overgrowth) is also known to be positively correlated to rosacea. Rosacea patients with SIBO are given a non-absorbable antibiotic called rifaximin which is never absorbed into blood circulation but acts on the bacteria in the guts.

Where rifaximin fails, metronidazole is the antibiotic of choice for rosacea caused by SIBO.

Demodex mites – Some studies have also shown that some rosacea patients do have high numbers of demodex mites living on their skins. These rosacea cases are mostly steroid-induced rosacea and the mites are believed to promote the actions of other rosacea triggers.

How Rosacea Is Treated

Although there is no known cure for rosacea, it can be prevented and even treated until it disappears.

However, rosacea is not acne and does not respond to over-the-counter acne medications.

Mild rosacea is often left untreated or covered up with skincare products. However, moderate to severe rosacea requires treatment.

The drugs used in rosacea treatment may offer temporary relief and clear off the redness on the face.  However, the symptoms return once the drugs are suspended. Long-term treatment is, therefore, necessary in most cases. However, some people do achieve permanent remission after a year or two of treatment.

It is best to avoid rosacea triggers. Some of these triggers vary for most people with the skin condition but a few are general. For example, exposure to sunlight is a common trigger for everyone living with rosacea.

To prevent rosacea breakout, sunscreen and wide-brimmed hats are recommended.

Oral and topical antibiotics are used to treat the symptoms shared by acne and rosacea. Oral tetracycline antibiotics and topical metronidazole are typical first-line treatment for rosacea.

Topical azelaic acid is also effective for reducing the inflammatory lesions while alpha hydroxyl acids can reduce the redness and lesions caused by rosacea.

For persistent inflammatory lesions, isotretinoin is prescribed to reduce papules, pustules and phymatous rosacea.

New studies have also demonstrated that natural remedies such as MSM and silymarin are effective in the treatment of rosacea.

Laser treatment is a particularly effective treatment for rosacea. The light from the laser penetrates the dermis and damages the capillaries. These capillaries are then reabsorbed by the cells of the immune system.

Laser is also used to treat phymatous rosacea by removing excess tissue.

Other milder light therapies such as photorejuvenation can be used to reduce redness and improve the appearance of the skin.





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