Rosacea is a skin condition characterised by redness and/or flushing, and a burning or prickly sensation. Find out more about the causes of and factors contributing to rosacea and how to keep it under control through FitFab Club’s interview with Dr Derrick Aw, senior consultant dermatologist from the Sengkang General Hospital.
Q: What is rosacea?
Rosacea is a form of chronic skin inflammation with intermittent flares which can affect anyone regardless of race or gender. It tends to affect females more than males, can run in families, and is more common among fair-skinned individuals who flush easily. Typically, the first signs of rosacea appear before age 30. It can show up as redness on the cheeks, nose and forehead, which comes and goes without worsening for some time. However, if the condition is left untreated, the redness may become more obvious and more permanent over time. Tiny blood vessels and inflamed lesions may show up too.
Q: What are the causes and symptoms of rosacea? Why is it hard to diagnose?
Rosacea symptoms often appear similar to symptoms of other skin conditions. For example, flushing may be seen as blushing due to embarrassment or nervousness; persistent redness may look like a sunburn or eczema; a stinging or burning sensation may be interpreted as sensitivity to skincare products; while pus-filled bumps may be mistaken for acne lesions. Rosacea can mimic and/or co-exist with conditions such as eczema, serborrheic dermatitis and acne, which makes it even more challenging to correctly diagnose.
Q: How can we differentiate rosacea from acne, eczema and allergic reactions?
- Acne = Acne lesions present with comedones (white/blackheads) while rosacea does not.
- Eczema = Characterised by itching, dryness and scaling. The underlying cause is associated with certain features. For example in seborrheic eczema, the redness and scaliness are concentrated on the folds of the nose and cheeks, eyebrows, and space between the eyes, sideburns and ears.
- Allergic reactions = There are a plethora of allergic reactions and each usually has specific features. For example in angioderma, there is intense swelling around the eyes/mouth, without redness. In allergic contact dermatitis, there are typical features of eczema (itch, dryness, redness, scaling) but the distribution depends on the physical contact between the allergen and skin.
Q: Why does rosacea come and go? And what triggers rosacea flare-ups?
The occurrence of rosacea symptoms is determined by the frequency and intensity of exposure to triggers and the patient’s natural ability to manage inflammatory responses at any given time. This is why patients should be aware of triggers and strive to avoid them as much as possible.
Flushing is the most common rosacea symptom. Some experts even believe that chronic flushing will eventually contribute to other rosacea symptoms. Flushing can be triggered by certain activities, including:
- Exposure to extreme temperatures (hot and cold)
- Exposure to sunlight
- Drinking or eating alcohol and spicy food
- Stress (such as during the exam period, or stage fright)
- Taking certain medication
- Having hot flashes from menopause
Each patient can have different triggers and experience different levels of triggers before flushing occurs. For example, one rosacea patient may severely flush when exposed to sunlight, while another rosacea patient may not.
Q: Is rosacea treatable? Can it be managed with skincare? What products should patients avoid if rosacea persists?
Rosacea has no cure, but it can be managed. In addition to avoiding triggers, the right skincare can improve skin barrier function, while medication can reduce inflammation and blood vessel dilation; all of which helps contain rosacea symptoms.
It is very important for rosacea patients to take good care of their skin. Reinforcing the skin’s barrier function will help it be less prone to flare-ups, which is why the first step to managing rosacea is a gentle, hypoallergenic skincare regime. To avoid damaging the skin’s barrier function, avoid harsh products which contain exfoliating agents (AHAs/BHAs), alcohol, astringents, and manual exfoliators with scrubs, sponges or rough cloths. You should also avoid products with fragrances, dyes, and formaldehyde-releasing agents that can trigger reactions and exacerbate the skin condition.
Topical medications are prescribed to patients with mild and moderate rosacea because they can control symptoms to a satisfactory level.
Metronidazole – This medication is antimicrobial, anti-inflammatory and anti-oxidative. While generally well tolerated, some people may experience stinging, dryness, and/ or irritation.
Ivermectin – Anti-parasitic and anti-inflammatory, ivermectin kills Demodex mites, which is one of the triggers of rosacea while treating the pus-filled bumps associated with rosacea.
Brimonidine – This gel treats redness and flushing by shrinking the blood vessels in the skin
Azelaic acid – Azelaic acid may be useful to treat some cases of rosacea. Side effects include itching, burning, and stinging.
Retinoids – This treatment is recommended for patients who suffer from acne and rosacea at the same time. Some patients who might initially be too sensitive to retinoids, may improve and be able to use retinoids later.
Tetracyclines – including tetracycline, doxycycline, and minocycline – are known as oral antibiotics, and they are known to help reduce inflammation in rosacea.
Usually, once severe rosacea can be managed with antibiotics, you can proceed with topical therapies such as ivermectin and metronidazole. Sometimes, doctors combine oral antibiotics and topical therapies early to achieve faster and greater control.
Q: What advice do you have for anyone who is concerned they might have rosacea?
Seek medical attention for an accurate diagnosis before starting treatment. Patients with inflammatory (pus-filled bumps) rosacea may think they have acne and apply topical antiseptic agents. Instead of getting better, the product damages the skin’s barrier function, making it more sensitive.
Some patients with rosacea are misdiagnosed as having eczema and treated with steroid creams. While they may experience some temporary relief from the redness, bumps and other symptoms, the skin becomes “dependent” on the steroid cream. Without it, these symptoms are exacerbated and may even induce rosacea.
Dr Aw is a Senior Consultant in the Department of Dermatology at Sengkang General Hospital.
*Cover image by Freepik.