Characteristics, types, and comprehensive management of rosacea: a complete guide

Rosacea It is a chronic inflammatory skin disease that primarily affects the midfacial area, including the cheeks, nose, forehead, and chin. It is a disorder of is the unknown, although it is considered multifactorial and often presents with different clinical manifestations that can be confused with other skin conditions. Rosacea is much more common than is often thought, affecting a significant percentage of the world's population and having a considerable impact on the quality of life of those who suffer from it. The objective of this article is to provide a comprehensive and up-to-date overview of the Characteristics, types, causes, diagnosis, psychological impact and therapeutic options of rosacea, integrating all relevant information available in current medical literature and the best available sources.

What is rosacea?

Rosacea is a chronic skin disorder characterized by a tendency to persistent or episodic redness (flushing), appearance of erythema (redness), telangiectasias (visibly dilated superficial blood vessels), edema, papules and pustules, as well as, in some cases, eye lesions and thickening of the skin (phymas). It is mainly located in the central area of ​​the face but can affect other sun-exposed areas such as the neck, décolletage, ears, scalp, and even the back. It is a disease not contagious and that is not related to poor hygiene, but does have a genetic basis and responds to environmental and personal factors.

A key aspect of rosacea is its tendency to occur with flares and remissions, which often makes it difficult to identify and control triggers. Episodes can last from minutes to days or weeks and generally develop slowly, although in some cases they can progress to more severe forms.

Photograph of rosacea on the face

Epidemiology and who may be affected

Rosacea is one of the most common dermatological diseases.. It can appear at any age, although it is more common in light-skinned adults between 30 and 50 years old, being more common in women, but more severe in men. However, it can also occur in adolescents, children and even in childhood. There is a genetic predisposition Important; up to 30-40% of patients have an affected family member. Skin type is important: people with light phototypes (I and II) are more susceptible, but it can occur on any skin tone, where the erythema may be more subtle or brown or purplish in color.

Rosacea primarily affects the face, but in certain cases it can extend beyond the face, especially in its granulomatous forms, where lesions can also be seen on the neck, décolletage, scalp, ears, or back. The psychological, social, and occupational impact of rosacea is considerable: up to 70% of patients report a decrease in their self-esteem and professional life, and a significant proportion may experience social isolation and emotional difficulties.

Causes and triggers

The cause of rosacea is complex and not fully known. It is accepted that the following are involved:

• Genetic predisposition.
• Neurovascular disorders: abnormal response of cutaneous blood vessels, with a tendency toward exaggerated and persistent vasodilation.
• Defects in innate immunity.
• Presence and proliferation of the mite Demodex folliculorum and the microorganism Bacillus oleronius.
• Skin barrier dysfunction: increased transepidermal water loss and sensitivity to external aggressors.
• Increased inflammatory response and increased sensitivity to environmental stimuli and topical products.

La chronic sun exposure and actinic damage are closely related. Ultraviolet radiation induces the production of mediators that damage dermal collagen, disrupt vascular support, and promote the extravasation of fluids, proteins, and inflammatory mediators.

There is no conclusive evidence that diet is a direct cause., although certain foods may be outbreak triggers (alcohol, spicy foods, hot drinks). Also, certain digestive diseases, such as infection by Helicobacter pylori, have been linked to rosacea in some studies, although the evidence is not conclusive and their treatment does not guarantee improvement of the skin condition.

Factors that aggravate or trigger rosacea flares

• exposure to sunlight
• Extreme heat and cold
• Strong wind
• Emotional stress or intense emotions
• Strenuous exercise
• Alcohol and hot drinks
• Spicy foods or foods that cause vasodilation
• Some medications (vasodilators, topical corticosteroids, vitamins B6 and B12)
• Irritating cosmetic products
• Tobacco

It is essential to identify and avoid, as far as possible, personal triggers to achieve better disease control.

Main signs and symptoms of rosacea

The symptoms and signs of rosacea can vary widely depending on the type and stage. The most characteristic symptoms include:

• Persistent facial redness (centrofacial erythema), which can be exacerbated by stimuli such as heat or emotions.
• Intense facial blush (flushing), of transient appearance.
• Telangiectasias, dilated vessels visible on cheeks, nose and chin.
• Papules and pustules (similar to acne but without comedones).
• facial edema and a feeling of bloating.
• Dry, tight, flaky, or rough skin.
• Burning, hot, stinging, or itching sensation.
• Skin thickening and enlarged pores in advanced cases (fimas).
• Eye injuries: blepharitis, conjunctivitis, dryness, blurred vision, light sensitivity, and foreign body sensation.

In the more advanced forms, especially in men, the development of rhinophyma (thickening of the nasal skin), and in rare cases granulomatous or fulminant forms.

Classification: Types and variants of rosacea

There are different classifications, but the most accepted is based on the predominant injury or symptom. The main types are:

1. Erythematous-telangiectatic rosacea

• Main symptoms: Persistent facial erythema and/or flushing. There are often marked telangiectasias and edema in the central regions of the face.
• The skin is especially sensitive and may experience itching, scaling, and a burning sensation.
• It is the most difficult form to control and the one that has the greatest impact on the patient's quality of life.
• It can also affect the neck, neckline and ears in certain cases.

2. Papulopustular rosacea

• Predominant symptoms: Inflammatory papules and pustules (similar to pimples, but without blackheads or whiteheads) located in the central area of ​​the face.
• Facial erythema is often present; telangiectasias are less common than in the previous variant.
• It can be easily confused with acne, but it does not present comedones.
• It is sometimes accompanied by prolonged facial edema (Morbihan disease).
• It is more common in adult women.

3. Phymatous rosacea

• Features: It mainly affects men.
• It presents thickening of the skin, increase in the size and number of sebaceous glands and dilated pores.
• Rhinophyma (nasal thickening) is the most common, although it can occur on the chin (gnathophyma), forehead (metofyma), ears (otophyma) and eyelids (blepharophyma).
• It may be accompanied by papules, nodules, telangiectasias and a sensation of an irregular, thick or "orange peel" skin surface.

Atypical manifestations and overlapping types

It is not uncommon for the same patient to present with signs of several types of rosacea simultaneously or successively. For example, phymatous rosacea often appears after years of erythematous or papulopustular forms. In childhood, the ocular form may be the only manifestation, making early diagnosis difficult. Furthermore, symptoms of seborrheic dermatitis or perioral, which further complicates the clinical approach.

rosacea diagnosis

The diagnosis is fundamentally clinically, based on the presence of persistent centrofacial erythema, flushing, telangiectasias, papules or pustules, absence of comedones and the location of the lesions. There are no specific laboratory tests nor diagnostic markers. The dermatologist may order tests to rule out other similar conditions, such as acne, lupus, seborrheic dermatitis, contact or perioral dermatitis, carcinoid syndrome, and connective tissue diseases.

• In cases of diagnostic doubt, especially in granulomatous forms, skin biopsies may be indicated.
• For eye involvement, consultation with an ophthalmology specialist is recommended.

Differential diagnosis

• Acne vulgaris: presence of comedones and usually affects adolescents and young adults.
• Seborrheic dermatitis: It causes redness and flaking, but is usually located on the scalp, eyebrows and oily areas of the face.
• Lupus erythematosus: facial erythema and skin lesions, but with systemic manifestations and other alterations.
• Perioral dermatitis: Small papules around the mouth and nose; may be related to the use of topical steroids and certain toothpastes.
• Contact dermatitis: redness, swelling, and itching as a reaction to an irritant or allergen.
• Others: mastocytosis, polycythemia vera, photoallergies, mixed connective tissue disease.

Psychological and social impact of rosacea

Beyond the skin symptoms, Rosacea profoundly affects the quality of lifeThe visible aspect of the disease causes insecurity, shame, anxiety, and, in extreme cases, depression. A high percentage of those affected report that their body image and self-esteem are severely affected. The professional and personal impact is undeniable, with some patients avoiding social gatherings or even losing job opportunities.

Psychological support and social assistance are essential to mitigate this impact and promote treatment adherence.

General management and recommendations for patients with rosacea

• Avoid triggers personal, paying attention to climatic, dietary and emotional triggers.
• Gentle hygiene: Regular cleansing with soap-free products specifically for sensitive skin, avoiding rubbing or irritating the skin.
• Suitable emollients and moisturizers to restore the skin barrier and minimize irritation.
• Daily photoprotectionUse broad-spectrum sunscreens (preferably containing titanium dioxide or zinc oxide and silicones to reduce irritation). SPF should be 50 or higher. Wearing hats and sunglasses is recommended.
• Non-comedogenic cosmetics, fragrance-free and oil-freeCorrective creams with a green tint can be used to camouflage erythema.
• Specific makeup To cover redness, improving physical appearance and confidence. Ideally, it should include sun protection.
• Avoid using irritating products such as astringent tonics, peels, aggressive exfoliants or abrasive masks.
• Record symptoms and possible triggers.

Therapeutic options for rosacea

The approach to rosacea should be customized according to type and severityThere are different treatment modalities:

1. Cosmetic care and general recommendations

• Photoprotection daily and systematic on the exposed areas.
• Frequent application of appropriate emollients and moisturizers.

2. Topical treatment

• Topical metronidazole: In cream, gel, or lotion form, it is the most widely documented. It is applied to papulopustular inflammatory lesions.
• Azelaic Acid: Available in 15-20% cream or gel. Effective in reducing inflammatory lesions and erythema.
• Topical ivermectin: useful for mild inflammatory lesions and to control the proliferation of Demodex.
• Topical brimonidine and oxymetazoline: alpha-adrenergic agonists that produce cutaneous vasoconstriction and are effective for persistent erythema.
• Other options: clindamycin, erythromycin, benzoyl peroxide (on non-sensitized skin), sodium sulfacetamide/sulfur, calcineurin inhibitors (with caution).

3. Oral treatment

• Tetracyclines (doxycycline, minocycline): fast and effective for moderate to severe inflammatory lesions, as well as ocular rosacea.
• macrolides (erythromycin, clarithromycin, azithromycin): indicated in cases of intolerance to tetracyclines.
• Oral metronidazole: reserved for specific cases.
• Oral isotretinoin: for severe, resistant, phymatous forms or granulomatous and fulminant variants.

4. Physical treatments and medical procedures

• Laser and intense pulsed light: fundamental in the control of erythema and telangiectasias, as well as in the treatment of rhinophyma and vascular lesions.
• Electrosurgery and cryosurgery: options for remodeling phymatous lesions.
• Blue light phototherapy: under development, effective for controlling erythema and burning sensation.
• Photodynamic therapy: useful in selected cases with associated actinic damage.

5. Surgery

• En phymatous rosacea severe: surgical resection, dermabrasion, cryotherapy, laser.

6. Treatment of ocular rosacea

• Daily hygiene of eyelids and eyelashes with wipes or gentle products.
• Artificial tears and lubricating drops to relieve irritation and dryness.
• Topical or oral antibiotics (tetracyclines, doxycycline) if there is severe inflammation.
• In severe cases, topical ophthalmic corticosteroids under medical supervision.
• Use sunglasses and protection against dust and wind.

New therapies and emerging treatments

• Latest generation lasers and advanced pulsed light: They allow deeper blood vessels and persistent lesions to be addressed with fewer side effects.
• Anti-inflammatory peptides and biological therapies: currently under investigation for resistant cases.
• Antagonists of flushing (such as beta blockers, clonidine, ondansetron): limited efficacy and use restricted to selected cases.

Practical recommendations for daily life

• Use warm water for facial hygiene and dry gently, without rubbing.
• Avoid hot baths, saunas and very hot environments.
• Do not manipulate injuries or seek aggressive "homemade" solutions.
• Consult a dermatologist regularly and follow their instructions.
• Seek psychological support if you feel emotionally affected.
• Keep a log of outbreaks and possible triggers to adjust your lifestyle.

Prognosis and evolution of rosacea

Rosacea is a chronic disease that requires prolonged and constant management. There is no definitive cure, but multiple alternatives to control symptoms and prevent the progression or worsening of the lesions. Most patients who are well advised and treated achieve significant improvement and a good quality of life.

Rosacea is a multifaceted condition that can affect the skin, eyes, and emotional state of those who suffer from it. Early diagnosis, control of triggering factors, cosmetic care, and adherence to medical treatments are key to managing the condition. Learn about different plant species It can help create environments that reduce some environmental triggers. Always consulting with a professional, individualizing treatment, and maintaining a healthy lifestyle are the pillars of living with rosacea and minimizing its impact.