Introduction

Red skin, visible blood vessels and pus-filled spots on the face are all typical symptoms of rosacea. This is a common facial skin inflammation that typically comes and goes in episodes.

Like any visible skin condition, rosacea can affect your wellbeing and self-esteem. But a lot of people aren’t aware that the blotchy red skin on their face is caused by a treatable condition. There are various ways to reduce the inflammation and prevent flare-ups.

Symptoms

Rosacea is a chronic, non-contagious inflammation of facial skin. It varies in severity and can affect the cheeks, chin, forehead and nose. Less commonly, it can also cause inflammation on the scalp and the skin on the back of your neck or on your chest.

Rosacea is often divided into four different types:

• Type 1 – vascular rosacea: Red areas of skin on the face, sometimes small blood vessels are visible.
• Type 2 – inflammatory rosacea: As well as facial redness, there are red bumps (papules) and pus-filled spots (pustules).
• Type 3 – phymatous rosacea: The skin thickens and may become bumpy, particularly on the nose.
• Type 4 – ocular rosacea: This type of rosacea leads to inflammations of the eyes and eyelids (blepharitis), sometimes with no noticeable skin symptoms.

The skin may also become dry, a little swollen, flaky and burn or itch. It is more sensitive and more irritable than healthy skin.

The symptoms of rosacea can vary quite a lot from person to person, and people often have a combination of the above-described types. So these four types are meant to serve only as a general guide. The treatment approach will always be mainly determined by your individual symptoms and skin changes.

Type 1 and type 2 rosacea (varying degrees of severity)

Type 3 and type 4 rosacea

Causes

The exact cause of rosacea is not clear, but the following factors are probably involved:

• Inflammatory and immune responses
• Changes in the blood vessels in the skin
• Genetic predisposition (your genes)
• Problems with the skin's natural ability to protect itself
• Hypersensitivity to certain mites that live near hair follicles (called Demodex mites) or bacteria

Possible triggers of rosacea flare-ups include sunlight, extreme heat or cold, and stress.

The long-term use of steroid medication can lead to rosacea-like symptoms. But this risk is very low if steroids are used properly.

Although rosacea can cause pus-filled spots on the skin, it isn't a form of acne. Unlike acne, rosacea isn’t associated with the production of too much oil in the skin.

Prevalence

Rosacea usually develops in people over the age of 30. About 2 to 5% of all adults in Germany are affected. It is more common in women and light-skinned people.

Outlook

Rosacea symptoms often come and go in episodes: There are periods when the symptoms are more severe, and there are periods when they improve or go away.

The skin may change over time, and other symptoms might appear. But they often stay the same for a long time.

Effects

Sometimes the changes in the skin and the overgrowth of skin tissue may cause the nose to become larger and bulbous. Known as rhinophyma, this is more common in men. It can be very distressing, especially if it changes the shape of the nose a lot.

If rosacea affects the eyes, it can cause them to water, turn red and itch. They may become more sensitive to light, too. If the sebaceous glands in the eyelids become blocked, the eyes may be dry. Other parts of the eye may become inflamed as well, including the edge of the eyelid, the cornea, and the conjunctiva (the membranes lining the visible part of the eyeball and the inner surface of the eyelids). This can be painful. It sometimes feels like you have something in your eye.

In very rare cases, complications directly affecting the eye, such as keratitis (inflammation of the cornea) may occur. Keratitis is an emergency because it can cause loss of vision. Possible signs include pain or the feeling that you have something in your eye, vision problems or changes in the cornea or the vitreous body (the gel that fills the eyeball). It's important to see an eye doctor quickly if you have these symptoms!

Diagnosis

Dermatologists (skin doctors) can tell whether you have rosacea based on the typical changes in the skin's appearance. If one of your eyes is also affected, it's usually a good idea to see an eye doctor too.

Prevention

To prevent the symptoms from coming back, good skin care is recommended. That includes protecting your skin from the sun, using soap-free cleansing products with a low pH, and avoiding irritants.

Possible irritants in skin care products might include alcohol, camphor, menthol, mint, eucalyptus, perfumes, fruit acids and substances used for chemical or mechanical peeling.

It's best to use lukewarm or cool water to wash your face and then dry it by gently dabbing it with a towel. If the water is too hot or too cold, it can trigger skin redness or make it worse.

If your skin is too dry, moisturizers can help. They also relieve itching and prevent the skin from cracking, which makes inflammation more likely.

It is often possible to find out what triggers are responsible for the flare-ups. Generally speaking, anything that can cause your face to flush might make the rosacea worse too. Typical triggers include the following:

• Alcohol
• Hot drinks
• Certain medications, e.g. drugs that dilate (widen) blood vessels
• Hot spices and spicy foods
• Sunlight
• Extreme temperatures

Keeping a rosacea diary can help you to find out what may be triggering your migraines. If you know what the triggers are, you can at least try to avoid some of them when possible.

Treatment

More severe skin problems can be treated with medication. Usually, it's enough to use medications that you can apply to your skin. The most suitable medications will depend on what kind of symptoms the rosacea is causing:

• A gel containing brimonidine is effective against reddened skin.
• Creams or gels based on the drugs azelaic acid, ivermectin or metronidazole help to reduce nodules and pimples.

If topical treatment for nodules and pimples doesn't help enough, you can take the anti-inflammatory antibiotic doxycycline in tablet form.

Nose-related symptoms (rhinophyma) can be treated with oral medication or surgery. This will also depend on whether the skin on your nose is "merely" inflamed, or whether visible growths have developed.

Everyday life

Although rosacea is usually harmless, having a red face or nose can affect your psychological wellbeing. It's not uncommon to be stared at, or to realize that others suspect that your nose might be red because you drink too much alcohol. These reactions usually occur because rosacea isn’t a well-known condition. So it can help to be open about the skin condition and tell your family, friends and colleagues what it is.

If the redness in your face is very noticeable, you can cover it up using a skin-friendly foundation or concealer. But doctors advise against using oily or greasy products: These irritate the skin even more because they are harder to remove. Products that have a greenish hue can help because the color balances out the redness caused by the rosacea. A dermatologist can help you to choose the right products.

Further information

When people are ill or need medical advice, they usually go to see their family doctor first. Read about how to find the right doctor, how to prepare for the appointment and what to remember.

Sources

• Augustin M, Herberger K, Hintzen S, Heigel H, Franzke N, Schafer I. Prevalence of skin lesions and need for treatment in a cohort of 90 880 workers. Br J Dermatol 2011; 165(4): 865-873. [PubMed: 21623753]
• National Rosacea Society (USA). Patients’ perspectives: living with rosacea. Dermatol Nurs 2007; 19: 105-110.
• Rebora A. Papulopustular rosacea. In: Williams H, Bigby M, Diepgen T, Herxheimer A, Naldi L, Rzany B (Ed). Evidence-based Dermatology. London: Blackwell Publishing; 2008. pp. 105-110.
• Van Zuuren EJ. Rosacea. N Engl J Med 2017; 377(18): 1754-1764. [PubMed: 29091565]
• Van Zuuren EJ, Fedorowicz Z, Tan J, van der Linden MM, Arents BW, Carter B et al. Interventions for rosacea based on the phenotype approach: an updated systematic review including GRADE assessments. Br J Dermatol 2019; 181(1): 65-79. [PMC free article: PMC6850438] [PubMed: 30585305]

• IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

  Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. We do not offer individual consultations.

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