Rosacea: Types, Signs, and Treatments
Rosacea is one of the most common skin conditions. According to statistics from 2010, it affects an estimated 16 million people in the United States alone.
This article provides details about the four types of rosacea, including their symptoms, causes, and treatment options. It also offers pictures of each type.
Rosacea is a chronic inflammatory skin condition that affects the face. Rosacea is usually on the cheeks and nose, but it can also occur on the chin, forehead, and eyelids.
This condition may cause general facial discoloration or bumpy eruptions that look like acne. The discoloration of the skin may extend to the back, chest, and ears.
Treatment can control rosacea symptoms. Without treatment, the condition will worsen. Rosacea is not the same condition as acne, and it is not treatable with over-the-counter (OTC) acne medications.
Rosacea generally affects people with fair skin who blush easily. It is most common in people ages 30–50 years.
It occurs more frequently in females than males, but males with rosacea tend to experience more severe symptoms. Females more often have cheek and chin involvement, whereas males have more nose involvement.
Rosacea often begins with easy blushing and flushing of the facial skin. These symptoms may come and go at first. Eventually, discoloration persists around the nose, extending to the rest of the face.
As rosacea progresses, additional facial symptoms — such as burning, stinging, pimples, swelling, dry skin, enlarged blood vessels, and eye involvement — may occur.
Combinations of these symptoms fall into four subtypes, which are as follows.
Subtype 1, facial redness (erythematotelangiectatic rosacea)
This stage of rosacea is also known as neurovascular rosacea. This subtype is characterized by the following symptoms:
- Flushing or continuous facial redness occurs.
- Small blood vessels are visible, especially spider veins around the nose and cheeks.
- The skin may be swollen, dry, rough, or scaly.
- The skin may be sensitive or feel like it is burning or stinging.
Subtype 2, bumps and pimples (papulopustular rosacea)
This subtype is characterized by the following symptoms:
- Pimples occur, and pus-like lesions may be present.
- Some people experience facial redness and enlarged facial blood vessels.
- The skin may feel like it is burning and stinging.
- Raised red patches called plaques are possible.
Subtype 3, enlargement of the nose (phymatous rosacea)
Without treatment, rosacea can progress to phymatous rosacea. With this rare subtype:
- The skin begins to thicken and develops an irregular texture.
- Thickening is most evident on the nose but can also occur on the ears, chin, cheeks, and forehead.
- Enlarged skin pores and large blood vessels are also possible.
Subtype 4, eye irritation (ocular rosacea)
This rosacea subtype is a serious eye condition. It may affect one or both eyes.
This subtype is characterized by the following symptoms:
- The eyes may be bloodshot, teary, itchy, dry, burning, or stinging.
- Your vision may be blurred, and you may have decreased vision.
- There may be a bacterial infection of an oil gland or eyelash follicle in the eyelid margin.
- The eyelids can become swollen.
- It is common to feel as though you have sand or grit in the eye.
Rosacea in people with skin of color
Skin redness and flushing may not be obvious in people with certain skin tones who develop rosacea. To prevent misdiagnosis, be aware of the other symptoms of rosacea, which include:
- skin warmth
- burning or stinging skin
- dry patches of swollen skin
- pimples that do not clear up with OTC acne treatments
- changes in skin texture, especially around the cheeks, nose, forehead, or chin
- hard bumps around the eyes or mouth that are yellowish-brown
Symptoms that might indicate a serious condition
In some cases, rosacea can be a serious condition that requires prompt evaluation. Seek immediate medical care for any of these serious symptoms:
- a bacterial infection of an oil gland or eyelash follicle in the eyelid margin
- persistent enlarged tissue of the nose
- red, sore eyes
- skin eruptions that ooze or crust
- skin tingling or burning
- vision changes
The cause of rosacea is not known. Researchers have been searching for what causes rosacea, but there are only theories so far. The main theories involve increased blood flow and inflammation.
The discoloration and flushing typical of rosacea may result from blood vessels that open too widely. This is called vasodilation, and it may also account for the tiny blood vessels that are visible under the skin.
Inflammation may be at the root of the skin thickening, bumps, and pimples that some people develop with rosacea. Inflammation is an immune system response that results in irritation and swelling.
Some possible causes of rosacea include the following.
Inherited variations of genes may increase the chance of developing rosacea. For example, if you are born with a tendency to blush easily, this blushing may develop into rosacea over time.
Experts suggest that this may happen when dilated blood vessels leak and cause thickening and damage to the skin.
An immune reaction to skin mites or mite bacteria
Skin mites are tiny organisms that normally live on your skin in hair follicles where rosacea occurs. Some older studies suggest that people with rosacea have more of these mites than people who do not have rosacea.
Rosacea may be a reaction to the mites or the bacteria (Bacillus oleronius) that live inside the mites. This may trigger the immune system to prompt inflammation, leading to skin discoloration, swelling, bumps, and pimples.
An immune reaction to gastrointestinal bacteria
Helicobacter pylori bacteria live in the upper digestive tract. They can cause acid reflux and stomach ulcers, but they may also play a role in several types of inflammatory skin conditions, including hives, psoriasis, and rosacea.
H. pylori may cause the immune system to produce substances called reactive oxygen species. These substances increase inflammation of the skin.
Some studies suggest that people with rosacea are more likely to have H. pylori infections than people who do not have rosacea. This may be another reason that some people with rosacea get better with antibiotics. However, many people with rosacea do not test positive for H. pylori.
Problems with the skin barrier
A protein called cathelicidin normally protects the skin from infection. Some studies suggest that people with rosacea have too much of this protein in their skin.
Normally, inflammation is the immune system’s way of getting rid of germs and other foreign invaders. However, this protein causes an overreaction of the immune system, which may lead to flushing, blood vessel dilation, and swelling.
Other possible causes
Other possible causes or contributing factors include:
- abnormal regulation of blood vessels by the nervous system
- consumption of hot drinks or alcohol
- emotional stress
- environmental triggers, such as sun, wind, and extreme hot and cold temperatures
- low levels of vitamin D
- repeated skin damage from the sun’s UV rays
- skin care products, especially oil-based products
- vigorous exercise
The true cause of rosacea remains unknown. There may be more than one cause, and the cause or causes may be different for different people.
Rosacea is a common skin condition that can affect almost anyone. However, some people are more at risk than others.
Knowing the factors that increase your risk of rosacea can help you be alert for early warning signs and symptoms of the condition. This is important because early diagnosis leads to early treatment.
Rosacea can occur at any age. Although children sometimes get rosacea, people most often develop it at 30–50 years old.
Rosacea is more common in females, and many first experience the condition when going through menopause. Males tend to have a more severe presentation of the condition.
People of all races and ethnicities can develop rosacea, but the risk is higher for people of Northern European or Scandinavian descent.
A number of factors can increase the risk of developing rosacea. Keep in mind that not all people with risk factors will get rosacea. Some risk factors for rosacea include:
- easy blushing or facial flushing
- fair skin, blue eyes, or blond hair
- a family history of rosacea
- a personal or family history of severe acne
Some studies suggest that making certain dietary changes has a role in managing rosacea. There is no special diet for rosacea, however, as the foods and beverages that can trigger its symptoms are different for different people.
The National Rosacea Society (NRS) compiled a list of food triggers identified by people with rosacea. Changing your diet to exclude these items could reduce your symptoms or limit the frequency of rosacea flare-ups. Some of the more common culprits to avoid include:
- alcohol, especially red wine, beer, champagne, and spirits
- chocolate and cinnamon, both of which contain cinnamaldehyde
- citrus fruits and tomatoes, which also contain cinnamaldehyde
- hot coffee and tea
- marinated meat
- spicy foods, garlic, and mustard oil
- vinegar and soy sauce
- yogurt, sour cream, and cheese
Rosacea and gastrointestinal conditions
Some research suggests a connection between rosacea and the gut microbiome. Specifically, people with rosacea have a greater likelihood of also having a gastrointestinal condition. Also, treating an overgrowth of bacteria in the small intestine can improve rosacea symptoms.
There is still much to learn about the role of gastrointestinal health in rosacea. However, consuming a diet that promotes a healthy gut microbiome may help people with rosacea.
Fiber is the main component of a healthy microbiome diet. A fiber-rich diet that may improve the overall health of the gut includes:
- complex carbohydrates, such as sweet potatoes
- foods with active bacterial cultures, such as yogurt
- However, avoid yogurt if this food is a rosacea trigger for you.
- healthy fats, such as fish, avocados, nuts, and seeds
- lean proteins
- probiotic supplements
- unprocessed foods
- whole grains
Ask your healthcare professional for guidance before making any significant changes to your diet.
Healthcare professionals can typically diagnose rosacea by examining the skin and eyes. This healthcare professional is usually a dermatologist. If your symptoms involve your eyes, you should contact an ophthalmologist.
There is no medical test capable of diagnosing rosacea. However, depending on your symptoms, your doctor may order skin and blood tests to rule out other possible conditions before diagnosing rosacea.
Your healthcare professional will likely ask you questions about your symptoms, medical history, and family history. Their questions may include:
- How long have you been experiencing these symptoms?
- Does your skin feel hot, like it is sunburned?
- Do you have a history of acne?
- Do you have a family history of skin conditions, including acne and rosacea?
- When do your symptoms occur?
- Do certain foods and drinks worsen your symptoms?
- Do certain activities or environments worsen your symptoms?
- Have you been under a lot of stress recently?
As part of your treatment plan, your healthcare professional will help you identify your potential triggers for rosacea so that you can reduce flare-ups. Your dermatologist may ask you to maintain a symptom diary to pinpoint your triggers and determine the pattern of your rosacea outbreaks.
Medical treatments for rosacea include the following.
Oral antibiotics for rosacea treatment
You can take oral antibiotics for rosacea by mouth. The course of treatment generally lasts for as long as it takes for your rosacea symptoms to lessen. Oral antibiotics for rosacea include:
- doxycycline (Monodox)
- minocycline (Minocin, Dynacin)
Topical treatments for rosacea
You can apply topical treatments for rosacea directly to your skin, and these are best for minor flare-ups. Topical treatments for rosacea include:
- azelaic acid (Finacea)
- isotretinoin (Accutane)
- metronidazole (Metrocream, Metrogel)
- sulfacetamide sodium/sulfur
- vitamin A
Procedures for rosacea
Laser and light-based treatments can reduce discoloration by treating visible blood vessels.
Also, surgical procedures can help reduce redness, remove damaged skin, or destroy damaged tissue with electricity. Surgery is generally reserved for very severe cases of rosacea. Surgical options for rosacea include:
- CO2 fractional laser
- laser surgery
Treatments for ocular rosacea
Ophthalmologists treat ocular rosacea. They may prescribe an eye medication or eye drops and suggest gently washing your eyelids several times per day. Applying warm compresses can also ease the symptoms.
Home remedies and self-care for rosacea
Strategies that may help prevent or limit rosacea outbreaks include:
- avoiding direct sunlight and temperature extremes
- avoiding OTC treatments that may contain ingredients that will make rosacea worse
- exercising without straining or weightlifting
- following the rosacea skin care and treatment plan that your healthcare team designs
- limiting spicy foods, hot beverages, and alcohol
- reducing stress, such as by getting restful sleep, engaging in physical activity, and meditating
- seeking treatment promptly, as untreated rosacea can worsen
- using mild cleansers and a soft cloth to wash your face, taking care not to scrub
- wearing a hat, sunglasses, and sunscreen when outdoors, even on cloudy days
Alternative treatments for rosacea
Anecdotal evidence suggests that these substances may have a positive effect on rosacea:
- nicotinamide, which is a vitamin with anti-inflammatory properties that is present in some skin care products
- omega-3 fatty acids, which are a type of healthy dietary fat that is also available as a supplement
- probiotic supplements, which can improve the balance of healthy to unhealthy bacteria in the body
- skin care products that contain anti-inflammatory agents, such as chamomile or Quassia amara
- zinc supplements, though studies investigating zinc and rosacea are not conclusive
Check with your dermatologist before taking oral supplements or applying alternative topical treatments to your skin. They may interact with medications you are taking for rosacea.
Many people with rosacea say that the condition affects their quality of life. In surveys sponsored by the NRS, almost 70% of respondents claimed that the effect of rosacea on their appearance had reduced their self-esteem and confidence. Additionally, 30% of respondents said that they had missed work because of their severe rosacea symptoms.
In social settings, people with rosacea may experience anxiety or feel embarrassed about facial discoloration and flushing. Other people may interpret this outward symptom as the result of having consumed too much alcohol.
Some people are concerned about their rosacea worsening, getting scars, and the side effects of the medications they use to treat rosacea.
The NRS surveys also suggested that participants’ social and emotional health improved with rosacea treatment. With fewer flare-ups and clearer skin, people with rosacea may be more motivated to interact with others in person, both socially and professionally.
Rosacea is a common inflammatory skin condition. There is currently no cure for rosacea, but getting early treatment is the best way to control it. Strategies that may help with rosacea flare-ups and symptoms depend on the type of rosacea you have and your individual triggers.
Oral and topical treatments are common remedies for rosacea. In severe cases, surgery may be necessary.
Learning more about rosacea may help you understand your potential triggers and inform treatment decisions.