Marie Nadeau, licensed aesthetician



A number of disorders with puzzling etiologies are growing to epidemic proportions. Today we’re going to talk about one that doesn’t get much press because it is not life-threatening. However, the fact that the skin disorder acne rosacea is estimated to afflict between 14 to 16 million Americans, with the number of sufferers growing by leaps and bounds, speaks to something rotten in the state of the union, to paraphrase Hamlet’s Marcellus. But before we explore why it might be that rosacea has joined the ranks of other diseases such as breast cancer and autism, disorders that are both mysterious in origin and growing in numbers, let’s look at what rosacea is.

Rosacea by Definition

The Journal of American Academy of Dermatology (United States), Apr 2002, 46(4) p584-7) gives us the following description:

"Rosacea is a chronic cutaneous disorder, primarily of the central face.

It is often characterized by remission and exacerbation and it encompasses

various combinations of such cutaneous signs as flush, erythema,

telangiectasias, edema, papules, pustules, ocular lesions, and rhinophyma.

Primary features considered as necessary for diagnosis include flushing,

erythema, papules, pustules, and telangiectasias. A variety of secondary

features are listed that may be absent or present as a single finding or

in any combination."

In other words, rosacea is a common, chronic, progressive inflammatory skin disorder based upon vascular instability. Primarily affecting the central part of the face, rosacea is characterized by facial flushing/blushing, facial redness, papules, pustules, and dilated capillaries. In severe cases, particularly in men, the soft tissue of the nose may swell, producing the bulbous enlargement known as rhinophyma-- two examples of rhinophyma are W.C. Fields, who had an extremely advanced case, and former President Clinton. A diagnosis of rosacea requires the presence of primary features such as flushing, facial redness, pustules and/or dilated capillaries. Ocular lesions, rhinophyma and/or swelling may or may not be present.

Rosacea generally occurs between the ages of 25 and 70 years, and is much more common in fair-complected people, in fact, it's often called the "Celtic curse." Women are more likely than men to have rosacea, although the disease is generally more severe in men. Rosacea is chronic, and can persist for years with periods of exacerbation and remission.

In addition to skin problems, up to 50 percent of people who have rosacea have eye problems caused by the condition. Typical symptoms of ocular rosacea include redness,

dryness, itching, burning, tearing, and the sensation of having sand in the eye. The eyelids may become inflamed and swollen. Some people say their eyes are sensitive to light and their vision is blurred or otherwise impaired.

The Acne Connection

Rosacea was originally called "acne rosacea" because its inflammatory papules and pustules so closely mimic those of acne vulgaris. Unlike acne vulgaris however, whose etiology is based on the interaction of abnormal keratinization, increased sebum production and bacterial-induced inflammation, rosacea's inflammation is vascular in nature. Rosacea is caused by the dilation of tiny microvessels called arterioles, capillaries, and venules, which occurs close to the surface of the skin. This causes the skin to break out with blotchy red areas called papules. A papule is a red solid elevated inflammatory skin lesion without pus (unless the papule is severe). These papules have three classifications; minor, moderate and severe. A minor Rosacea papule is the size of a small measles lesion. A moderate Rosacea papule is the size of a pencil eraser. A severe papule is the size of a coin and also contains pustules (pus-filled inflammatory bumps).

Because changes are gradual, rosacea may be hard to recognize in its early stages. Many people mistake rosacea for a sunburn, a complexion change, or acne--especially the latter, as some rosacea sufferers do have a significant acne component in their symptoms. A few discernible differences can help to make the correct diagnosis: rosacea usually does not present with the blackheads that are seen with acne vulgaris, the papules and pustules are less follicular in origin, the age of onset is older, and the location of redness is usually restricted to the nose, cheeks, chin and forehead. Rosacea will probably have an underlying redness that is related to flushing and thus will look different than acne vulgaris, as acne sufferers normally do not have the accompanying redness. Rosacea can develop gradually as mild episodes of facial blushing or flushing which, over time, may lead to a permanently red face.

The identifying features of rosacea are:

* a diffuse transient redness of the skin of the face and neck caused either by emotion (blush) or physical/external stimuli (flush), such as drinking hot liquids or eating spicy foods

*increased oiliness of the skin

*blemishes/pimples (papules and pustules)

*enlargement of the small blood vessels of the face (telangiectasias)

*increased pore size

*swelling of the skin, especially of the nose (rhinophyma)

*eye involvement (blepharitis, conjunctivitis, iritis, keratitis)

A predisposition to rosacea or "prerosacea" may be identified in the teens and twenties. The patient may have a family history of rosacea, easily blush, and frequently develop transient redness and/or burning and stinging in response to topical anti-acne medications or over-the-counter skin care products such as sunscreens, astringents, cleansers, perfumes, colognes or after-shave preparations. Without treatment, prerosacea (early rosacea) can progress through the three stages of rosacea that may eventually lead to severe facial disfigurement.

Stages of Rosacea

"Rosacea is primarily a disorder of the facial blood vessels. Experts from

across the world agree that vascular abnormalities are central to all

stages and symptoms of rosacea". --Beating Rosacea, Vascular, Ocular and Acne Forms, by Geoffrey Nase PhD, Nase Publications 2001.

Rosacea experts talk about rosacea symptoms appearing in 4 stages. Over time rosacea can progress from one stage to the next.

Pre-Rosacea: in the first cardinal sign of rosacea blood vessels dilate to

more stimuli, open wider and stay open for longer periods of time compared

to normal persons. No visible damage can normally be seen.

Mild Rosacea: begins when the facial redness induced by flushing persists

for an abnormal length of time - usually 1/2 an hour or more after a

trigger. Those who have frequent pre-rosacea flushing are highly

susceptible to progressing to mild rosacea.

Some of the common triggers for a facial flush are heat, cold, emotions,

exercise, topical irritants and allergic reactions.

Moderate Rosacea: as facial flushing becomes more frequent and intense,

vascular damage occurs. This can result in long lasting redness, swelling

and inflammatory papules and pustules. Telangiectasia (damaged micro blood

vessels, often visible on the surface of the skin) may be noticed in the

areas where flushing is worst.

Severe Rosacea: characterized by intense bouts of facial flushing, severe

inflammation, facial pain, swelling and burning sensations. Sufferers may

develop intolerance to products they were able to use before. Also

inflammatory papules, pustules and nodules may be present. Some experience

a bulbous enlargement of the nose known as rhinophyma.

Flushing—What Triggers It

A common denominator for rosacea sufferers is that they have more facial vessels or the vessels that they have are severely damaged. The result is that anything that stimulates facial dilation cannot be handled easily or properly. The more blood vessels one has near the surface of the skin, the more one is likely to flush and stay flushed. Rosacea is a progressive skin disorder unless treated. The blood vessels continue to grow with age and are stimulated and damaged by stress, food/drinks, dehydration, weather, sun exposure, abrasive soaps/exfoliating medications, hot bath, exercise, etc.

The following descriptions of flushing triggers should be considered in context--flushing occurs as part of a complex interaction of several systems.

Clock rosacea or systemic flushing- The body operate on a biological clock. Hospital medical staff have been aware for years that the lowest body temperature of the 24 hour day is usually around 3:00 to 4:00 A.M. while the highest temperature of the day is generally 7:00 to 8:00 P.M. The average rosacea sufferer does not have hospital waking and sleeping hours, therefore their temperature lows and highs may vary 3 to 5 hours each way. A high temperature for some may be as early as 3:00 P.M.

Nervous system flushing--Flushing usually occurs when the body becomes fatigued and/or stressed. This stimulates the autonomic sympathetic nervous system, specifically, the sympathetic postganglionic efferent nerves. Any activation of these nerves causes vasoconstriction of "body blood vessels" except in the "facial blush/flush areas" where it induces potent vasodilatation or flushing with the resulting "rosacea flush". The following events can stimulate the sympathetic nervous system to produce flushing.

Stress

Lack of sleep

Anxiety (fight or flight)

Increase in internal body temperature

Nervousness or embarrassment

The sympathetic nervous system is especially important to rosacea patients who tend to have one or more of the following:

* Genetically weak blood vessels

* Damaged blood vessels from years of sun

* Damaged support system for blood vessels (collagen-elastin of skin)

* Increased number of blood vessels.

Heavy meal flushing and sugar/carbohydrate flushing- This flushing or vascular dilation is caused by more stress on the digestive system resulting in a higher blood flow to the digestive system with the residual blood flow being heavier to the face. Remember that simple carbohydrates such as donuts, sugars, alcohol, etc. enter the blood stream quickly causing hyperglycemia (high glucose spikes). This rapid influx of sugar into the blood stream is a potent vasodilator.



Steroid flushing - "Never, never, never, ever prescribe steroids for rosacea" Dr.Kligman (Dermatology-University of Philadelphia) & Dr. Pleig (Dermatologische Klinik Und Poliklinik der Universitat Munchen, Germany) state in their 1973 book, Acne & Rosacea, First edition. Likewise, their second edition in 1993 harshly criticizes dermatologists who prescribe steroids for rosacea. Here is what they have to say:

“When a rosacea patient is erroneously treated for a prolonged time with topical steroids the disorder may at first respond, but inevitably the signs of steroid atrophy emerge with thinning of the skin and marked increase in telangiectases. The complexion becomes dark red with a copper-like hue. Soon the surface becomes studded with round, follicular, deep papulopustules, firm nodules, and even secondary comedones. The appearance is shocking with a flaming red, scaling, papule-covered face. Steroid rosacea is an 'avoidable condition' which in addition to disfigurement is accompanied by severe discomfort and pain. Withdrawal of the steroid is inevitably accompanied by exacerbation of the disease, a trying experience for a patient and physician. Always avoid steroids or cortisones for any purpose. If you are on them now, get off as quickly as possible as the body and skin continue to be further addicted to steroids or cortisones for any medical purpose. Most dermatologists know not to prescribe a steroid for rosacea." (1)

Adrenaline flushing - This kind of vascular dilation is caused by an adrenaline rush accompanied by immediate or instant flushing. It has the same appearance as that caused by sympathetic nerve involvement, but the main trigger here is hormone release. Stress is the body's reaction to a perceived threat. Adrenaline and hormones are released and the nervous system is activated to sharpen our senses, increase pulse rate, tense muscles and shut down the immune system. People under stress may experience fatigue, upset stomach, frequent headaches, and a flushing face.

Exercise flushing—as the cardiovascular system pumps harder and faster blood vessels dilate and cause flushing. Exercise should be done moderately in a cool area keeping the body well hydrated with water to minimize the redness.

Cigarette flushing –Smoking depletes the skin of vitamin C (essential for the formation of collagen), accelerates the cross linkage of collagen and the hardening of elastin, and creates free radicals which destroy capillary structures. Smoking robs the skin of oxygen and is a potent initiator of telangiectasis. In addition, the smoker may have a variety of medical problems such as high blood pressure and mineral deficiencies which can cause the appearance of telangiectasis.

Hot shower/bath flushing --The stimulation of hot showers/baths causes vascular dilation.

Alcohol flushing - There are several factors that contribute to alcohol flushing. First of all, allergy redness can result from drinking beer and red wine. In addition, alcohol is a diuretic which pushes water out of the body cells. In this state of dehydration the body is prone to flushing. Besides the above, alcohol is a concentrated source of calories and is metabolized very quickly, causing the blood vessels to dilate.

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Chilly or cold weather flushing -- These flushing flare ups result from coming in from the cold into a warm room. When the rosacea sufferer is outside in the cold weather the cardiovascular system is pumping hard, however, due to conservation of energy the extremities such as the feet, hands, ears, and nose get less blood supply than the rest of the body. When this person enters a heated room the warmer temperatures quickly warms the facial skin areas and extremities while the cardiovascular system is still in a moderately high exercise mode.

Pollen and contact flushing - Spring in most countries is the time for pollen and mold spores, which can affect many rosacea sufferers.

Sun exposure flushing-- All forms of ultraviolet radiation are believed to contribute to the development of skin cancer, and likewise cause havoc for the rosacea sufferer.

UVA rays constitute 90-95% of the ultraviolet light reaching the earth. They have a relatively long wavelength (320-400 nm) and are not absorbed by the ozone layer. UVA light penetrates the furthest into the skin and is involved in the initial stages of suntanning. UVA tends to suppress the immune function and is implicated in premature aging of the skin.

UVB rays are partially absorbed by the ozone layer and have a medium wavelength (290-320 nm). They do not penetrate the skin as far as the UVA rays do and are the primary cause of sunburn.

UVC