What is Rosacea?

Definition by a famous dermatologist:
Rosacea is a chronic (long term) skin disorder that most often affects the nose, forehead, cheekbones, and chin (Dr. Berasques).

Groups of tiny microvessels (arterioles, capillaries, and venules) close to the surface of the skin become dilated, resulting in blotchy red areas with small papules (a small, red solid elevated inflammatory skin lesion without pus, that is minor when the size is of a small measles lesion, moderate when about the size of a pencil eraser, and severe when the papule is the size of a small currency coin or the tip of the little finger) and pustules (pus-filled inflammatory bumps). The redness can come and go, but eventually it may become permanent. Furthermore, the skin tissue can swell and thicken and may be tender and sensitive to the touch.

Note:
Pustules are NOT pimples. Pimples have a bacterial component to their pathogenesis and are also mainly localized in and around the hair follicles.

The inflammation of rosacea can look a great deal like acne, but blackheads and whiteheads are almost never present. It is a fairly common disorder -- about one in every twenty Americans is afflicted with it (Drs. Faria and Edward).

Rosacea Flushing:
Rosacea usually begins with frequent flushing of the face, particularly the nose and cheeks. This facial flushing is caused by the swelling of the blood vessels under the skin. This "red mask" can serve as a flag for attention. Telangiectasis is easy to recognize, characterized by the visible presence of capillaries, bright red in color.

Diffuse redness frequently precedes the appearance of telangiectasis and is a constant flushed appearance. True diffuse redness is quite different from a localized erythema as seen in cases of sunburn, inflammation or over stimulation. With both telangiectasis and diffuse redness, the redness is not transitory and there generally is not an increase in skin temperature, but particularly there are no alterations in the tissue structure or biochemistry as seen in rosacea. The circulatory network of the skin is extensive and the capillaries are the smallest, most delicate vessels.

During normal blood circulation the capillaries undergo constant changes. In between beats the pressure is relieved and the vessels constrict back to their normal size. This return to normal size is accomplished by the natural elasticity in the structure of the capillary. If telangiectasis is present, the capillaries' elasticity is deteriorated so they remain slightly dilated.

The constant influx of blood perpetuates this slight dilation. The skin gradually becomes congested and eventually the capillaries become visible through the skin's surface. When it comes to telangiectasis, sometimes a person's lifestyle and habits can be the skin's worst enemy.

In a fair, delicate skin predisposed to telangiectasis, a steady diet of hot, spicy food, chronic alcohol consumption and eating meals too quickly will promote telangiectasis. And many retinoids used for acne as well as many harsh soaps continue to aggravate the skin.

Ocular Rosacea:
Rosacea can also cause a persistent burning and feeling of grittiness in the eyes or inflamed and swollen eyelids with small inflamed bumps, eyelashes sometimes fall out, compounded by bloodshot eyes. (Dr. Thiboutot).

The ophthalmic signs are exceedingly variable, including blepharitis, conjunctivitis, iritis, iridocyclitis, hypopyoniritis, and even keratitis. The term ophthalmic rosacea covers all these signs. The ophthalmic complications are independent of the severity of facial rosacea. Rosacea keratitis has an unfavorable prognosis, and in extreme cases can lead to corneal opacity with blindness. The most frequent signs, which may never progress, is chronically inflamed margins of the eyelids with scales and crusts, quite similar to seborrheic dermatitis, with which it is often confused. Pain and photophobia may be present. It is instructive to ask rosacea patients how their eyes react to bright sunlight. (Drs. Gerd Plewig & Albert M. Kligman).

Rosacea flushing can be triggered by many factors, such as sunlight, physical or mental stress or fatigue, consumption of fatty (or acidic) foods, drinking alcohol or caffeinated beverages, and extremes in temperature. It is important to note that each patient reacts to rosacea triggers in different ways; what triggers one person's rosacea may not trigger another person's rosacea. The most important link between all of these factors is that they are acidic on the pH scale. Our body naturally wants to be pH neutral or alkaline. When we are exposed to our rosacea triggers, the natural balance is thrown off and the immune system reacts causing rosacea redness. The good news is that you can buffer or offset the acidic triggers by consuming more alkaline foods and drinking water.

Stages - Plewig and Kligman Classification of Rosacea

Stage I: The erythema may persist for hours and days, hence the old term erthema congestivum. Erythema lasting only a few minutes is not early rosacea. Telangiectases becomes progressively prominent, forming sprays on the nose, nasolabial folds, checks, and glabella. Most of these patients complain of sensitive skin that stings, burns, and itches after application of a variety of cosmetics, especially certain fragrances and sunscreens. Trauma from abrasives and peeling agents readily induces long-lasting erythema, thus the facial skin is unusually vulnerable to chemical and physical stimuli.

Stage II: Inflammatory papules and pustules crop up and persist for weeks. Some papules show a small pustule at the apex, justifying the term papulopustular. The lesions are always follicular in origin, mainly in sebaceous follicles but also in the smaller and more numerous vellus follicles. Comedones do not occur. The deeper inflammatory lesions may heal with scarring, but scars are inconspicuous and tend to be shallow. Facial pores become larger and prominent. If there has been much solar exposure over decades, the stigmata of photodamaged skin becomes superimposed, namely yellowed, leathered skin (elastosis), wrinkles and solar comedones. The papulopustular attacks becomes more and more frequent. Finally, rosacea may extend over the entire face and even spread to the scalp, especially if the patient is balding. Itchy follicular pustules of the scalp are typical. Eventually, the sides of the neck as well as the retroauricular and presternal area may be affected.

Stage III: A small proportion of patients goes on to develop more serious expressions of the disease, namely large inflammatory nodules, furunculoid infiltrations, and tissue hyperplasia. These derangements occur particularly on the cheeks and nose, less often on the chin, forehead, or ears. The facial contours gradually become coarse, thickened, and irregular. Curiously, patients may not notice these disfigurements. The deranged appearance becomes evident when photographs from previous years are reviewed. Finally, the patient shows diffusely inflamed, thickened, edematous skin with large pores, resembling the peel of an orange. These coarse features are due to extensively inflammatory infiltration, connective tissue hypertrophy, massive fibrosis and elastosis, diffuse sebaceous gland hyperplasia, and extreme enlargement of individual sebaceous glands forming dozens of yellowish unbilicated papules on the cheeks, forehead, temples, and nose. Thickened folds and ridges may create a grotesque appearance mimicking leonine facies of leprosy or leukemia. The ultimate deformity is the phymas, of which rhinophyma is the prototype. (Drs. Plewig & Kligman)

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This page was last updated on July 9, 2008 .

Definition, Stages & Classification