Rosacea | A complete guide to understanding your diagnosis

Updated: Nov 13

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What is Rosacea?



It’s best to think of Rosacea as a 'reactive' skin condition. The skin reacts to a trigger to result in dilation of the blood vessels and result in an increased sensitivity of the skin overall. Because of this, rosacea causes can vary.



 
RELATED | Dr. Erum Ilyas discusses Rosacea with Everyday Health



 




What are triggers for Rosacea?



Rosacea triggers include anything that makes the skin sensitive to reflexively lead to blood vessels dilating which results in flushing or blushing followed potentially by breakouts. Since rosacea is a chronic condition, although we have many treatments meant to control the symptoms, ultimately it is best managed by avoiding triggers.

High histamine foods can also cause vasodilation or a relaxation of the blood vessels. These include:

  • Alcohol

  • Smoked meats

  • Shellfish

  • Canned foods

  • Legumes


This can only exacerbate or make rosacea flare. Since high histamine foods can trigger rosacea it is best to try to find to consider dietary changes if you find a connection.




Does inflammation play a role in rosacea?



There are so many dietary fads and trends focused on inflammatory foods and anti-inflammatory diets. A day does not go by where I am not asked what role inflammatory foods play in various skin conditions.



 
RELATED | Dr. Erum Ilyas discusses Rosacea with Everyday Health


 


When it comes to rosacea, the key is avoidance of foods that result in flushing as a result of dilating our blood vessels. There are some studies that have linked a higher prevalence of GI disorders and bacterial overgrowth in our gut to flaring rosacea. Along these lines, a diet high in fiber may actually help reduce flares and reduce inflammation. This is referred to as a “prebiotic” diet.

A prebiotic diet is rich in fiber that is not processed until it gets to the colon. Probiotics are the “good” bacteria for your colon. Prebiotic foods feed or support probiotics. Prebiotic fibers include:

  • Onions

  • Raw garlic

  • Bananas

  • Endives

  • Asparagus

  • Whole grains


How can I tell if I have a dietary trigger for my rosacea?

Identifying triggers for rosacea can be difficult. Sometimes the initial flushing is missed as people are more often bothered by breakouts that can follow a few days later. There can be a delay in seeing the breakouts that make it tougher to tie back to specific foods. When trying to identify triggers, it helps to get out a traditional month-at-a-glance calendar and track the worst days for rosacea flares. Focusing on routine aspects of your diet is far more helpful than the random menu item you happen to choose while on vacation. Many of my patients note early in the week flares. Sometimes this is triggered more by red wine with a weekend dinner.

If your rosacea is flaring early in the week but settles down through the week, focus on your weekend habits. If you start the week out great but feel like your skin spirals out of control during the week, take a good look at your routine habits during the week. Consider how excess coffee or caffeine or lunch at work may play a role.
Sometimes the issue is less dietary and more stress-related. This is worth keeping in mind if your flares are isolated to just a few days a month on your calendar but show no other signs of consistency.



 
RELATED | Dr. Erum Ilyas discusses Rosacea with Everyday Health


 



Can anyone get Rosacea?



Although traditionally many people think of rosacea as primarily affecting people of Northern European ancestry, I would argue that it is underdiagnosed and flat-out missed in almost every other ethnicity. I routinely have patients of color that have seen numerous other doctors and had their diagnoses missed simply because their skin type did not show the classic “rosy cheeks” because it's not as apparent. As a dermatologist of color, I always worry that our resident physicians are not taught to look for other signs and symptoms of rosacea outside of rosy cheeks to accurately make a diagnosis.


Most of my patients of color are only diagnosed with rosacea once it has become severe with potential scarring. The key to diagnosis is to ask good questions and not just go by the visual appearance of the skin.

  • Does your skin sting, burn, or feel warm to the touch when you drink alcohol, eat spicy foods, or are you in stressful situations?

  • Do you have breakouts that kind of look like acne but do not behave like acne- i.e., when you try to pop a pimple nothing comes out of it- just clear fluid AND it looks worse after?!

  • Does the skin on your cheeks have an “orange peel” look with the pores looking widened and skin somewhat thickened?



What is ocular rosacea?



Ocular rosacea is a form of rosacea that affects the eyes. It can affect about 50-70% of patients with rosacea. It may or may not be associated with rosacea of the skin. There is no specific diagnostic test for ocular rosacea.

Ocular rosacea is characterized by:

  • Bloodshot eyes

  • Excess dryness

  • Gritty or foreign body sensation

  • Itching

  • Photophobia

  • Fear of lights.


Untreated ocular rosacea can result in eyelid and eye surface inflammation that can involve the cornea and even affect vision over time. The treatment of choice is oral doxycycline.


Is there a cure for rosacea?




Rosacea can vary in its progression and appearance but for many, it's a chronic progressive disease. It can start with flushing or blushing that comes and goes, then this starts to stick around. As it fluctuates people struggle with their skin feeling oily but also flaky or dry.


What is the classic progression of rosacea?



Classically they will say they put on moisturizer and an hour later their skin is flaky again. It’s challenging to figure out if they should moisturize or dry out their skin.

This phase turns into breakouts that look like acne but do not behave like acne (you go to pop a “pimple” but they don’t really come to a head- they just get angrier at you). This is followed by the skin starting to swell or thicken and taking on a p’eau d’orange or orange-peel skin appearance with widened patulous pores. If it continues then the skin can become even thicker and result in “phymatous” changes. This is the classic “WC Fields” nose but can also occur on the chin, cheeks, or forehead. Early diagnosis and treatment are key to controlling the progression of this chronic disease! Ultimately the potential for scarring or at the very least permanent changes to the overall appearance of the skin can occur.


I have definitely used and recommended this treatment in specific circumstances such as sudden onset of rosacea not otherwise explained or in those resistant to other treatments. It’s safe, effective and well tolerated. Even if it doesn’t work, it helps to address this as a potential cause directly.


How can I tell if I have Rosacea or Acne?

Differentiating between acne and rosacea is essential to find a treatment plan that works. Most of my rosacea patients misinterpret the ‘breakouts’ they get as acne and resort to OTC acne products. The breakouts from rosacea are different, however, and can often worsen with the use of traditional acne products. Acne is based on clogged pores referred to as comedones. These clogged pores result from an overproduction of oil or sebum that gets ‘stuck’ inside the pores. Most acne products are focused on exfoliating the skin, unclogging the pores, and reducing oil production. All the things that acne treatments to do treat acne only make rosacea worse! Rosacea is best thought of as overly sensitive skin. The skin flushes easily in response to heat, stress, spicy foods, and a variety of other triggers.



How are breakouts with Rosacea different from Acne?

Although we can get breakouts with rosacea, they are not the same. Anyone with rosacea that has tried to ‘pop’ their pimples will tell you it doesn’t work! Maybe you will get some clear fluid out of it but the satisfaction of popping a pimple and seeing it go away isn’t there. If anything, the pimple gets mad at you for trying and gets redder, puffier, and more unsightly!

What types of treatments are available for Rosacea?


Rosacea is best managed by calming the skin down- not exfoliating. It’s important to use anti-inflammatory ingredients, hydrating ingredients, and less irritating products. Many cases that have already reached the ‘pimple’ stage will need oral antibiotics to resolve. There can always be an overlap between these two conditions. This is why seeing a board-certified dermatologist who can provide you with a treatment regimen is important as there are only a handful of products that overlap in treating both conditions simultaneously. In terms of treatment options, the early disease can be managed with over-the-counter topicals containing azelaic acid or redness-reducing products. More persistent flushing can be managed with prescription topicals. Most of these function as anti-inflammatories. Choosing the right one can at times be a bit of a trial and error game of determining which ingredient works best for you or driven by insurance coverage as this can be variable. There is a range of options from topical antibiotics to ivermectin to vasoconstrictors, etc. available as a prescription. The more advanced disease tends to respond best to oral antibiotics such as Doxycycline.




Is ivermectin really used to treat rosacea?

Treatment of rosacea with permethrin or ivermectin is not new. Soolantra was the first cream specifically FDA approved with this ingredient for rosacea. However, it has been well known for years that one of the potential triggers for rosacea in a subset of patients can be a mite known as Demodex that lives on our skin. Demodex may reside in our hair and oil glands and trigger inflammation associated with rosacea. Ivermectin is thought to work both by treating this mite in addition to working as an anti-inflammatory agent to reduce the inflammation associated with rosacea. Rosacea is a chronic and multifaceted condition that can have a number of triggers. However, in a subset of patients ivermectin can be highly effective oral or topical. In some cases, rosacea resistant to other therapies in a biopsy will actually reveal the mites on the skin and help guide therapy.

Are there any products that you think are best suited for Rosacea-prone skin?

I routinely advise my patients with rosacea that "less is more". Avoid overdoing it with a skin care regimen and start to limit your product choices to only what is needed. Simple cleanser, Moisturizer with an SPF, and a nighttime cream to protect and/or repair the skin overnight. Avoid products with fragrances or preservatives that could aggravate your skin.








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