Acne Rosacea, the Red Face
In Canada, it is estimated that 2 million people (about 7% of the population)
have the red face of Rosacea. The highest incidence is in white women between
the ages of 30 to 50 years. The red flushing of topical rosacea is confined to
the cheeks, nose and central forehead. The skin becomes dry and flaky skin and
reacts to most medicines, lotions and creams. Red pimple-like bumps often
develop in the affected skin. While Rosacea is common and most sufferers consult
their MDs for treatment, there has been little progress in understanding and
managing this disorder.
Skin capillaries dilate with heat, causing
flushing, and grow slowly to form permanent reddening Papules, nodules,
and pustules can develop. Pustules are small (<1mm) and tend to occur on
the apex of papule. Telangiectasias are clusters of capillaries that
overgrow and leave the skin permanently red. When the capillaries grow,
they leak fluid and deliver immune cells to the skin.
Significant cosmetic disfigurement may occur in the most severe Rosacea with
skin swelling and enlargement. This is more common in men - the red face and
bulbous nose of a chronic alcoholic is the classic presentation of the chronic,
severe version of the disease. Sebaceous glands enlarge with skin edema that
disfigure the nose, forehead, eyelids, ears, and chin. Rhinophyma is an enlarged
nose; metophyma is a cushion-like swelling of the forehead, blepharophyma is
swelling of the eyelids related to marked sebaceous gland hyperplasia, otophyma
a cauliflower-like swelling of the ear lobes and gnathophyma is swelling of the
The Rosacea diagnosis includes a range of inflammatory events in facial skin.
The range is so broad that it is reasonable to ask if Rosacea is too fuzzy
a term that can apply to diverse immune-mediated events in the skin with
The reader can recall our understanding of the skin as a meeting place for
many characters in an ecological drama that unfolds every day. There is some
evidence that the microbes and little animals who live on the skin participate
in the Rosacea drama. It is also reasonable to suggest that sun exposure to the
face damages the skin sufficiently that inflammatory events are more frequent
and prolonged. Facial flushing is a normal response to heat, embarrassment and
to some food and drinks such as coffee, tea, alcohol and hot spices. The
sebaceous glands in the affected skin are often involved and may enlarge.
Exposure to sun and all forms of heat causes exacerbations.
The oil glands in the skin of the nose and adjacent cheeks are prone to
plugging with sebum that dries and stops flowing. The surface sebum turns black.
The sebum plugs are good homes for bacteria and fungi and may contribute to skin
Problems can arrive in the skin from the blood stream. When immune cells
enter skin, they often take over with an inflammatory response that causes the
skin to swell, itch, burn, and turn red. The red face and bulbous nose of
chronic Rosacea has been associated with high living and heavy drinking;
however, most people with Rosacea are not overindulgent hedonists.
A food connection has also been implicated and standard Rosacea advice has
included abstinence from alcohol, coffee, tea, and spices that cause flushing.
Delayed pattern food allergy may be a factor. Complete diet revision is
advisable if other symptoms of food allergy are present.
Topical Treatment of Rosacea
Standard treatment involves oral and topical antibiotics - usually daily
metronidazole cream or gel 0.75% to 1.0 %. The response to antibiotic treatment
is partial at best and seldom cures the condition. Some skin eruptions are
sometimes associated with scalp fungal infections and may respond to vigorous
treatment of the scalp with Nizoral and/or Selsun shampoos. The oil glands
in the skin of the nose and adjacent cheeks are prone to plugging with sebum
that dries and stops flowing.
Seborrhea is a related condition that involves the hair-bearing skin of the
scalp and face and has been related to the fungus, pityriasis ovale. Scalp
scaling and inflammation can be treated with Nizoral and/or Selsun Blue
shampoos. Seborrhea can involve the central forehead, skin under the
eyebrows and beard and may contribute to and be confused with Rosacea. Topical
application of antifungal agents ( such as Tinactin) to facial skin,
especially around the nose may be helpful.
Steroids are known to occasionally aggravate Rosacea although why this occurs
is not known. Steroid treatment alone may interfere with infection control
in the skin and increased growth of bacteria and/or fungi may exacerbate
Rosacea. Combined topical steroid, metronidazole and nizoral may sometimes be
successful in controlling an aggressive inflammatory flare of Rosacea.
Protection from the sun is essential for Rosacea management. The nose and
cheeks receive maximum sun exposure, compared with other parts of the body. The
best sun protection is staying out of direct sun light. Wear a peaked cap or
broad-brimmed hat. Sun screens are always used when outdoors. (see discussion of
UV protective measures).