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Rosacea

 

Rosacea is a common but poorly understood chronic (long-term) skin condition that mainly affects the face. Symptoms begin with episodes of flushing (when the skin turns red).

People with rosacea may experience spots and persistent redness of their skin. Small blood vessels in the skin can become visible. In the most severe cases, the skin can thicken and enlarge, usually on and around the nose.

There is no cure for rosacea, but treatments are available to control the symptoms.

How common is rosacea?

Rosacea most commonly affects fair-skinned people from northern Europe and is estimated to affect up to 1 in 10 people.

Rosacea affects twice as many women as men, although it is usually more serious in men. The symptoms usually begin between the ages of 30 and 50.

Triggers of rosacea

While the exact cause of rosacea is unknown, several triggers have been identified that may make the symptoms worse in some people. These include:

  • exposure to sunlight
  • stress
  • cold weather
  • hot drinks
  • alcohol
  • eating certain foods, such as spicy foods

Identifying and avoiding the triggers of rosacea can be a useful way of controlling the symptoms.

Outlook

As well as avoiding the triggers, you can control the symptoms of rosacea by using a number of different medicines

Rosacea is a relapsing condition, which means that it will keep returning. People with rosacea will have periods when their symptoms are particularly bad, followed by periods when the condition is less severe. However, most cases of rosacea can be effectively controlled with medication.

The symptoms of rosacea often vary from person to person. Although the condition has a number of common symptoms, not everyone will experience all of the possible symptoms. The common symptoms of rosacea include:

  • flushing
  • persistent redness
  • papules and pustules
  • visible blood vessels
  • thickened skin
  • eye irritation

These symptoms are explained below.

Flushing

Flushing (when your skin turns red) is usually the first sign of rosacea. Episodes of flushing can last up for up to five minutes. The flush can spread to your neck and chest, and you may experience an unpleasant feeling of heat.

Persistent redness

With rosacea, episodes of flushing are sometimes followed by episodes of persistent facial redness. This redness is like a blush or a patch of sunburn that does not go away.

Papules and pustules

If you have rosacea, you may develop:

  • papules: round red bumps that rise from your skin
  • pustules: pus-filled swellings

These spots will appear on your face and are similar to teenage acne. However, unlike acne, your skin should remain free of blackheads (small, blocked pores).

Visible blood vessels

If you have rosacea, you may experience inflammation of the small blood vessels in the surface of your skin. This can cause your skin to appear red and swollen, producing the sort of blotchy skin that is often associated with excessive alcohol consumption. This can be upsetting for people with rosacea, as people often mistakenly assume that they are heavy drinkers.

The medical name for visible blood vessels is telangiectasia.

Thickened skin

In the most serious and developed cases of rosacea, the skin can thicken and form excess tissue, usually around the nose. This causes the nose to take on a large, bulbous appearance. This is known as rhinophyma.

Rhinophyma is a rare symptom of rosacea. When it does occur, it is usually more common in men than women.

Eye irritation

Over half of people with rosacea also experience symptoms that affect their eyes, such as:

  • feeling like there is something in your eyes
  • dry eyes
  • sensitivity to light (photophobia)
  • irritated and bloodshot eyes, which can often lead to related eye conditions such as blepharitis

Rosacea that affects the eyes is known as ocular rosacea.

Other symptoms

Other symptoms associated with rosacea include:

  • a burning or stinging sensation on your face
  • dry, rough skin
  • raised red patches, known as plaques, on your skin
  • facial swelling
  • not being able to use cosmetics because your skin is sensitive to them

Most people with rosacea have periods when their symptoms are particularly troublesome, followed by periods where their symptoms are less problematic.

Permanent damage to the face, such as scarring, almost never occurs in rosacea.

The exact cause of rosacea is unknown. However, most experts believe it may be caused by a number of related factors. These are outlined below.

Blood vessel abnormalities

Many dermatologists (skin specialists) believe that abnormalities in the blood vessels of the face may be a major contributing factor for rosacea. This may explain the symptoms of flushing, persistent redness and visible blood vessels. However, it is not known what causes these abnormalities. 

Demodex folliculorum

Demodex folliculorum is a microscopic mite (tiny insect) that may contribute to rosacea. These mites usually live harmlessly on human skin, but higher numbers of mites have been found on people with rosacea. However, it is uncertain whether the mite is a cause or an effect of rosacea.

Helicobacter pylori bacteria

Helicobacter pylori bacteria, which are found in the digestive system, have been suggested as a possible cause of rosacea, although the link is not proven. The bacteria may stimulate the production of a protein called bradykinin, which is known to cause blood vessels to expand.

Genetics

Rosacea seems to run in families. However, it is not known which genes are involved or how they are passed on.

Triggers of rosacea

Most people who have rosacea notice that certain triggers make their symptoms worse. Different people can have different triggers, but the most commonly reported ones include:

  • exposure to sunlight
  • stress
  • hot weather
  • exposure to wind
  • strenuous exercise
  • alcohol
  • hot baths
  • cold weather
  • spicy foods
  • humidity
  • caffeine (found in tea, coffee and cola)
  • dairy products
  • acute (short-term) medical conditions, such as a cold or fever (high temperature)
  • chronic (long-term) medical conditions, such as high blood pressure (hypertension)
  • vasodilatory medicines, which are often used to treat high blood pressure

See your GP as soon as possible if you think you have rosacea. The sooner treatment for rosacea begins, the less likely you will develop the more serious symptoms of the condition, such as thickened skin.

There is no specific clinical test for rosacea. Your GP will make a diagnosis by:

  • examining your skin
  • asking you about your symptoms
  • asking you about any possible triggers you may have

In some circumstances, your GP may recommend you have further tests, such as a blood test, to rule out other conditions that have similar symptoms, such as:

  • lupus, a condition where the immune system (the body's natural defence against infection and illness) attacks healthy tissue
  • the beginning of the menopause (when a woman's monthly periods stop)

The symptoms of rosacea can be treated in a number of ways. These are described below.

Facial flushing

Making lifestyle changes, such as avoiding possible triggers or wearing sunscreen, can be a good way of controlling the symptoms of facial flushing (when your skin turns red).

Creams and gels

A number of treatments are effective in treating the spots and pimples caused by rosacea. Your GP can recommend a cream or gel as the first treatment option.

Metronidazole

Metronidazole cream or gel (topical metronidazole) is usually recommended for the treatment of mild to moderate spots and pimples.

When applying metronidazole cream or gel, be careful not to get any in your eyes or mouth. You will need to apply topical metronidazole once or twice a day for several months.

Metronidazole does not usually cause any side effects, although it may irritate your skin. Avoid exposure to strong sunlight or UV light (used in some lamps and nightclubs).

Azelaic acid

An alternative to topical metronidazole is azelaic acid. Azelaic acid helps to unblock pores and reduce inflammation (redness and swelling).

You will need to apply azelaic acid cream or gel twice a day and avoid contact with your mouth and eyes. As with topical metronidazole, you may need to use azelaic acid for several months before you notice any significant improvement in your symptoms.

The side effects of azelaic acid can include:

  • burning and stinging of the skin
  • itchiness
  • dry skin

About a third of people who use azelaic acid will experience side effects. However, any side effects are usually short-lived.

Antibiotic medicines

For more serious symptoms of spots and pimples, oral antibiotics may be recommended. In this case, the antibiotics are used for their ability to reduce inflammation of the skin rather than for their ability to kill bacteria.

As with the other treatments, you will need to take oral antibiotics for several weeks before you notice a significant improvement in your symptoms. You may need to take oral antibiotics once or twice a day for several months or longer.

The two antibiotics that are most commonly used to treat rosacea are:

  • tetracyclines
  • erythromycin

Tetracyclines

Tetracyclines are not suitable for:

  • women who are pregnant or breastfeeding, as they can cause birth defects in unborn children and interfere with normal bone development in breastfed children
  • people with a history of kidney disease

Tetracyclines should be used cautiously in people with:

  • a history of liver problems
  • myasthenia gravis, a condition that causes weakness in some muscles
  • systemic lupus erythematosus, a condition where the immune system (the body's natural defence system) attacks healthy tissue

Tetracyclines may cause oral contraceptives (the contraceptive pill) to fail during the first few weeks of treatment. Sexually active women of childbearing age should use a barrier method of contraception while taking tetracyclines, such as a condom, to avoid becoming pregnant.

Tetracyclines can also make your skin more sensitive to the effects of sunlight, so avoid exposure to direct sunlight.

Tetracyclines can interact with a number of medications, including:

  • warfarin, an anticoagulant (blood-thinning medicine) that is used to stop your blood clotting
  • antacids, which are taken to treat indigestion and heartburn

Tell you GP if you are taking any other medicines. They can advise you about whether your dosage needs to be changed.

Some tetracyclines should be taken on an empty stomach because food and milk may prevent the medicine from being properly absorbed by your body. Ask your GP if you are not sure how to take your medicine.

A rare, but potentially serious, side effect of tetracyclines is that they can cause an increase in the pressure of the fluid that surrounds your brain. This is known as benign intracranial hypertension. The symptoms of benign intracranial hypertension include:

  • a severe headache
  • a disturbance in your vision

If you have these symptoms, stop taking tetracyclines and contact your GP.

Erythromycin

Erythromycin can be used in women who are pregnant or breastfeeding. It should be used cautiously if you have:

  • a history of liver or kidney problems
  • myasthenia gravis, a condition that causes some of your muscles to become weak 

Erythromycin can interact with a number of medications, including:

  • warfarin, an anticoagulant (blood-thinning medicine) that is used to stop your blood clotting
  • statins, which are taken to lower your cholesterol levels

Tell your GP if you are taking any other medicines. They can tell you whether your dosage needs to be revised.

Isotretinoin

Isotretinoin is a medicine that is often used to treat severe acne. However, it is also occasionally used to treat rosacea. As isotretinoin is a very strong form of medication, it can only be prescribed by a dermatologist (an expert in treating skin conditions) and not your GP.

Isotretinoin can cause a number of side effects, including:

  • birth defects in unborn babies
  • dry skin, lips and eyes
  • headaches
  • back pain
  • muscle or joint pain
  • bleeding and bruising more easily
  • blood in your urine

See the patient information leaflet that comes with your medicine for a full list of side effects.

Visible blood vessels (telangiectasia)

The symptoms of visible blood vessels associated with rosacea are known as telangiectasia. Treatment for telangiectasia will usually require a referral to a dermatologist.

Laser treatment is one of the most widely used treatments for telangiectasia. Lasers are narrow beams of light that are aimed at the visible blood vessels on your face. The heat from the lasers damages the dilated (widened) red veins and causes them to shrink so they are no longer as visible. 

Laser treatment can cause some pain, but most people do not need to have an anaesthetic.

Side effects of laser treatment are usually mild and can include:

  • bruising
  • crusting of the skin
  • swelling and redness of the skin
  • blisters (in rare cases) 
  • infection (in very rare cases)

These side effects usuall y only last a few days and are rarely permanent. An infection will require treatment with antibiotics.

Persistent redness

It may be possible to disguise patches of persistent red skin using specially designed 'camouflage' make-up.

Your GP or dermatologist can refer you to the skin camouflage service and prescribe skin camouflage make-up.

Thickened skin (rhinophyma)

Thickened skin (rhinophyma) is a symptom of rosacea that often affects the nose. If you have severe rhinophyma, your GP may refer you to a dermatologist or plastic surgeon.

A number of surgical treatments are available to remove any excess tissue and remodel the nose into a more pleasing shape. This may be done with:

  • a carbon dioxide laser (a beam of carbon dioxide)
  • a scalpel

Ocular rosacea

If the rosacea symptoms affect your eyes (ocular rosacea), you may require further treatment such as:

  • Ocular lubricants. Eye drops or eye ointment can be used to treat dry eyes
  • Eye hygiene measures. If you have blepharitis (inflammation of the eyelids), you may need to clean your eyelids with a warm compress (a cloth warmed with hot water) or cotton bud
  • Antibiotics such as tetracyclines (see above).

Antibiotics
Antibiotics are medicines that can be used to treat infections caused by micro-organisms, usually bacteria or fungi.

Immune system
The immune system is the body's defence system, which helps protect it from disease, bacteria and viruses.

Inflammation
Inflammation is the body's response to infection, irritation or injury, which causes redness, swelling, pain and sometimes a feeling of heat in the affected area.

Over-the-counter treatments

  • Over-the-counter (OTC) medicines are not effective for treating rosacea and sometimes they may make it worse.
  • Topical corticosteroids (cream, gel or ointment that contains steroids, such as hydrocortisone) should not be used because they can make the symptoms worse in the long term. 
  • Your pharmacist can give you advice about using moisturisers, sunscreens and soaps.

Rosacea can cause complications that affect you physically and psychologically.

Eye problems

Rosacea that affects your eyes (ocular rosacea) can lead to a number of eye conditions.

Blepharitis (inflammation of the eyelids) is the most commonly reported eye condition resulting from rosacea. It can usually be successfully treated by adopting a daily eye-cleaning regime and by using antibiotic tablets and creams.

Up to 1 in 20 people with rosacea may experience symptoms that affect their cornea (the clear outer layer at the front of the eyeball). This can:

  • make your eyes bloodshot and watery
  • cause scarring of your cornea

In severe cases, if it is not treated, ocular rosacea can lead to vision loss. Your GP may refer you for treatment with an ophthalmologist (a doctor who specialises in eye conditions and their treatment or surgery). 

Psychological and social effects

Any chronic (long-term) condition can have an adverse psychological effect, but rosacea can be particularly troublesome because it affects your appearance. This can change how you feel about yourself and also how you interact with other people.

Many people with rosacea have reported feelings of:

  • low self-esteem
  • embarrassment
  • frustration

It is important to come to terms with the fact that you have a chronic condition which, although incurable, is controllable. Persevering with your treatment plan and avoiding your individual triggers are the best ways of controlling your rosacea symptoms.

As your physical symptoms begin to improve, you will start to feel better psychologically and emotionally.

If you have rosacea, try to take comfort knowing that you are not alone. There are millions of people across the world, who are living with the condition. You can find more support and information from organisations such as:

  • the National Rosacea Society, an American charity whose website has some useful information and advice for people with rosacea

Speak to your GP if you are feeling depressed as a result of your condition. They may recommend further treatment.

You can take steps to prevent your symptoms of rosacea from flaring up.

Avoiding triggers

Avoiding known triggers can help reduce the severity and frequency of your rosacea symptoms. To establish what is triggering your symptoms, you could keep a diary of your daily activities to record their impact on your symptoms.

Advice about how to avoid some of the common triggers of rosacea is explained below.

Sunlight

As sunlight is the most commonly reported trigger of rosacea, it is recommended that you use sunscreen every day, even on overcast days.

A sunscreen cream with a sun protection factor (SPF) of at least 30 is recommended. Using sunscreens specifically designed for children may help reduce any irritation to your skin.

During the summer months, minimise your exposure to the sun, particularly in the middle of the day when the sun is at its hottest. However, remember that the sun can also be very strong in the morning and evening, so you will need to take adequate precautions at these times as well.

To reduce your exposure to the sun:

  • regularly apply sunscreen to your skin
  • wear a wide-brimmed hat

Stress

After sunlight, stress is the second most reported trigger of rosacea. Successfully managing your stress levels can help control your rosacea symptoms.

You can reduce stress by:

  • taking regular exercise
  • eating a healthy, balanced diet
  • getting the right amount of sleep

As strenuous exercise can trigger an outbreak of rosacea, a low-intensity exercise programme, such as walking or swimming, may be better than high-intensity activities, such as running or aerobics.

You may also want to try some relaxation techniques, such as:

  • deep breathing exercises
  • meditation
  • yoga

Food and drink

The most commonly reported food- and drink-related triggers are alcohol and spicy foods. You may want to completely remove these from your diet to see if your rosacea improves.

However, there are many other dietary triggers that can adversely affect some people with rosacea. Include information about how your diet affects your rosacea symptoms in your rosacea diary.

Cold weather

Covering your face and nose with a scarf can help protect your skin from cold temperatures and wind.

If you need to spend considerable time outside during cold weather, you can protect your face with a balaclava.

Skincare techniques

The advice below about skincare techniques may also help control your rosacea symptoms:

  • Do not rub, scrub or massage your face. Doing so can irritate your skin.
  • Use a moisturiser to soothe your skin if it feels sore.
  • Do not use oil-based make-up, scented soaps, alcohol-based skin cleansers or other facial or hair products that contain ingredients that might irritate your skin, such as alcohol and fragrances.
  • Look for products that are suitable for sensitive skin or non-comedogenic (will not block pores and cause spots).
  • Gently clean your skin every morning and evening using a gentle, non-abrasive cleanser.
  • Rinse your face with lukewarm water and allow your skin to dry thoroughly before you apply any medication or make-up.
  • Men may find that using an electric razor, rather than a blade, helps reduce skin irritation.
  • Do not use steroid cream unless you are specifically instructed to by your GP. It may make your symptoms worse.

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.