The "Red
Flags" of Rosacea:
Ancient Malady, New Remedies
by Annet King
Training
and Development Manager
The International Dermal Institute
The inflammatory condition known as Rosacea most certainly is nothing new. But what is new is today’s widespread Rosacea “epidemic”. Multiple factors contribute to an alarming rise in this progressive neurovascular disorder which generally affects the facial skin and sometimes the eyes. The bad news is: there currently is no cure. The good news, however, is that, with information and diligence, Rosacea now may be effectively managed and contained to prevent irreversible damage.
For a truly graphic illustration of Rosacea unchecked, visit the Louvre. There hangs the 16th century masterpiece, “Old Man and his Grandson” by Florentine artist Ridolfo Ghirlandaio. The old man looks down wistfully at the flushed cheeks of the angelic little boy in his arms. We can only hope that the lad’s rosy glow is not the harbinger of the disfiguring condition which has ravaged the face of the old man (not to be a downer, but rosy cheeks, especially in fair-skinned people, may indeed be a “red flag” for future Rosacea).
The grandfather appears to be suffering from what would today be classified as advanced or “Stage 3” Rosacea, most notably in his apparent Rhinophyma, or excess growth of tissue on the nose. This growth is the result of chronic lymphedema, the swelling which occurs when normal lymph drainage is slowed to a crawl, due essentially to “leaky” blood vessels. The erythema (redness) and swelling of facial tissues and sebaceous glands leads to enlargement of the cheeks and nose, as well as coarsening and thickening of the skin. Also portrayed in this poignant painting is telangiectasia, or visible damage to the blood vessels at the skin’s surface. In the most severe cases, and poor grandpa appears to be well on his way, the sufferer takes on a “lion-like” (and this is being charitable) appearance, with hypertrophy of connective tissue and accumulation of collagen producing massive nodules and furuncles on the chin, cheeks, forehead, ears and nose.
In grandpa’s day, this condition was probably inherited. The likely treatment: leeches, applied directly to the affected areas of the face (Yikes!), or perhaps a little classical bloodletting for good measure. Today, both probable cause and recommended treatment have changed considerably. And while many more people are experiencing some form of Rosacea, the options for treatment have come a long way since Ghirlandaio’s time, or even since the time of American film icon W.C.Fields, circa 1935, whose bulbous red nose was erroneously attributed to the actor’s legendary taste for hard liquor (although alcohol consumption may indeed worsen Rosacea symptoms).
What is Rosacea, precisely?
In spite of the fact that this malady has been around for centuries, there still is much that we do not know. First, Rosacea is primarily a disorder of the facial blood vessels.Theories abound regarding Rosacea’s origins, including links with Helicobacter pylori, Demodex mite infestation, bacteria, vasomotor changes, connective issue malfunction, drugs and psychogenic factors. None of these theories is conclusive. What we do know is this: in simple terms, for whatever reason or combination of reasons, the blood vessels become hyper-responsive to a wide range of stimuli. These stimuli may include physical exertion, sun, hormonal/adrenal shifts, stress, artificial sweeteners, chocolate, tomatoes, citrus, hot soups, hormones, spicy foods, smoking and alcohol to name but a few. In response, the blood vessels dilate and engorge with blood more frequently than is normal, and ultimately stay that way. This state of increasingly frequent and ultimately permanent dilation and engorgement finally damages the blood vessels to the point where they no longer function effectively.
Rosacea generally affects the face, and is most common in individuals between the ages of 30- 50. Yes, sad to say, as we age the Stratum Corneum thins out, leading to greater susceptibility to irritants in many of us. The urge to scratch—something we never seem to outgrow—can escalate the initial irritation into the equivalent of a full-blown wildfire in the skin. Women are three times more likely than men to develop Rosacea (menopause often is a trigger), and Rosacea affects men and women differently: men tend to manifest the condition around the nose, while women most often are affected in the cheek and chin areas. Rosacea cannot be cured at this writing, but can persist as a chronic condition for years, with cycles of aggravation and remission.
It all begins with the blushing, or flushing. Sure, we all blush or flush a little when we’re young and in love, or when we get caught with our hand in the cookie jar. For Rosacea sufferers, however, rosy cheeks are simply the first sign of a prognosis which may be less than rosy. Historically, some people were simply genetically predisposed to this condition. These people would have been called “sensitive”. They were often of Celtic or Nordic descent (in other words, the fairest of the fair), and many may have had an inherited family tendency toward allergies, asthma or eczema, all of which put the skin on high alert. The combination of light skin pigmentation, thin epidermal layer and “sensitive” skin containing a higher than average number of reactive blood vessels give rise to the most classic sign of early Rosacea: blushing, or “flushing”.
Understanding Rosacea today means understanding the difference between “sensitive” skin, meaning fair, thin, Northern European skin which has a genetic predisposition to irritation, versus “sensitized” skin, which affects many millions of us, regardless of racial or ethnic background, skin color and thickness, or family history. Our urban world is rife with environmental pollutants, including the toxic chemicals which are part of our indoor work and home environments. These omnipresent toxins, from second-hand cigarette smoke to the nasty fumes emitted by our dry-cleaned clothes, are not kind to even the sturdiest skin, and the new breed of Rosacea is one of the most immediately visible results.
Often, today’s challenge lies in recognizing Rosacea for what it truly is. This phenomenon is so new that the disorder, which often produces pimples and pustules as it advances, may often be misdiagnosed as Acne Vulgaris (common acne), or as a form of dermatitis. And correct diagnosis and informed treatment are critical, since treatment for acne, notably the use of salicylic acids, S.D. alcohol or benzoyl peroxide may actually make matters much worse.
Regardless of whether skin inherits or acquires its sensitivity, the behavior of the blush is a telling indicator of things to come. Normal skin flushes (meaning, the capillaries dilate with blood) in response to a stimulus or trigger, then immediately returns to its normal state, in which the capillaries are relatively relaxed. In the early stages of Rosacea, the flush may appear 30 – 60 minutes after a trigger, and may take hours or even days to disperse. If this lingering flush is accompanied by sensitivity, itching, burning and a lowered tolerance for skin care products, especially in the central areas of the face which typically have sustained the most sun damage, Stage 1 or early Rosacea may be showing its true colors.
Stage 2 or the middle stage is indicated by more frequent and intense facial flushing, to the point where it is almost a constant state and the affected areas take on an engorged, nearly purple hue. Telangiectasia (damaged micro blood vessels, often visible on the surface of the skin) may be noticed where the flushing is the worst. This long-term engorgement often results in vascular damage, accompanied by swelling and inflammatory papules and pustules (leading to the confusion with acne, although typically Rosacea will not produce the classic acneic comedone, or blackhead). As Rosacea advances, the veins become weakened and begin to leak, leading to Stage 3, where the impaired blood vessels cannot remove lymph through the system in a normal fashion. As a result, the sebaceous glands of the cheeks and nose become enlarged and all affected tissues begin to swell. The ultimate result, if the Rosacea is untreated or incorrectly treated, may resemble the kindly grandfather in Ghirlandaio’s painting.
Ocular or Ophthalmic Rosacea may accompany facial Rosacea, and may often be confused with seborrheic dermatitis. The most common symptoms are chronically inflamed margins of the eyelids with scales, crusts and styes, as well as a persistent burning and feeling of dryness and grittiness in the eyes, including the sensation of a foreign body in the eye. Eyelashes sometimes fall out, compounded by bloodshot eyes, pain and photophobia (acute sensitivity to light). Common sense tells us that anything involving our eyes requires immediate and expert attention, and this is especially true when dealing with Rosacea keratitis, which in extreme cases can lead to corneal opacity with blindness!
What to do?
A dermatologist can prescribe topical and oral antibiotics (oral tends to work faster), such as Tetracycline or Zithromax (azithromycin) to decrease pimples and nodules. Your MD can prescribe Monoxidine and Clonddine (anti-hypertensives) to reduce flushing, which not only minimize the redness associated with Rosacea but more importantly reduce the damaging dilation/engorgement action of the blood vessels.
In addition to drugs, treatment by a professional skin therapist offers relief in many holistic ways:
1. Manual Lymphatic Drainage, a specialized, advanced massage technique, does not stimulate the blood flow unlike classic European-style massage, and works to prevent the swelling facial features which results from impaired blood vessel capacity.
2. Aromatherapy Essential Oils, including calming and soothing lavender, sandalwood and chamomile, are hydrating and oxygenating, helping to reinforce the capillaries and decongest areas affected by Rosacea.
3. Cool marble stones give immediate, non-invasive relief to redness and swelling.
4. Reflexology, pressure point massage and stress-relief techniques also may bring relief through non-pharmaceutical means.
Photothermolysis (marketed as PhotoFacial ™) is a laser light treatment which has demonstrated excellent results in treating Rosacea. The laser is used to selectively destroy damaged micro vessels in the dermal capillary bed, reducing redness and stimulating healthy collagen growth which in turn smoothes out the rough, capillary-webbed appearance of Rosacea-affected skin.
Cosmetic surgery also may be recommended for clients with advanced Rosacea. A fine diathermy needle, argon laser or pulsed dye laser can eliminate dilated and broken blood vessels, especially blood vessels on the nose. For advanced Rhinophyma, perhaps the most feared and disfiguring symptom of Rosacea, traditional surgical techniques may be employed, along with dermabrasion and laser treatments.
In terms of day to day management of Rosacea, conventional exfoliation is a no-no. Only microfoliation with an extremely fine, non-intrusive particle such as rice bran is appropriate to fragile, Rosacea-prone skin. Likewise, waxing must be approached with caution, given the compromised state of the skin’s lipid barrier. Extremes of temperature, especially when washing the face, must be avoided to minimize capillary expansion. Additionally, topical preparations such as Retin-A, Renova, acne drugs, AHAs and Vitamin A derivatives are generally bad news for Rosacea sufferers
In terms of selecting skin care products, certain ingredients are key, including:
People with Rosacea may feel “unclean”, believing perhaps subconsciously that their condition is the result of poor hygiene (it isn’t!), and that they can somehow wash the symptoms away. Beware: harsh cleansers, which “de-fat” the skin, clearly are contraindicated. Likewise, frantically trying every product on the shelves can exacerbate matters as well; it’s wise, when dealing with Rosacea, to try to actually REDUCE the number of products used, as well as the quantity of product used, so that a minimal number of ingredients actually are in contact with the traumatized skin. A good moisturizer, especially during severe weather and when traveling by air, along with a good sun protection product, remain key staples. Beyond these, regular visits to your skin care professional for treatment and professional product recommendation are the wisest course of action. And of course, the classic irritants such as lanolin, S.D. alcohol, artifical fragrance, artificial color, mineral oil and glycerin are to be avoided like, well, like the plague!The first step in living with Rosacea is getting an accurate diagnosis. The earlier the intervention, the easier it will be to manage this difficult and increasingly common disorder. (For more information, visit www.rosacea.org).
UK native Annet King, Training and Development Manager for The International Dermal Institute, lives and works in Los Angeles. King has recently introduced a new class about Rosacea into the international curriculum.The use of this document is governed by our terms of use.