Rosacea and acne are two of the most common skin conditions people struggle with. Treatment is different in each case, so your first step is figuring out which condition you are dealing with. Rosacea is often experienced as red flushes on the face, especially after drinking wine or eating spicy food. It can also occur in a too-warm room on a cold day. The key difference between the 2 conditions is that acne comes with comedones, whilst rosacea does not. Comedones are either open, like a blackhead, or closed with a white middle. Comedones are not red, swollen or painful. However, type 2, or papulopustular rosacea, is also often mistaken for acne as it causes red, painful pumps that look a lot like acne. These inflamed bumps are a feature of both conditions. The even worse news is that you might have both conditions at the same time.
But what is Rosacea?
Rosacea is a common, chronic inflammatory skin disease of the central facial skin. It isn’t clear what causes it or how the disease progresses but recent findings show that it has a genetic component and often runs in families. Certain environmental factors like sunlight, temperature (hot and cold), alcohol, strong emotions and stress, hot beverages or spicy foods can trigger it in the first place. Rosacea can also lead to sensitive skin and harsh skincare products will therefore also aggravate it. Rosacea is generally activated by external factors, whilst acne is usually triggered by internal factors like hormones or medication. These external factors set off abnormal processes in our inherent and adaptive immune systems via the skin and its blood supply, leading to the onset of rosacea lesions.
Lastly, rosacea is usually diagnosed after the age of 30 while acne normally starts during puberty or adolescence. Acne can appear anywhere on the body but rosacea generally affects the centre of the face (cheeks, chin, forehead, nose) symmetrically. If you aren’t 100% sure we recommend visiting your dermatologist for a professional diagnosis. Treatment is a must for rosacea, as if left untreated it will get worse with time and the redness and swelling can become permanent.
Incidence, distribution and diagnosis of rosacea
In the USA alone more than 16 million people are affected by rosacea whilst in Celtic countries, this figure is as high as 18%. Worldwide, the prevalence is estimated to reach over 5%. Males and females are affected equally.
An overgrowth of oil glands in the skin on the nose (rhinophyma) nearly always presents in males only. Flushing and redness of the skin (erythema) is often the first sign of the disease in younger ages whilst small broken veins (telangiectasias) make up the first rosacea lesions in older ages.
The overall appearance of rosacea includes flushing, transient or persistent redness, dilation of the capillaries under the skin (telangiectasia), small red lumps (papules), small red lumps with a discharge (pustules) and micro-swelling (oedema) of the skin. Additionally, people often report a stinging or burning pain. Itchy sensations are experienced in rare cases.
Rosacea, like acne, can make the sufferer extremely self-conscious. Psychosocial symptoms including low self-esteem, problems in socialising, and even changes in the way you think, feel or cope are all a result of the condition. Recent epidemiological studies confirm significant psychological symptoms and a decreased quality of life for those with rosacea.
Causes of rosacea
As mentioned, rosacea can initially be triggered or aggravated by a variety of internal and external factors including heat, extreme cold, ultraviolet (UV) exposure, and even by certain foods and beverages. Wind, heavy exercise, alcohol consumption, emotional stress, skincare products and cosmetics (especially those that contain formaldehyde), medication and a variety of microorganisms have also been identified in rosacea.
Identifying the factors that trigger rosacea for each individual is the fundamental focus of any treatment plan - it is important to narrow down and then try to avoid any factors that aggravate the disease. This strategy is most beneficial for those suffering from rosacea that is more dynamic in nature, especially where flushing and temporary redness are the most obvious symptoms.
For instance, a bald gent with an enhanced sensitivity to UV rays is most likely to develop a papulopustular rash on the forehead and temples. This rash consists of papules and pustules. Someone who is not sensitive to UV in the same way is unlikely to have this reaction or develop these lesions.
New thoughts on how rosacea develops
Rosacea skin is characterised by an inflammatory response, dilation of small blood vessels, lymphatic dilation and oil gland enlargement. The adaptive immune system along with the innate immune system might take a central part in rosacea’s disease forming process.
In acne, the bacterium Propionibacterium acnes is the cause of inflammation. This mechanism could also be relevant in rosacea since some studies found patient colonisation with Demodex, Bacillus oleronius, Staphylococcus epidermidis, Helicobacter pylori, and Bartonella quintana alongside the development of rosacea.
Rosacea’s association with facial Demodex spp. infestation was described quite some time ago, but its role in the development of the disease is still not understood and is even disputed by some. Multiple clinical trials that achieved a reduction or eradication of Demodex colonisation did not always observe a marked improvement in the clinical presentation of rosacea in participants, leading some to doubt that the presence of Demodex has a role in causing the disease. The part played by Demodex in causing rosacea will need to be further investigated.
Another pathogen that has been suggested to be involved in the pathophysiology of rosacea is H. pylori, the bacterium commonly associated with gastric ulcers. However, a recent meta-analysis of data found only a weak association between H. pylori infection and rosacea and between the successful eradication of H. pylori and improvement of rosacea manifestations.
So how best to manage rosacea?
Non-irritating skincare products can significantly prevent rosacea aggravation and improve your quality of life. Skincare advice consists firstly of avoiding trigger factors (including the management of any stress), limiting (but not totally avoiding) sun exposure and opting for gentle cleansing of the face with a liquid cleanser (not soap). It is also recommended to avoid products that contain paraben preservatives, sulphates, alcohol derivatives, phthalates and fragrances. It may be worth keeping a journal to identify which products, foods and other factors trigger or aggravate your condition.
This focuses on the symptoms of rosacea that are experienced as inflammation, which leads to redness, swelling, a burning sensation and a feeling of heat.
- Flushing and erythema
According to recent guidelines, two approved topicals can be used to treat persistent redness in adults with rosacea: brimonidine and oxymetazoline hydrochloride 1% cream.
Certain laser therapies can be used to reduce the incidence of redness and flushing, but they should be avoided in those that are sensitive to pain. For these sufferers, an analgesic therapy with lidocaine gel (4%) and a non-steroidal anti-inflammatory cream (for example, ibuprofen) can be of assistance. Some studies also recommend anti-depressants (for example, amitriptyline), or anticonvulsants in more severe cases.
Only a few options exist for the treatment of telangiectasia – these are commonly physical laser therapy to reduce the appearance of spider veins and capillaries under the skin or intravascular injections of aethoxysklerol (0.5%–1%).
- Papules and pustules
Sufferers with mild to moderate papules and pustules benefit from topical treatment with metronidazole (1%) and azelaic acid (15%).
Therapy using hypochlorous acid as a surface application has achieved good results. Hypochlorous acid is strongly anti-pathogenic, anti-inflammatory and stimulates healing.
- Phymata (raised red nodular lesions)
Low-dose isotretinoin appears to reduce phymata through its anti-inflammatory capacity, by reducing the number of sebaceous glands and by inhibiting their proliferation.
- Facial (lymph) oedema
No US Food and Drug Administration-approved therapy exists for this condition.
- Ocular rosacea
The appropriate treatment of ocular rosacea requires a multidisciplinary effort from ophthalmologists and dermatologists.
A starting point is practising good basic lid hygiene routines like the application of warm compresses and by using lubricating eye drops. Artificial tear substitutes help ocular dryness and any accompanying burning and stinging. Successful therapy with topical ivermectin has also been recently reported. In more severe cases, cyclosporine eyedrops and systemic tetracycline can be prescribed. Again, Hypochlorous acid as a treatment option can provide rapid relief as it is a non-toxic, non-irritating anti-bacterial with anti-inflammatory effects. Hypochlorous acid can also be applied (as a facial spray) directly into the eyes, without any side effects.
Summary and future directions
Clinical research has significantly increased our understanding of the common skin disease rosacea, leading to new anti-inflammatory and anti-erythematous treatments. Combination therapies, like those used for acne and atopic dermatitis, are a key for the successful therapy of this disease.
Our GF2 Skin Rejuvenation products have been used successfully by several rosacea sufferers who report a reduction in pain, redness and inflammation with regular use with an improvement in the overall look and experience of the condition.
- Joerg Buddenkotte et al. Recent advances in understanding and managing rosacea. Department of Dermatology and Venereology, Hamad Medical Corporation, Doha, Qatar. 03 December 2018. (https://doi.org/10.12688/f1000research.16537.1)