All about rosacea: Causes, triggers and treatment

Skin redness affects most of us from time to time. If you've just exercised, been in a heated environment, eaten a hot curry or had a glass of red wine, your face may flush and turn pink or red.

But if the facial flushing and redness don't go away, you may have rosacea, a chronic inflammatory skin condition [1].

If you have rosacea, you're not alone.

In 2018, the US-based National Rosacea Society estimated this common skin ailment affects over 415 million people worldwide [2]. Mainly occurring in people over 30, the physical effects of rosacea can create adverse psychological effects.

It's true that rosacea can be an incredibly tricky skin condition to manage and stressful to deal with, especially during a flare-up. First, you’ve got to figure out what subtype you have, then work out your triggers, and finally get to grips with an effective skincare routine to give you relief. 

But the good news is we’re going to arm you with all the knowledge you need, including exactly what rosacea is, what causes it, and how to get rid of it permanently — well, as much as you can anyway.

What is rosacea?

According to Dermnet NZ, "rosacea is a chronic inflammatory skin condition predominantly affecting the central face and most often starts between the age of 30–60 years" [1].

There are 4 subtypes of rosacea and each can range from mild to severe [3]:

1. Erythematotelangiectatic (persistent redness)
2. Papulopustular (often known as acne rosacea due to pustules present)
3. Phymatous (thickened skin)
4. Ocular (rosacea of the eyes).

Rosacea typically presents on the central part of the face, across the cheeks and nose. It's characterised by visible red blood vessels across your face, persistent facial redness, and pimples or pustules on your face.

Rosacea symptoms can flare up and then dissipate. While rosacea isn't contagious, it can make you feel embarrassed and less confident if untreated. 

What causes rosacea?

There can be multiple causes of rosacea that include [1]:

Genetics

It’s thought that you’re more likely to experience rosacea if you have a family history of the condition. Though that’s not been solidly proven, there is a strong link [4].

Blood vessel abnormalities 

Abnormalities with the vascular system could have a possible link with rosacea flare-ups, some research says.

Although this gets quite complicated, to put it simply: the way the vascular system and the nervous system work in some people might be the cause of typical symptoms of rosacea like flushing and inflammation [5].

Bacteria 

The bacteria known as Helicobacter pylori (H. pylori) is another theory; yet to be proven.

It’s thought that the bacteria in the digestive system disrupt the body’s inflammatory response. In turn, this bacteria can cause the development of acne rosacea (papulopustular) specifically [6].

For these causes, often getting to the bottom of the bacteria can impact the skin. But again, this isn’t solidly proven and doesn’t explain the causes of other subtypes of rosacea. 

Mites 

Yep, you read that right. Mites is another theory. But don’t panic because we’re talking about demodex folliculorum, microscopic mites. These mites live on our skin harmlessly — often in our eyelashes — whether we have rosacea or not [7].

The issue, however, is that some studies have shown people with rosacea have an increased number of these mites [8].

It gets a little worse — sorry. Some researchers think that our skin is reacting to the mites' faeces and causing symptoms of rosacea. We know, it’s not a very sexy theory at all. 

Overactive immune system 

Ongoing research looking into the immune systems cathelicidins — a type of antimicrobial peptide that helps fight off bad bacteria and illness — shows that this is increased in rosacea patients [9]; resulting in inflammation and pustules associated with papulopustular rosacea.

Who gets rosacea?

In 2018, an estimated 5% of adults worldwide had rosacea [2]. Affecting both women and men, rosacea tends to present after the age of 30. It can be more prevalent in people of Celtic or North European descent. 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases states, "Anyone can get rosacea, but it is more common among these groups [9]:

• Middle-aged and older adults.
• Women, but it tends to be more severe when men get it.
• People with fair skin, but it may be underdiagnosed in darker-skinned people because dark skin can mask facial redness."

What are the common symptoms of rosacea?

The pattern and number of symptoms will vary from person to person. While rosacea is a chronic skin condition, it cycles between flare-ups, where you experience signs, and periods where you don't.

Common skin symptoms of rosacea include:

• Eye irritation: Also called ocular rosacea, your eyes will become dry, watery, sore, red, and itchy. If you have these symptoms, it's essential to get them treated as they can result in eye damage and even loss of vision.
• Facial redness: This can be a flush or blush that persists for extended periods. A tingling or burning sensation can also accompany it. In some people, this redness will become scaly and rough.
• Rash: This rash may develop pus-filled bumps that resemble acne.
• Skin thickening: This can occur on the nose, creating an enlarged and bulbous appearance. Skin thickening primarily affects men.
• Visible blood vessels: These generally appear as thin red lines on your nose and cheeks.

Rosacea vs acne: What's the difference?

Rosacea is a chronic facial inflammatory condition characterised by flushing and a feeling of warmth on the face [1]. Acne is "a common chronic skin disorder that affects the hair follicle and sebaceous gland, in which there is expansion and blockage of the follicle and inflammation" [10].

 A 2017 Australian study found acne "affects more than 90 per cent of Australian adolescents aged 16–18 years [12]. It may have a significantly deleterious effect on their self-esteem and emotional state. Moderate-to-severe acne can lead to scarring."

Rosacea and acne have only one thing in common; an abnormal infiltration of immune cells that gather at skin sites with a high density of sebaceous glands. This includes the face, back, and chest. 

The primary therapeutic targets to treat acne surround inflammation and sebum alterations of the skin. Rosacea is treated differently from acne and includes controlling symptoms, avoiding triggers, topical treatments, and oral medications. 

What triggers rosacea?

The American Academy of Dermatology Association defines a trigger for rosacea as anything that causes it to flare up [13]. These triggers will differ from person to person but can include:

Sunlight 

Protecting your skin from UV rays is the first step in managing symptoms, as sunlight is a major trigger for most people with rosacea — 81% in fact [14].

Staying outside of direct sunlight during peak hours for extended time periods, wearing UV protective clothing, and regularly applying sunscreen are all important to reduce sunlight triggers. 

Additionally, get into the routine of wearing sunscreen every day (yep, every day), even when it’s cloudy or raining. Oh, and make sure your sunscreen hasn’t expired as this reduces its effectiveness.   

Heat and weather fluctuations 

Alongside sunlight, heat increases facial flushing and can trigger rosacea, and 53% of people note hot weather for their worsening symptoms [15]. Similarly, fluctuations in temperature, i.e. being in cold weather and then heading into a heated building, can cause flare-ups. 

In the same way, hot beverages can make rosacea worse for some people.

Exercise 

Vigorous exercise is also said to be a trigger among 39% of people thanks to a rising body temperature [15]. The advice here is to stay cool whilst exercising, not exercise in excessive heat or sunlight and break up training to avoid overheating. 

Stress

Research by Dr. Richard Granstein and his team shows that people with rosacea have an increased nerve, blood flow and sweating response when exposed to heat and stress, which can exacerbate symptoms like redness [15]. 

Learning to reduce stress is easier said than done but doing so can prevent flare-ups.

Spicy foods 

Your skin is, indeed, what you eat. Spicy foods are a trigger for quite a few rosacea sufferers as they can stimulate receptors that cause redness and feelings of facial burning. 

Alcohol 

Alcohol is another trigger for many, with red wine specifically being noted as the biggest culprit. In addition to being a trigger, a 2017 study showed that there’s a higher risk of developing rosacea if you’re a regular alcohol drinker [16].

The bottom line: It can be a little overwhelming figuring out what your triggers are but there’s no rush. Take it slowly by writing down a list and using a process of elimination.

While rosacea flare-ups are annoying, your skin can stay redder for longer each time they happen. This can result in permanently red and thickened skin where visible blood vessels appear in some people.

Understanding what triggers your rosacea flare-ups can help you:

• Reduce your exposure to them
• Improve the results from your treatment
• Prevent your rosacea from progressing to severe rosacea.

Making a note of what you drink and eat, the products you use, your activity levels and the weather can help you identify what causes your rosacea to flare up.

How is rosacea diagnosed?

In 2017, a panel of 17 dermatologists and 3 ophthalmologists decided to use a common approach to diagnosing rosacea [17]. The following 2 clinical features were independently considered diagnostic for rosacea: 

• A flushed face, skin irritation, papules or pustules, telangiectasia and persistent facial erythema [18][1]. This can include burning, stinging, dryness, and ocular changes.
• Raised and thickened skin on the nose, forehead, chin, ears, or eyelids. This type of rosacea is called Phymatous rosacea.

Rosacea diagnosis and treatment should be based on clinical presentation. The consensus was achieved to support this approach for rosacea treatment strategies.

Can rosacea be cured permanently?

The question of how to get rid of rosacea permanently is a tricky one.

Sadly, there is no known cure for rosacea but symptoms can be improved greatly so that they’re almost undetectable in the cases of erythematotelangiectatic and papulopustular rosacea.

Once you’ve identified your triggers and have a great treatment plan in place, you can significantly reduce symptoms, especially when it comes to persistent redness and pustules. 

As with many chronic conditions, your rosacea will likely worsen and improve during various stages of your life. These fluctuations can be due to hormones, other health conditions, lifestyle factors and periods of stress, for example.

This means that rosacea requires a long-term plan that is consistently updated as needed.

How is rosacea treated?

A 2021 clinical dermatology study advised, "the first step in the treatment of rosacea is to advise the patient to identify and then avoid triggers such as UV light, spices, weather changes, and alcoholic beverages."

Skincare recommendations to treat rosacea included:

• Using pH-balanced skin cleansers
• Applying broad-spectrum sunscreen with SPF 30 and higher
• Wear a wide-brimmed hat
• Regularly using moisturiser.

Treating rosacea involves treating inflammation and the dilated blood vessels for people with erythema. Common treatments for rosacea include:

• Topical or oral medication, 
• Light and laser treatment therapy
• Using soothing skin care products.

A good rosacea treatment will be tailor-made just for you and your skin. This is why Software's health practitioners create formulas personalised for your skin type and concern.

All you need to do is upload selfies and share your skin goals with your online practitioner. Then, a pharmacist creates your custom bottle, which is shipped straight to you. You also get access to professional, personalised advice on your skin, as well as ongoing, follow-up support from your practitioner as you use your treatment.

What products should you avoid with rosacea?

There are a few products that experts recommend avoiding (or, at the very least, proceeding with caution) if you have rosacea symptoms:

Fragrance 

For most people, fragrance won’t cause an issue.

However, in rosacea patients who have highly sensitive skin, you might find it exacerbates your symptoms, so look for products that are fragrance-free until you can rule it out as not being a trigger. 

Essential oils

Essential oils are a lesser-known trigger.

Although some evidence suggests that certain essential oils like tea tree can help with mites, they're a common trigger for redness and sensitivity, so are best avoided. 

Strong acids 

Ingredients like glycolic and salicylic acid are great for exfoliation but can be a little too strong for sensitive skin types.

It’s best to avoid strong exfoliants where possible until your rosacea is a little more under control. Unlike acne, these treatments typically don't work for the breakouts experienced with rosacea-prone skin.

Or, if you really want to use these products, work with an expert or dermatologist to correctly incorporate them into your routine.

What are the possible complications of rosacea?

Possible complications of rosacea include affecting your eyes and the skin around your nose [19].

Rhinophyma is a skin condition where the sebaceous glands become larger, causing a red, swollen, and pulpy appearance. Men can be more prone to this complication of rosacea than women.

Rosacea can also cause inflammation of the eye membrane, resulting in a red or pink appearance on your bottom eyelid.

Another complication of rosacea affecting the eyes is known as ocular rosacea. Symptoms include:

• Dry eyes
• Bloodshot and irritated eyes
• Feeling like you've got something in your eyes
• Skin inflammation of your eyelids (also called blepharitis).

Ocular rosacea may also cause your cornea (the transparent layer at the front of your eyeballs) to become damaged and inflamed. This condition is known as keratitis and has the potential to threaten your sight. 

If you suspect you've got issues with your corneas, please get in touch with your GP immediately or visit your local hospital, where an eye specialist can treat you and prevent permanent vision loss.

Photo credit: Getty Images