Rosacea is a chronic condition known to cause skin inflammation. It can manifest in many different ways, resulting in bloodshot eyes, spider veins on the face, and pimples. There is a wide variety of rosacea symptoms and an even larger number of options to treat these symptoms. With so many factors to take into account, consulting with an expert is crucial for effective relief.
What is rosacea?
Rosacea is a fairly common condition, affecting approximately 16 million Americans from all walks of life, and some 45 million people worldwide.
The condition is easy to misdiagnose. People with rosacea frequently make the mistake of thinking they have acne. Recalling their teenage years, they buy over-the-counter acne treatments only to find the products can irritate their skin or even exacerbate the problem.
However, much like acne, rosacea is a chronic, possibly inflammatory, condition. Among fair-skinned people, it produces redness that periodically intensifies (erythema) over the face and various other parts of the body. In dark-skinned people, the redness may appear as a darker shade of brown, or even purple.
A second symptom that may appear by itself or with the erythema is a change in the texture, color and thickness of the skin (phymatous changes).
According to guidelines outlined by the National Institutes of Health (NIH) released in February, 2017, either one of these two symptoms is sufficient to diagnose rosacea. The condition can also cause a range of other symptoms, including pimples, spider veins, and itchy, red eyes. The severity of these symptoms varies from patient to patient.
Types of Rosacea
Up until recently, rosacea was divided into four main sub-categories:
This is the most common type of rosacea, causing redness in the cheeks, lower nose and forehead. Spider veins on the cheeks or nose are also included in this category, although they are not always present. In its mildest form, the red color may not be striking except during bouts of facial flushing.
This variation is also sometimes called acne rosacea because the red skin is accompanied by pimples and pustules. The term should be avoided, however, because acne and rosacea do not share the same cause. Flare-ups of this type of rosacea may be accompanied by burning or stinging sensations.
Rosacea may be accompanied by a variety of ocular symptoms including blood-shot, watery eyes, itching, the feeling that something is in your eye, sensitivity to light, and blurry vision. If left untreated, the eyes can become permanently damaged.
The skin becomes thicker, marked by irregular nodules and swelling. Phymatous rosacea is most commonly observed in the nose, but can also appear on the ears, cheeks or forehead. Deep red coloring and spider veins can also accompany this condition.
By simply reading the descriptions of these variations of rosacea, it’s evident that there is an extensive overlap of symptoms, and that not all symptoms need be present in a defining type. Ocular rosacea, for example, may have many symptoms or only a few, while erythematotelangiectatic rosacea is present to some degree in almost every instance of the condition.
The adjustment to the 2017 guidelines for diagnosing rosacea are an acknowledgement that the earlier categorization was not truly successful in sorting symptoms or causes. The new guidelines recommend treating each case of rosacea according to its own set of observable symptoms.
How can you tell if You have acne or rosacea?
Although acne is considered a problem for adolescents and rosacea is associated with adults, this stereotype doesn’t always hold true. Teenagers with acne may be told by their doctor that they also have rosacea, or appear to be at special risk of acquiring rosacea later in life, and as such should take precautions now. Adults with rosacea may sometimes have acne as well.
As the two conditions have different causes and necessitate different treatments, you’ll definitely need a doctor’s diagnosis to be certain of which disease is afflicting you.
Other skin conditions sometimes confused with rosacea include eczema, which can arise from an allergic reaction, and cutaneous lupus.
visible symptoms of rosacea
Rosacea is most easily observed on people with white skin. Darker skin can mask the condition’s presence, causing it to be under-reported. Women more commonly get the periodic intense reddening, while men are more apt to see changes in their skin texture. It may affect people of any age but is most common among the middle-aged (40-60). Symptoms include:
The most common symptom is a red glow to the face (cheeks, forehead, nose or chin). From time to time, this rosy hue can flare up into a more intense red. When appearing around the eyelids, it is sometimes confused with adult blepharitis or allergic conjunctivitis. Occasional flushing of the face need not indicate rosacea, but recurring episodes are common in many clinical cases.
Spider veins (telangiectasias)
Small connections between the arteries (which carry blood away from the heart) and veins (which bring blood back to the heart) can become malformed and visible as a series of small red dots on the surface of the skin. Other symptoms may mask the spider veins so they only become noticeable after these other symptoms have been successfully treated.
Hard pimples (papules)
The appearance of pimples on the face can lead people to think they’ve somehow developed acne, even though they’re well out of their teens and may never have experienced acne when they were teenagers.
Although adults can have acne, the pimples associated with rosacea are different from acne pimples. Acne is caused by dead skin cells and oils that build up and clog the pores. Classical acne treatments (topical rubs placed on the skin) can actually make rosacea-based pimples more irritating.
Softer pimples containing pus (pustules)
These pimples may only be tiny pinpoints but the quantity of pus produced can be alarming. Pimples and pustules may be accompanied by a burning or stinging sensation.
Almost half of all rosacea patients are believed to have dry skin. Rosacea patients with dry skin should be especially vigilant about applying moisturizer every day. Other skin conditions (e.g., dandruff, oily skin) may also occur with rosacea.
Strawberry nose (rhinophyma)
Thickening skin with nodules (phymatous) is another primary symptom of rosacea and often found on the nose. The thickened skin may also appear on the chin, forehead, ears, or eyelids. This condition is often a late development of uncontrolled rosacea with pimples or pustules.
Sensitivity to facial makeup
Rosacea can make the skin more sensitive, causing it to react strongly to facial makeup such as foundation.
Red and watery eyes
The eyes may become dry, irritated, and watery. Other issues that can arise with the eyes may include frequent styes or infections, redness, and sensitivity to light (photophobia). Sometimes the eyes may feel as though they have grit or another foreign body in them.
It is especially critical to see a doctor if the rosacea affects your eyes. Persistent rosacea can eventually damage the cornea and even lead to blindness.
Rosacea can also lead to an inflammation of the inner edge of the eyelid (posterior blepharitis). This condition causes irritated, itchy eyes and should be treated by a doctor.
One of the normally beneficial life forms living on the epidermis is a tiny, nearly invisible mite called demodex.
Normally, demodex is no cause for alarm, but some studies have found that these microorganisms are unusually plentiful during rosacea flare-ups. They may be especially important in producing pimples and pustules that often accompany rosacea, and some treatments are expressly designed to reduce the presence of demodex.
Damaged blood vessels
Some of the secondary symptoms associated with rosacea (e.g., spider veins) are known to arise from damage to the vascular system (blood circulation). These symptoms are not always present in rosacea, and may only be contributing factors in certain clinical cases rather than primary causes of the disorder. Blood vessels may swell, making the red visible through the skin.
What causes rosacea?
Rosacea is a symptom of skin damage, although the cause of that damage is uncertain. Reassuringly, rosacea is not contagious. If you have rosacea, there is no need for friends or acquaintances to worry that they might catch it from you.
It’s possible that due to the range of symptoms and the differences in treatment success, rosacea has more than one cause. Despite the uncertainty, there are a few known triggers:
Ultraviolet light from the sun can penetrate through clouds. Even on an overcast day, this light reaches your skin. It is known to cause skin damage, and some medical authorities postulate that the damage brings capillaries in the hypodermis closer to the skin’s surface, or even close to the bottom of the epidermis. This change would explain both the reddened skin and a secondary symptom, small red dots sometimes called spider veins.
Immune system disorders
One popular belief is that a hypervigilant immune system may cause rosacea flare-ups. Normally, the immune system kills and removes alien invaders, but sometimes it overreacts and damages the body it is supposed to protect. In this case, the skin itself may be attacked.
This account would explain the red coloring in the skin as part of an inflammatory response to halt a non-existent invasion. It might also explain why, even after rosacea has been successfully treated, there are periodic flare-ups. An overactive immune response might trigger a reaction.
One particularly relevant part of the immune system is the mast cell, a type of white blood cell. Studies of rosacea patients indicate that they have more than the normal amount of mast cells. This could indicate, however, that mast cells resist rosacea rather than cause it.
One interesting study discovered that if mice with mast cells are injected with material from a patient with rosacea, they begin showing symptoms of rosacea. If the mice do not have mast cells, an injection with the same material does not produce any symptoms. With further study, it’s hoped the mechanisms that provoke rosacea will be better understood and a target for treatment identified.
There is some evidence that supports the premise that rosacea runs in families, although no gene or combination of genes has been identified as making the disorder more likely.
A genetic effect is often indirect. For example, a hereditary predisposition might make a person more susceptible to skin disorders caused by ultraviolet light. In that case, the rosacea would not be directly inherited, but a greater susceptibility to the disorder would be passed down through the generations.
The three causes outlined above are all possible explanations for the reddish color of the skin. However, no concrete hypothesis has yet emerged to explain the excess tissue (phymatous) that constitutes the second primary symptom of rosacea. There is, however, a popular folk explanation: long-term alcoholism.
The logic is simple: sometimes alcohol causes a person’s face to redden, and eventually the drinker’s face might remain in a permanent flush. Alcohol can indeed be one of the triggers of a rosacea flare-up, except many alcoholics never get the excess tissue, while non-drinkers occasionally do.
As a general rule, refraining from alcohol or drinking in moderation is the most prudent guideline to follow, even if being phymatous is not a sign of excessive drinking.
Common rosacea triggers
While the causes of rosacea remain uncertain, the triggers that lead to flare-ups of the condition are understood. Triggers bring blood to the face; drinking wine represents one such example. Rosacea flare-ups can also accompany menopause, or be a symptom of caffeine withdrawal.
The National Rosacea Society has surveyed over 1,000 patients and found a long list of triggers. Most of them were reported by a minority of patients, but the following five were common to more than half of the patients surveyed.
The best technique to avoid triggers is to keep a record of your flare-ups, noting the weather, your emotional state, any recent activities and the foods you’ve eaten. If a pattern emerges, you’ll know which triggers to avoid.
Exposure to the sun is the most commonly reported trigger. It’s recommended patients wear broad-brimmed hats and apply sunscreen regularly. Strong winds and hot weather in general will trigger flare-ups in many cases.
Another trigger almost as widely reported as sun exposure is emotional stress. This trigger can be especially upsetting to patients at work where the rosacea flare-up can even increase the stress. It can also complicate an already embarrassing social situation when the rosacea suddenly reddens a face, signalling to everyone just how upset the person is.
While not as common as the sun or stress factors, lifestyle can also trigger flare-ups. Exercise, alcohol and hot baths can actually intensify rosacea.
Of course, people who find that exercise triggers intense rosacea shouldn’t stop exercising. Instead, they only need to change their exercise programs so they become less intense. Stay well hydrated by drinking plenty of water, and when the workout is finished be sure to cover your head with a cool, wet cloth.
Many people report how certain foods can trigger a flare-up. While trigger foods varied among sufferers, spicy foods were found to be the most common dietary trigger.
Rosacea flare-ups can sometimes be a side effect of certain medications. If that happens, don’t stop taking the drug, but speak with your doctor and see if a substitute medication is available.
Can rosacea be cured?
There is no cure for rosacea, but its symptoms can be treated and in some cases, even permanently eliminated. Once the condition is treated, patients will need to adjust their habits and lifestyle to keep flare-ups to a minimum.
Rosacea treatment options vary depending on the symptom being treated. The redness and spider veins associated with rosacea can be addressed through a number of options, such as intense pulsed light (IPL) and pulse dye lasers. The pimples associated with the condition can be treated using creams and gels like ivermectin, metronidazole, and benzoyl peroxide.
Most rosacea treatments require little to no downtime. Over-the-counter products, IPL, and most topical treatments can be used to treat certain rosacea symptoms without missing any time from work or daily activities. More invasive and intense procedures like electrosurgical treatments, pulse dye laser, and carbon dioxide laser surgery can sometimes require several weeks of recovery following treatment.
Each treatment option carries its own unique set of risks. A common side effect that typically results when patients pursue milder treatment options (such as using over-the-counter products) is the risk of irritating the skin, causing additional redness, blistering, and scabbing.In addition to these side effects, more invasive treatment options can also lead to visible scarring and pigmentation issues.
How to Prevent Rosacea Flare-ups
Once treatment has reduced or eliminated symptoms, patients should develop a daily routine to manage their condition and keep flare-ups to a minimum.
Manage your diet
The idea is to eat healthy, enjoyable foods without triggering a rosacea flare-up. Almost every rosacea sufferer has some trigger foods, but these differ from case to case.
As a general rule, avoid spicy foods and acidic foods (e.g., citrus fruits, pineapples, grains, and sugar). Avoiding sugar is particularly difficult as it’s included in almost all processed and fast food. Pay close attention to how much sugar you are actually consuming. Keep your skin properly hydrated and drink water throughout the day.
Treat your face gently
Wash with a soft soap. A useful cleanser is Sulfacetamide 10%-Sulfur 5%. Use hypoallergenic cosmetics. Rub moisturizers into your skin every day. Men should use moisturizers before they shave, and they should try to use an electric razor. If you prefer disposable blades, change the blade every week. Reapply moisturizer when you have finished shaving.
Guard against sun damage
Apply sunscreen daily to your skin. The sunscreen must contain zinc oxide to be truly effective, although titanium dioxide is also acceptable. SPF measures blockage of ultraviolet radiation. SPF 30 blocks 97% of the rays, which is sufficient for most people.
The noon sun is the most damaging, and you should ensure you use sunglasses, a wide brimmed hat and a long sleeved shirt when you go out.
Protect your eyes
Keep your eyes moist and clear. Use eye drops (artificial tears) when first waking up in the morning, as needed during the day, and just before going to bed for the night.
To avoid irritating your eyes, wash your hair with baby shampoo.
Avoid direct sunlight by wearing a hat and sunglasses. The sunglasses should block 100% of ultraviolet light. Wraparound glasses are the most effective for protecting against side exposure.
Adapt your routine to colder weather
Summer poses an obvious risk with all that sun, but winter carries risks as well. When outdoors in a chill wind, use a scarf to protect your face and don’t forget to keep using sunscreen. Indoor heaters may be tempting in winter, but stay far enough away from the heat to avoid triggering a rosacea flare-up.
Use a humidifier to keep your skin from drying out.
When to See a Doctor
There is no blood test or other test for rosacea, but your doctor can diagnose the disease on the basis of the collection of symptoms you display.
You should especially seek advice if you notice that a normally rosy complexion has turned a deeper shade of red. This change may indicate that your rosacea has advanced to a more severe stage and other symptoms may develop. Your primary care doctor may not be able to recommend particular treatments or management programs, but can recommend an appropriate specialist.
Mild rosacea with a simple reddening of the cheeks and forehead may seem trivial, but there are good reasons for having a doctor examine it. With time, rosacea tends to become more severe; the rosy color can deepen and other symptoms may appear.
It’s never too early — or too late — to start taking care of your skin in order to prevent the exacerbation of rosacea.
The Bottom Line
While rosacea is typically associated with patches of redness on the face, the symptoms of this inflammatory condition come in many forms. Strawberry nose, spider veins, and red, watery eyes can all be signs of rosacea.
There is no cure for rosacea, however, flare-ups can often be managed and the symptoms treated. Certain foods, habits, and medications can trigger bouts of rosacea. These and environmental factors like strong winds and hot weather can be avoided in order to reduce incidents of flare-ups. In some patients, certain emotional states, particularly stress, also contribute to flare-ups.
Once symptoms appear, there is a vast selection of treatment options available. In many cases, milder options like topical treatments, over-the-counter products, and IPL will effectively treat the signs of rosacea. However, some people may require more invasive options like electrosurgery or carbon dioxide laser surgery for proper treatment. The options best suited to your situation will vary depending on the symptoms you’re experiencing.
- Laun, J., Gopman, J., Elston, J. B., & Harrington, M. A. (2015). Rhinophyma. Eplasty, 15, ic25 ncbi.nlm.nih.gov/pmc/articles/PMC4426765
- National Rosacea Society (2019) rosacea.org
- Weiss, E., & Katta, R. (2017). Diet and rosacea: the role of dietary change in the management of rosacea. Dermatology practical & conceptual, 7(4), 31–37. ncbi.nlm.nih.gov/pmc/articles/PMC5718124