Facial redness that doesn’t go away? Inexplicable bumps and pimples? Irritated eyes? All are signs of rosacea, a potentially serious disorder that can now be diagnosed with more precision than ever before. April has been designated as Rosacea Awareness Month to educate the public on this often life-disruptive condition now affecting more than 16 million Americans – and most of them don’t know it.
“Even though signs of rosacea have been documented in art and literature for centuries, virtually all that is understood about this disorder in medical science has been discovered in the last 15 years,” said Dr. Richard Gallo, chairman of dermatology at the University of California – San Diego, who recently headed a committee and review panel of 28 rosacea experts in the development of the new standard diagnostic guidelines.1 “Unlike the mysteries of the past, dermatologists are now able to identify the various signs and symptoms of rosacea based on a thorough understanding of the disease process.”
Beyond its immediate physical impact, new research has also found that rosacea may be associated with increased risk of a broad range of potentially serious systemic disorders. These include a growing list of cardiovascular, gastrointestinal, neurological and autoimmune diseases, as well as certain cancers.2
According to the new standard system, the presence of one of two signs or symptoms known as phenotypes – persistent redness of the facial skin or, less commonly, the thickening of the facial skin, often around the nose – is considered diagnostic of rosacea. Additional major phenotypes, which often appear with the diagnostic features, include bumps and pimples, flushing, visible blood vessels and irritation of the eyes. The presence of two or more major phenotypes independent of the diagnostic features is also considered diagnostic of rosacea. Secondary phenotypes, which must appear with one or more diagnostic or major phenotypes, include burning or stinging, swelling and dry appearance.
The red face of rosacea was described as early as the 1300s in Chaucer’s “Canterbury Tales,” and the less common swollen nose was shown in the 1540 Renaissance painting “The Old Man and his Grandson” by Ghirlandaio. Among the most famous modern rosacea sufferers is former President Bill Clinton, whose doctors disclosed that he has this condition in the New York Times. Others reported to have suffered from rosacea include Princess Diana, singer Sam Smith, model Dita Von Teese and comedian Amy Schumer.
Despite its prevalence and damaging consequences, in a recent NRS survey of 1,459 rosacea patients, 47 percent said they had never heard of rosacea prior to their diagnosis and 95 percent said they had known little or nothing about the condition. In other NRS surveys, 90 percent of rosacea patients said rosacea’s effect on personal appearance had lowered their self-esteem and self-confidence, and 52 percent said they had avoided face-to-face contact because of the disorder. Among those with severe symptoms, 51 percent said they had even missed work because of their appearance.
Adding insult to injury is the common myth that rosacea sufferers who have a ruddy complexion or enlarged nose may be heavy drinkers. In fact, while alcohol may aggravate rosacea, these symptoms can be just as severe in a teetotaler. Another common misconception is that rosacea is caused by poor hygiene, when in reality it is unrelated to personal cleanliness – nor is it contagious in any way.
What is Rosacea?
Rosacea typically first strikes any time after age 30, and may initially resemble a simple sunburn or an inexplicable blush. Suddenly, without warning, a flush comes to their cheeks, nose, chin or forehead. Then just when they start to feel concerned, the redness disappears.
Unfortunately, it happens again and again, becoming more severe and lasting longer each time, and eventually visible blood vessels may appear. Without treatment, bumps and pimples often develop, growing more extensive over time, and burning, itching and stinging are common.
In around half of rosacea patients, the eyes are also affected, including visible blood vessels on the eyelid margin and a bloodshot appearance, as well as inflammation and growth of fibrous tissue. Burning, stinging, light sensitivity and the sensation of a foreign object may also occur, as well as conjunctivitis, inflammation of oil glands at the rim of the eyelids (blepharitis) and crusty accumulations at the base of the eyelashes.
In severe cases, especially in men, the nose may become enlarged from the development of excess tissue. This is the condition that gave comedian W.C. Fields his trademark red, bulbous nose.
Recent studies have shown that the initial redness appears to be the start of an inflammatory continuum initiated by neurovascular dysregulation and the innate immune system. The role of the innate immune system in rosacea has been the focus of groundbreaking studies funded by the NRS, including the discovery of irregularities of key components known as cathelicidins. Research has further demonstrated that a marked increase in mast cells, located at the interface between the nervous system and vascular system, is a common link in all major presentations of the disorder. Other studies have documented a possible genetic component, as well as the potential role of the human microbiome, including Demodex mites and certain bacteria.
“It’s now well established that a complex but consistent disease process underlies the various physical manifestations of rosacea, and these are now increasingly well understood,” Dr. Gallo said. “At the same time, today there is a much wider range of therapeutic options to treat the various potential signs and symptoms, so it makes sense to focus on the individual phenotypes that may be present.”
Although the ultimate cause of rosacea remains unknown, a vast array of lifestyle and environmental factors has been found to trigger flare-ups of signs and symptoms in various individuals. Common rosacea triggers include sun exposure, emotional stress, hot or cold weather, wind, heavy exercise, alcohol, spicy foods, heated beverages, humidity, certain skin-care products and potentially an overabundance of Demodex mites.
“The good news is that rosacea can be effectively controlled with medical therapy and lifestyle changes,” Dr. Gallo said. “Through ongoing progress in medical research, a growing number of medical therapies are now available that can be tailored to each individual case and substantially reduce the impact of rosacea on people’s lives.”
Individuals with any of the following warning signs of rosacea are urged to see a dermatologist for diagnosis and appropriate treatment:
- Redness on the cheeks, nose, chin or forehead
- Small visible blood vessels on the face
- Bumps or pimples on the face
- Watery or irritated eyes
During April and throughout the year, people who suspect they may have rosacea can contact the NRS for more information. The NRS encourages those interested in spreading awareness during the month of April to visit the official Rosacea Awareness Month landing page and follow the online conversation using the hashtag #RosaceaAwareness. The NRS may also be followed on Facebook, Twitter or Pinterest for up-to-date information and tips on rosacea. Further information may be obtained by writing the National Rosacea Society, 196 James Street, Barrington, Illinois 60010; via email at firstname.lastname@example.org; or by calling its toll-free number at 1-888-NO-BLUSH.
1. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018 Jan;78(1):148-155. doi: 10.1016/j.jaad.2017.08.037. Epub 2017 Oct 28.
2. Gallo RL, Granstein RD, Kang S, et al. Rosacea comorbidities and future research: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol 2018 Jan;78(1):167-170. doi: 10.1016/j.jaad.2017.06.150. Epub 2017 Nov 1.