Rosacea

and Sabine Schrör, medical journalist

Marian Grosser studied human medicine in Munich. In addition, the doctor, who was interested in many things, dared to make some exciting detours: studying philosophy and art history, working on the radio and, finally, also for a Netdoctor.

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Sabine Schrör is a freelance writer for the medical team. She studied business administration and public relations in Cologne. As a freelance editor, she has been at home in a wide variety of industries for more than 15 years. Health is one of her favorite subjects.

More about the experts All content is checked by medical journalists.

Rosacea (rosacea) is an inflammatory, chronic disease of the skin of the face that runs in bouts. It starts with reddening of the skin. Later on, vasodilatation, vesicles, nodules and new tissue formations can occur. Those affected suffer from itching and pain, and the cosmetic impairment is also a burden. Find out everything you need to know about rosacea - symptoms, causes, diagnosis, treatment and prognosis.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. L71

Brief overview

What is rosacea? Chronic inflammatory skin disease that progresses in attacks and of varying degrees of severity. The face is usually affected, rarely other parts of the body.
Symptoms: initially volatile skin reddening (erythms), later often vasodilatation, inflammatory blisters and nodules as well as new tissue formation (phyma). In addition, burning, itchy skin and stabbing pain. The special form of ophthalmorosacea affects the eye and, if left untreated, can lead to severe visual disturbances.
Trigger and risk factors: strong, long-lasting UV radiation (sunbathing, solarium), heat, hot bathing and showering, certain cosmetics, washing lotions with an alkaline pH value (> 7), certain medications, coffee and tea, alcohol and nicotine, stress.
Treatment: medication (ointments, creams, lotions, antibiotics), laser treatment, sclerosing, photodynamic therapy, surgery; Avoid typical triggers such as UV radiation, heat, spicy food, alcohol and certain care products and cosmetics
Causes: Still unclear. It is assumed that there is a genetic predisposition in conjunction with various immunological, microbacterial and neurological factors.
Prognosis: Chronic course, not completely curable. With the right treatment, care and an adapted lifestyle, the symptoms can be easily controlled and the relapses reduced. Sometimes the disease suddenly comes to a standstill.

Rosacea: symptoms

Rosacea (rosacea, "copper rose") is a skin disease (dermatosis). Classically, it affects the face and rarely other parts of the body.

The rosacea runs in bouts and different degrees of severity, which are associated with typical complaints. In addition, the symptoms can vary from patient to patient, so that they cannot always be clearly assigned to a degree of severity.

Pre-stage: rosacea diathesis

Sudden, volatile reddening of the skin (erythema) is typical for the onset of rosacea. They mainly affect the cheeks, nose, chin, and the central forehead area. Rosacea rarely shows up in other parts of the body such as the eyes, scalp, chest or neck.

Severity I: Rosacea erythematosa-telangiectatica

In addition to the reddening of the skin, there are vasodilatations (telangiectasias) in the skin of the face. The skin is dry and occasionally flakes easily. In addition, those affected suffer from itching and burning, stabbing pain.

Severity II: papulopustular rosacea

In this stage form, additional inflammatory red blisters (pustules) and nodules (papules) appear as rosacea symptoms. They usually only go away after several weeks. Sometimes lymphedema (fluid retention) also develops in the facial tissue.

Because acne-like inflammatory skin changes develop in rosacea, the disease was incorrectly called "acne rosacea" in the past.

Severity III: Glandular-hyperplastic rosacea

This is the most severe form of rosacea. Connective tissue and sebum glands enlarge, creating bulbous growths (phymes), for example a bulbous nose or potato nose (rhinophyma). For cosmetic reasons, those affected usually suffer severely from these skin changes.

Unlike acne, rosacea does not form blackheads. If you observe typical rosacea symptoms and blackheads at the same time, you are probably suffering from a mixture of these.

Special forms of rosacea

In addition to the classic rosacea, there are some special forms that occur comparatively rarely.

Ophthalmorosacea is seen in around one in five people. It affects the eye, either in addition to the classic skin disease rosacea or in isolation. Typical symptoms are dilated blood vessels in the eyes and inflammation of the eyelids (eyelid margin inflammation = blepharitis) and conjunctiva (conjunctivitis = conjunctivitis). The eyes are also mostly dry and often stinging. The ophtalmorosacea should be monitored particularly closely. If left untreated, it can cause inflammation of the cornea (keratitis), which in extreme cases can lead to blindness.

In the case of rosacea fulminans, the typical symptoms appear particularly pronounced within a few days or weeks. Mostly young women are affected, men, on the other hand, almost never. Once rosacea fulminans has been overcome, it usually does not reappear.

Gram-negative rosacea occurs when the disease has already been treated with antibiotics for several weeks without lasting success. Then only certain pathogens were destroyed. Other so-called gram-negative bacteria survived. They multiply and subsequently cause further skin reactions.

If the rosacea is treated with glucocorticoids (steroid hormones such as cortisone), a steroid rosacea can develop after stopping the medication. This is often much more difficult than the rosacea that you actually wanted to treat. For this reason, rosacea is only treated with these drugs in exceptional cases.

Typical forms of rosacea

The inflammatory skin disease rosacea manifests itself mainly as severe reddening of the face. With a special form, the eyes can become ill and be damaged.

Rosacea: treatment

With special medication and the right cosmetic care, the symptoms of rosacea can often be significantly alleviated. If left untreated, however, rosacea usually worsens in stages.

Additional therapy methods can be used in addition to or as an alternative to drug treatment. These include sclerosing, photodynamic therapy and surgical interventions. In addition, people with rosacea should keep an eye on their diet and avoid typical triggers of the symptoms as much as possible.

Some patients use homeopathy for the treatment of rosacea (often in addition to conventional medical therapy). The effectiveness of the alternative healing method has not yet been scientifically proven. However, some patients report an improvement in symptoms.

Rosacea treatment with medication

Drug treatment is the most important component of rosacea therapy. A distinction is made here between local and systemic therapy. Experience has shown that the combination of local and systemic rosacea therapy is particularly effective.

Local (topical) rosacea treatment

The medication is applied directly to the affected areas of the skin as an ointment, gel or lotion. Which dosage form is most effective and best tolerated depends on the individual case. The external treatment of rosacea is usually carried out over a very long period of time (as topical maintenance therapy). The two most important active ingredients that are used are:

Metronidazole (an antibiotic)
Azelaic acid

Both active ingredients are said to have an anti-inflammatory effect in rosacea. They may also slow down the immune system, which is typically overreacting in rosacea. The azelaic acid also ensures that certain skin cells (keratocytes) do not grow too strongly.

In addition, other substances can be used for local rosacea therapy:

Permethrin: When properly dosed, the actual poison has a positive effect on rosacea.
Clindamycin: The antibiotic is also used locally in exceptional cases.
Retinoids: like permethrin, they are also used for acne.
Calcineurin inhibitors: They mainly help with steroid rosacea.

The active ingredients mentioned primarily fight the nodules and vesicles. However, they usually do not help against the typical reddening of the face. In contrast, a special gel with the active ingredient brimonidine was developed in the USA. It has also been approved in the EU since 2014. The drug causes the blood vessels in the skin of the face to contract. This will make the redness fade.

Systemic rosacea treatment

Local treatment is sufficient for some milder forms of rosacea. In more severe cases, systemic rosacea treatment is also necessary. The drug is used internally, for example in the form of tablets. In this way, the active ingredient reaches the entire body via the blood. On the one hand, this makes systemic rosacea therapy more effective than local. On the other hand, there are often more severe side effects.

Mostly, antibiotics are used for systemic rosacea therapy, in particular two groups:

Tetracyclines: Doxycycline and minocycline are the most commonly used drugs in this group of active ingredients. They are the first choice for the treatment of rosacea with antibiotics because they are better tolerated by the stomach and intestines than macrolides.
Macrolides: This group of active ingredients includes, for example, erythromycin and clarithromycin. Macrolides are used when patients cannot tolerate tetracyclines.

Antibiotics are actually used to fight bacteria. Rosacea treatment uses a different mechanism of action of these substances: In small doses, the antibiotics mainly have anti-inflammatory and dampening effects on the overreacting immune system - similar to metronidazole and azelaic acid in local rosacea treatment.

In addition to antibiotics, active ingredients that are normally used for local treatment are sometimes used for systemic rosacea treatment - for example, tablets with metronidazole.

Retinoids such as isotretinoin can also relieve rosacea symptoms when used internally, studies show. However, isotretinoin is only approved for the treatment of severe acne in Germany. It is therefore only used in severe rosacea in exceptional cases outside of the official approval ("off label"). Great caution is advised here because taking isotretinoin capsules can have many side effects (including severe ones), for example skin and mucous membrane irritation. In addition, isotretinoin must not be taken by women who could become pregnant (risk of child malformations!).

In contrast to many other skin diseases, rosacea is only treated with glucocorticoids ("Kortiosn") in exceptional cases, as these agents usually worsen the clinical picture. Even after an initial improvement, the symptoms usually return all the more strongly after stopping the cortisone preparation.

Laser treatment and desolation

The persistent redness and vasodilatation (telangiectasias) can usually be removed well with a laser treatment. For this purpose, the affected areas of the skin are treated with bundled, high-energy rays of light. Phymes can also be removed in this way.

Vascular dilatation can also become obliterated with the help of electric current.

Photodynamic Therapy (PDT)

In photodynamic therapy, rosacea patients first receive a substance that makes the skin more sensitive to light. This so-called photosensitizer attaches itself to the affected areas of the skin. Then these areas are irradiated with light of a certain wavelength. This changes the structure of the photosensitizer. As a result, the substance destroys defective skin structures.

Surgical therapy

Rosacea can also be treated surgically, for example with dermabrasion or dermashaving.These methods are mainly used with phymes. They are therefore described in more detail in the article "Rosacea: Rhinophyma".

Change your diet & avoid triggers

It is also very helpful when people with rosacea change their diet. While there is no specific rosacea diet. However, since experience has shown that hot spices, very hot food and drinks and alcohol can lead to vasodilatation in the face, it is better for you as a patient to avoid them. Maintain a healthy, balanced diet. In particular, reduce your fat and sugar consumption in favor of lots of fruits and vegetables. This is how you can prevent the pores on the skin of your face from clogging. This in turn has a positive effect on the complexion.

In addition, you should test how your rosacea reacts to different foods. To do this, consciously refrain from eating individual foods again and again and observe whether and how the rosacea symptoms change as a result.

It is also important that you avoid the typical triggers of a rosacea flare-up:

strong, long-lasting UV radiation (sunbathing, solarium)
Heat, hot bathing and showering, going to the sauna
Washing lotions and soaps with an alkaline pH value (> 7)
certain cosmetics
certain drugs
coffee and tea
alcohol
nicotine
stress

Hormonal changes, for example during pregnancy, can trigger a disease flare-up. Talk to your doctor about it.

Rosacea patients react differently to the various possible triggers. Therefore, pay close attention to the stimuli to which your skin reacts and adapt your lifestyle accordingly.

Rosacea: care

Rosacea skin should be properly cared for. This can support treatment with medication and / or other therapy methods. Because certain ingredients and improper use of care products can irritate the skin and thus exacerbate the symptoms.

Proper skin care

Keep the following tips in mind when caring for your skin:

Only clean the skin of the face with lukewarm water. Extreme water temperatures and rapid temperature changes can lead to sudden reddening of the skin (flush).
Do not use facial peelings, as they irritate the rosacea skin even more.
Only use care and washing products without menthol, camphor, sodium lauryl sulfate and astringents.
Avoid water with a high degree of hardness.
After washing, gently pat the skin of the face dry with a towel instead of rubbing it with the towel.
Use soaps and washing lotions with a slightly acidic pH value (<7).

When it comes to facial cleansing, so-called washing syndets are well suited for rosacea patients. These are artificial detergent substances with a relatively low pH value (4.5 to 5.5), which are much gentler on the skin than classic soaps.

The fine vessels of the skin expand

The skin of the cheeks is red because the smallest blood vessels expand (telangiectasia) - the small veins are clearly visible.

Watch out, sun!

UV rays are an important risk factor for those affected by rosacea. Therefore, you should carefully protect your skin from (strong) UV radiation:

Avoid direct sunlight between spring and autumn.
Refrain from going to the solarium.
Use sun protection products with a high sun protection factor (50+) and apply them several times a day. Prefer physical sun blockers with titanium dioxide or zinc oxide (pharmacy). In the case of rosacea, these are considered to be more skin-friendly than chemical sunscreens.

Rosacea: Cream, Ointment, or Lotion?

The products differ in terms of water and fat content. An ointment contains no water at all, only fat. In contrast, a cream has a certain amount of water. A lotion actually contains more water than fat. It is therefore also known as an oil-in-water emulsion.

For rosacea patients, products with a high water content are ideal, i.e. creams and lotions. Because they do not form a pore-closing grease film on the skin, but allow the skin to breathe without drying it out. The same applies to preparations based on glycerine or silicone oil (cyclomethicone, dimethicone).

You should completely avoid products with added fragrances or dyes, as these irritate the skin unnecessarily.

Tip: Get detailed advice from the pharmacy before buying your care products.

Make-up for rosacea

Basically, you can also use makeup with rosacea. However, you should make sure that the products are free of skin-irritating ingredients such as menthol, camphor, sodium lauryl sulfate and astringents. In addition, the cosmetics should not clog the sebum glands, i.e. not be comedogenic.

Avoid using very thick make-up. Because this is difficult to remove, which in turn can cause skin irritation. On the other hand, it makes sense to use a special rosacea make-up that covers the reddening of the face well and is also easy to remove.

Rosacea sufferers can react very individually to cosmetics. If you notice that you cannot tolerate a product, you should stop using it immediately and try an alternative.

Rosacea: rhinophyma

Rhinophyma is a symptom of rosacea that can develop if the disease is severe. It is an overgrowth of the connective tissue and the sebum glands (Phyme). Rhinophyma usually occur on the nose. This so-called bulb nose or potato nose is particularly common in older men.

Phymes are treated with medication or surgery. Good optical treatment successes can be achieved today, especially in the surgical field. However, there is a possibility that a new bulbous nose will form later.

You can read more about the "rhinophyma" in rosacea in the article Rosacea: Rhinophyma.

Rosacea: causes and risk factors

Depending on which study is used, between 2 and 20 percent of the population in Germany suffer from rosacea. People over 30 are most likely to be affected. But even children can develop rosacea in exceptional cases. Serious differences between the sexes cannot be observed - rosacea occurs only slightly more frequently in women. In addition, light skin types are more often affected than dark ones.

The typical symptoms of rosacea are based on permanent widening of the blood vessels and chronic inflammation of the skin. The reasons for this have not yet been fully clarified. A genetic predisposition is suspected. Experts believe that it could lead to the development of rosacea in combination with various factors.

How does rosacea develop?

Among other things, the body's immune system probably plays a role. It produces certain antimicrobial substances in the skin that are supposed to fight off invading pathogens. Some of these substances cause inflammation and also cause new vessels to form (angioneogenesis). This is normal and useful to destroy invading pathogens. However, significantly increased concentrations of these antimicrobial substances have been detected in the blood of rosacea patients. This could explain the pathological inflammation of the skin and new tissue formation.

Certain microorganisms are suspected to be the trigger of the immune reaction. The skin of those affected by rosacea is often more heavily populated with so-called hair follicle mites (Demodex folliculorum). The microscopic animals can be found on the skin of every human being. In rosacea patients, however, they seem to occur more frequently and trigger the above-described immune reaction leading to inflammation.

There is also evidence that receptors of the immune system do not work properly in rosacea. These receptors recognize organisms that are foreign to the body and produce certain substances to combat them. In the event of a dysregulation, however, the receptors overreact and thus trigger persistent skin inflammation.

Last but not least, inflamed nerves in the face also seem to play a role in the development of rosacea. The nerves control the blood vessels by expanding them when it is hot and contracting when it is cold. However, in rosacea patients, communication between nerves and blood vessels in the face does not work properly because the nerves are inflamed. This leads to malfunctions - even with weak stimuli such as spicy food, the blood vessels expand without subsequently contracting completely again.

Rosacea: examinations and diagnosis

The dermatologist can usually recognize rosacea based on the typical symptoms (reddening of the skin, enlarged vessels, etc.). Special examinations are therefore usually not necessary.

Sometimes the doctor will take a skin sample (biopsy) if rosacea is suspected. It is examined more closely under the microscope. In this way, visually similar skin diseases can be excluded, such as the rarer butterfly lichen or stewardess disease (cosmetic acne). The examination also helps to assess the severity of the rosacea.

Rosacea: disease course and prognosis

Rosacea is usually chronic and intermittent - phases with more severe symptoms alternate with times in which the symptoms subside or at least improve. While the condition is not completely curable, it can be easily controlled with the right treatment, skin care, and lifestyle. Sometimes the rosacea even comes to a standstill without developing any further.