The disease has a wide range of symptoms and signs, but rarely do patients go through each stage of rosacea. Variable erythema and telangiectasia is seen on cheeks and forehead. Inflammatory papules and pustules are seen mainly on the nose, the forehead, and the cheeks. Rarely, the neck and the upper part of the chest are involved.

In severe cases, thickened and disfigured noses (rhinophyma) are seen due to prominent sebaceous glands. Patients may complain of drying and peeling of the skin. Ocular lymphedema may be outstanding but is not seen commonly. Usually, rosacea does not cause any scarring.

Sometimes rhinophyma is the only presenting symptom and no other signs of rosacea are seen. Lymphedema can be predominant in periorbital area and sometimes be the only presenting symptom.

Ocular rosacea can be associated with conjunctival infection, and, rarely ever with chalazion and episcleritis.

Rosacea fulminans (pyoderma faciale) is a rare complication which is identified by the formation of nodules and abscesses with development of a sinus tract along with systemic signs.

A rare granulomatous type of rosacea (acne agminata/lupus miliaris disseminatus faciei) can present with inflammatory erythematous or flesh-colored papules spread symmetrically on the upper part of the face, especially around the eyes and nose. This type of rosacea may be associated with scarring and sometimes do not respond to regular treatment.

• Swelling

  Swelling: Facial swelling ( edema ) can occur independently or can accompany other signs of rosacea. Signs beyond the face: Signs and symptoms might develop beyond the face, affecting areas including the neck, chest, scalp, or ears. [my.clevelandclinic.org]

  […] of other facial areas including the eyelids – blepharophyma Persistent redness and swelling or solid oedema of the upper face due to lymphatic obstruction – Morbihan disease. [web.archive.org]

  About half of those with the condition also have eye symptoms like redness, burning, tearing, swelling or the sensation of something being in their eye. [aurorahealthcare.org]

  Some researchers think rosacea is caused by a condition that swells blood vessels. This leads to redness and flushing. Others think tiny organisms or mites clog oil glands on the face. That makes the skin swollen and red. [aao.org]

  It may also cause swelling and skin sores that look like acne. The cause is not known. You may be more likely to have this if you are: Age 30 to 50 Fair-skinned A woman Rosacea involves swelling of the blood vessels just under the skin. [nlm.nih.gov]

• Flushing

  Scientists consider the condition something of a mystery, but most believe a mix of genetics and sun damage kick-start this tendency to flush easily and often, at almost everything—and sometimes nothing at all. [allure.com]

  At first, telangiectasias may be hidden by the redness of flushing or blushing, but they usually reappear after this redness fades. [drugs.com]

  If you have severe, persistent flushing, there are other possible causes of flushing requiring laboratory tests; see your doctor. [skinsight.com]

  General measures: Avoid the triggers of flushing, as discussed above. [dermcoll.edu.au]

• Acne Vulgaris

  Unlike acne vulgaris, rosacea is typically localized commonly over the central face (i.e. medial cheek, nose, forehead, and chin). Acne Vulgaris vs. [stanfordmedicine25.stanford.edu]

  The affected child may be predisposed to more severe acne in adolescence. acne papulo´sa acne vulgaris with the formation of papules. acne rosa´cea a form of acne in which the skin around each pustule is a rosy red; it is usually seen in persons over [medical-dictionary.thefreedictionary.com]

  Rosacea, also referred to as acne rosacea, is different from acne vulgaris, which normally affects younger people. [acne.org]

  Acne Vulgaris Acne vulgaris is the most common skin disease in the United States.21 It is characterized by noninflammatory; open or closed comedones; and inflammatory papules, pustules, and nodules. [mdedge.com]

  They are easily irritated if you apply harsh acne medicines to them, thus behaving more like a rash than acne. Also, unlike regular acne vulgaris, adult acne rosacea does not cause blackheads. [drbaileyskincare.com]

• Eruptions

  We report a case of a rosacea-like eruption in a 39-year-old woman occurring after the use of pimecrolimus cream for 12 months for atopic dermatitis. [ncbi.nlm.nih.gov]

  The treatment at the Ailesbury Clinic is aimed at the control of redness, inflammation, and skin eruptions through the use of topical or oral anti-biotics or laser therapy. [ailesburyclinic.ie]

• Acneiform Eruption

  […] definition An acneiform eruption occurring mostly in middle-aged adults and appearing generally on the forehead, cheeks, nose, and chin. [dermis.net]

  Steroid-induced acneiform eruption Steroid-induced acneiform eruption is not a variant of rosacea and can occur as an inflammatory response in any patient during or after chronic corticosteroid use. [rosacea.org]

  eruptions Perioral dermatitis Diagnosis Physicians experience a challenge when diagnosing rosacea because of the numerous ways it can present itself. [acne.org]

  eruption Folliculitis Uncommon Lupus erythematosus Dermatomyositis Drug reaction, e.g. isoniazid Sarcoidosis Demodicosis (mange) Source: References 1, 4, 6 Clinical manifestations The presence of at least one of the following primary features indicates [ncbi.nlm.nih.gov]

• Red Skin Lesion

  These symptoms often progress to include development of bumpy red skin lesions, pimples, and tiny, tortuous vessels in the skin known as telangiectasias (tel-an-jee-ek-TAY-zee-ahs). [allaboutvision.com]

• Blepharitis

  We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea. [ncbi.nlm.nih.gov]

  MARAZZI / SCIENCE PHOTO LIBRARY Other symptoms can include: dry skin swelling, especially around the eyes yellow-orange patches on the skin sore eyelids or crusts around roots of eyelashes – this could be blepharitis thickened skin, mainly on the nose [nhs.uk]

  “Blepharitis, an inflammation of the edge of the eyelids, is very common in rosacea and in fact may be present in a majority of rosacea cases,” he says. “You need to seek medical advice if your eyes become sore or irritated.” [thetimes.co.uk]

• Foreign Body Sensation

  Patients with ocular rosacea may say they have a gritty, burning or foreign body sensation in their eyes. The eyes may be red (image below) and irritated. They are more likely to have styes (hordeolums) and be at risk of infection. [stanfordmedicine25.stanford.edu]

  Symptoms of ocular rosacea may include inflammation of the eyelids, conjunctiva, iris, sclera, cornea, or a combination that causes itching, a feeling as though something is in the eye (foreign body sensation), redness, and swelling of the eye. [merckmanuals.com]

  Ocular Foreign body sensation in the eye, burning or stinging, dryness, itching, ocular photosensitivity, blurred vision, telangiectasia of the sclera or other parts of the eye, or periorbital edema. [rosacea.org]

• Conjunctival Injection

  The main symptom is conjunctival injection, which is sometimes accompanied by chalazion or episcleritis. Rosacea patients should therefore be seen by an ophthalmologist early in the disease course [ 100 ]. [doi.org]

• Facial Redness

  Physicians are often presented with patients complaining of facial redness and difficult to control rosacea. [ncbi.nlm.nih.gov]

  Acne rosacea is a common and chronic skin condition that often triggers facial redness. Also known simply as rosacea, it can spread to other areas of the body as well and cause other symptoms. [stanfordhealthcare.org]

  The skin condition, which typically manifests as facial redness, visible blood vessels, or little red pustules, has been attributed to a whole host of causes, from abnormalities in the the blood vessels to an increase of microscopic mites on the surface [bustle.com]

  The facial redness, which might come and go, often is the earliest sign of the disorder. Persistent redness: Persistent facial redness might resemble a blush or sunburn that does not go away. [my.clevelandclinic.org]

• Bulbous Nose

  This actor's memorable large bulbous nose is an example of rhinophyma. Rhinophyma can occur in men after years of untreated adult acne, known as acne rosacea. [skinema.com]

  Complications People with long-term severe rosacea (usually men) sometimes develop a distinctive, red swollen or bulbous nose, with enlarged pores. [mydr.com.au]

  It usually starts with redness on the cheeks and nose, and also can affect the forehead and chin. The late comedian W.C. Fields, who was known for his wicked wit and red, bulbous nose, had an advanced case of rosacea. [health.harvard.edu]

  In the later stages, hyperplasia of the sebaceous glands develops, resulting in phymatous growths such as the frequently observed bulbous nose or rhinophyma. Ablative laser treatments have largely replaced classical abrasive tools. [ncbi.nlm.nih.gov]

  Symptoms may include: Redness of the face Blushing or flushing easily A lot of spider-like blood vessels (telangiectasia) of the face Red nose (called a bulbous nose ) Acne-like skin sores that may ooze or crust Burning or stinging feeling in the face [nlm.nih.gov]

• Red Nose

  Eventually, redness will persist around the nose area, extending to the rest of the face. [uclahealth.org]

  Symptoms may include: Redness of the face Blushing or flushing easily A lot of spider-like blood vessels (telangiectasia) of the face Red nose (called a bulbous nose ) Acne-like skin sores that may ooze or crust Burning or stinging feeling in the face [nlm.nih.gov]

  […] and cheeks that cause an enlarged, bulbous red nose (almost only seen in men) In addition, rosacea often affects the eye and eyelid. [hopkinsmedicine.org]

  Reduce Redness A red nose is synonymous with rosacea, and rhinophyma is no exception. [rosacea.ie]

• Facial Edema

  We herein report the case because it presented in atypical fashion, as a solitary indurated plaque on the nose, likely representing Morbihan's disease or solid persistent facial edema of rosacea (rosacea lymphedema). [ncbi.nlm.nih.gov]

  Edema. Edema may accompany or follow prolonged facial erythema or flushing. Sometimes soft edema may last for days or be aggravated by inflammatory changes. [rosacea.org]

  Hisashi Uhara, Shigeo Kawachi and Toshiaki Saida, Solid Facial Edema in a Patient with Rosacea, The Journal of Dermatology, 27, 3, (214-216), (2015). Gerd Plewig and Albert M. [doi.org]

  Persistent erythema of the central face, subtle telangiectasias, facial edema, and ocular inflammation may also be present. [ahdbonline.com]

  edema Phymatous (subtype 3) Marked skin thickening and irregular nodularities of nose, chin, ears, forehead, or eyelids More common in men Rhinophyma Ocular (subtype 4) Watery, bloodshot eyes Affects nearly 60 percent of patients with rosacea Dry eye [aafp.org]

• Nose Enlargement

  Long-standing rosacea results in overgrowth of the skin and connective tissues, particularly of the nose. Rhinophyma results from thickening of the skin over the nose, producing nose enlargement. [docdoc.com.sg]

  The oil glands and the blood vessels on the nose enlarge so much that the nose becomes very bulbous in appearance. Thick bumps can develop on the nose and may require surgery to treat. About half of the patients with rosacea have eye symptoms. [skintour.com]

• Agitation

  Symptoms are likely to become more agitated if they are left untreated and the affliction can occur alongside other skin conditions such as seborrheic dermatitis. [avogel.co.uk]

The diagnosis is made clinically. Sometimes a skin biopsy is done to rule out other cutaneous diseases, like lupus or sarcoidosis. The typical history and visible signs are more than sufficient to diagnose a case of rosacea.

• Demodex Folliculorum

  The causative role of Demodex folliculorum should be considered in immunocompetent children with rosacea or rosacea-like refractory eruptions. In such cases, treatment with ivermectin can be beneficial. [ncbi.nlm.nih.gov]

  The microorganisms that have been associated include Helicobacter pylori, Demodex folliculorum, Staphylococcus epidermidis, and Chlamydia pneumonia ; all the studies have been inconclusive. [doi.org]

Prior to any therapy, it is better to identify and avoid the triggering factors that flare up the patient's rosacea. These factors can be different for every individual. In some patients, it is seen that regular facial massage helps in reduction of lymphedema. Fairly high doses of prednisolone (30-60 mg/d) followed by oral isotretinoin helps in treatment of rosacea fulminans.

All patients with rosacea should use a broad-spectrum sunscreen that protects against both UV-A and UV-B rays on a daily basis [4]. 

Laser treatment can be done to treat enlarged or dilated blood vessels or remove surplus nose tissue in cases of rhinophyma.

Cosmetic change of rhinophyma can be done by various techniques like mechanical dermabrasion, carbon dioxide laser peel, and surgical shave.

The first line of treatment is generally topical metronidazole. Topical azelaic acid, sulfacetamide products, and topical acne medications are frequently used. Antibiotics are also very effective in both ways i.e. orally or topically, and for ocular rosacea, they are generally the first-line therapy. Some people also recommend using retinoids for treating rosacea [5] [6] [7].

Medicines that help in reducing the flushing like beta-blockers, clonidine, naloxone, ondansetron, and selective serotonin reuptake inhibitors can also help in treating rosacea.

In some patients who complain of rosacea that worsens with their hormonal cycles, oral contraceptive therapy can be beneficial.
Dapsone is helpful for patients who cannot take isotretinoin [8] and is used in cases of severe refractory rosacea.

Development of rosacea is different for every individual, depending on various factors like genetics, skin sensitivity, skin complexion, amount of time spent in sunlight without sunscreen, intake of alcohol and spicy foods, and exposure to extreme temperatures. With the help of suitable treatment and avoidance of triggering factors, rosacea can be controlled.

The etiology of rosacea is unknown. Different aggravating factors leading to incidents of flushing and blushing play a role in developing rosacea.

Various factors like vasculature, climatic exposures, pilosebaceous systems abnormalities, dermal matrix degeneration, chemicals and consumed agents, microbial organisms, reactive oxygen species (ROS), increased neoangiogenesis, ferritin expression, and dysfunction of antimicrobial peptides (AMPs), may also lead to its development [1].

It primarily affects people of northwestern European descent. Although it affects both the sexes, women are three times more prone to it as compared to men. 30-60 years is the most vulnerable age to suffer from rosacea.

As the exact cause of rosacea is unknown, following are the theories that explain the development of this skin condition:

• Vasculature: High amount of blood flowing through the vessels of face and numerous blood vessels that are nearer to the facial surface might be the cause of redness and flushing related to rosacea.

• Climatic conditions: Harsh climatic conditions harm the cutaneous blood vessels along with the dermal connective tissue. Hence we know the reason why rosacea is prevalent on the face and flares up in spring due to the solar irradiation exposure.

• Dermal matrix degeneration: Rosacea leads to the damage of endothelium and deterioration of the dermal matrix.

• Chemicals and ingested agents: Spicy foods, alcohol, and hot beverages are generally considered as triggering factors for flushing in rosacea patients. Also, medications like amiodarone, topical steroids, nasal steroids, and increased dosage of vitamins B-6 and B-12, can also lead to flares in rosacea patients.

• Inflammation: An inflammatory infiltrate present in either perivascular or a perifollicular area or present in both the places may also lead to rosacea.

• Microbial organisms: Demodex species (mites generally seen human hair follicles) might lead to development of rosacea. Research suggests that Demodex has preference for rosacea afflicted areas of the skin like nose and cheeks [2].

• Ferritin expression: Iron acts as a catalyst in converting hydrogen peroxide to free radicals that cause injury to the tissues by destroying cell membranes, proteins, and DNA. Skin biopsy of the patients with rosacea when immunohistochemically analyzed, showed significant rise in number of ferritin-positive cells in diseased individuals in comparison to controlled individuals. Also, raised ferritin positivity correlated with more progressive subtypes of rosacea. Hence, marked release of free iron from proteolysis of ferritin can cause oxidative damage to the skin, which can also speed up the development of rosacea [3].

• Reactive oxygen species: In the beginning of an inflammatory process, the neutrophils release the reactive oxygen species (ROS), which are considered to play a vital role in the inflammation that is associated with rosacea.

Rosacea cannot be prevented but the symptoms can be controlled by knowing and avoiding the common triggering factors [9] [10] like hot drinks, exercise, alcohol, spicy foods, emotions, caffeine, sunlight, extreme heat or cold. These factors increase the blood flow and lead to dilation of small blood vessels of the facial skin. It is necessary to identify one’s own trigger factors and pay special attention towards avoiding them.

Rosacea is a common chronic skin condition characterized by symptoms of facial erythema (redness) and a wide range of clinical signs, like telangiectasia, roughness of skin, and an inflammatory papulopustular eruption looking like acne.

Age is no bar for rosacea affection. Rosacea can be divided into four types, of which three affect the skin and the last one affects the eyes.

Rosacea is a chronic inflammatory skin disease manifested as widespread redness and red boils generally over the forehead, cheeks, and nose. It is commonly seen in females of the reproductive age group and is easily diagnosed just by seeing.

As there is no way of preventing rosacea, measures can be taken to reduce the symptoms and their frequency of development. The first and foremost step is avoiding the triggering factors. Then comes, taking care of the skin in general by cleansing and moisturizing your face regularly. Prefer facial products that do not burn, sting, irritate or cause redness when use. One must develop a habit of washing face with lukewarm water and a mild soap.

One must avoid alcohol and acetone based products like toners, scrubs, etc. as they tend to dehydrate the skin. Hydroxy acids and tretinoin like Retinon A have good chances of sensitizing your skin to sun and thereby worsening rosacea. Patients must make it a norm to use broad spectrum sunscreens and sun blockers daily and generously for protecting your face [4]. Use sunscreens that have SPF factor of 30 or more.

During winter patients must take extra care of face by using a scarf or ski mask to protect it. In case one wants to use makeup, one can go for green-tinted foundation creams and powders as they are designed specially to prevent redness of the skin.

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