The diagnosis and therapy of rosacea is one of the specialities of Prof. Steinkraus, who is also a member of the German Rosacea Association.
Rosacea is an inflammation of the skin on the face that can affect virtually anyone of any sex based on a genetic predisposition or genetic factors. It usually affects middle-aged people, but occasionally occurs in the very young and the very old. Rosacea can appear acutely within a few days, but it usually develops over weeks and months and becomes chronic. The inflammation manifests itself with redness, small papules and pustules and, as it progresses, occasionally with small sebaceous gland growths in the central regions of the face, especially on the nose, forehead, cheeks and chin.Rosacea is an inflammatory skin disease that is not infectious and therefore not contagious. It can be treated excellently. The prerequisite for an effective therapy is a confirmed diagnosis.
Manifestations and course of rosacea
Rosacea is a non-infectious inflammation of the facial skin that manifests itself with redness, small papules and pustules (spots and pustules) on the face. The skin changes primarily affect the central areas of the face such as the nose, cheeks, forehead and chin. They are almost always asymptomatic, meaning there is no burning sensation or any pain or discomfort.
Typically, rosacea is divided into 3 stages:
- Stage I: An early form of rosacea in which the skin is permanently red due to increased veins that are also dilated. If there are more dilated veins in the skin, more blood flows through them, which explains the permanent redness (rosacea teleangiectatica).
- Stage II: The inflammatory form of rosacea, in which papules and pustules, i.e. small inflammatory nodules (pimples) and spots of pus appear, especially in the central areas of the face (rosacea papulopustulosa).
- Stage III: The maximum expression, characterised by sebaceous gland overgrowth (mostly on the nose) and swelling of the facial skin.
Difference to acne
Rosacea is an acne-like inflammation, but it has nothing to do with acne. Acne is an inflammation of the sebaceous glands that starts with blackheads (comedones) and typically occurs in young people during puberty. Because acne is triggered by male hormones (androgens), it favours the male sex, although women (women also have androgens) can also develop severe acne. Acne also affects all areas of the body that are rich in sebaceous glands. These include the face, the décolleté, and the upper back. None of this is the case with rosacea. Rosasea is usually a disease of the facial skin only, occasionally of the eyes and/or scalp.
Age at first signs of rosacea
Rosacea affects people of all sexes with a slight preference for the female sex. The first symptoms usually appear between the ages of 20 and 50.
Causes of rosacea
The causes of rosacea are unknown. What is certain is that there is a genetic predisposition that favours rosacea.
Provoking factors of rosacea, i.e. what leads to the outbreak of the disease and what irritates or worsens rosacea?
The immediate reasons why rosacea breaks out are unknown. A genetic predisposition alone is not a reason enough for the outbreak of the disease. Causes for the outbreak can be stress, hormonal factors or also wrong skin care with products that irritate the skin. It is certain that rosacea is irritated by events that influence the vascular system of the skin, i.e. that are vasoactive. These include excitement and stress or emotionally stressful situations, thermal stimuli such as cold or heat (e.g. also sauna), hot or strongly spiced food, alcohol or cleansing or care that irritates the skin. The sun also usually leads to a worsening of rosacea due to heat and the widening of veins and blood vessels in the skin. The warmth of the sun's rays increases the blood flow to the skin and thus also promotes inflammatory processes in the skin.
Treatment of rosacea
- Stage I
Early forms of rosacea, which are characterised by redness and dilatation of veins (blood vessels in the skin), can only be treated effectively with appropriate laser therapies. All other therapies (e.g. treatments using creams with stimulation of alpha-adrenergic receptors on the blood vessels of the skin with the aim of narrowing them and thereby improving the redness) have not proven effective, despite corresponding concepts. The white stripes on the skin that result from the therapy are also cosmetically disturbing, do not solve the problem and are therefore even counterproductive. Meditative therapies such as autogenic training or psychovegetative rhythms are definitely useful, but usually fail because it is difficult for those affected to learn the therapies effectively and then to implement them regularly. This requires a lot of time, calm and leisure. These approaches can therefore only be recommended as complementary measures.
- Stage II
The inflammatory form of rosacea with papules and pustules can be treated excellently. If treated correctly, complete healing usually occurs. If this does not happen, either the treatment is wrong or the diagnosis is incorrect. Treatment with anti-inflammatory creams and creams against the infestation of the hair follicle mite Demodex folliculorum has proven effective. This mite is not the cause of rosacea, but it is often involved in the inflammatory process. A standard therapy is, for example, a cream with metronidazole (e.g. Metrocreme) in the morning and a cream with ivermectin (e.g. Soolantra cream) in the evening. In addition, this form of rosacea must be treated with tablets right from the start. Everything else is a waste of time. Creams alone can slightly improve this stage of rosacea, but they cannot heal it. Tetracyclines or isotretinoin (off label) are available as tablets. I prefer isotretinoin for various reasons and it is excellently tolerated, but it must be discussed in detail by a dermatologist and closely monitored.
- Stage III
This stage can also be treated excellently, namely with isotretinoin tablets and, if necessary, additionally with ablative surgical measures or surgical laser procedures.
Medical cosmetics for rosacea
A relatively unknown but excellently effective additional (adjuvant) therapy for rosacea is manual therapy with anti-inflammatory masks containing nicotinic acid, which exercises the skin's blood system. This active ingredient, in conjunction with certain massage techniques on the facial skin, leads to a brief, very pronounced reddening by dilating the skin vessels. After removal of the mask, there is a reflex constriction of the vessels (reflex vasoconstriction) that goes beyond the initial situation. As a result, the face is less red a few hours after the medical cosmetic treatment than before the treatment. The effect is impressive and trains the vascular system of the facial skin in the long run.
Special features of rosacea
Couperosis is a special form of stage I rosacea that never progresses to stages II or III. It is treated in the same way as stage I rosacea. Rarely, there is rosacea of the eyes (ophthalmorosazea), which can only be treated with cleansing rinses and with tablets (tetracyclines). Isotretinoin is less effective here, but can be used in individual cases. Also rare in rosacea are small inflammatory red or reddish-yellowish, occasionally slightly glassy nodules, which are a special form of rosacea (rosacea granulomatosa). This form has a protracted, somewhat more persistent course and can usually only be improved with isotretinoin. Another rare special form of rosacea is fulminant rosacea, which is very severe and has to be treated with cortisone and isotretinoin. This form of rosacea should only be treated by specialists who are very familiar with the treatment of rosacea and the possible side effects of the therapy.
Care of rosacea-prone skin
In an acute episode, rosacea must be treated as described above. However, in intervals when rosacea is not present, rosacea-prone skin may be mildly cleansed and cared for in the same way as any other skin, making sure that the skin care is free of irritating ingredients, especially aggressive emulsifiers. This should be the case with most modern care concepts today, which have been composed in a reflective way. In addition, rosacea-prone skin usually tolerates vitamin A, vitamin C and hyaluronic acid serums well in intervals when they do not appear. As always, vitamin A should be used carefully and gradually and then only in the evening.