David pascoe 2012-05-02 04:00:02
Maintainer: David Pascoe
CVS Version: $Id: faq.txt,v 1.15 2003/01/16 08:45:11 anonymous Exp $
Disclaimer: the following information is a guide only. Self diagnosis is a
dangerous pastime without all of the information. This Frequently Asked
Questions is a simple guide to rosacea, and a pointer to more information.
This text should not be used in the place of professional advice from
1. What is Rosacea ?
Rosacea (said rose-ay-shah) is a potentially progressive neurovascular
disorder that generally affects the facial skin and eyes.
The most common symptoms include facial redness and inflammation across
the flushing zone – usually the nose, cheeks, chin and forehead ; visibly
dilated blood vessels, facial swelling and burning sensations, and
inflammatory papules and pustules.
Rosacea can develop gradually as mild episodes of facial blushing or
flushing which, over time, may lead to a permanently red face.
Ocular rosacea can affect both the eye surface and eyelid. Symptoms can
include redness, dry eyes, foreign body sensations, sensitivity of
the eye surface, burning sensations and eyelid symptoms such as chalazia,
styes, redness, crusting and loss of eyelashes.
A panel of experts have agreed on a standard classification system for
Rosacea. This system is a brief text that is not intended to be
exhaustive, but is a place to start.
Their classification system was published in the Journal of American
Academy of Dermatology (United States), Apr 2002, 46(4) p584-7)
“Rosacea is a chronic cutaneous disorder, primarily of the central face.
It is often characterized by remission and exacerbation and it encompasses
various combinations of such cutaneous signs as flush, erythema,
telangiectasias, edema, papules, pustules, ocular lesions, and rhinophyma.
Primary features considered as necessary for diagnosis include flushing,
erythema, papules, pustules, and telangiectasias. A variety of secondary
features are listed that may be absent or present as a single finding or
in any combination.”
1.1 Are there different types of Rosacea ?
The panel of Rosacea experts agreed on the following broad, non exclusive
text (i.e. there are other factors and types that come into play).
“The system divides rosacea into four subtypes: erythematotelangiectatic,
papulopustular, phymatous, and ocular. As presently worded, papulopustular
rosacea is noted as often being observed following or with
erythematotelangiectatic disease and phymatous rosacea as following or
occurring together with either erythematotelangiectatic or papulopustular
rosacea. However, Dr. Wilkin emphasized that while those descriptions are
consistent with common concepts about rosacea natural history, they are
provisional and subject to change.”
“In its current iteration, the classification system excludes rosacea
fulminans, steroid-induced acneiform eruptions, and perioral dermatitis
without rosacea signs from the diagnosis of rosacea.”
1.2 How is Rosacea different to Acne Vulgaris ?
As rosacea is a neurovascular disorder it affects the flushing zone.
Is is common that Rosacea does not present with blackheads that are
seen with Acne Vulgaris. Also the age of onset, and the location of
redness is a clue. Rosacea is commonly an adult disease, and is generally
restricted to the nose, cheeks, chin and forehead. It can coexist with
Some rosacea sufferers have a significant acne component in their symptoms
so it can be easily confused with acne vulgaris. The papules and pustules
of rosacea tend to be less follicular in origin.
Rosacea will probably have an underlying redness that is related to
flushing and thus looks different to acne vulgaris. Acne sufferers
normally do not have the accompanying redness.
Rosacea usually begins with flushing, leading to persistent redness.
As both conditions are inflammatory, the treatment for rosacea and acne
vulgaris can be somewhat similar, but some of the acne vulgaris regimes
are too harsh for rosacea affected skin and can severely aggravate the
Rosacea sufferers are cautioned against using common acne treatments such
as alpha hydroxy acids (glycolic and lactic acids), topical retinoids
(such as tretinoin, Retin-A Micro, Avita, Differin), benzoyl peroxide,
topical azelaic acid, triclosan, acne peels, chemical peels. Additionally
the caution extends to topical exfoliants, toners, astringents and alcohol
1.3 What is the difference between Rosacea and Seborrheic Dermatitis ?
Seborrheic Dermatitis and Rosacea are closely related, they both involve
inflammation of the oil glands. Rosacea also involves a vascular component
causing flushing and broken blood vessels.
Seborrheic Dermatitis may involve the presence of somewhat greasy flaking
involving the T zone, crusts, scales, itching and occasionally burning,
and may also be found on the scalp, ears and torso. It does not usually
involve red bumps as in Rosacea.
The T zone is the area shaped like a `T’ composed of your forehead, nose
and around your mouth.
Just to confuse things further, the two conditions are often seen
1.4 What causes Rosacea ?
From “Beating Rosacea, Vascular, Ocular and Acne Forms”, by Geoffrey Nase
PhD, Nase Publications 2001.
“Rosacea is primarily a disorder of the facial blood vessels. Experts from
across the world agree that vascular abnormalities are central to all
stages and symptoms of rosacea”.
To paraphrase: Rosacea blood vessels undergo changes in function and
become hyper-responsive to internal and external stimuli. These changes
are ultimately responsible for the progression of all rosacea symptoms.
As with many conditions, there appears to be a genetic propensity to
1.5 How does rosacea progress ?
“Rosacea normally progresses in the same generalised fashion, frequent
dilation of facial blood vessels leads to vascular hyper-responsiveness
and structural damage.”
Rosacea experts talk about rosacea symptoms appearing in 4 stages. Over
time rosacea can progress from one stage to the next.
From Dr. J Wilkin:
“Most textbooks and literature citations characterize rosacea as a disease
that gradually evolves from early to later subtypes. However, there is not
conclusive evidence to substantiate that course and we want to know if it
really occurs. Nevertheless, the individual features within a subtype can
get worse, so early treatment is advocated, even if there is not
progression from one stage to the next,”
1.6 What are the stages of rosacea ?
Dr. Nase talks about 4 stages, called Pre-Rosacea, Mild Rosacea, Moderate
Rosacea and Severe Rosacea.
Pre-Rosacea: the first cardinal sign of rosacea: blood vessels dilate to
more stimuli, open wider and stay open for longer periods of time compared
to normal persons. No visible damage can normally be seen.
Mild Rosacea: begins when the facial redness induced by flushing persists
for an abnormal length of time – usually 1/2 an hour or more after a
trigger. Those who have frequent pre-rosacea flushing are highly
susceptible to progressing to mild rosacea.
Some of the common triggers for a facial flush are heat, cold, emotions,
exercise, topical irritants and allergic reactions.
Moderate Rosacea: as facial flushing becomes more frequent and intense,
vascular damage occurs. This can result in long lasting redness, swelling
and inflammatory papules and pustules. Telangiectasia (damaged micro blood
vessels, often visible on the surface of the skin) may be noticed in the
areas where flushing is worst.
Severe Rosacea: characterised by intense bouts of facial flushing, severe
inflammation, facial pain, swelling and burning sensations. Sufferers may
develop intolerance to products they were able to use before. Also
inflammatory papules, pustules and nodules may be present. Some experience
a bulbous enlargement of the nose, known as rhinophyma.
This is just a guide, you may of course experience symptoms outside these
2. How can Rosacea be treated ?
The best answer is “working with the support of your registered health
professional”. There are medications available that control the redness
and reduce the number of papules and pustules associated with rosacea.
Current run-of-the-mill treatment might include oral antibiotics and
topical metronidazole. One study showed that the use of topical
metronidazole alone can help some sufferers to reduce rosacea flare-ups
once the rosacea is brought under control.
For those sufferers that do not benefit from the metronidazole based
treatments, there are many other options. Quite a few treatments options
are often discussed on the rosacea-support email group. Some of their
posts can be found under the `Treatments’ tree on the list highlights page
see – http://rosacea.ii.net/toc.html
Experts agree that a gentle cleansing regime is very important. Avoiding
chemicals that aggravate the rosacea, but will clean and moisturise the
skin is a step in the right direction.
As the sun is a strong trigger for many rosacea sufferers, a good
non-irritating sunscreen used daily is very important. For those who react
badly to chemical sunscreens, a physical sunscreen may be more suitable.
Physical sunscreens rely on the reflective properties of the main
ingredients (rather than the ability of some chemicals to absorb the sun’s
energy). The most common physical sunscreens are based on zinc oxide or
The vitamin A derivative isotretinoin (known as Accutane or Roaccutane),
has been shown to be effective against severe papopustular rosacea. It
works by inhibiting sebaceous gland function and physically shrinking the
glands. It also has potent anti-inflammatory properties, making it ideal
to treat resistant rosacea. At low doses, accutane has also been shown to
reduce other symptoms such as facial burning and redness. Accutance is a
strong drug, and even at the low doses found beneficial to rosacea, should
be used under strict supervision of your doctor.
Low does accutance may be more suitable than the regular dose, as there
are less side effects and lesser chance of aggravating redness.
The mixed light pulse laser – Photoderm is showing promise as a treatment
for the vascular component of rosacea. It works by targeting facial
microvessels that are damaged.
One treatment that has been shown to help some is Rosacea-LTD III. It is
the third generation of topical mineral salt based treatment. The minerals
shrink facial vessels as well as reduce papules and pustules. More
information is available at http://www.rosacea-ltd.com
For those wanting to treat the flushing side of their rosacea, 2 drugs are
worth investigating. Monoxidine and Clonodine are 2 anti-hypertensives
that you could look at with your doctor.
From a subjective view of the rosacea-support list members it would appear
that one person’s treatment does not necessarily suit another, so your
mileage may vary with any recommended treatment. Experiment a little and
find what helps you. Depending on the stage of your rosacea, some
treatments may be aggravating, while for others the same treatment may not
cause problems. Every rosacea patient is unique and needs individual
Whatever path you choose, the support of a doctor or dermatologist that is
willing to work with you will be very important, so shop around until you
are happy with your health professional.
Dr. Nase’s book will serve as a valuable resource – it contains detailed
and proven current rosacea treatment information.
2.1 What about steroids ?
Steroids have long been prescribed for rosacea because of their perceived
quick relief. Milder (1% hydrocortisone) over the counter preparations are
also popular as they are thought to be safer than the prescription
Sufferers should be aware of the following warnings:
“Topical steroids can worsen all rosacea symptoms by dilating facial blood
vessels, thinning the protective skin barrier, and thinning the dermis by
breaking down the collagen and elastin support structures”.
“Medical experts stress that rosacea sufferers should not use topical
steroids (of any strength) to treat their symptoms”.
These quotes are from Dr. Nase’s book. They are backed up by several pages
of studies and comments. Topical steroids can induce rosacea and worsen
pre-existing rosacea. It must be avoided in patients with rosacea.
2.2 Can you be cured of Rosacea ?
Perhaps not cured in the sense of cured of a cold, but you can reduced
your symptoms to a manageable level. There are plenty of treatment options
out there, you may just need to experiment with a few.
If you want to feel encouraged that Rosacea really can be practically
cured, check out Geoffrey Nase’s before and after photographs at
3. What information is available on the Internet about Rosacea ?
There are some pages that are worth visiting. You can find a list of
reviewed Internet resources relating to Rosacea as part of the Open
There you will find sections on companies offering treatment products,
research results as well as medical texts on rosacea.
3.1 Are there any email mailing lists relating to Rosacea ?
Many interesting and useful discussions have taken place on the mailing
list since it was created in October 1998. There are 2 Doctors on the list
who have hugely contributed to the group and posted great articles. You
can see the list highlights categorised by treatment, symptoms and more at
There is a Rosacea forum for those who use AOL as their internet company.
The address is aol://5863:126/mB:144806
Another place to try is http://www.esfbchannel.com/forum , the
Blushing/Flushing and Sweating forum. This forum deals more with issues of
hyperhidrosis, facial blushing and flushing as well as ETS issues.
3.2 Are there any Usenet Newsgroups relating to Rosacea ?
Not exclusively for Rosacea. Perhaps the best 2 to try are
alt.skincare.acne and alt.support.skin-diseases. You can read and post to
these forums using the Google Groups facility at http://groups.google.com
You could also try your local feed of these newsgroups if your browser is
configured: news:alt.support.skin-diseases news:alt.skincare.acne
3.3 Are there any Books about Rosacea I should read ?
There are very few books about Rosacea. In the last year of so there has
A recently published book by Dr. Geoffrey Nase is destined (we believe) to
become a seminal text on Rosacea. You can read a detailed discussion of
the contents of the book at http://www.drnase.com The book is titled
“Beating Rosacea, Vascular, Ocular and Acne Forms”. It is only available
from his web site.
3.4 Is this Frequently Asked Question list on the Internet ?
Yes, you may find a more up to date listing if you check
You can find the official html’ised archived version of this FAQ at
Also, you can get this FAQ via email. The address of the faq server is
First, get the directory listing with the `index’ command, and then fetch
the latest version of the FAQ with the `send’ command. You should include
the commands in the _body_ of the message, the subject will be ignored.
All messages to the mail server should be on one line only, if your email
program inserts carriage returns because the line is too long, you may
find retrieving the FAQ difficult.
For example, to get version 1.12 of the FAQ you would send the following
texts in the body of 2 emails (first one to get directory and second, once
you know the filename you want).
4. Are there any support groups related to Rosacea ?
You may want to check out The National Rosacea Society and the
rosacea-support email list.
The National Rosacea Society is a non profit organisation set up to
provide information about Rosacea. You can find them at
http://www.rosacea.org/home.html They publish newsletters online as well
as conduct surveys about rosacea sufferers. Also they make published
information available to sufferers via regular mail. The National Rosacea
Society are an introductory organisation that are a good first point of
contact for information. The depth and breadth of information that they
make available is something that we hope that they will be able to devote
some resources to.
There is an email support group that you can subscribe to. This email
group is free and unmoderated. Currently there are about 1800 users and
about 10-40 messages per day. Digest versions are available. To find out
more information about the list, visit http://rosacea.ii.net/ml.html or go
straight to the email hosting page at
An alternative list archive on the web is also located at
http://www.escribe.com/health/rosacea-support this site has a slightly
more traditional feel to it, you may prefer to read from this archive.
Rosacea Reading Glossary
As you read more about Rosacea, you might come across lots of terms that
are new to you. Below is a short list of some of the terms you might come
accutane: a powerful vitman A derivate that was originally prescribed for
severe acne vulgaris. Has been used effectively for rosacea as well. Also
known as roaccutane.
for more info http://www.rocheusa.com/products/accutane/pi.html
blepharitis: inflamation and crusting of the eyelid.
cutaneous: pertaining to the skin.
demodex mites: (demodex folliculorum and demodex brevis): microscopic
mites that lives in the skin. Some have suggested that this is the cause
of rosacea, but most experts discount this theory. According to Dr Nase,
“This theory has now been disproved. Rosacea experts all agree that this
mite plays no real role in the development or progression of rosacea
(except for the odd pustule).”, pg. 110 in Beating Rosacea.
chalazion: a lump on the eyelid that is caused by a clogged duct of one or
more of the meibomian glands on the eyelid.
conjunctivitis: inflammation of the conjunctiva (the thin transparent
lining in the front of the eyeballs and eyelids).
dry eye: a condition brought about by abnormal production in the quantity
or quality of tears.
edema: presence of abnormally large amounts of fluid in the intercellular
tissue spaces of the body, especially wrt subcutaneous tissues.
epifacial: another term referring to a full face treatment using
epilight: a treatment very similar to photoderm, originally intended for
hair removal. differs by using different filters to photoderm. For more
information see http://www.skinandhealth.com
erythema: inflammatory redness of the skin.
erythematotelangiectatic: having symptoms of both erythema and
ESB: Endoscopic Sympathetic Block, clamps used to block the transmission
of the neural impulses in the sympathetic chain. Is considered a
reversible procedure. See http://privatix.magenta.net
ETS: Endoscopic Transthoracic Sympathectomy (or endoscopic transthoracic
sympathicotomy) a procedure where a surgeon excises the major sympathetic
nerves that supply the hands, neck and face. Main indications for ETS are
blushing and hyperhidrosis. One place for more information:
fotofacial: a treatment regime using photoderm pioneered by Dr. Patrick
Bitter Jnr., for more information, see http://www.fotofacial.com
Helicobacter pylori: bacteria that live in the cell lining of the stomach.
According to Dr. Nase, “Most rosacea specialists now conclude that H.
Pylori only play a small role in a minor number of rosacea patients.” pg.
109 in “Beating Rosacea”.
hypertrophy: the enlargement or overgrowth of an organ or part due to an
increase in size of its constituent cells.
hyperemia: abnormally increased blood flow
IPL: Intense Pulse Light, a description of the technology used in the
family of machines made by ESC. For more information, see
isotretinoin: the a vitamin-A derivative that is the active ingredient in
accutane (also known as roaccutane).
keratitis: infection or inflammation of the cornea of the eye.
ketoconozole: the active antifungal ingredient in nizoral, helpful for
seborrheic dermatitis and dandruff.
lupus: an auto-immune disease that causes inflammation in various parts of
the body such as the skin, joints and kidneys. Skin flushing is an
important symptom of lupus.
metrogel: a 0.75% metranidazole treatment. For more information
metronidazole: a topical treatment for rosacea. Has been found by some to
effective against rosacea. Has a yet to be understood anti-inflammatory
action. Is the active ingredient in metrogel, metrocream, metrolotion,
rozex and noritate.
meibomitis: inflammation of the oil producing meibomian glands of the
Multilight: a member of the Intense Pulsed Light family, along with the
photoderm machine. For more information see http://www.skinandhealth.com
Can also be used for hair removal.
noritate: a 1% metronidazole treatment. for more info
ocular: of the eye.
papulopustular: having symptoms of both papules and pustules.
papule: a small, solid, elevated skin lesion, less than 0.5cm in diameter.
perioral dermatitis: perioral refers to the area around the mouth, and
dermatitis indicates redness of the skin. In addition to redness, there
are usually small red bumps or even pus bumps and mild peeling.
photoderm: an intense light source, fired at the facial skin to reduce
flushing associated with rosacea. a new treatment for rosacea that
is producing some exciting results. For more information see
photofacial: a treatment regime using photoderm, pioneered by Dr. Patrick
Bitter Snr., for more information, see http://www.photofacial.com
photorejuvenation: a broad term used describe Intense Pulsed Light
treatments. photorejuvenation treatments are aimed at stimulating
phymatous: having symptoms of abnormal growth, as found in rhinophyma.
pustule: a vesicle filled with cloudy fluid, such as pus, often associated
with a hair follicle but can exist independently.
Quantam SR: a member of the Intense Pulsed Light family, along with the
photoderm machine. For more information see http://www.skinandhealth.com
rhinophyma: abnormal growth of the soft tissue of nose, caused by sebaceous
gland hypertrophy and hyperplasia (increased growth and number of
roaccutane: a powerful vitman A derivate that was originally prescribed for
severe acne vulgaris. Has been used effectively for rosacea as well. Also
known as accutane. for more info
rosacea fulminans: a rare form of rosacea that appears very quickly.
rozex: 0.75% metronidazole based treatment also known as metrogel. for
more info http://www.medsafe.govt.nz/consumers/cmi/r/rozexgel.htm
rosacea-ltd: a non-prescription topical treatment for rosacea, see
seborrheic dermatitis: an inflamatory skin condition, associated with
itchy flaking skin.
sebaceous gland: a gland often associated with a hair follicle, that
stye: inflammation of an eyelash follicle on the edge of the eyelid.
subcutaneous: under the skin.
telangiectasias: damaged micro blood vessels, often visible on the surface
of the skin.
tetracycline: an antibiotic often prescribed for rosacea.
V-beam: the fifth generation (hence roman 5=V) of the pulse dye laser. for
more information, see http://www.vbeamlaser.com
vascular: of the blood vessels.
vasculight: a IPL+laser machine that can be used to give mixed wavelength
and fixed wavelength treatments. Can target large and deep blood vessels.
For more information see http://www.skinandhealth.com
versapulse: a type of laser, for more information, see
David Pascoe, firstname.lastname@example.org, Western Australia