5 Clinical Features of Acne Rosacea: How to Cure?

Acne Rosacea is a condition that commonly starts in one’s teenage years and the early signs of which go unnoticed. Several adults present to me for treatment in their mid-thirties and forties with symptoms that seem to date back to their teenage years. In this article, we hope to educate parents and teenagers on the warning symptoms of this condition that they may also seek early intervention. Including an excerpt from Acne Care Bible: Dermatologist’s Tips For Acne Treatment & Prevention by Dr. Teo Wan Lin, dermatologist at TWL Specialist Skin & Laser Centre.

Why is this important?

Firstly, acne rosacea can lead to long-term cosmetic disfigurement because it results in skin thickening. The most dramatic cosmetic disfigurement is a condition known as rhinophyma whereby one ends up with a bulbous-looking nose that has to be treated surgically. This is regarded as the end stage of acne rosacea. In addition, a lot of acne rosacea symptoms may be similar to acne but it does have some distinct differences. Acne rosacea is commonly mistaken as acne by non-dermatologists. Here are some of the key clinical features you can look out for if you suspect that either you or your child has acne rosacea.

1. A family history of rosacea 
2. Red patches that occur predominantly over the sun-exposed areas of the face such as the cheeks, the forehead, and sparing areas such as the nasolabial fold under the jaw and around the eyes. 
3. Increase the intensity of redness when exposed to the sun, coming out of a hot shower, intake of spicy foods, or hot soups.
4. Acne-like bumps that do not respond to conventional acne treatment.
5. Red, watery eyes with symptoms of irritation (ocular rosacea).

The key process that is occurring in acne rosacea is a state of overactivity of the skin’s blood vessels. In typical settings when we are exposed to heat, our blood vessels will expand, a process we call vasodilation which is an attempt to cool down by increasing blood flow to the surface of the skin, increasing heat loss. When we shift to a cold environment, this vasodilation in turn becomes vasoconstriction which is when the blood vessels contract.

This is responsible for the flushing that happens even in normal individuals when they are exercising and after they cool down, the redness then disappears. In acne rosacea, one of the key features observed is the inability of the skin to revert to its original state after exercise. You may get redder after exercise but it stays red. 

How does this bother individuals suffering from acne rosacea? 

My patients are bothered by it because it causes some degree of embarrassment and increases their self-consciousness. This is compounded by the fact that many of them could have suffered from this condition for many years. Insensitive comments from those around them could also make them more prone to feelings of embarrassment and shame. It’s important to understand that there is no specific cause of acne rosacea although they are well-defined genetic risk and trigger factors.

There is also some evidence that individuals who suffer from acne rosacea are colonized with a type of skin mite known as the Demodex mite. This is the basis for the treatment of acne rosacea with topical ingredients i.e. metronidazole. The treatments of the vasodilation can be with vasoconstrictors such as brimonidine. However, I tend not to use this in my practice as I find that it can cause significant rebound skin erythema without treating the underlying condition of skin inflammation. It can lead to an awkward demarcated area of skin “whiteness” which is equally disturbing cosmetically.

If you suspect that you have acne rosacea, what should you do?

First of all, if your symptoms are visible, it is good to visit a dermatologist just to ensure that appropriate medical treatment is administered from the earliest time possible. This may be in the form of cosmeceuticals, topical anti-inflammatories and calcineurin inhibitors, which have been used with success in individuals with acne rosacea. It is important to understand that you may have acne rosacea and also concomitant dry sensitive skin condition which may lead to some parts of your skin having flaking in addition to redness. 

Acne rosacea itself does not cause flaking but it is possible to have both rosacea and flaking. An individual can have more than one condition happening at the same time. Your dermatologist will be able to discern the conditions affecting your skin and administer appropriate treatment. If your acne rosacea is of moderate severity, it is of utmost importance that we start you on medical treatment with oral antibiotics, such as doxycycline and erythromycin. 

Some individuals will need oral isotretinoin, for severe cases of acne rosacea. Medical treatment is essential because although acne rosacea itself is not life-threatening, it has a cumulative effect which can lead to cosmetic disfigurement-mainly in the form of skin thickening. This is how I explain it in a simple way to my patients. If you have a lot of blood flow to your face all the time, the skin gets a lot more nutrients than what it’s supposed to. Over time, the body decides to use these nutrients to grow more skin. This is not entirely accurate because the entire process is very complex, but it’s a very simple schematic to try to understand what’s going on. 

Can acne rosacea be cured? 

The answer is no. It can never completely go away without treatment, but it can be successfully treated and maintained such that another person wouldn’t observe that you have acne rosacea. Thus as far as possible, you do not want your skin to be red. The goal of any dermatologist is to have to restore your baseline to one that is not red and have it maintained.

What are some of the medical treatments available for acne rosacea? 

You have to treat acne rosacea with oral medications 70% of the time. This applies to moderate to severe cases of rosacea and it always involves oral antibiotics such as erythromycin, doxycycline which are not performing as antibiotics per se but they are anti-inflammatory. They are often used in conjunction with barrier creams such as those containing ceramide, as well as other types of moisturizers which function as cosmeceuticals. There is increasing evidence about the use of cosmeceuticals in the treatment of acne rosacea and I have personally used it with successful antioxidant serums in individuals with long-standing rosacea as part of maintenance treatment. 

These are cosmeceuticals that have all been used in success in my clinical practice. The key thing is as long as it’s an antioxidant, it is able to suppress inflammation and the underlying process of inflammation.

In terms of pharmacotherapy, I often start my patients on an anti-inflammatory topical steroid for a period of two to three days just to bring down inflammation. This is by no means a long-term treatment, in fact, it should not be used beyond three days because it can cause rebound steroid acne and rebound redness. However, I had found it very useful in controlling the initial redness. I advocate the use of a good skin barrier repairing moisturizer that contains ceramide such as the Multi-CERAM moisturizer.

I feel that cosmetic camouflage is an important part of acne rosacea treatment that we should not forget. As a teenager, while you are getting better with medical treatment, there is a process and there is a period of time where you will have visible redness on your face.

It is perfectly acceptable to start with a concealer for mild areas of redness but my personal preference for rosacea patients would be the use of color correctors. Specifically, we use the color green to counteract red and infuse this in a cosmeceutical base so that the effects are both natural and the formula is also well-absorbed by the skin to exert its skincare functions as well.

Long-term management of acne rosacea is really monitoring for flare-ups. Before you flare-up, it’s always best to know what triggers off your flare-ups. The good news is that it’s rather universal for treatment of rosacea and it would be firstly, UV exposure. Thus, sunblock is absolutely essential. A medical-grade sunblock with SPF 50 broad-spectrum protection.

The CUIONS and ZINCOOL UV-protective biofunctional textile face masks which I invented for our biomaterials arm are designed to be both therapeutic for treatment of the skin microenvironment as well as a practical (more effective) sun protection measure in the era of the COVID-19 pandemic. I currently recommend UV protective face masks for photoprotection as there is no need for reapplication of sunblock and UPF50+ textiles are also very efficient at blocking up to 98% of the suns’ rays.

You should avoid showers with warm water but rather go with cool water and totally avoid hot showers. Do not take any spicy foods or hot soups, refrain from activities such as going to the sauna where there is excessive heat and definitely never use facial steaming devices. The long-term management of acne rosacea will have to take into consideration scarring. 

As mentioned before, the endpoint of rosacea is actually skin thickening and texture irregularities. If you do struggle with acne rosacea that is not well controlled, as you grow older and the disease progresses, you may observe enlarged pores and irregular skin texture. The end stage of acne rosacea is rhinophyma, whereby severe skin thickening on the nose area leads to cosmetic disfigurement. All these changes would become more prominent as you age as well due to the loss in collagen and elastin in your dermis.

Other aspects of treatment that we are going to focus on here are the physical therapies that are effective for acne rosacea. I have used in clinic LED red light therapies with some success as an adjunct physical treatment for patients on oral medication for rosacea. Red light stimulates the mitochondria of your skin to enter into a state of renewal and repair. It is free of side effects as well.

I also perform the carbon laser using the 1064 qs laser machine for my patients as there is some evidence for reducing redness, inflammatory papules and for improving the quality of skin with gentle ablation that helps to resurface the skin. A lot of adult patients who have had chronic rosacea starting from their teenage years will need fractional CO2 laser resurfacing.