Note: This discussion is not meant to diagnose or rule out any skin or medical condition.

While rosacea manifests throughout the year, in honor of April being Rosacea Awareness Month, we’ll be providing a series of blogs dedicated to this troubling skin condition. If you have questions like “what is rosacea and how is it treated?” or “what is rosacea of the eye?” We’ve got the answers.

What is Rosacea?
The word rosacea is from the Latin rosaceus meaning “pink-like.” Rosacea is a chronic microcirculation disorder and disease of inflammation, which can be distressing for the sufferer. Rosacea is progressive and, without treatment, may evolve into advanced stages and lead to permanent skin damage. While there is currently no “cure,” it can be treated with avoidance of triggers, lifestyle changes, proper skincare, and professional treatments. Once under control, rosacea is considered in remission but will most likely require continued treatment, as it can flare or relapse.

Rosacea Symptoms
Feeling flush? That could be a sign you have rosacea. Symptoms of rosacea can include flushing or blushing or persistent redness and/or red patches, visible blood vessels (dilated capillaries), red pimple-like bumps (papules and pustules), dryness, flakiness, and roughness. Rosacea is usually seen in the center of the face – t-zone (nose, forehead, chin) and cheeks but can also affect the neck, upper chest, scalp, ears, scalp, and eyes in advanced cases. Skin affected by rosacea is generally hypersensitive with sensations of itching, burning, stinging, sensitivity, tightness, pain, and tenderness. In addition, skin can feel warm or hot to the touch, which increases when rosacea sufferers flush or blush. Red eyes and skin thickening, swelling, and nose enlargement from excess tissue are additional rosacea signs.

Who Suffers from Rosacea & When?
Approximately 15 million Americans and 415 million people or almost 10% of people worldwide are afflicted with rosacea. In general, fair-skinned folks are more likely to get rosacea than people with darker complexions since Caucasians or people primarily descended from north Western Europe (Celtic descent) are genetically predisposed to rosacea. If your skin sunburns easily, or you have a family member with rosacea, there is a higher possibility that you, too, will develop rosacea. Rosacea affects both men and women. However, it is about three times more frequent in women, while men with this disorder experience more extreme symptoms. In women, rosacea is usually seen on their cheeks and chin, while men exhibit it more with swelling on the nose. Symptoms may occur during the teen years, but most people experience the onset of rosacea in their 30s, 40s, and 50s.

Grades of Rosacea
Rosacea can be classified into 4 Rosacea Subtypes or Grades that can range from pre-rosacea with just redness and sensitivity to full-blown rosacea with bumps, pimples, swelling, etc.

Rosacea Grade 1: Also known as Rosacea Subtype 1, or Pre-rosacea, it includes pink or red skin with flushing or blushing that comes and goes initially, becoming persistent as time goes on. Rosacea Grade 1 can include visible blood vessels that contribute to the appearance of redness along with stinging, burning, swelling, and inflammation. Roughness, scaling or flaking, sensitivity, and dryness of the skin may also occur with Rosacea Grade 1.

Rosacea Grade 2: Also referred to as Rosacea Subtype 2, redness is now persistent and accompanied by possible bumps and pimples in the nose and cheek area, red patches, roughness and/or scaling. Though this grade is also frequently called Acne Rosacea, rosacea and acne are not the same disorder. However, someone may have both conditions. Rosacea does not typically feature blackheads or whiteheads as a symptom, while acne does.

Rosacea Grade 3: Rosacea Subtype 3, or Phymatous Rosacea, manifests in thickening of the skin, irregular surface bumps, and enlargement of the nose from excess tissue. Rosacea Grade 3 more often occurs in men, but women can get this type of rosacea as well. W.C. Fields, an actor from days of yore famous for his red, swollen, and misshapen nose. Former president Bill Clinton is a public figure with this type of rosacea. Laser, plastic surgery, and other cosmetic treatments are required to treat this grade of rosacea.

Rosacea Grade 4: Subtype 4, or Ocular Rosacea, involves the eye area. In fact, all stages of rosacea may have eye involvement with about 50% of rosacea sufferers experiencing eye symptoms. Rosacea triggers cause the blood vessels of the eye to dilate, resulting in the following symptoms:

• Red or bloodshot eyes
• Dry, or watery eyes prone to tearing
• Swollen or chronically inflamed eyelids and styes
• Sensitivity to light
• Irritation, burning/stinging, gritty or scratching sensation, on up to intense pain
• Inflammation of the thin tissue that covers the whites of the eye and the front part of the eye (corneal ulceration)
• In extreme cases, blood vessels may invade the colored part of the eye and the see-through covering over it and the pupil, which causes scarring, blurry vision, and potential vision loss from corneal damage
• Mucus, with or without infection (conjunctivitis or “pink” eye)

Rare Forms of Rosacea
Rare and severe complications of rosacea, such as rosacea conglobata and rosacea fulminans can also occur.

Rosacea Conglobata is a disfiguring form of rosacea that includes tender, pink to deep red, swollen and bleeding pus-filled sores, and hardened raised, and solid flat-topped lesions. Rosacea Conglobata occurs mainly in females and is progressive and chronic.

Rosacea Fulminans is rare and mimics severe cystic acne with bumps and pimples that appear suddenly and develop into hard round bumps, draining tracks that connect the cysts, abscesses, and ulcers. Facial swelling with a blue-red color and possible scarring are also symptoms. Note: This is not acne rosacea, and no flushing or eye involvement is present. Rosacea Fulminans affects the faces of women after adolescence between the ages of 20 and 40 who may have never had acne. Unlike acne, there are no comedones, and it lasts about one year without recurring. The causes of both forms of rosacea are unknown but may be due to issues with the immune system, hormones, or vascular system. Some sources link it with Crohn’s disease, Hepatitis C therapy, and even high doses of vitamins B6 and B12.

Some sources state that greasy scales with possible yellow patches and itching (seborrhea or seborrheic dermatitis) are present before this condition develops. Treatment of these rare forms of rosacea includes 3-6 months of oral and or topical corticosteroids to calm the inflammation, Accutane (isotretinoin), oral antibiotics, and oral contraceptives with antiandrogens. Some sources list yet another type of rosacea, “neck rosacea,” which appears on the sides of the neck in a v shape and includes dilated capillaries with brownish/reddish color changes.  It also exhibits a bumpy texture and appearance. This form of rosacea directly results from UV overexposure and accompanying damage to the outer and deeper layers of skin (epidermis and dermis), except the skin immediately around hair follicles.

What Rosacea Isn’t
There are several medical conditions and disorders that affect the skin, with symptoms that are similar to the visible signs of rosacea. These masqueraders are unrelated to rosacea and can be rather serious. This is why consulting a dermatologist or a doctor who can analyze your skin, make a medical diagnosis, and rule out other possibilities is vital. While estheticians are equipped to support rosacea improvement within the scope of their license and can recommend self-care products to complement dermatologist-prescribed treatments, they cannot officially diagnose rosacea. Therefore, the best practice is to refer clients to dermatologists for confirmation or treatment of more advanced stages.

Disorders That Mimic Rosacea

• Sensitive Skin: Often associated with rosacea and having similar symptoms and solutions, it is not the same. Not all fair-skinned individuals with redness, itchiness, flaking, and skin warmth have rosacea. These symptoms can also be an indication of sensitive or sensitized skin.

• Acne: If you’ve wondered “what is acne rosacea?”, you aren’t alone! Despite having similar-looking papules and pustules, the different origins, types of lesions, and sometimes the age of onset separate acne from rosacea. Acne begins in the hair follicle due to thick, sticky excessive sebum, dead skin cell accumulation (retention hyperkeratosis), and bacteria, which can result in milia, comedones (blackheads), papules, or pustules. Acne is more prevalent in adolescents and may recur in menopausal women. In contrast, rosacea includes a microscopic skin mite or parasite, and rosacea-related papules and pustules usually will not have the scarring associated with acne. Rosacea has a later onset, usually between ages 30-50, and may have ocular involvement.
  
  In general, comedones, ocular involvement, and scarring are the keyways to differentiate acne from rosacea. If no comedones are present, it is most likely rosacea. (Note that acne and rosacea can coexist, as well.) Unfortunately, people often misdiagnose or mistake rosacea papules or pustules with acne. They then become bewildered or frustrated after using acne products to treat what they believed to be “acne,” which usually exacerbates rosacea.

• Perioral Dermatitis: Red papules, usually around the nostrils and mouth, often caused by fluoride toothpastes or fluorinated topical glucocorticoid steroids, may mimic rosacea.

• Roseola: It may look or even sound like the word rosacea, but roseola is a viral infection seen in children under age 3. Symptoms typically begin with high fever, fatigue, and respiration issues, followed by a pink or red rash with spots on the torso. The cause is human herpes virus type 6 or 7.

• Mange (Demodicidosis): Despite rosacea's association with demodex folliculorum, it is not the same as demodicidosis (mange), which is a separate condition, albeit similar in appearance to rosacea.

• Poikiloderma: Often mistaken for rosacea since it includes prominent blood vessels, poikiloderma also includes increased and decreased pigmentation and skin thinning. Other conditions of mistaken rosacea identity include staph infection, allergy, or eczema.

• Lupus Erythematosus: Similar looking with a rash of round or disk-shaped bumps, and red, raised patches, this systemic disorder is usually accompanied by whitish scales and plugged hair follicles. It often occurs in a “butterfly rash” or malar rash on the nose. Common symptoms are chest pain upon taking deep breaths, fatigue, fever with no other cause, discomfort or malaise, hair loss, mouth sores, sunlight sensitivity, and swollen lymph nodes. Headaches, numbness, tingling, seizures, vision problems, personality changes, abdominal pain, nausea, vomiting, abnormal heart rhythms, coughing up blood, difficulty breathing, patchy skin color, and fingers that change color when cold (Raynaud’s) can also occur.

Want to maximize results for your healthiest skin ever? Boost skin health with an in-depth consultation by a professional esthetician who can determine if you have rosacea or sensitivity. Visit Find A Spa for an oasis near you offering the ideal Pevonia treatments and products to care for your skin.

Stay tuned for our next article detailing rosacea causes and triggers.