Rosacea: what it is, causes and treatments

Rosacea is a chronic inflammatory skin disease of the face. It shows mainly as persistent redness in the center of the face, which worsens with heat, sun, alcohol or stress, and may include pimples, visible tiny vessels and a burning sensation. It affects about 5% of the adult population and is often mistaken for acne or for «sensitive skin».

It has no definitive cure, but it can be managed well. There are treatments with solid evidence for each sign, and the current goal is clear or almost clear skin, not just «better». We explain how it is recognized, why it happens and what works.

What it is and how to recognize it

Specialists have stopped dividing rosacea into fixed «subtypes». The international ROSCO panel proposed looking at the signs each person has, because the same person can have several at once and they change over the years (Tan et al., 2017; Schaller et al., 2020).

Diagnosis is clinical: no test can confirm it. It is made with one diagnostic sign, or with two major signs.

Rosacea or acne?

In rosacea there are no comedones (blackheads and whiteheads), the background redness remains between the pimples and burning is common. It appears mainly after age 30.

Who gets rosacea

A meta-analysis of 32 studies estimated a prevalence of 5.46% in the adult population: 5.4% in women and 3.9% in men, peaking between ages 45 and 60 (Gether et al., 2018). It is easier to see in light skin, but it also occurs in dark skin, where redness is less obvious and diagnosis tends to come later.

Why it happens

The exact cause is not fully understood, but several mechanisms are known to act together (Fisher et al., 2023):

• An overreactive skin immune system. In rosacea there are more TLR2 receptors and more activity of an enzyme (KLK5) that turns a natural defense peptide, the cathelicidin LL-37, into inflammatory fragments. These fragments dilate vessels and activate mast cells.
• Hypersensitive nerves and vessels. TRPV receptors, which detect heat and spicy substances, are increased. This explains why heat, spicy food and hot drinks cause flushing and burning.
• Weakened skin barrier. The skin loses more water and becomes more reactive to products and the environment.
• Demodex mites. They normally live on the skin of all of us, but in rosacea they tend to be present in greater numbers and may fuel inflammation. This is why topical ivermectin works.
• Predisposition. It is more common in people with relatives who have rosacea.

The most common triggers

In a survey of 1,066 people with rosacea, the factors most often reported for flare-ups were (National Rosacea Society, 2002):

Triggers vary greatly from person to person. A diary kept for 2 to 4 weeks helps you work out which ones are yours.

Treatments: what the evidence shows

Treatment is chosen according to the signs present. People with several signs generally benefit from combining approaches (Schaller et al., 2020). The Cochrane review on rosacea, with 106 studies and more than 13,600 participants, provides the basis for the following table (van Zuuren et al., 2015). Choose the sign to see only the treatments that correspond to it.

Three important points

• Topical treatments take time. Allow 8 to 12 weeks to assess the response. Giving up after 2 weeks is the most common mistake.
• Visible blood vessels do not disappear with creams. Topical treatments act on inflammation. Dilated vessels that have already formed respond mainly to light-based treatments.
• Maintenance matters. Rosacea is chronic: once it is under control, a gentle treatment and daily skin care are kept up to space out flare-ups.

All of these treatments require a medical diagnosis and prescription. Corticosteroid creams, sometimes used on one's own initiative to "calm" redness, can make rosacea worse and should be avoided.

Daily skin care that helps

Skin care does not treat rosacea on its own, but it reduces flare-ups and improves tolerance of the treatments.

• Gentle cleansing. Lukewarm water, never hot, and a soap-free product. Pat dry without rubbing.
• Daily moisturising to repair the skin barrier, with simple, fragrance-free formulas.
• Sunscreen every day. The sun is the most commonly cited trigger. Mineral filters are usually better tolerated. See how to choose in Tinted sunscreen: how to choose and how to apply.
• Less is more. Avoid gritty scrubs, alcohol, menthol, eucalyptus, camphor and strong acids unless medically advised.
• Test first. Try new products behind the ear or along the jawline for a few days.
• Manage your triggers. Warm drinks instead of hot ones, protection from wind and cold with a scarf, and exercise in cool environments. There is no need to cut everything out: only what triggers flare-ups in you.

More details in Sensitive skin and redness: everyday care.

When to seek a medical assessment

It is worth booking an appointment if:

At Luxmed, the Facial Aesthetics consultation assesses the signs present and sets out a plan that can combine medical treatment, daily skin care and light-based treatments for redness and visible blood vessels.

This article is for information only and does not replace a medical consultation.

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