Basic Rosacea Information

The Dilemma of Rosacea

Rosacea is generally considered an "idiopathic" disorder, meaning that the exact cause of the condition is unknown. Dermatology textbooks describe triggers for rosacea. These factors include dietary factors, exercise, and exposure to sun, heat, humidity, cold, wind, and medications. Textbooks have not described the role of the gut, other than discussing the controversy of H. pylori infection of the stomach. New discoveries have been made linking disturbances in the balance of gut bacteria with rosacea, however research is slow in its pace.

Classification and Causes for Rosacea

Rosacea is a disorder of poorly understood origin (Steinhoff, 2013). Rosacea is a chronic skin disorder affecting primarily the central face (cheek, nose, chin and forehead). Over 13 million Americans have this condition and is the 5th most common reason to visit a dermatologist. A standard classification system for rosacea was published in the Journal of the American Academy of Dermatology in 2002. Developed by the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea and reviewed by rosacea experts worldwide, it describes primary and secondary features of rosacea and recognizes 6 patterns of signs and symptoms, designated as subtypes. These include: flushing, vascular congestion (erythema or redness), increased vascularity, papulopustular skin lesions (pustules or enlargement of the oil glands) and thickening of the skin. Ocular involvement includes damage to the meibomian glands with subsequent dry eyes, conjunctiva and sclera inflammation with subsequent risk for corneal damage and loss of visual acuity. A seventh pattern being proposed is flushing and erythema with pain as being the main problem – this painful rosacea may consist of the following symptoms: burning, stinging and irritation.

The various clinical forms of rosacea exhibit very different clinical features and trigger factors which suggest that rosacea is a disorder of multiple causes. The fact that a person may have one or more forms with flushing, chronic inflammation and fibrosis further suggests a complex pathophysiology involving different regulatory systems. Despite active research into the interplay of the various dysregulated systems (immune, vascular, and nervous), the cause for rosacea remains a mystery. Altered regulation in the internal immune and neurovascular systems is very important. Genetics play a role, but, as in most diseases, one's genetic makeup influences the likelihood of developing rosacea after acquiring a triggering event.

What is the role of infections in the skin? A recent review addresses this question (Hughes, 2013). Studies support an inflammatory reaction against the presence of Demodex folliculorum, a naturally occurring mite. A few studies suggest roles for Staphylococcus epidermidis, Chlamydophila pneumoniae, and Bacillus oleronius; however, none of these studies provides a good understanding of the mechanism by which these bacteria trigger the development of rosacea.

The role of small intestinal bacterial overgrowth (SIBO) in the pathophysiology of rosacea is becoming a key factor, though its importance is not well-known amongst most physicians.


General Medical Treatment for Rosacea

Current therapy includes use of topical astringents, topical antibiotics and oral antibiotics. Rosacea is treatable but generally cannot be cured at this time by FDA-approved therapy. In this section we review:

  • Rosacea triggers
  • General skin care
  • List of medical treatments
  • Overview of antibiotic therapy


Rosacea Triggers

Non-specific Dietary Triggers

  • Red wine
  • Alcohol
  • Beer
  • Caffeine
  • Hot beverages
  • Sugars
  • Lactose (dairy sugar)
  • Spicy food
  • Aged cheeses
  • Yogurt
  • Bacon

Specific Dietary Triggers

For those with small intestinal bacterial overgrowth (SIBO) please refer to a SIBO diet. The "Rosacea Diet" that has been promoted on the Internet is a low sugar diet. This actually makes sense if there is underlying SIBO.

Environmental Triggers

  • Sun
  • Wind
  • Heat
  • Cold
  • Going from the cold to a warm room

Other Triggers

  • Certain cosmetics
  • Stress
  • Obesity
  • Niacin
  • Microdermabrasion
  • Chemical peels
  • High dosages of isotretinoin
  • Benzyl peroxide
  • Steroids


General Skin Care

  • Wash with a mild soap such as glycerin bar soap.
  • Use moisturizers if your skin is dry - a mild one is Lubriderm - an alternative this is to use a sunscreen alone
  • Sunscreen - this is important to use. Rosacea patients are sensitive to the sun. Photosensitivity is worsened by several triggers. These include but are not limited to perfume, deodorant soaps and various medications including antibiotics that are prescribed by physicians.


List of Medical Treatments

  • Topical therapy that is often offered by physicians:
    • Azelaic acid 15% and 20% twice a day (cream or gel) – FDA approved for rosacea as "Finacea"
    • Sodium sulfacetamide 10% once or twice a day (cream, foam, lotion, or wash)
    • Metronidazole antibiotic 0.75% twice a day or 1% once a day (cream, gel or lotion) – FDA approved for rosacea as “Metrogel”
    • Soolantra - The active ingredient in Soolantra Cream is ivermectin, which is reported to have anti-parasitic and anti-inflammatory properties; however, the exact mechanism of action of Soolantra Cream in the treatment of rosacea is unknown – FDA approved for rosacea
    • Clindamycin antibiotic 1% applied twice a day (solution, lotion or gel) (this can be used if metronidazole is not tolerated)
    • Clindamycin/benzyl peroxide 1%/5% daily (gel)
    • Tretinoin 0.01% to 0.1% daily (cream or gel) for maintenance therapy and must be used with caution
    • Brimonidine cream – FDA approved for rosacea associated redness as “Mirvaso”
  • Topical therapy might be an alternative to prescription medications
    • Curcumingel. This has not been formally studied.
    • Other Internet topical products. These have not been formally studied.
  • Oral antibiotic therapy that is used when topical therapy is inadequate
    • Oracea low dose Doxycycline 40 mg daily – FDA approved for rosacea
    • Tetracycline 250-500 mg once or twice a day
    • Doxycycline 50-100 mg once or twice a day (the above antibiotics can increase photosensitivity to the sun)
    • Metronidazole or Amoxicillin 250 mg-500 mg twice a day (for refractory cases)
    • Erythromycin 30-50 mg/kg/daily
    • Azithromycin 5-10 mg/kg 3 times per week
  • Oral therapy that has been used off-label by dermatologists
    • Rifaximin
    • Isotretinoin


Overview of Antibiotic Therapy

The history of antibiotic use for rosacea is shown in the chart below. Oral antibiotics, such as tetracycline, doxycycline, and metronidazole may be effective treatment for papulopustular rosacea. Topical metronidazole and clindamycin may also be effective for pustular and papular rosacea; however, some patients experience burning and stinging. Oral tetracycline and doxycycline may control ocular rosacea symptoms in some patients. Oral and topical antibiotics are often ineffective for the treatment of persistent redness and flushing forms of rosacea. The most recent development of antibiotic therapy for rosacea by a pharmaceutical company is the use of very low-dose doxycycline. This method utilizes the anti-inflammatory activity of the antibiotic as opposed to its anti-bacterial function. Use of rifaximin has been reported in the literature but is not FDA-approved for rosacea.


Rosacea Information Resources