Dr Zein Obagi describes the four main subtypes of rosacea and how a comprehensive skincare regime can help to treat mild to moderate cases
Rosacea is a chronic skin condition that tends to be common in fair skin types and is often referred to as “The Curse of the Celts”. It affects both men and women, most notably between the ages of 30 and 60, and typically begins as redness on the central face across the cheeks, nose or forehead. In some cases it can also affect the neck, chest, ears, and scalp.
This chronic inflammatory disease of the skin can have devastating effects on an individual’s quality of life. Patients often show signs of depression and avoid social situations due to feelings of embarrassment and low self-esteem. Just a small fraction of the millions of individuals who suffer from rosacea are aware of this condition and seek treatment. An even smaller fraction of these individuals receive optimal treatment, which helps them cope with anxiety and other social stigma.
Rosacea is a heterogeneous skin disorder. Flushing and persistent redness are the most common early signs of the skin disorder. For some individuals, symptoms may only include mild, intermittent facial redness and flushing. For others, symptoms may be more severe and persistent such as redness, pustules, papules and telangiectasias, thickened, rough skin (rhinophyma) as well as ocular manifestations. Many rosacea patients also report skin sensitivity and facial dryness.
Rosacea is cyclic, and flares may last for weeks to months after which symptoms typically abate. Its progression can vary substantially from one patient to another. It is a progressive condition with no cure, but it can be controlled and healthy skin can be maintained, often by using topical creams alone. For more severe cases, oral medication or photodynamic therapy is occasionally required.
Long-term medical supervision is the best approach to treating rosacea. Delay of treatment may result in skin damage. As a skin disease, rosacea requires medical consultation and proper treatment from a qualified skin care professional Many patients present having used over-the-counter products to treat the condition with no improvement. These patients require medical care.
Rosacea is an inflammatory process, the specific cause of which is still unknown. Other factors that play a role in rosacea aetiology include hormonal fluctuations and genetics. In addition, hyperactive oil glands lead to increased sebum production. Increased sebum, in turn, irritates the skin to cause the inflammation and sensitivity that occur with the condition.
While there is no cure, effective treatment regimens do exist and can be tailored to individual symptoms and rosacea severity.
An important component of any rosacea treatment involves recognising and avoiding triggers. These tend to vary by individual, but often include extreme temperatures, sun exposure, alcohol, spicy food and stress. Keeping a diary can help patients identify rosacea triggers.
Facial redness, flushing, visible blood vessels
Flushing and redness in the centre of the face.
Visible broken blood vessels or thread veins.
Skin may be very sensitive.
Skin may sting and burn.
Dry skin, roughness or scaling.
Tendency to flush or blush easily.
Acne-like breakouts, usually where the skin is very red.
Skin may be very sensitive.
Skin may burn and sting.
Visible broken blood vessels.
This subtype is rare but when it does occur, the patient often presents with signs and symptoms of another subtype of rosacea first. The signs of this type may include:
Bumpy texture to the skin.
Skin begins to thicken, especially common on the nose, as in rhinophyma.
Skin may thicken on the chin, forehead, cheeks and ears.
Visible broken blood vessels.
Eyes are affected
Rosacea can also occur in the eyes with one or more of the following symptoms:
Watery or bloodshot appearance.
A gritty feel, often feels like sand in the eyes.
Eyes burn or sting.
Eyes are very dry.
Eyes sensitive to light.
Visible broken blood vessels on an eyelid.
Cyst on the eyelid.
Loss of vision.
Rosacea presents in many forms, so four subtypes typically identify it. Redness, involuntary flushing or blushing, red capillaries over the cheeks and nose, rough texture due to large oil glands, large pores, oily skin, discolouration, acne-like cysts and nodules and dry flaky skin are all signs of dermatological rosacea. Ocular rosacea often occurs simultaneously in the eyes and can affect lashes and eyelids.
Some patients may have more than one rosacea subtype at the same time. Each subtype also requires different treatment regimen.
The way I treat rosacea depends on the appearance of the skin and the stage of the condition. For milder cases, in which there may only be mild inflammation and no acne-type lesions, I recommend a daily skincare regimen to soothe and calm the skin and repair the skin barrier.
For moderate to severe cases, with redness, irritation and weakened, oily skin, I prefer a combination of therapeutic treatments and daily at-home use of anti-redness products. The right combination of therapies, controlled peels and retinol products can improve the signs and symptoms of rosacea and restore skin to optimal health.
Dermatologists and skincare professionals should evaluate a patient’s skin condition before recommending therapy. More severe rosacea cases marked by telangiectasias, enlarged pores, papules and pustules often require a more aggressive treatment approach. For severe cases of rosacea, oral medicine or photodynamic therapy including intense pulsed light or vascular lasers may be indicated.
However, in most cases, rosacea can be well controlled and skin can look healthy with consistent use of a regimen of topical creams alone.
Dr Zein Obagi is a board certified dermatologist in Beverly Hills, California and Medical Director of ZO Skin Health, Inc.
Six-step ZO Medical treatment process
1. Use ZO Medical Oilacleanse every morning and evening to exfoliate and cleanse skin and remove oil and other impurities that contribute to skin inflammation.
2. ZO Skin Health Offects Exfoliating Polish exfoliates dead skin cells and increases epidermal turnover. Patients should use two to three times a week in the morning or more often if skin is oily. This polish is replete with antioxidants Vitamins A, C, E, and C-Esters to help maintain skin barrier function.
3. ZO Medical Cebatrol oil control pads should be used twice a day. These exfoliating pads contain an emollient complex to soothe skin and reduce redness. Mandelic acid helps reduce inflammatory agents that cause irritation and triclosan provides additional antibacterial benefit.
4. Patients can apply two or three pumps worth of ZO Skin Health Ossential Daily Power Defense to their face and neck each morning. Including retinol, antioxidants and DNA-repairing enzymes that work around-the-clock, this therapy restores skin function and elasticity.
5. Nightly treatment with ZO Skin Health Ossential Radical Night Repair Plus or tretinoin. The Ossential product comprises a full 1% concentration of retinol to stimulate new cell activity and collagen production for strengthening and building skin tolerance.
6. Judicious use of a non-irritating sunscreen such as Oclipse-C SPF 50 or Oclipse SPF 30. Daily sun protection is important for all patients, but rosacea patients should be especially vigilant. Sun exposure is considered a major trigger for rosacea flares.
Other steps in this regimen are optional, including the use of prescription metronidazole gel 1%. Metronidazole decreases the redness, but is not a cure for rosacea. When using this regimen, it should be applied before ZO Ossential Radical Night Repair Plus for best results. ZO Ommerse Overnight Recovery Crème can be applied before ZO Ossential Radical Night Repair Plus or after tretinoin in the evening.