There are four types of rosacea:
1. Erythematotelangiectatic type: Facial Redness
This type of rosacea presents with generally red facial skin—especially the upper cheeks, the nose and the center of the skin. There can be a general redness that persists even when not overheated or flushed. The redness worsens with triggers such as spicy foods, wine, exercise, overheating and embarrassment. Sometimes, countless telangiectasias (little blood vessels) can be seen covering the face. Another clinical presentation is a general “gritty” texture to the red skin and yet another variant of erythematotelangiectatic rosacea is an almost “thickened” appearance to the gritty red skin—my general opinion is that this is a very early precursor to the fourth type of rosacea; rhinophyma. It should be noted that there are many other conditions that can cause redness of the face like lupus, drug reactions and a sun burn to name a few. They each have a unique appearance to a trained eye.
This type of rosacea is very inflamed and bumpy. Pink and red papules may be scattered all over the face—usually distributed over the cheeks, the nose bridge, the central forehead and chin. This form of rosacea is associated with increased growth of demodex folliculorum mites. The bumps can have a little pustule in the center (this is where it is easiest to do a scraping of the follicle contents with a small blade to see the mites). It is easiest to find the mites in smaller pustules that are about 1-2mm. Larger, more inflamed papules that are almost cysts can also accompany papulopustular rosacea and begin to approach what we call “granulomatous rosacea” where the face becomes so overwhelmingly swollen and inflamed that it is extremely disfiguring and painful.
2. Phymatous Rosacea or Rhinophyma: Thickened Skin
This is where the affected skin becomes thickened. The pores become enormous in size and the skin becomes almost waxy yet boggy. Surface nodules are apparent. These changes can affect the cheeks, chin AND nose, or sometimes these changes can affect the nose predominantly. When the nose is affected, it can become quite remarkably enlarged exceeding the size of one’s nose of their youth by two times.
3. Ocular Rosacea
Styes in the eyelids and a gritty sensation of the eyeballs. This form of rosacea can be the only sign of rosacea one may have with little cyst-like styes along the upper or lower lid line. The inflammation and irritation of these styes can cause the eyes to be very irritated, itchy and inflamed and can even scratch the cornea leading to vision loss.
Most Recent Findings
Rosacea has been one of those diseases that we as dermatologists know how to control but not how to cure. With the most recent research however, I think we should be able to cure rosacea if the correct measures are taken.
- Lipid Deficiencies: We have known about an increased number of hair follicle mites called Demodex in rosacea for many years. Most recently however, it has been discovered that people who have rosacea have developed an inflammatory antibody against a bacteria INSIDE the mites! Great. Not only do we have a problem parasite on our skin but the parasite has a problem parasite too! The bacteria inside the Demodex is called Bacillus oleroneus. Even more interesting however, is that these people who have increased numbers of Demodex mites ALSO have a deficiency in skin lipids compared to people who do not have rosacea! I find this so very interesting as we have yet another skin condition that is directly associated with a faulty skin barrier due to essential skin lipid deficiency.
- Easy access to food—your skin cells! With a deficiency in the skin lipids, the Demodex have an easy path to their food supply—your skin cells. Demodex live inside of the hair follicles and eat the cells inside the follicle. It is possible that perhaps a deficiency of skin lipids makes it easier for the mites to get to the part of your hair follicle skin that it wants to eat. With easy access, more and more inflammation ensues and the easier it would be for our body to form antibodies to the bacteria inside of the Demodex and start the inflammatory pathways.
- Inflammation: Recent research has shown a faulty inflammatory response in rosacea as well. In rosacea-prone skin, there is too much of an enzyme called Kallikrein 5. Kallikrein 5 initiates inflammation which then leads to production of excessive amounts of a protein called Cathelicidin. Cathelicidin is one of the skin’s own antibiotics that acts by triggering more inflammation, dilation of the blood vessels (vasodilation) and proliferation/growth of the blood vessels. As we all know, the effects of the excessive cathelicidin is very obvious when you look at rosacea-prone skin with its excessive collections of blood vessels. This is why it makes all the sense in the world to use anti-inflammatory molecules like niacinamide and 18-B glycyrrhetinic acid in a product for rosacea. Both of these molecules are known to be anti-inflammatory.