The 4 Types of Rosacea – and How to Treat Them
Rosy cheeks are a lovely winter weather beauty bonus–but for some people, the added rouge is a full-time skin dilemma that can spread and flare without warning. It's a skin condition called rosacea.
"Rosacea is a condition with flushing and blushing of the skin, associated with inflamed blood vessels and easily irritated sensitive skin," says Melissa Piliang, MD, dermatologist at the Cleveland Clinic. "The foundation is that the face turns red very easily with different triggers, from hot food, wine, cold, wind, sun, stress, and more."
While you may think rosacea is just flushed cheeks, it can also appear on other parts of the body. "Rosacea usually occurs on the mid-face, nose, and cheeks, but it can also occur on the forehead and chin," says dermatologist Margaret Parsons, MD, spokesperson for the American Academy of Dermatology (AAD). It can even show up on the chest, upper back, and the inside your eyes(!)–but more on that in a bit.
What causes rosacea?
First, a little background: The exact cause of rosacea is still to be determined, but dermatologists and researchers think it’s likely a mix of genetic and environmental factors. A 2015 study published in the Journal of the American Academy of Dermatology found that rosacea may also be connected with other chronic inflammatory conditions, including food allergies, metabolic disease, and hormonal imbalances.
But lifestyle choices can also affect your risk. "Certain studies suggest that obesity, a past smoking history, and increased alcohol consumption may be risk factors for rosacea in women. So maintaining a healthy weight, minimizing alcohol intake, and not smoking may possibly reduce your chances of rosacea," says David Lortscher, MD, board-certified dermatologist and founder of Curology.
Another potential cause? An overgrowth of something called demodex. "It’s possible that microbes in or on the skin may stimulate inflammatory reactions of rosacea," says Dr. Lortscher, including demodex, “a mite that lives on our follicles normally.”
There are also those environmental triggers to watch for. “Anything that can make your blood vessels dilate can lead to a rosacea flare,” says cosmetic dermatologist Joshua Zeichner, MD, also an AAD spokesperson. “This includes emotional stress, extremes in temperature (both hot and cold), spicy foods, hot beverages, and alcohol consumption.”
The different types of rosacea
Because rosacea can appear in different forms and places on the body, it can be difficult to diagnose. However, if you think you're experiencing it below your chest, it's likely not rosacea.
"Rosacea is almost always on the face and eyes–not on the legs or arms. If you suspect you have rosacea on these parts of your body, it's probably something else, like eczema or keratosis pilaris," says Dr. Piliang.
The National Rosacea Society classifies the skin condition based on phenotypes. The different types of rosacea are the result of progressing inflammation, Dr. Lortscher explains. (Bummer.)
Dermatologists consider there for be four main phenotypes of rosacea. They can affect different parts of the body and carry different symptoms.
- Erythematotelangiectatic rosacea (ETR): The most common type of rosacea, characterized by dilated blood vessels, redness, and flushing.
- Papulopustular rosacea: Acne-like bumps on the face that can cause swelling and form pustules, resembling whiteheads.
- Phymatous rosacea: A thickening of skin, sometimes on the nose, that results in a bumpy texture. Some people with this type of rosacea may also develop rhinophyma. "The nose gets very big and bulbous, and cheeks can become the same," says Dr. Piliang. This is very rare, and occurs mostly in men.
- Ocular rosacea: "This is characterized by watery or bloodshot appearance, irritation, burning, or stinging of the eyes," says Dr. Lortscher. Eyes can also become gritty, dry, or itchy and may crust.
How to treat rosacea
Treating rosacea has a lot to do with which type you're dealing with. A dermatologist can help determine which you have and the best treatment plan for you. That might include over-the-counter skincare products, prescription ointments, oral meds, or in-office treatments.
Skincare products you pick up at your local pharmacy won’t do much to permanently reduce visible blood vessels. “However, you can improve temporary redness due to inflammation with ingredients like niacinamide and azelaic acid," says Dr. Lortscher.
Since people with rosacea often have sensitive skin, choosing mild cleansers and moisturizers free of alcohol is important. And since the sun can cause rosacea flare-ups, sunscreen is also vital. "I recommend rosacea patients use an SPF of at least 30 every day," says Dr. Piliang.
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The antibacterial cream metronidazole (known by brand names including Metrogel and Noritate) has been found to reduce populations of demodex, which may be causing your rosacea.
Other treatments your doctor might prescribe include vasoconstrictors that narrow blood vessels, making them less visible, says Dr. Lortscher, such as brimonidine (Mirvaso) and oxymetazoline (Rhofade).
“No definite bacterial pathogen has been identified in rosacea," says Dr. Lortscher, however antibiotics are often used to treat all types of rosacea.
"Doxycycline at both antimicrobial (50-200 mg daily) and anti-inflammatory (<50 mg daily) doses have been shown to reduce inflammatory lesion counts in rosacea with inflamed bumps and pustules,” he says.
And ivermectin, an oral anti-parasite medication, has been found to reduce demodex populations as well.
Laser and light therapy
Light and laser treatments may reduce the visibility of blood vessels. According to the AAD, patients often see up to a 75% reduction of those visible vessels after one to three visits.
Laser resurfacing treatments are also used to reduce thickened skin in people with phymatous rosacea.
"A carbon dioxide laser can be used to treat rhinophyma,” Dr. Piliang adds, “to remove skin thickness and make the nose significantly smaller.”