Acne Rosacea

Rosacea is not a skin condition that is typical associated with skin of color. A main feature of rosacea is redness or erythema of the face. But rosacea does occur in people of color, including African Americans, Latinos and Asians, and is often undiagnosed or misdiagnosed.

What is rosacea? Also termed “adult acne”, it is a chronic skin disorder characterized by facial redness, papules (bumps) or pustules (pus-filled bumps) that may be confused with acne, and other skin disorders. The condition affects more than 13 million Americans, typically between the ages of 30 and 50 years old. Though it is more commonly diagnosed in fair skinned people, it does affect people with brown skin, particularly those who derive their heritage from multiple racial and ethnic groups, including Africans, Asian, Native Americans, Latin and Caucasians. Depending on skin tone, rosacea may look very different in people of color, but it is no less distressing psychologically.

The cause of rosacea is not fully understood. Leading theories include an increased reactivity of the vascular (blood vessel) system, lack of tissue support of blood vessels, or even an infectious cause (i.e. a mite that triggers rosacea in some people). Rosacea is exacerbated by various trigger factors, including hot or spicy foods, hot beverages such as coffee or tea, alcohol (especially red wine), sun exposure and a hot climate, to name just a few (see chart below).
Signs of rosacea may vary greatly from individual to individual, and even in one individual over time since the condition tends to flare up at times and recede at other times. There are 4 subtypes of rosacea which are listed below. An individual may have one or more than one of these subtypes.

Rosacea Subtypes

  • Erythematotelangiectatic: facial flushing, persistent redness and telangiectasias
    (small squiggly red blood vessels)
  • Papulopustular: bumps or pustules (pus-filled bumps)
  • Phymatous: thickening of certain areas of the skin that may lead to enlargement of the nose, chin or ears
  • Ocular: redness of the eyes with burning, stinging, or dryness

People with rosacea tend to have not only dilated blood vessels, but an increased number of blood vessels, resulting in the skin redness. With erythematotelangiectatic rosacea, the redness most often shows up on the central face, including the cheeks, chin, nose and forehead. It may also appear elsewhere on the body such as the neck, ears, scalp, back, extremities and abdomen. Other signs usually include easy flushing or blushing of the face and telangiectasias. Burning or stinging of the facial skin is not uncommon. The skin may be very sensitive and dryness and swelling may be present.

Papulopustular rosacea, closely resembles acne vulgaris with papules (small red or flesh-colored bumps) and pustules (pus-filled bumps) but it is distinguished from acne vulgaris in that it does not have comedones (whiteheads or blackheads). The papules and pustules commonly occur on the cheeks, between the eyebrows and on the chin and they are often superimposed upon the redness or erythema. Symptoms associated with this type of rosacea include stinging or burning. The skin may also be very dry or ashy. Some people with brown skin have both rosacea and acne vulgaris, making the former difficult to diagnose.

With phymatous rosacea, there is growth of fibrous tissue and resulting enlargement of certain areas of the face, such as the nose and chin. Fortunately, this is an uncommon subtype of rosacea and occurs rarely in women.
Ocular rosacea affects the eyes with redness, irritation and inflammation (conjunctivitis). The eyes often burn or sting and may feel scratchy.

Rosacea can be confused with other skin disorders including acne vulgaris, subacute cutaneous lupus erythematosus (a skin form of lupus) and the inappropriate use of cortisone creams. A dermatologist can distinguish between these skin problems and prescribe the appropriate medication.

Treatment of Rosacea
Most people with rosacea will need some combination of prescription topical and oral medications. Though in some people, rosacea will diminish without treatment, there is no cure. It is also important to realize that people with rosacea have very sensitive skin and this is compounded in women with brown skin who already have a tendency towards sensitive skin and hyperpigmentation. Therefore, care must be given in the selection of daily skin care products including cleansers, toners and moisturizers. Harsh and abrasive products should be avoided in rosacea-prone skin. Since prescription medications will undoubtedly be required to treat your rosacea, visit your dermatologist. He or she will select the most appropriate medications for your skin.

Oral antibiotics
Although there is no confirmed microbiologic cause of rosacea, antibiotics and antimicrobials agents work well in rosacea. More severe or resistant forms of rosacea can be treated with an oral antibiotic. The most effective oral antibiotics are those in the tetracycline family and include tetracycline, minocycline and doxycycline. Some dermatologists prescribe low dose doxycycline for this condition. It is thought that low dose antibiotics reduce the inflammation in the skin without causing resistance of bacteria. With all antibiotic treatment, 4 to 8 weeks are required. Many patients may be able to discontinue the oral antibiotics and maintain an improved appearance with topical treatment only.

Topical antibiotics and antimicrobials
Mild rosacea is effectively treated with topical antibiotic or antimicrobial agents. These include azelaic acid, clindamycin 1% combined with benzoyl peroxide 5%, sulfur 5% combined with sulfacetamide sodium 10% and metronidazole 0.75% or 1%. These topical antibiotic agents come in the form of gels, creams, lotions or washes. They are typically applied to the face once or twice daily and must be used for a period of 6-8 weeks before improvement is seen. Possible side effects may include burning, stinging or irritation of the facial skin. Clindamycin 1%/benzoyl peroxide 5% gel and azelaic acid gel 15% have recently been demonstrated to be effective in the treatment of rosacea with the azelaic acid gel 15% demonstrating superiority as compared to some of the older topical treatments.

The following is a list of some of the more common treatments for rosacea.

Oral antibiotics Brand names

  • Tetracycline 250, 500 MG BID
  • Minocycline 50, 75, 100 MG QD-BID Minocin, Dynacin
  • Doxycycline 20, 50, 75, 100 MG QD-BID Monodox, Doryx, Adoxa
  • Doxycycline 1/100 Pack, 2/100 Pack Adoxa
    (MG=milligrams; QD= once a day; BID= twice a day; DS=double strength)

Topical antibiotics and antimicrobials Brand names

  • Azelaic acid 15% Finacea
  • Clindamycin 1%/ Benzoyl peroxide 5% Benzaclin, Duac
  • Sulfacetamide sodium 10% /Sulfa 5% Rosac, Rosanil, Ovace
  • Metronidazole 1.0% Noritate Cream
  • Metronidazole 0.75% Metrogel, Metrocream, Metrolotion

Other treatments for rosacea utilizing laser light and intense pulse light have been demonstrated to improve the redness and telangiectasias seen in rosacea. The number of treatments required range from as few as one to over four. However, women with brown skin must be cautious as hyperpigmentation may develop as a result of these procedures. Make sure to discuss this possibility with your treating dermatologist.

Rosacea Trigger Factors

  • Foods: hot or spicy foods
  • Hot beverages: coffee or tea,
  • Alcohol: red wine
  • Hot climates
  • Steam showers

Steroid rosacea (A Beauty Disaster)
Steroid rosacea has become an all too common form of rosacea in women with brown skin. This type of rosacea is caused by the inappropriate and prolonged use corticosteroid (cortisone) creams typically on the facial skin. These cortisone creams may be either the over-the-counter variety (hydrocortisone) or prescription cortisones or those that are sold illegally in beauty supply stores (several names include Dermovate and Movate). Prescription cortisone creams are often used to treat skin disorders such as eczema, psoriasis and other types of inflammation. However, women with brown skin get into trouble when they use cortisone creams on their faces for beauty reasons. Many of the patients that I see have used these creams for prolonged periods of time (months or even years). Why? Because initially cortisone creams will give the skin a smooth, soft and blemish free appearance. Many women use them because they have heard that the cortisone creams will even skin discolorations and skin tone. Unfortunately, these women are headed for a beauty disaster. Eventually, a rosacea-like eruption will develop first with telangiectasias and redness and then with bumps. The skin may become very thin (atrophy) and shiny. When the cortisone cream is discontinued, the skin undergoes “withdrawal”. It is as if the skin is addicted to the cortisone cream and when it is stopped the skin begins to burn and itch and a rash develops. The withdrawal process may last for weeks or months but several of the medications used to treat rosacea can be used to minimize the withdrawal process. Women with brown skin must realize the harm associated with the use of cortisone creams on the face and avoid their use.

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