Photodynamic Therapy & Rosacea
In dermatology, PDT with the photosensitizer Levulan Kerastick (20% delta-aminolevulinic acid HCl) is used for the treatment of very early, thin skin cancers called actinic keratoses (AK). The initial approval was specifically for the treatment of actinic keratosis of the face and scalp with a combination of an application of the photosensitizer followed by a timed exposure to a special blue light source. PDT is also used for acne, rosacea, skin cancer, sun damage, cosmetic skin improvement, oily skin, enlarged sebaceous glands, wrinkles, rejuvenation (anti-aging), warts, hidradenitis suppurativa, psoriasis, and many other skin conditions.
What is rosacea? Is rosacea contagious? What does rosacea look like?
Rosacea (ro-zay-sha) is a common, acne-like benign inflammatory skin disease of adults, with a worldwide distribution. Rosacea is estimated to affect at least 16 million people in the United States alone and approximately 45 million worldwide. Most people with rosacea are Caucasian and have fair skin. The main symptoms and signs of rosacea include red or pink facial skin, small dilated blood vessels, small red bumps sometimes containing pus, cysts, and pink or irritated eyes. Many people who have rosacea may just assume they have very sensitive skin that blushes or flushes easily.
Rosacea is considered an incurable auto-inflammatory skin condition which waxes and wanes. As opposed to traditional or teenage acne, most adult patients do not "outgrow" rosacea. Rosacea characteristically involves the central region of the face, mainly the forehead, cheeks, chin, and the lower half of the nose. It is most commonly seen in people with light skin and particularly in those of English, Irish, and Scottish backgrounds. Some famous people with rosacea include the former U.S. President Bill Clinton and W.C. Fields. Rosacea is not directly caused by alcohol intake, but it can be aggravated by it. Rosacea is not considered contagious or infectious.
The redness in rosacea, often aggravated by flushing, may cause small blood vessels in the face to enlarge (dilate) permanently and become more visible through the skin, appearing like tiny red lines (called telangiectasias). Continual or repeated episodes of flushing and blushing may promote inflammation, causing small red bumps, or papules, that often resemble teenage acne. Rosacea is also referred to as acne rosacea. One of the most unpleasant aspects of rosacea is the overgrowth of dermal tissues producing a "phymatous" change in the skin. This appears as a thickening and permanent swelling of the facial tissues. A bulbous nose called rhinophyma is an example of this change.
Is rosacea like acne?
Rosacea, although distinct from acne, does have some similarities. It is occasionally referred to as "adult acne." Unlike common acne, rosacea occurs most often in adults (30-50 years of age). Unlike acne vulgaris, rosacea is devoid of blackheads and characteristically does not resolve after puberty. Rosacea strikes both sexes and potentially all ages. It tends to be more frequent in women but more severe in men. It is very uncommon in children, and it is less frequent in people with dark skin.
What are causes and risk factors of rosacea?
The exact cause of rosacea is still unknown. The basic process seems to involve dilation of the small blood vessels of the face. Currently, it is believed that rosacea patients have a genetically mediated reduction in the ability to dampen facial inflammation that is incited by environmental factors such as sunburn, demodicosis (Demodex folliculorum in the hair follicles), flushing, and certain medications. Rosacea tends to affect the "blush" areas of the face and is more common in people who flush easily. Additionally, a variety of triggers are known to cause rosacea to flare. Emotional factors (stress, fear, anxiety, embarrassment, etc.) may trigger blushing and aggravate rosacea. A flare-up can be caused by changes in the weather, like strong winds, or a change in the humidity. Sun exposure and sun-damaged skin is associated with rosacea. Exercise, alcohol consumption, smoking, emotional upsets, and spicy food are other well-known triggers that may aggravate rosacea. Many patients may also notice flares around the holidays, particularly Christmas and New Year's holidays.
Rosacea risk factors include fair skin, English, Irish, or Scottish heredity, easy blushing, and having other family members with rosacea (called "positive family history"). Additional risk factors include female gender, menopause, and being 30-50 years of age.
What are rosacea symptoms and signs?
Typical signs and symptoms of rosacea include
- facial flushing,
- skin redness (erythema),
- red bumps and pustules,
- small cysts, and
- thickening of the facial tissue, especially the nose.
The symptoms and signs of rosacea tend to come and go. The skin may be clear for weeks, months, or years and then erupt again. Rosacea tends to evolve in stages and typically causes inflammation of the skin of the face, particularly the forehead, cheeks, nose, and chin.
When rosacea first develops, it may appear, then disappear, and then reappear. However, the skin may fail to return to its normal color, and the enlarged blood vessels and pimples arrive in time. Rosacea rarely resolves spontaneously.
Rosacea generally lasts for years, and if untreated, it tends to gradually worsen.
How long does facial flushing from rosacea last?
Early in the course of rosacea, facial flushing is transient, lasting for minutes to hours. Later, as the disease progresses, the flushing becomes permanent and the redness does not resolve.
Is it possible to prevent rosacea?
It is not possible to prevent rosacea, but it is possible to limit one’s exposure to triggering factors. Once the diagnosis of rosacea is made, it is wise to avoid factors like spicy foods, hot liquids, smoking, and irritating cosmetics that are known to trigger rosacea.
What tests do health care professionals use to diagnose rosacea?
Rosacea is usually diagnosed based on the typical red or blushed facial skin appearance and symptoms of easy facial blushing and flushing. Rosacea is largely underdiagnosed, and most people with rosacea do not know they have the skin condition. Many people may not associate their intermittent flushing symptoms with a medical condition. The facial redness in rosacea may be transient and come and go very quickly.
Dermatologists are physicians who are specially trained in the diagnosis of rosacea. Generally, no specific tests are required for the diagnosis of rosacea.
In unusual cases, a skin biopsy may be required to help confirm the diagnosis of rosacea. Occasionally, a noninvasive test called a skin scraping may be performed by the dermatologist in the office to help exclude a skin mite infestation by Demodex, which can look just like rosacea (and may be a triggering factor). A skin culture can help exclude other causes of facial skin bumps like staph infections or herpes infections. Blood tests are not generally required but may be used to help exclude less common causes of facial blushing and flushing, including systemic lupus, other autoimmune conditions, and dermatomyositis.
While most cases of rosacea are fairly straightforward, there are some atypical cases that are not as easy to diagnose. Other skin diseases and rosacea look-alikes include
- acne vulgaris,
- Demodex folliculitis,
- staph infection,
- systemic lupus erythematosus,
- medication reaction (for example, niacin),
- seborrheic dermatitis,
- allergic or contact dermatitis,
- seasonal allergies,
- allergic conjunctivitis,
- perioral dermatitis,
- carcinoid syndrome,
- impetigo, and
- herpes simplex.
Recently, there has been an association noted between rosacea and certain auto-inflammatory diseases, including diabetes, inflammatory bowel disease, and cardiovascular disease.
How does rosacea affect the nose and the eyes?
The nose is typically one of the first facial areas to be affected in rosacea. It can become red and bumpy and develop noticeable dilated small blood vessels. Left untreated, advanced stages of rosacea can cause a disfiguring nose condition called rhinophyma (ryno-fy-ma), literally growth of the nose, characterized by a bulbous, enlarged red nose and puffy cheeks (like the classic comedian W.C. Fields). There may also be thick bumps on the lower half of the nose and the nearby cheek areas. Rhinophyma occurs mainly in men. Severe rhinophyma can require surgical correction and repair.
Some people falsely attribute the prominent red nose to excessive alcohol intake, and this stigma can cause embarrassment to those with rosacea.
Rosacea may affect the eyes. Not everyone with rosacea has eye problems. A complication of advanced rosacea, known as ocular rosacea, affects the eyes. About half of all people with rosacea report feeling burning, dryness, and irritation of the tissue lining of the eyes (conjunctivitis). These individuals may also experience redness of the eyelids and light sensitivity. Often the eye symptoms may go completely unnoticed and not be a major concern for the individual. Many times, the physician or ophthalmologist may be the first one to notice the eye symptoms. Untreated, ocular rosacea may cause a serious complication that can damage the cornea permanently damaging vision, called rosacea keratitis. An ophthalmologist can assist in a proper eye evaluation and prescribe rosacea eyedrops. Oral antibiotics may be useful to treat skin and eye rosacea.
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What about using acne medicine for rosacea?
Since there is some overlap between acne and rosacea, some of the medications may be similar. Acne and rosacea have in common several possible treatments, including (but not limited to) oral antibiotics, topical antibiotics, sulfa-based face washes, isotretinoin, and many others. It is important to seek a physician's advice before using random over-the-counter acne medications since they can actually irritate skin that is prone to rosacea. Overall, rosacea skin tends to be more sensitive and easily irritated than that of common acne.
Does rosacea get worse with age?
Yes. Although rosacea has a variable course and is not predictable in everyone, it tends to gradually worsen with age, especially if untreated. In small studies, many rosacea sufferers have reported that without treatment their condition had advanced from early to middle stage within a year. With good therapy, it is possible to prevent progression of rosacea.
What types of doctors treat rosacea?
Dermatologists are most familiar with which option might be best for each individual. Ophthalmologists treat rosacea-related eye disease.
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What is the treatment for rosacea?
There are many treatment choices for rosacea depending on the severity and extent of symptoms. Available medical treatments include antibacterial washes, topical creams, antibiotic pills, lasers, pulsed-light therapies, photodynamic therapy, and isotretinoin.
Mild rosacea may not necessarily require treatment if the individual is not bothered by the condition. More resistant situations may require a combination approach, using several of the treatments at the same time. A combination approach may include prescription sulfa facial wash twice a day, applying an antibacterial cream morning and night, and taking an oral antibiotic for flares. A series of in-office laser, intense pulsed light, or photodynamic therapies may also be used in combination with the home regimen. It is advisable to seek a physician's care for the proper evaluation and treatment of rosacea.
What types of medications treat rosacea?
With the proper treatment, rosacea symptoms and signs can be controlled. Popular methods of treatment include topical (skin) medications applied by the patient once or twice a day. Topical antibiotic medication such as metronidazole (Metrogel) applied one to two times a day after cleansing may significantly improve rosacea. Azelaic acid (Azelex cream, Finacea gel 15%) is another effective treatment for patients with rosacea. Both metronidazole and azelaic acid work to control the redness and bumps in rosacea.
Some patients elect combination therapies and notice an improvement by alternating metronidazole and azelaic acid: using one in the morning and one at night. Sodium sulfacetamide (Klaron lotion) is also known to help reduce inflammation. Other topical antibiotic creams include erythromycin and clindamycin (Cleocin). Topical ivermectin cream (Soolantra Cream, 1%) is also available.
Recently, a new topical prescription gel has become available designed to relieve the redness so characteristic of rosacea. Brimonidine gel (Mirvaso) and oxymetazoline hydrochloride cream (RHOFADE) applied once a day can produce a prolonged period of blanching of previously red skin in rosacea patients.
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What types of medications treat rosacea? (Part 2)
Oral antibiotics are also commonly prescribed to patients with moderate rosacea. Tetracycline (Sumycin), doxycycline (Vibramycin, Oracea, Adoxa, Atridox), and minocycline (Dynacin, Minocin), are oral antibiotics commonly prescribed are presumed to work by reducing inflammation. A newer low-dose doxycycline preparation called Oracea (40 mg once a day) has been used in rosacea. The dose may be initially high and then be tapered to maintenance levels. Common side effects and potential risks should be considered before taking oral antibiotics.
Short-term topical cortisone (steroid) preparations of minimal strength may in occasional cases also be used to reduce local inflammation. Some mild steroids include desonide lotion or hydrocortisone 0.5% or 1% cream applied sparingly once or twice a day just to the irritated areas. There is a risk of causing a rosacea flare by using topical steroids. Prolonged use of topical steroids on the face can also cause irritated skin around the mouth (perioral dermatitis).
Some doctors may also prescribe tretinoin (Retin-A), tazarotene (Tazorac), or adapalene (Differin), which are prescription medications also used for acne. Rarely, permethrin (Elimite) cream is prescribed for rosacea cases that are associated with skin mites. Permethrin is also used for follicular Demodex mites if warranted.
Isotretinoin is infrequently prescribed for severe and resistant rosacea. Often it is used after multiple other therapies have been tried for some time and have failed. It is used as a daily capsule for four to six months. Isotretinoin is not typically used in rosacea, and it is most commonly used in the treatment of severe, common acne called acne vulgaris. Close physician monitoring and blood testing are necessary while on isotretinoin. Generally, at least two forms of birth control are required for females using this medication, as pregnancy is absolutely contraindicated while on isotretinoin.
In addition, prescription or over-the-counter sensitive skin cleansers may also provide symptom relief and control. Harsh soaps and lotions should be avoided, whereas simple and pure products such as Cetaphil or Purpose gentle skin cleanser may be less irritating. Patients should avoid excessive rubbing or scrubbing the face.
Other recommended cleansers include
- sulfa-based washes (for example, Rosanil) and
- benzoyl peroxide washes (for example, Clearasil).
What are other treatments for rosacea?
Laser and intense pulsed light
Many patients are now turning to laser and intense light treatments to treat the continual redness and noticeable blood vessels on the face, neck, and chest. Often considered a safe alternative, laser and intense pulse-light therapy may help to visibly improve the skin and complexion.
Laser treatment may cause some discomfort. While most patients are able to endure the procedure, ice packs and topical anesthetic cream can help alleviate the discomfort. Multiple treatments are typically necessary, and the procedure is not covered by most insurances. Treatments are recommended in three- to six-week intervals; during this time, sun avoidance is necessary. Risk, benefits, and alternatives should be reviewed with a physician prior to treatment. Laser treatments may be combined with photodynamic therapy (light-activated chemical using Levulan) for more noticeable results.
Photodynamic therapy (PDT) is one of the newly available treatments. PDT uses a topical photosensitizer liquid that is applied to the skin and a light to activate the sensitizer. Levulan (aminolevulinic acid) and blue light, commonly used to treat pre-cancers (actinic keratosis) and acne vulgaris, can also be used to treat some rosacea patients. The use of PDT in rosacea is considered off-label, since it is primarily designed for regular acne. PDT is thought to work at reducing the inflammation; PDT is performed in a physician's office. The treatment takes anywhere from one to one and a half hours to complete. Strict sun avoidance for approximately one to three days is required after the treatment. Mild discomfort during the treatment and a mild to moderate sunburn appearance after the treatment is common. Some patients have experienced remissions (disease-free periods) of several months to years from these types of treatments. Other patients may not notice significant improvement.
Glycolic-acid peels may additionally help improve and control rosacea in some people. The chemical peels can professionally be applied for approximately two to five minutes every two to four weeks. Mild stinging, itching, or burning may occur and some patients experience peeling for several days after the peel. Any peel can irritate very sensitive skin and cause flares for some people. Peels should be used with caution in rosacea as not everyone is able to tolerate these treatments.
Sun exposure is a well-known flare for many rosacea sufferers. Sun protection using a wide-brimmed hat (at least 6 inches) and physical sunscreens (like zinc or titanium) are generally encouraged. Because rosacea tends to occur in mostly fair-skinned adults, the use of an appropriate daily SPF 50 sunscreen lotion and overall sun avoidance is recommended.
What are rosacea triggers? Is there a rosacea diet? What foods are good for rosacea?
While not all rosacea people are exactly the same, there are some common rosacea triggers. Avoiding these potential triggers may also help relieve symptoms and disease flares. It may be helpful to keep a personal diary of foods and other triggers that flare rosacea symptoms.
Smoking, spicy foods, hot drinks, and alcohol may cause flushing and should be avoided. Exposure to sunlight and to extreme hot and cold temperatures should be limited as much as possible. Red wine and chocolate are two well-known rosacea triggers. Some listed foods may have no effect on one patient's rosacea but severely affect someone else. Individual reaction patterns vary greatly in rosacea. Therefore, a food diary may help to elucidate one's special triggers.
Possible rosacea dietary triggers include
- dairy, including yogurt, sour cream, cheese (except cottage cheese);
- alcohol, including red wine, beer, vodka, gin, bourbon, and champagne;
- soy sauce;
- yeast extract;
- eggplants, avocados, spinach;
- some beans and pods, including lima, navy or peas;
- citrus fruits, including tomatoes, bananas, red plums, raisins, or figs; and
- spicy and temperature hot foods.
Potent cortisone or steroid medications on the face should be avoided because they can promote widening of the tiny blood vessels of the face (telangiectasis). Some patients experience severe rosacea flares after prolonged use of topical steroids.
Vasodilator pills can also flare rosacea. Vasodilators include certain blood pressure medications like nitrates, calcium channel blockers (such as nifedipine [Procardia]), and thiazide diuretics (such as Dyazide).
These potential triggers are found in many skin cleansers and should be avoided in rosacea.
- Witch hazel
- Eucalyptus oil
- Clove oil
- Salicylic acid
Foods that decrease rosacea flares include less spicy meals, nonalcoholic cool beverages, caffeine-free drinks, nondairy cheese, and thermally cooler meals.
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What natural rosacea treatments or home remedies can help?
Rosacea skin tends to be fairly sensitive and may easily flare with self-treatment or common acne therapies. Any home treatment or attempts for natural remedies should be approached with some caution. As with any rosacea therapy, some people may experience sensitivity or irritation with treatment. Several possible natural remedies, including dilute vinegar cleansing and green tea applications, may be useful in rosacea.
Dilute white vinegar facial soaks or cleansing daily or weekly using approximately 1 part regular table vinegar to 6 parts water may be helpful. Vinegar is thought to help as a natural disinfectant and can help decrease the number of yeasts and bacteria on the skin. Since vinegar may flare rosacea in some people, a small test area should be tried before applying to the entire face.
Green tea soaks to the face may also help decrease the redness and inflammation seen in rosacea. Green tea is thought to have anti-inflammatory properties. A few commercially available products also use green tea as the active ingredient.
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What is the prognosis for rosacea?
Rosacea currently is considered an incurable chronic condition. While it cannot be cured, it can be controlled with proper, regular treatment.
There are some forms of rosacea that may be significantly cleared for long periods of time using laser, intense pulse light, photodynamic therapy, or isotretinoin (Accutane). Although still not considered a "cure," some patients experience long-lasting results and may have remissions (disease-free period of time) for months to years.
How should people with rosacea care for their facial skin?
Proper skin care involves using a gentle cleanser to wash the face twice a day. Over-washing may cause irritation. A sunscreen lotion is advisable each morning. A physician may prescribe a topical antibiotic to use once or twice a day under sunscreen.
Rubbing the face tends to irritate the reddened skin. Some cosmetics and hair sprays may also aggravate redness and swelling.
Facial skin care products such as soap, moisturizers, and sunscreens should be free of alcohol or other irritating ingredients. Moisturizers should be applied very gently after any topical medication has dried. When going outdoors, sunscreens with an SPF of 50 are needed.
Quick GuideRosacea, Acne, Shingles: Common Adult Skin Diseases
How are the telangiectasias (the red lines) treated?
Telangiectasias are the small blood vessels that arise on the surface of the skin, commonly on around the nose, cheeks, and chin.
Simple cover-up makeup can be used for the telangiectasias. There are some green-based moisturizers or tinted foundations that may help conceal the redness.
Telangiectasias can also be medically treated in a health care professional's office with a small electric needle, a laser, intense pulsed light, or minor surgery to close off the dilated blood vessels. Usually, multiple treatments are required for best results, and only a portion of the blood vessels may be improved with each treatment. Not everyone responds the same to these types of treatments, and a physician can help someone decide which treatment is best for his or her skin type, condition, and size of blood vessels.
- Intense pulsed light therapy
How is rhinophyma (the W.C. Fields nose) treated?
Rhinophyma of the nose is frequently treated by surgery. The excess tissue may be removed with a scalpel, laser, or electro surgery. Dermabrasion can help improve the look of the scar tissue. Follow-up treatments with laser or intense pulsed light may help lessen the redness. Medical maintenance therapy with oral and or topical antibiotics may be useful to decrease the chance of recurrence.
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What effect may rosacea have on a person's life?
Rosacea may affect someone's life minimally, moderately, or severely depending on how active the condition is and one's overall tolerance of the skin symptoms and signs.
Some individuals have absolutely no symptoms and are not bothered at all by their rosacea. They may enjoy perfectly healthy normal lives without any effect from this benign skin condition. Some patients really like the pink glow to their cheeks and find it gives them a pleasant color without having to use blush. They may not even know they have rosacea. They usually do not want to use any treatment.
Patients with moderate rosacea may have periodic flares that require treatment with oral antibiotics, lasers, and other therapies. They may require oral antibiotic therapy for years. Some patients complain of looking like they have been drinking alcohol when in fact they don't drink at all. Although rosacea is not a grave medical situation, severe cases may damage some patient's lives. It is important for these patients to express their concerns with their physician and to get professional help in treating their rosacea.
Overall, promptly diagnosed and properly treated, rosacea should not prevent people with the condition from enjoying long and productive lives.
Where can people get more information about rosacea?
For more information on rosacea, contact the National Rosacea Society (NRS) at http://www.Rosacea.org or 888-no-blush. Support information and research updates may be regularly available from NRS. NRS also sponsors research grants and studies on rosacea treatment.
Additional information is available from the American Academy of Dermatology at http://www.AAD.org. Names of U.S. board-certified dermatologists are available on this web site.
While online chat groups are available on http://www.Rosacea-Support.org, these should not replace the advice of a physician. Online public posts and comments may not be scientifically or medically accurate and should be evaluated cautiously.
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Medically Reviewed on 6/9/2017
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