Many clients may walk through an aesthetician’s door with common facial manifestations, often agonizing over what once was clear skin that has now erupted into inexplicable redness, dryness, skin thickening, and even bumps and pimples that resemble acne. While these symptoms may be a sign of a variety of skin conditions, they may also be characteristic of the widespread, yet poorly understood facial disorder known as rosacea, a chronic skin disease now estimated to affect more than 16 million Americans, many of whom do not know they have it. Knowing how to spot the potential signs and symptoms of this medical disorder before serving a client could be the difference between having a repeat customer and exacerbating their condition.
Rosacea is a chronic and potentially life-disruptive disorder primarily of the facial skin, often characterized by flare-ups and remissions. It typically begins any time after age 30 as a redness on the cheeks, nose, chin or forehead that may come and go. In some cases, rosacea may also occur on the neck, chest, scalp, or ears. Over time, the redness tends to become ruddier and more persistent, and visible blood vessels may appear. If left untreated, bumps and pimples often develop and in severe cases, the nose may grow swollen and bumpy from excess tissue. In some cases, the eyes can be affected.
Although rosacea can affect all segments of the population, individuals with fair skin, particularly those of Celtic and northern European descent who tend to flush or blush easily, are believed to be at greatest risk. The exact cause of rosacea is unknown and several theories about its origin have evolved over the years. Facial blood vessels may dilate too easily and the increased blood near the skin’s surface makes the skin appear red and flushed. Various lifestyle and environmental factors – called triggers – may also increase the redness response. Acne-like bumps may appear, often in the central area of the face. This may be due to factors related to blood flow, skin bacteria, microscopic skin mites (Demodex), irritation of follicles, sun damage of the connective tissue under the skin, an abnormal immune or inflammatory response, or
While none of these possibilities have been proven, potential inflammatory pathways have been identified in recent ongoing research – including an immune response triggered by a type of antimicrobial protein known as a cathelicidin. A recent study also found that certain bacteria present on Demodex mites – normal inhabitants of facial skin that appear in greater numbers in those with rosacea – might prompt an inflammatory response in
Rosacea is also known to progress across subtypes in many clients. According to a National Rosacea Society survey of 1,231 patients, 72 percent reported that their rosacea had evolved from one subtype to another and 77 percent said they had experienced more than one subtype at one time. The disease is more frequently diagnosed in women, but more severe symptoms, especially subtype 3, are often seen in men.
The frequency of symptoms also varies from person to person. According to another National Rosacea Society survey, more than 55 percent of 954 patients said they experienced an outbreak at least once a month with 24 percent noting a flare-up every few days. Fifteen percent experienced a flare-up once a week while another 25 percent said they have a flare-up every few months.
Though the order of appearance of signs and symptoms also varies from person to person, flushing and redness are commonly the first to be noticed. Other signs and symptoms mostly appeared in the following order: bumps (third, 30 percent, or fourth, 24 percent), pimples (third, 28 percent, or fourth, 20 percent), visible blood vessels (third, 17 percent, or fourth, 28 percent), burning or stinging (third, 14 percent, or fourth, 26 percent), dry appearance (fourth, 18 percent, or fifth, 21 percent), raised red patches (fourth, 16 percent, or fifth, 14 percent) and swelling (fifth, 15 percent, sixth, 12 percent, or seventh, 13 percent).
Regardless of the frequency and progression of the signs and symptoms of rosacea, the emotional impact is often substantial. Eighty-two percent of 1,675 patients surveyed said the condition had a negative impact on their general outlook on life, and that figure rose to 90 percent for those who considered their symptoms to be moderate to severe. Many also reported a wide range of other negative feelings, including frustration, anxiety, helplessness, depression, anger, and isolation.
The impact does not stop there. In a separate survey, 74 percent of 660 respondents reported that they had avoided public contact or canceled a social engagement because of the condition’s effect on their personal appearance, and some even canceled or postponed business meetings.
While there is no cure for rosacea and the cause is unknown, medical therapy and lifestyle management are available to help control or alleviate its signs and symptoms. For subtype 1, prescription therapy is now available to reduce facial redness and visible blood vessels may be reduced with lasers or IPL therapy. However, several sessions are typically required for satisfactory results and touch-up sessions may later be needed, as the underlying disease process is still present. In specific cases, extensive flushing may be moderated somewhat through the use of certain prescription drugs.
A number of medications have been extensively studied and approved for subtype 2 papulopustular rosacea and may also be used on a long-term basis to prevent recurrence of symptoms.
In mild to moderate cases, doctors often prescribe oral and topical rosacea therapy to bring the condition under immediate control, followed by long-term use of the topical therapy alone to maintain remission. A version of an oral therapy with less risk of microbial resistance has also been developed specifically for rosacea and has been shown to be safe for long-term use.
Higher doses of oral antibiotics may be prescribed and other drugs may be used for clients who are unresponsive to conventional treatments.
Although mild cases of subtype 3 rhinophyma may be treated with medications, moderate to severe manifestations typically require surgery. A wide range of surgical options is available, including cryosurgery, radiofrequency ablation, electrosurgery, tangential excision combined with scissor sculpturing, and skin grafting. A surgical laser may be used as a bloodless scalpel to remove excess tissue and recontour the nose, often followed by dermabrasion.
Treatment for mild to moderate ocular rosacea (subtype 4) may include artificial tears, oral antibiotics, and the daily cleansing of the eyelashes with baby shampoo on a wet washcloth. More severe cases should be examined by an eye specialist, who may prescribe ophthalmic treatments, as potential corneal complications may impair vision.
Caring For Rosacea
Rosacea clients naturally have sensitive skin, and gentle skin care and avoidance of irritating ingredients and certain aesthetic procedures are important to avoid exacerbating a client’s condition. While the National Rosacea Society recommends that anyone with signs of rosacea be referred to a dermatologist for proper medical examination and diagnosis, here are some dos and don’ts when caring for a client in your spa with the signs and symptoms of rosacea.
Do not use common irritating ingredients. In surveys conducted by the National Rosacea Society, many patients cited the following ingredients as triggers for flare-ups: alcohol, witch hazel, fragrance, menthol, peppermint, and eucalyptus oil. Most respondents also said they avoided astringents, exfoliating agents, and other types of products that may be too harsh for sensitive skin.
Do not use the wrong procedures. While many clients may benefit from facial scrubs, exfoliants, and steaming, avoid using these common skin care practices on rosacea sufferers. Scrubs and exfoliants may lead to further irritation and heat is one of the most common trigger factors cited, so any kind of treatment that involves steam may cause a rosacea flare-up.
Ask questions. Rosacea is a condition with symptoms that come and go, with many sufferers experiencing transient flare-ups; some may not be having a flare-up at the time of a visit. If your client has fair skin, is over 30, and has redness or visible blood vessels on the convexities of the face (cheeks, forehead, nose, or chin), ask if they have been diagnosed with rosacea. If they are unsure, ask them if they have ever experienced unexplained facial redness or flushing after eating spicy foods or while drinking red wine, both common rosacea triggers, or after sun exposure, the most common rosacea trigger, according to National Rosacea Society patient surveys. Stinging, blemishes, and eye irritation are also common.
Refer them to a dermatologist. Rosacea may get worse without proper treatment. If your client appears to have rosacea, refer him or her to a dermatologist for proper diagnosis and medical therapy before the disorder becomes increasingly disruptive in their lives.
Brandy Gonsoulin serves as an online editor for the National Rosacea Society, and is also active as a writer for health and medical communications. She lives in Chicago.