Rosacea is a persistent neurovascular disorder of unknown origin and can be triggered by an indication of blushing or flushing. First studied by Charles Darwin in his book, The Expressions of the Emotions in Man and Animals published in 1872, ‘flushing’ and blushing’ are often used interchangeably, but in fact designate different conditions. Flushing and blushing occurs with equal frequency in persons with skin of color but can be difficult to discern clinically due to skin pigment influences.

Flushing
Flushing is an unpleasant and sudden intense diffuse reddening of the face (and other areas of the neck and chest) that is an exaggeration of the normal vasodilatatory response to hypothermia or other factors. It is caused by a precipitatous extensive facial vasodilatation leading to increased cutaneous blood flow. Flushing may be precipitated by dietary factors, alcohol, drugs, environment, and hormonal change or can appear for no apparent reason. Flushing is also more widespread than blushing extending in a diffused fashion from the hairline to involve the neck and upper anterior chest.
Some of the drugs and common food that may induce flushing are, but not limited to: vasodilators (nitroglycerin), calcium channel blockers (nifeipine), nicotine acid, topical steroids, caffeine withdrawal certain foods, histamine-rich foods, and drinks are also culprits. These will be presented later in this editorial.

Blushing
Blushing is involuntary and implies an episodic, sudden, transient, often blotchy, involuntary redding of the face (that can include sides of the neck and ears) which is precipitated by emotion or psychological upset (shame, anger, embarrassment, guilt, pleasure, or anxiety). Blushing is usually limited to the lateral cheeks and is often blotchy in appearance.
The Latin word rosacea means “like roses,” however, this disorder is anything but. The duration of lesions last days, weeks, months, and also many years. Textbooks generally claim rosacea occurs in approximately five percent of people, which is grossly underestimated given our aging population. When examining the epidemiology and etiology of rosacea, the most common age groups rosacea strikes are age 30 to 50 years old with the peak incidences at ages 40 to 50.
Previously called “acne rosacea,” this lesion-like disease is unrelated, yet quite often coexists with acne; which by the activity of the latter may have preceded the onset of the rosacea condition. Although acne may have preceded the outbreak of rosacea by years, rosacea may and usually does arise de novo without any preceding history of acne or seborrhea. Rosacea also presents itself as a sensitive and/or inflamed skin that exhibits telangiectasia (small blood vessels) near the skin’s surface. These lesions can become pustular, causing it to be mistaken for acne. Rosacea is not acne.
The disease of facial rosacea not only affects an individual’s psychological wellbeing, it is also the cause of significant cosmetic disfigurement. Individuals are concerned about their cosmetic facial appearance since they are often perceived as being alcoholic due to the chronic reddening of the face and nose. This alcoholic perception could account for the association with the 1930s actor, W.C. Fields, who also suffered from rosacea. A non-drinker, the rosacea condition associated this actor with alcoholism and to this day the stigma remains. So much so is the association grade four rosacea has the nickname of ‘W.C. Fields acne’ due to the rhinophyma enlarged nose associated with this specific subtype.
Rosacea predominately is more common in females; however, rhinophyma, subtypes 3 rosacea, is more prevalent in males. The pathogenesis of rosacea is multi-factorial and poorly understood. The prevalence of rosacea among professional women is increasing rapidly, which stress has been blamed due to the competitive workplace, juggling of personal and professional life, hormone shifts, and other factors. Stress does not cause rosacea, but is the fuel for redness in addition to exacerbating the condition. Not only does stress intensify the disease in the rosacea-prone, but the high visibility of the disease itself creates more stress, establishing a vicious cycle that can eventually impact the psychological well-being of the client. It is estimated at least 25 percent of women in their 30s and 40s have rosacea and although it has been reported that stress intensifies and aggravates rosacea, this culprit has not yet been proven and still remains anecdotal. This observation makes total sense given stress lowers the immune capacity of the skin. The evidence is extremely strong that the element of stress is a major contributor to rosacea flare-up and should be an important factor when making a skin assessment.

Central Suspects
Rosacea is a skin disease with three central culprits involving the sebaceous follicle, a primary oil factory of the skin that contains a tiny hair anchored within its complicated environment. Although the sebaceous gland is the responsible perpetrator for acne major and minor, it is not the factor in the case of rosacea other than it hosts a very interesting resident called the demodex skin mite.
Demodex mites live in and around these follicles and have four short legs located by the head and neck. These creatures choose to move mostly at night, certainly giving new meaning to creepy crawlers in the dark. The level of infestation increases with age and these microscopic mites frequently lie in pairs covered by a semi transparent cuticle surface. This infestation is a world-wide phenomenon called “demodicosis” and is usually symptom-free giving little or no indication there could be an invasion of mites hosted by the thousands of sebaceous follicles on the face.
Demodex mites are implicated factors of rosacea and suspected to be one of the major trip wires causing redness. In rosacea challenged skin, demodex mites are five to 15 times more numerous and host bacteria engaged in rosacea development (staphylococcus aureus). The demodex mite is found on the face and produces an enzyme called lipase, the second suspect of rosacea.
Lipase breaks down sebum on the skin surface and is found in all rosacea sufferers. It occurs when the skin heats up to 99°F, or higher, and appears to be the cause of inflammation in papules and pustules. The good news is this condition can be controlled by cleansing the skin twice daily with a lipid soluble cleanser containing AHAs.
The third suspect is more scientific and complicated involving a growth of new capillaries (blood vessels) identified as Vascular Endothelial Growth Factor (VEGF). VEGF inspires angiogenesis, a formation of new blood vessels from pre-existing vessels that are believed to have stopped production in youth. Although VEGF is associated with cancer cells, there is no relationship linking cancer to rosacea. Study of rosacea patients who show elevated levels of VEGF have been documented to be without elevated incidence of skin cancer. Skin cancer is directly connected with UVR – the major trigger for photo-damaged skin and associated with aggravating rosacea. UVR compromises the skin’s immune system and when treating rosacea, SPF becomes an integral part of the daily skin care protocol for skin health.

Sun Protection Type
The level of environmental ‘reactivity’ causing skin to sunburn or tan is directly linked to sunlight UVR exposure. Skin color change associated with the environment is categorized as ‘SPT’ or sun protection type, and indicates the level of protection by the skin against ultraviolet radiation. This important skin ‘typing’ was first established decades ago by Dr. Fitzpatrick and is still used today as a measuring stick for skin color identification. However, skin classification juxtaposing UVR environmental reaction has become a redefined science due primarily to the many cross blending of skin colors and should be a principal coding practice of all aestheticians prior to any clinical treatment of rosacea.
The most susceptible skin types affected by rosacea are SPT I and II. These classifications of skin are generally found among the Scotch-Irish Celtic race (Northern European and European); however, Italians, SPT III and IV in the southern region of the country have also been recorded to be effected by this disease which is due to the sunny climate affecting these Mediterranean types of skin. In fact, one of the world authorities on rosacea, Alfredo Reborra, gained his experience on Italians living in Genoa, Italy. SPT V and VI rarely acquire this disorder, but are not rosacea free by any means. Rosacea also occurs in black and darker skin, however only experienced individuals are able to detect rosacea in these skin types. Further your proficiency in skin typing by attending a “skin of color” course to fully comprehend the dynamics of skin blends and how each responds to ultraviolet light, ingredients, and different clinical remedies.
With rosacea, there is a UVR sun connection related to a chronic photo-dermatosis condition. All rosacea clients have intensive heliodermatitis by histologic criteria. Elastosis is prominent, with a great increase in glycosaminoglycans. Lymphocytes and macrophages, associated with collagenolysis diffusely infiltrate the dermis. Every rosacea sufferer has severe photo-damage, even in the early stages.

During the summer months when ultraviolet radiation is more abundant, your ‘red faced’ clients who suffer from rosacea often complain of increased facial skin sensitivity (stinging, burning, or itchy feeling). The true cause of sensitive skin is not fully understood, however it has been substantiated an impaired skin barrier repair function (BRF) with loss of amino acids, ceramides, hylauronic acid, and an increase in trans epidermal water loss (TEWL) has a shared link to ‘sensitive skin.’
The imbalance of inner cellular substances can have perilous consequences on the skin’s health as skin hydration depends on moisture diffusion to the horny layer. The rate of evaporation of moisture from the skin surface in part reflects the moisture-retaining ability of the horny layer and surface film and its lipid content. An imbalance of one or several of these elements for clients suffering from rosacea may predispose them to ‘having’ sensitive skin and exacerbate the problem.

Rosacea Assessment
Before any home care or clinical treatment can be initiated, detailed photo dermatology analysis is essential for comprehending the many faces of rosacea. It is always a challenge to extract precise information from any client; however, in the case of rosacea, it can be even more challenging regarding their blushing and flushing tendencies. Clients are often unaware of the associations until you begin to ask specific questions.
Start with basic everyday issues such as sweating, exercise, embarrassment, sunlight sensitivity, foods, beer, wine, spicy treats, drugs, etc, and subjective discomforts from skin care topical products and medications. Follow a specific list and dispel all misinformation such as coffee and other suspected culprits and fine-tune the process of elimination. For example, coffee does not cause flushing; hot coffee is the instigator. All hot drinks can cause flushing. Record all food, environment, skin care you suspect might irritate the rosacea. Educate your client to the “who, where, what, why, and how” they can manage their skin condition based on your assessment discovery and teach them to take back control of the disease and begin the journey to healthy skin with clinical treatment and proven home care skin formulas.
The key to correct diagnosis is the skin history of the client, especially in the early stages of rosacea. Rosacea usually starts on the skin, but if left untreated, many cases will progress after decades to affect the eyes in
some form.

Rosacea Sub-Types
When we more closely examine rosacea, it is important to recognize the stages of evolution associated with this skin ailment since not all conditions are the same. The following descriptions will help the clinical skin care specialist determine at what stage rosacea is affecting the skin and the appropriate clinical remedies to use.

1. Subtype I or Episodic Erythema: this is a flushing and blushing occurrence, the rosacea diathesis erythema with early telangiectases tiny papules, tiny pustules. Facial redness stage (Erythematotelangiectatic Rosacea).
2. Subtype II: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; may rarely have persistent “solid” edema of the central part of the face, as occurs with acne, but not to be mistaken as acne. Bumps and pimples (Papulopustular Rosacea).
3. Subtype III: Thickening and disfigurement of the skin, especially in the nose as indicated in the W.C. Fields example. This stage affects males only and requires medical attention such as laser treatments. Phymatous Rosacea/Rhinophyma.
4. Ocular rosacea: Red, dry, and irritated eyes and eyelids. Some other symptoms include foreign body sensations, itching, and burning.

Physical examination of the skin lesions must also be noted as part of the assessment for treatment. Rosacea is one of those skin conditions that many people didn’t know they had until permanent changes take place, or they became fed up with the way they looked. This editorial is focused specifically on how the aesthetician can manage rosacea; however there will be individuals you cannot help due to elements out of your aesthetic control. You will not be the cause of failure and in some cases, medical options must intervene and you need to know when to refer your client to a dermatologist.

Rosacea Facts 

• Occurs in people of SPT European or Scandinavian origin
• Usually starts after age 30
• More common in women
• More severe in men
• Affects over 13 million Americans

Rosacea Appearance
The following features are characteristic of rosacea. Each sufferer can have a combination of any of these:

• Red, sometimes swollen, skin around the middle of the face - the forehead, cheeks, and nose.
• Red bumps that may have pus in them, similar to acne.
• Tiny blood vessels, called telangiectasias, over the nose and cheeks that are visible up close but appear as a red blush at a distance.
• An enlarged, pitted, bulbous nose, called rhinophyma, which occurs as fibrous tissue and sebaceous glands get bigger.

Skin Lesions
The primary lesions are a diffused redness, papules pustules, and later, dilated venules, mainly of the nose, the cheeks, and the forehead are seen. Secondary lesions are severe, long-standing cases that eventuate in the bulbous, greasy hypertrophic nose characteristic of rhinophyma (W.C. Fields nose).
Early: papules (two to three millimeters), pustules (often smaller than one millimeter) and on the apex of the papule. Nodules. No comedones.
Later: telangiectasia. Chronic rosacea can be associated with marked sebaceous perplasia and lymph edema, causing disfigurement of the nose, forehead, eyelids, ears, and chin.
Color: Red faces, papules, and dusky-red nodules.
Shape: Papules and nodules are round, dome shaped.
Arrangement: Scattered, discrete lesions.
Distribution: Characteristic is a symmetrical localization on the face such as cheeks, chin, forehead, glabella, and nose. Rarely will these be found on the neck, chest (V-shaped area), back, and scalp.

An inducted Legend in American Aesthetics by DERMASCOPE Magazine and Aesthetics International Association (AIA) in 2008, Christine Heathman has been a practicing licensed master aesthetician, educator, and a leader in the research and development of skin care and progressive clinical protocols for over 25 years. A recent testimonial to Heathman’s skin knowledge selected her amazing product formulas out of thousands and recently featured them on the nationally syndicated TV show called The Doctors, as an alternative option to cosmetic surgery. www.glymedplus.com