The Four Types of Rosacea – All About it

Have you ever noticed your face getting bright red the moment you exert a little bit of force and do anything that increases your heart rate, or have you grown up with people asking you, “Why are your cheeks so red?” all the time? Do your nose and cheeks flush way too easily whenever the temperature starts to soar, or when you’re having a spicy meal in your favourite Thai restaurant? And when you look in the mirror closely, you notice lots of broken, spidery capillaries running across the creases of your nose and cheeks that you always try to cover up? You just might have a condition called rosacea!

The Four Types of Rosacea in Singapore

Rosacea is generally a term used for people who blush and flush easily, but there’s a lot more going on with that condition than just having a red nose and cheeks. It is actually a chronic inflammatory skin condition and is something that is more likely to be genetically inherited although there are many environmental factors that influence it as well. Although this condition has been around for decades, it was only recently officially classified into 4 subtypes of rosacea in 2002, which is what we will be talking about today. This classification has actually brought a lot of help to not just people suffering from rosacea, but the clinicians who are treating it as well – a good classification means that it helps clinicians to efficiently evaluate therapeutic success in each subtype.

Type 1: Erythematotelangiectatic Rosacea (ETR)

The first type of rosacea in Singapore is ‘erythematotelangiectatic rosacea’. Try saying that 3 times fast! ETR is typically characterised by:

• Frequent episodes of facial flushing and persistent central redness on the face (called ‘erythema’)
• Sometimes accompanied by telangiectasias (dilated or broken blood vessels located near the surface of the skin or mucous membranes such as around the creases of your nose. They often appear as fine pink or red lines, which temporarily whiten when pressure is applied on them)
• Facial oedema (swelling), burning, or stinging

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ETR can be hard to treat since the standard oral medications are usually ineffective (e.g. topical/oral antibiotics, beta blockers, or spironolactone). For such types of rosacea, non-ablative lasers such as the Pico Laser can help some patients over multiple treatments.

Type 2: Inflammatory Rosacea (Papulopustular)

This type of rosacea is also known as ‘inflammatory rosacea’ for the fact that it is commonly mistaken as the inflammation seen in acne since they often present as pus-filled or red bumps grouped close together on your skin. It can occur together with Type 1 ETR. When looked under a microscope, papulopustular rosacea is shown to have neutrophilic infiltration in hair follicles which causes acne-like pus formation.

• Papules and/or pustules that come and go, without blackheads or whiteheads
• May also affect the back, shoulders, and chest
• Comes with temporary or persistent central facial redness and visible blood vessels
• Burning and stinging
• Raised, scaly red patches on the skin (‘plaques’)

Topical and oral antibiotics are the standard treatment for papulopustular rosacea, as well at dietary regulation to reduce inflammatory substances.

Type 3: Phymatous Rosacea

Phymatous rosacea can affect the nose (rhinophyma), chin (gnathophyma), forehead (metophyma), ears (otophyma), and eyelids (blepharophyma). Rhinophyma is the most frequent location – around the nose. Under the microscope, it shows increased cell production of sebaceous (oil) glands, scarring and thickening of skin cells, and widening of hair follicles.

• Obvious skin thickenings and irregular surface nodules around the affected areas, especially of the nose – looks like red and bumpy lumps under the skin
• ‘Spider web veins’ (telangiectasia) are also present around the areas
• Scarring and thickening of skin cells
• Tends to be more prevalent in the European populations (particularly Scottish people), and also in males due to the influence of male sex hormones (androgens)
• Treatment tends to focus on oral antibiotics as well as laser treatments as the first-line choice of rosacea treatments in Singapore.

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Type 4: Ocular Rosacea

Ocular rosacea is the only rosacea among the 4 types of rosacea in Singapore to affect the eyes. The word itself, ‘ocular’, refers to ‘of or connected with the eyes or vision’. It is quite straightforward that ocular rosacea involves a form of inflammation of the skin and tissues around the eyes and eyelid.

Ocular symptoms have quite a wide range, which can make it hard to seek help from the right sources since we may think that there might be an infection or something caught in our eyes.

Mild symptoms can look like:

• Minor irritation of the eyes, with redness and a watery sensation (feeling like you’re tearing up)
• Foreign body sensation
• Dryness
• Blurry vision

More moderate to severe ocular symptoms may instead look like:

• Severe ocular surface disruption and inflammation of the surface of the cornea (redness, profuse tearing up, sensitivity to sunlight, corneal clouding, intense pain)
• A constant gritty feeling in the eye
• Blepharitis (inflammation of the eyelids, causing the tiny oil glands to become blocked and a crusty yellow layer forming)
• Conjunctivitis (‘Pink eye’ – pus discharge and leaking around the eye can make it hard to open)

It can also come along with other types of rosacea findings such as conjunctival telangiectasias (broken blood vessels around the eyelid), and rarely are there any sight-threatening side effects with ocular rosacea. Treatment usually focuses on ocular hygiene and the use of steroidal or moisturising eye drops and ointments to keep any clogged ducts or infections at bay.

Currently, there is no cure for rosacea although there are many treatments available which can help manage the inflammation from this condition. Prescription medications like topical gels (azelaic acid, metronidazole) or oral antibiotics (minocycline or doxycycline) can help to reduce the formation of pus-filled pustules and nodules. Over-the-counter products that contain sulphur have been shown to help reduce redness from lesions in inflammatory rosacea. For those with visible blood vessels, some light laser treatments may also help rosacea types in Singapore – give your trusted skin doctor in SL Aesthetic Clinic a call to see if any of these options can help your condition today!