The Comorbidities of Rosacea

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Widespread disorder now linked to serious comorbidities

The red and ruddy complexion of a person with rosacea can appear like the first blush of love or the wrath of progressed acne. Commonly rosacea presents as red blotches that, left undisguised, can appear like painted doll cheeks. Often the redness spreads to other parts of the face and body – including the eyes.

Informed clinicians know that rosacea is not a matter of cosmetics. It is a treatable chronic inflammatory condition with so many symptoms that it has been divided into four subtypes:

Erythematotelangiectatic rosacea – Redness, flushing, visible blood vessels, on central portion of the face.
Papulopustular rosacea – Redness, swelling, and acne-like papules and pustules.
Phymatous rosacea – Skin thickens and displays irregular nodularities and enlargement, especially of the nose.
Ocular rosacea – Eyes red and irritated, eyelids can be swollen, and patient may have sensation of foreign particles in the eye, with the appearance of a sty.

Comorbidities Discovered

The latest research brings an important new consideration to the clinical discussion. “It now appears that rosacea often is associated with a variety of comorbidities,” said Richard Odom, MD, professor of clinical dermatology at the University of California-San Francisco. Odom is also one of the original members of the board of directors of the National Rosacea Society (NRS), dedicated to spreading information about rosacea to both patients and clinicians. As such, he is eager to get the word out about April’s designation as Rosacea Awareness Month, as well as new insights into the disease.

Rosacea affects about 5% of the U.S. population – “. that’s about 16 million Americans living with it,” Odom told ADVANCE. He recommended clinicians make the connection between the skin variety and the subtype that affects the eyes. “We are finding that diagnoses of conjunctivitis or sty are often really ocular rosacea. When clinicians diagnose rosacea on the skin, they should always ask patients about their eyes – if they are irritated, dry, sticky or feel as if there is sand in them. If so, they should be evaluated for ocular rosacea.”

Beyond the skin-eye connection, a recent clinical study conducted by Johns Hopkins University found a significant association between rosacea and allergies, respiratory diseases, gastroesophageal reflux disease (GERD), diabetes, urogenital diseases and female hormone imbalances. Additionally, the Nurses Health Study II, following the medical history of 116,000 nurses since 1989, found that the 6,000 nurses identified as having rosacea were 1.59 times more likely to have thyroid cancer and 1.5 times more likely to have basal cell carcinoma than those without rosacea.

Odom believes that the associations, though not causal, may be attributed to the inflammation that underlies so many diseases. “We’ve known for quite a while that psoriasis has comorbidities, particularly cardiovascular issues, obesity and others. Now we know that rosacea, too, is a chronic inflammatory disease. I believe we will eventually find that all inflammatory diseases can affect your entire body – be it via skin, joints (arthritis), lupus, or any systemic inflammatory condition. The body’s primary organ is the skin; it is not a stretch to believe that inflammatory diseases of the skin can affect internal organs,” explained Odom. “Clearly, this is not just a facial problem.”

Who Is at Risk?

According to the American Academy of Dermatology, most people who get rosacea are:

  • Between 30 and 50 years of age.
  • Fair-skinned, and often have blond hair and blue eyes.
  • From Celtic or Scandinavian ancestry.
  • Likely to have someone in their family tree with rosacea or severe acne.
  • Likely to have had lots of acne – or acne cysts and/or nodules.

The academy also noted on its website that women are a bit more likely than men to get rosacea (although two famous males with rosacea are W.C. Fields and former President Bill Clinton). Women, however, are not as likely as men to get severe rosacea. And while it is most evident on those with lighter skin, people of all skin colors get rosacea.

While the exact cause of rosacea is still not clear, studies have found specific clues:

  • Rosacea appears to have a genetic link, and runs in families.
  • The immune system may play a role. Studies have found that most people with acne-like rosacea react to a bacterium – bacillus oleronius. This causes their immune system to overreact. Scientists still do not know whether this has a causal effect.
  • H. pylori, a bug that causes infections in the intestines, is common in people who have rosacea.
  • Demodex, a mite that lives on everyone’s skin and in hair follicles, may play a role. Many studies found that people with rosacea have large numbers of this mite on their skin. However, not all people with a large demodex population develop rosacea.
  • Cathelicidin, a protein that normally protects the skin from infection, may cause the redness and swelling. How the body processes this protein may determine whether a person gets rosacea.

Odom is hopeful that clinicians will reinforce with their patients the medical significance of what was once largely considered a cosmetic nuisance, and guide them to informational sources (including the National Rosacea Society website (http://www.rosacea.org/), which is strictly non-commercial).

“There are a lot of emerging developments as well as long-standing information available about rosacea,” said Odom. “Patients need to be educated on the fact that rosacea is not acne. It is an inflammatory disease for which adequate treatments are available. Moreover, rosacea may serve to alert patients and providers to risks for possible serious comorbidities. I would advise everyone: Do not ignore rosacea.”

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Valerie Neff Newitt

Valerie Neff Newitt is a former staff member of ADVANCE.

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