Quality of Life in Rosacea

The remarks can be hurtful. “Wow. It looks like you had fun. Did you get sunburned this weekend?” or teasing, “Oooh. You’re blushing! You must like him!” or even questioning competence, “You look flustered. Are you sure this project isn’t too much work for you?”

Although these offhand remarks may seem harmless enough in themselves, over time they can be frustrating, embarrassing, and even hurtful for individuals suffering from rosacea. Skin often reflects internal feelings, and rosacea can confuse an onlooker to perceive the redness as embarrassment. Rosacea commonly affects the face, usually in the form of flushing, redness, irritated spots, pus-filled pimples, and dark red caused by chronic dilation of the capillaries.^[1,2] Rosacea is a cyclical inflammation of the skin, that “flares” periodically, particularly when there is an ongoing and underlying trigger.^[1] While the exact underlying cause is still under investigation, increased activity of facial blood vessels, sun damage, damaged skin barrier, and psychological stress could potentially worsen rosacea as triggers.^[3,4]

First impressions often lead to the judgment of others and facial redness often leads to a negative perception both at a personal and professional level.^[5] Participants in a study ranking images of people with and without red faces showed that red faces were associated with worse health and negative personality traits.^[5] With the prevalence of negative opinions, rosacea can lead to a decreased quality of life; in a Danish study of 4 million people, approximately 26% of individuals suffering from rosacea experienced moderate to severe anxiety or depression.^[6] In addition to anxiety and depression, patients suffering from rosacea also have higher incidences of social embarrassment.^[7]

How Common Is Rosacea?

Rosacea commonly affects individuals older than age 30, usually fair-skinned individuals.^[8] Studies examining the prevalence of rosacea estimated that between 1.3% to 2.1% of the United States population suffers from this condition.^[9] While rosacea has been reported during childhood in some cases, it has not been as extensively studied as adult rosacea.^[10]

What Are Some Rosacea Misconceptions?

As the rosacea worsens over time, the face becomes redder, and blood vessels may become more visible; the increased development of bumps and pimples can lead to increased tissue volume on the nose.^[11] These severe cases in which more tissue is added to the nose are called rhinophyma. Shakespeare and Chaucer associated the enlarged nose with frequent alcohol intake but this inaccuracy unfortunately still permeates into modern day.^[12] This disfigurement of the nose, popularized by Hollywood’s W.C. Fields during the 20^th century, aided to the misunderstanding that alcohol consumption directly causes rosacea due to his fondness for drinking.^[13] While alcohol can trigger rosacea, the disease can develop in individuals who do not drink as well.^[14,15]

Psychological Stress of Rosacea

Rosacea is associated with patient anxiety and depression, but the exact level of association is not always equal to the degree of change in appearance.^[16] While rosacea can make individuals feel frustrated, unhappy, and have low self-esteem, usually after treatment, emotional well-being, professional interactions, and social life improve with medical therapy.^[17] Discussing rosacea with close friends and coworkers can be daunting, but it can help fix any misunderstandings or concerns like the condition could affect work performance.^[17,18]

Unique Psychological Features for Each Type of Rosacea

Rosacea has four different subtypes: erythematotelangiectatic, papulopustular, phymatous, and ocular; each may lend to differences in perception of self and worth.^[19]  

TYPE 1: Rosacea with redness and flushing (erythematotelangiectatic rosacea)

This subtype, which shows as redness and dilated capillaries across the face is the most common subtype but is often the most difficult to treat of the four different subtypes.^[1,20] Patients with this subtype of rosacea may also experience stinging or burning sensations on their face, as well as dry or rough skin.^[21] As redness can be associated with embarrassment or other feelings, patients with this subtype, particularly women, can be perceived as insecure, less successful, and less intelligent than women with clear skin.^[5,6,20]

TYPE 2: Rosacea with redness and pimples (papulopustular rosacea)

This subtype of rosacea is known as the “classic” form of rosacea, featuring pimples filled with pus as well as other raised lesions, often occurring around the mouth, nose, and eyes.^[1,20] In particular, this type is observed in mainly middle-aged women and can look like acne.^[1] As this is the classic presentation, the papulopustular form of rosacea can be socially stigmatizing under the misconception that alcohol directly causes rosacea.^[22]

TYPE 3: Rosacea with enlarged nose, ear, forehead, or chin (phymatous rosacea)

This subtype of rosacea shows as skin thickening as well as irregular nodules, particularly to the nose.^[20] The phymatous rosacea subtype most often affects men, usually between age 50-70.^[23] Of all the different subtypes, this one is usually most distressing and anxiety inducing, causing the highest decrease in quality of life for rosacea patients.^[7] As the nose is one of the more prominent features of a face, any flaw, however minor, can cause significant distress in an individual.^[24] A change to the nose can affect an individual’s sense of identity.^[24]

TYPE 4: Rosacea with eye inflammation (ocular rosacea)

This subtype of rosacea features redness in and around the eyes, and patients have described the irritating inflammation often as if something is inside their eyes.^[20] As this subtype often shows as bloodshot eyes, misperceptions of this disease could incorrectly link it to poor hygiene or unsavory social habits.^[20]

Rosacea Treatment and Tips

An ounce of prevention...and lasers

The best treatment for rosacea is the prevention of symptoms, such as avoiding triggers like ultraviolet (UV) exposure.^[1] The specific treatment of rosacea is usually dependent on the subtype of rosacea. While treatment can range from creams, lasers, to surgery, the treatment needs to be matched to what is appropriate for the specific subtype of rosacea.^[1] 

Makeup options: yellow may be better than green

The best makeup to help cover the affected areas is mineral based and green, or preferably yellow tinted, to help cancel out the redness.^[25,26] While green can help cancel out the red color, often the face still appears green or gray under the layers of foundation, so yellow is often advised more than green according to makeup experts.^[25] 

Help patients with explanations

While rosacea can be distressing emotionally, most often the probing questions are due to curiosity and lack of knowledge about the condition, not usually from unkind intentions.^[17] While explaining the condition to close coworkers and family can be challenging, it can help eliminate misunderstandings and stigmas of the disease.^[17] Practitioners are best served to help ask and guide their patients with explaining their condition since many may receive questions about their rosacea.