Don’t be caught red faced: The truth about rosacea in skin of colour

Research shows that when people with skin of colour develop rosacea, the signs are often missed. This means that people with skin of colour often have the condition for a longer period of time and have more aggressive and advanced rosacea by the time they see a dermatologist.

What is rosacea?
Rosacea is a chronic rash involving the face that most often occurs in those with lighter skin types. There are several possible reasons that rosacea occurs but it is likely a combination of genetic tendency, ultra-violet radiation exposure, hair follicle mites (called demodex) and the gut microbiome.

What are the signs and symptoms of rosacea in skin of colour?
The common symptoms of rosacea are burning, stinging and skin irritation on the face. Flushing or a feeling of heat in the face is also common. In the earliest stages of rosacea, only redness may be seen. This is called erythrotelangiectatic rosacea. Redness is easy to see in white skin but is difficult to see in skin of colour. So, this early sign of rosacea is often missed in people with Chinese, Indian, African and even Middle Eastern and Hispanic skin types. Sometimes the redness is replaced with a subtle brown or purplish discolouration on the skin.

Rosacea looks a lot like acne. But blackheads and whiteheads (which are seen in acne) are not seen with rosacea. Pimples and acne-like breakouts are often seen on the cheeks, chin, forehead and nose. This type of rosacea is called papulopustular rosacea. In those with darker skin types, brown spots and small skin coloured lumps can be seen.

In the later stages of acne, swelling and thickening of the skin can be seen. This is called phymatous rosacea. The most common area of involvement with this type of rosacea is the nose and central cheeks though other areas can be involved too.

Occasionally rosacea can affect the eyes and can cause dry, burning, gritty feeling in the eyes. Swelling and redness of the eyes can also occur. Without treatment, ocular rosacea can affect eyesight.

Granulomatous rosacea is a specific type of rosacea that is more common in those with skin of colour. It presents with small skin coloured hard-ish lumps on the skin that is more difficult to treat, even when tablets are used.

What are the triggers for rosacea?
Triggers of rosacea include sunlight, heat, spas, saunas, exercise, hot drinks, spicy food and alcohol. Anything that increases body temperature and causes flushing can worsen rosacea. Other triggers include topical steroid creams and oil-based skin care products. More about triggers

What treatments are available for rosacea?
Rosacea is a chronic condition and while there is no cure, treatment is important to control symptoms and progression of the condition. Unfortunately, research shows that those with Indian skin, Chinese skin, African skin, Middle Eastern skin and even Hispanic/Latino skin will often have symptoms for longer than 12months before seeking medical attention. This Is because redness is not easy to see. On top of this, clinicians will often miss the diagnosis because the signs are not easily seen by the untrained eye.

In those with skin of colour, complications like ocular rosacea are more common. Treating patients early and recognising the signs in darker skin is critical to good outcomes.

Generally speaking, the same kinds of treatments are available to all patients with rosacea.

1. Avoid triggers

Reduce things that cause flushing (like the things mentioned above)
Avoid topical steroids on the face
Wear a good broad-spectrum sunscreen is being used on a regular basis
Avoid oil-based facial creams

2. Creams

Topical vitamin B creams, metronidazole (antibiotic), azelaic acid and ivermectin (ivermectin can help with those that have demodex (common mite) in the skin) can all be used for small pimple like spots and some of these can be used as maintenance. A cream also exists (brimonidine) to help reduce redness but this cream only works for about 12 hours and can cause rebound redness so laser treatment for background redness is preferred (see below)

3. Tablets

Antibiotics like doxycycline can be used at low doses for their anti-inflammatory effect. They can be used to settle flares of pimples. Taking antibiotics for more than 8-12 weeks at a time should be discouraged if possible because antibiotic resistance can occur with long-term use of antibiotics

Vitamin A derived tablets ( low dose isotretinoin) can be very helpful for those with chronic pimples and swelling on the face. This medication is most commonly used for acne but it is a safe long term option for those that keep needing oral antibiotics.

Tablets to reduce for those that have flushing regularly can also be helpful for some patients.

4. Lasers

Vascular laser that target redness are great in Caucasian skin. They will help settle redness with a series of treatments (often about 4-5 treatments) and patients don’t have to worry about downtime.

But these lasers are not safe in darker skin types because the brown in the epidermis (first layer) of the skin is also the target of the same laser. This means that side effects like burning and scarring may result with this laser in some people with skin of colour. Learn more about laser services at Chroma Dermatology 

5. Surgery

Surgery can be used for those with phymatous rosacea and nice results can be achieved with certain types of lasers that carve away excess tissue in the area.

Don’t get caught red-faced. Rosacea does occur in those with pigmented and darker skin types. Most people are just unaware of what the signs and symptoms are in those with skin of colour.