Pathophysiology
- Exact cause unknown; likely dysregulated innate immune response, neurovascular dysfunction, and environmental triggers
- Neurovascular instability: Exaggerated flushing response. Chronic vasodilation leads to persistent erythema
- Cathelicidin overproduction: Abnormally high antimicrobial peptide levels contribute to inflammation
- Telangiectasias: Permanently dilated vessels from chronic vasodilation and angiogenesis — do not resolve with treatment
- Demodex mites: Higher density of D. folliculorum in rosacea patients may contribute to inflammation
- Four subtypes: Erythematotelangiectatic (flushing, redness), papulopustular (resembles acne), phymatous (rhinophyma), ocular (eye involvement)
Signs and Symptoms
Hallmark Indicators
- Recurrent flushing progressing to persistent central facial redness (cheeks, nose, forehead, chin)
- Telangiectasias on cheeks and nose
- Papules and pustules WITHOUT comedones — key distinction from acne
- Burning/stinging sensation, especially with trigger exposure
- Rhinophyma: Progressive thickening and enlargement of the nose (predominantly in men)
- Ocular symptoms: dry eyes, burning, blepharitis
- Heat sensitivity: flushing worsens with warmth
Red Flags and Rule-Outs
- No comedones: Distinguishes rosacea from acne vulgaris
- Rhinophyma: Late-stage complication — predominantly in men
- Ocular symptoms: Screen for ocular rosacea subtype. May need ophthalmology referral
- Distinguish from lupus butterfly rash: Lupus rash crosses the nasal bridge. Rosacea spares it
MT Considerations
- Not contraindicated generally; facial massage requires caution
- Heat avoidance: Do not apply hot towels, steam, or heated modalities to the face. Keep treatment room temperature moderate
- Gentle pressure: Very light facial massage to avoid worsening erythema
- Lubricant selection: Fragrance-free, hypoallergenic. Avoid essential oils and alcohol-based products
- Prone positioning: Face cradle pressure and friction may exacerbate rosacea. Offer alternatives
- Active pustular phase: If papules/pustules are actively inflamed, avoid facial massage — local contraindication
- Not contagious: Standard hygiene only
CMTO Exam Relevance
- Chronic inflammatory facial condition — NOT an infection, NOT contagious
- Key distinction from acne: rosacea has NO comedones
- Heat sensitivity is a major trigger — hot towels and steam cause flares
- Telangiectasias are permanently dilated vessels. They do not resolve
- Rhinophyma is a late-stage complication predominantly in men
Key Takeaways
- Rosacea is a chronic inflammatory facial condition with flushing, erythema, telangiectasias, and possibly papules/pustules
- Distinguished from acne by the absence of comedones and presence of telangiectasias
- Heat is a major trigger — avoid hot towels, steam, and heated modalities on the face
- Use very light pressure and fragrance-free products for facial massage
- Not contagious. Primarily a neurovascular and inflammatory disorder