Cause of Rosacea Revisited

None of these theories have been proven nor is this list complete since there are other theories that may be added to this list in the future. As you can see, the jury is still out on what causes rosacea. But depending on which one of the theories you may believe, your belief in the theory will definitely effect what treatment you choose. Just remember that you may be wrong to put your trust in just one theory. Due to not knowing the cause of rosacea there is an X-Factor Phenomenon in controlling rosacea. As the source below so clearly admits, there may even be a 'variety of pathogentic routes' so remember that all these are simply different theories.

"...Rosacea seems to be a reaction pattern to which a variety of pathogenetic routes may lead..."
source

"The pathophysiology of rosacea is still a subject of controversy." source

"The pathogenesis of rosacea thus remains obscure. What is certain, however, is that rosacea patients are constitutionally predisposed to blushing and flushing. The basic abnormality seems to be a microcirculatory disturbance of the function of the facial angular veins. Statistical associations between rosacea-related flushing and migraine suggest a shared disorder of vascular regulation but there is no direct evidence that rosacea is primarily a vascular disorder. The response of the facial vessels to adrenaline, histamine and acetylcholine is normal, and the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls. In addition, the distribution of rosacea is not identical with the flush area. A very important background feature is sun damage. Rosacea is always associated with solar elastosis and often with heliodermatosis. Fair-skinned patients with rosacea type I will often give a history of sun sensitivity. " > Rosacea: classification and treatment, Thomas Jansen, MD and Gerd Plewig, MD source

"...No one knows for certain what causes rosacea..." International Rosacea Foundation
> http://internationalrosaceafoundation.org/

"...rosacea is characterized by a fragmented understanding of its pathogenesis. Our limited knowledge regarding the pathologic mechanisms and pathways that cause rosacea has been a major barrier, ultimately preventing the development of new treatments..." New Perspectives on Rosacea, Supplement to the October 2003 Skin & Aging
source > http://skinandaging.com/sa/supplements/pdf/Berlex_Rosacea.pdf

"...While the cause of rosacea is unknown and there is no cure, today medical help is available that can control the signs and symptoms of this potentially life-disruptive disorder..." National Rosacea Society source > http://www.rosacea.org

"...Currently, neither a specific cause nor a laboratory indicator of rosacea has been suggested...." ---Rosacea: current thoughts on origin. Bamford JT., Department of Family Practice and Community Health, University of Minnesota-Duluth Medical School, MN, USA. Jbamford@smdc.org---source of article > http://www.ncbi.nlm.nih.gov:

"...Pathogenesis is not clearly understood...' -- Thissen MR, Neumann HA., Academisch Ziekenhuis --- source of article > http://www.ncbi.nlm.nih.gov:

Vascular Theory

"...rosacea may be thought of as a disease spectrum with 2 primary etiologic components, vascular and inflammatory. The earliest manifestations of the disease are cutaneous vascular dilatory changes with subsequent increased blood flow in the form of telangiectasias and erythema....The later stages of rosacea are marked by inflammatory changes in the form of papules and pustules in the midface, rhinophyma (bullous nose), blepharitis and meibomitis, and corneal vascularization. A type 4, cell-mediated hypersensitivity reaction has been hypothesized as a possible mechanism. Demodex mites also have been implicated as a possible inflammatory stimulus. Additionally, Helicobacter pylori has been postulated to be a causative factor in a subset of patients. Whatever the underlying mechanism, there is a fundamental abnormality in the sebaceous glands of the face and eyelids, which leads to the inflammatory changes exhibited....In the US: More than 10% of the general population exhibits dermatologic characteristics of rosacea..." source > "Occular Rosacea," by J Bradley Randleman, MD, and C Diane Song, MD >
http://www.emedicine.com/OPH/topic115.htm

"A leading theory suggests a vascular basis..." 1974 source

According to Dr. Geoffrey Nase, Ph.D. Microvascular Physiologist, in his book, Beating Rosacea Vascular, Ocular & Acne Forms, A Must-Have Guide to Understanding & Treating Rosacea which is probably one of the most comprehensive work of medical information on rosacea published in book form to date, he lists one of the longest list of some of the proposed triggers (or causes) as follows; "bacteria, yeast, mites, blood vessel damage, nerve dysfunction, systemic infection, gastrointestinal abnormalities, immune system alterations, psychological problems, liver problems, leaky intestines, collagen damage, sun damage, skin irritation, hormonal variations, stress, exercise, facial parasites, blood toxins, sebaceous gland hyperactivity, hair follicle abnormalities, stomach hyperacidity, nervous system defects, cardiovascular abnormalities, food allergies, environmental damage, etc..." However, Dr. Nase discounts the above proposed triggers as causes stating that "rosacea is surrounded by confusion, unproven theories, and erroneous speculation." For instance, he says the H. Pylori theory is only a minimally important rosacea trigger, that there is no evidence that liver problems cause or worsen rosacea, and that the demodex mite plays no real role in the development of rosacea 'except for the odd pustule.' Dr. Nase states in his book that "rosacea is primarily a facial vascular disorder in which the affected blood vessels are functionally and structurally abnormal" and "is a mysterious disorder that continues to receive very little focus by the general medical community." More information on his book can be obtained by ordering his book. Read his latest comment on the 'heart of rosacea.'

"Rosacea is primarily a disorder of the facial blood vessels." Dr. Nase - source

According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, "Some researchers believe that rosacea is a disorder where blood vessels dilate too easily, resulting in flushing and redness."

"The cause of rosacea is unknown, but it is commonly thought to be of vascular origin because of a clinical association with flushing, development of telangiectasia and tissue swelling, and ultimately, tissue proliferation and rhinophyma (enlargement of the nose)." February 1999 Postgradate Medicine February 1999

"...Dr. Nase feels as though this is a vascular problem. O.K. A vascular problem that manifests itself on the exterior of the body. But, for heavens sake, what does that mean systemically??? I mean, if we are only seeing the exterior results of a vascular problem......what is it doing to the rest of the vascular system? Also, there doesn't seem to be any coordination between health care providers on this topic. Some people are seeking treatment from opthamologist, some from derms, some from Dr's providing photoderm or laser treatments, some from internists/family practitioners, some even from gastroenterologists. No one knows what the other hand is doing. No continuity of care between them. My theory is that they just do not understand it enough to figure out what to tell us. All the treatment seems to go towards treating the symptoms only, because the cause is unknown" - A nurse's insightful comment on the cause of rosacea > http://groups.yahoo.com/group/rosacea-support/message/34090?threaded=1

"The pathogenesis of rosacea thus remains obscure. What is certain, however, is that rosacea patients are constitutionally predisposed to blushing and flushing. The basic abnormality seems to be a microcirculatory disturbance of the function of the facial angular veins. Statistical associations between rosacea-related flushing and migraine suggest a shared disorder of vascular regulation but there is no direct evidence that rosacea is primarily a vascular disorder. The response of the facial vessels to adrenaline, histamine and acetylcholine is normal, and the vessels do not seem abnormally fragile so the main abnormality is probably in the dermis surrounding blood vessels rather than in vessel walls. In addition, the distribution of rosacea is not identical with the flush area. A very important background feature is sun damage. Rosacea is always associated with solar elastosis and often with heliodermatosis. Fair-skinned patients with rosacea type I will often give a history of sun sensitivity. " > Rosacea: classification and treatment, Thomas Jansen, MD and Gerd Plewig, MD

"It has been argued that facial rosacea is a cutaneous vascular disorder; however, researchers have not found any evidence that a vascular dysfunction causes rosacea." source

Genetic Theory

"A primary genetic cause for rosacea is suggested as single genes often control such mediators: enzymes, neuroendocrine transmitters, and cytokines are found in pathways to rosacea signs and symptoms. Currently, neither a specific cause nor a laboratory indicator of rosacea has been suggested." source

"... Rosacea is a genetic based disorder where there are protein alterations in blood vessels, nerves and the epidermis. This is the heart of rosacea. Everything else is secondary..." Dr. Nase source

"Subject:  The Heart of the Rosacea Beast -- Neuro-vascular Alterations at Genetic Level" Dr. Nase - source

"...The problem is that it is the hardest part of the disorder to study and thus has been elusive to pin down the exact neuropeptides, blood vessels and their receptors. But that is where it all starts and progresses..." Dr. Nase source

"...The blood vessels that are dysfunctional are derived in the embryo from a certain cell line common to only the face and eyes. Not to any other organs or blood vessels..." Dr. Nase source

"There is a genetic predisposition to flushing, the earliest manifestation of facial rosacea." source

"Two Major Causes - Genetics & The Sun"
source

 

Inflammatory Theory

"While research has not completely ruled out a microbial component in the pathogenesis of rosacea (e.g., Demodex mite overgrowth), there is strong evidence that rosacea is primarily—if not solely—an inflammatory disease." source

"The pathophysiology of rosacea appears to be inflammatory..." source

"Although the fundamental pathogenesis of rosacea remains unknown, inflammation is a central process in this disorder." source

"...Many pharmacologic agents that effectively treat the symptoms of rosacea show anti-inflammatory and/or immunomodulating effects, providing further evidence that rosacea is an inflammatory disorder..." source

"...It can be argued that all the stigmata of rosacea are manifestations of an inflammatory process: neutrophilic dermatosis.....The pathophysiology of rosacea is still a subject of controversy. Research suggests that various immune cells and inflammatory mediators play a role in the vascular, inflammatory, and hyperplasia stages of this disorder." The Proposed Inflammatory Pathophysiology of Rosacea: Implications for Treatment, Larry Millikan, MD source > http://groups.yahoo.com/group/rosacea-knowledge/message/1447

The four cardinal signs of inflammation are "redness, swelling, heat, and pain." The basic components of the inflammatory process are vasodilation, increased vascular permeability, and emigration of white blood cells. source

A tiny organism called Demodex folliculorum, a mite that lives in facial hair follicles, may be involved. Some researchers believe that these mites clog the sebaceous gland openings, leading to inflammation. Other investigators have shown a possible link between rosacea and Helicobacter pylori, a bacterium that causes infection in the gastrointestinal system. Also, some research has suggested that the immune system may play a role in the development of rosacea in some people...."
source of article - http://www.nih.gov/niams/healthinfo/rosacea.htm

"The stigmata of rosacea may be manifestations of an inflammatory process: neutrophilic dermatosis." source > http://www.medscape.com/viewarticle/448505_5

Based on the theory that rosacea shares the same inflammatory features of acne a recent study showed that, just as the combination of benzoyl peroxide 1 percent and clindamycin 5 percent gel is a powerful treatment modality for reducing Propionibacterium acnes levels, it also significantly reduces the papules and pustules of rosacea, according to Debra L. Breneman, M.D. ...."Benzaclin, once daily, was found to be well tolerated and effective in the reduction of papules and pustules in patients with rosacea," said Dr. Breneman. "This lends credence to the theory that P. acnes is a potential aggravating factor in rosacea. This gives dermatologists a very effective treatment for rosacea." Source > http://www.dermatologytimes.com

Dan Fries' comment • 2 • 3 •

Rosacea Support Resource Pages - Wiki article

Inflammatory Role of Rosacea

Cathelicidin

An article in the June 1, 2004 Dermatolgy Times by Michelle Stephenson quotes Richard L. Gallo, M.D., Ph.D., who says rosacea may be an 'abnormality in the innate immune system...caused by too much cathelicidin." Dr Gallo says, "if we believe that the disease is caused by too much cathelicidin, we could develop a strategy to block the effects of the cathelicidins by making molecules that mimic that protein but don't have the same effects." source

More on this theory

Bacteria Theory

An article in the June 1, 2004 Dermatolgy Times by Rebecca Bryant quotes Michael Detmar, M.D., as saying, "Bacteria are likely involved because what works to some extent as a treatment are antibiotics. Also there appears to be a relationship to photo damage. The nervous system may be involved, because exertion, emotions, and weather trigger the disease, in addition to other triggers such as heat, certain types of food, alcoholic beverages, various topical balms and cosmetics, and various drugs. We're clear that blood vessels are dilated but don't know if that comes first or later. A new area of research suggests that lymphatic vessels are involved." [source]

"Etiology The cause of rosacea is poorly understood, although numerous theories have been offered. Hypotheses have included gastrointestinal, psychological, infectious, climatic and immunological causes, although scientific evidence has not substantiated any of these as primary (10). Controlled studies have not demonstrated consistent preponderance of gastrointestinal symptoms in rosacea patients (24). Similarly, neither a distinct psychological abnormality nor one pharmacological mechanism has been isolated in rosacea patients. Perhaps the most commonly touted of the etiologic theories is based on the presence of Demodex folliculorum in patients with rosacea. Demodex folliculorum has been considered a causative agent of rosacea in the past (25,26). The organism feeds on sebum, and in some cases treatment of demodex infestation has noted improvement in the rosacea (14,27). However, in a review of 79 biopsies, Marks noted demodex folliculorum in only 19% of the specimens (28). A bacterial cause for the disease has been hypothesized, but no consistent findings of one bacteria have been demonstrated (5). Climate, specifically exposure to extremes of sun and cold, may have an effect on the course of the disease, but the role of climate in what appears to be a connective tissue disorder is not clear. Finally, an auto immune process has been suggested, and tissue fixed immunoglobulins have been reported in patients with chronic inflammation of rosacea, but no other evidence has been found (29). Recent experimental evidence has suggested this disease may represent a type of hypersensitivity reaction (30)." ----Chapter 41, Acne Rosacea, Marian S. Macsai, Mark J. Mannis, and Arthur C. Huntley - © 1996 by Lippincott-Raven Publishers
source of article >http://dermatology.cdlib.org/DOJvol1num2/review/rosacea.html

It has been stated that antibiotics that worked against gram negative bacteria are more helpful than not, but this should be carefully studied.

More on Bacteria and Rosacea

Immune System Theory

"Rosacea is increasingly being viewed as an immune-based disorder." source

"It is suggested that altered immune function plays a significant role in the pathogenesis of the disease." source

Fungus Theory

Psychological Theory

Lymphatic Theory

Photo Damage

Helicobacter Pylori

"The exact cause of rosacea is unknown, although several theories exist. One theory of rosacea's origin is that the disease may be a component of a more generalized disorder of the blood vessels, which could explain why rosacea sufferers have a tendency to flush. Another theory is that changes in normal skin bacteria or infection of the stomach by Helicobacter pylori may play a role. Other theories suggest that the condition is caused by microscopic skin mites (Demodex), fungus, a malfunction of the connective tissue under the skin or even psychological factors. None of these possibilities has been proven." source > http://www.rosacea.org/patients/faq.html

More on H Pylori and Rosacea

Nervous System

An article in the June 1, 2004 Dermatolgy Times by Rebecca Bryant quotes Michael Detmar, M.D., as saying, "Bacteria are likely involved because what works to some extent as a treatment are antibiotics. Also there appears to be a relationship to photo damage. The nervous system may be involved, because exertion, emotions, and weather trigger the disease, in addition to other triggers such as heat, certain types of food, alcoholic beverages, various topical balms and cosmetics, and various drugs. We're clear that blood vessels are dilated but don't know if that comes first or later. A new area of research suggests that lymphatic vessels are involved." [source]

The National Rosacea Society reports, "Rosacea can't be cured..." source > Rosacea - What You should Know, page 3

American Academy of Dermatology states:

"Unfortunately, there’s not yet a cure for rosacea."

source > http://www.aad.org/ss98/ss98rosacea.html (this is a dead link now, but the last line of article actually said this)

Now this same source says, "The condition rarely reverses itself and may last for years...."
source > http://www.aad.org/pamphlets/rosacea.html

"....no therapy is highly effective in eliminating the vascular flushing associated with rosacea..." - source > http://www.ncbi.nlm.nih.gov:

The National Rosacea Society reports, "Rosacea can't be cured, but it can be controlled." source > Rosacea - What You should Know, page 3

"While there is no cure for rosacea, medical therapy is available to control or reverse its signs and symptoms. Individuals who suspect they may have rosacea are urged to see a dermatologist for diagnosis and appropriate treatment." National Rosacea Society source > http://www.rosacea.org/patients/whatis.html

"Although rosacea is incurable, its progress can be controlled and even halted through medical therapy and lifestyle modification..." - Postgraduate Medicine source of article - http://www.postgradmed.com/issues/1999/02_99/millikan.htm

 

Sources

The pharmacologic therapy of rosacea: a paradigm shift in progress.
Bikowski JB. - 2005

Rosacea: an update.
Buechner SA.
Department of Dermatology, University Hospital Basel, Basel, Switzerland. 2005

Treating beyond the histology of rosacea.
Draelos ZD.
Department of Dermatology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA. 2005

Reactive oxygen species and rosacea.
Jones D.
Department of Dermatology, Harvard Medical School, Cambridge, Massachusetts, USA. - 2004

The Proposed Inflammatory Pathophysiology of Rosacea: Implications for Treatment
Larry Millikan, MD
SKINmed 2(1):43-47, 2003. © 2003 Le Jacq Communications, Inc.

Ultraviolet light and rosacea.
Murphy G.
Department of Dermatology, Beaumont Hospital, Dublin, Ireland. 2004

Rosacea: where are we now?
Bikowski JB, Goldman MP.
Bikowski Skin Care Center, 500 Chadwick St, Sewickley, PA 15143, USA.-2004

Rosacea: I. Etiology, pathogenesis, and subtype classification.
Crawford GH, Pelle MT, James WD.
Department of Dermatology, University of Pennsylvania Medical Center, USA. 2002

Rosacea and the pilosebaceous follicle.
Powell FC.
Regional Centre of Dermatology, Mater Misercordiae Hospital, Dublin, Ireland. 1974

Rosacea: current thoughts on origin.
Bamford JT.
Department of Family Practice and Community Health, University of Minnesota-Duluth Medical School, MN, USA

Involvement of immune mechanisms in the pathogenesis of rosacea.
Manna V, Marks R, Holt P.-1982

Rosacea as an inflammatory disorder: a unifying theory?
Millikan LE.
Department of Dermatology, Tulane University Health Sciences Center, New Orleans, Louisiana, USA. - 1973

Inflammation
Southern Illonois University School of Medicine
http://www.siumed.edu/~dking2/intro/inflam.htm

The Proposed Inflammatory Pathophysiology of Rosacea:
Implications for Treatment
Larry Millikan, MD
SKINmed 2(1):43-47, 2003. © 2003 Le Jacq Communications, Inc.

Rosacea: classification and treatment.
T Jansen and G Plewig
Department of Dermatology, Ludwig-Maximilians-University, Munich, Germany.