In a recent encounter with a patient, she asked “What type of rosacea do I have – type 1 or 2?” I was a little caught off guard because I rarely use a number system when remembering or discussing rosacea, but I thought it would be good to review the types of rosacea for myself and patients alike. Don’t get me wrong, I’m all about rosacea as I have rosacea myself. It’s just that as dermatologists we tend to describe the types of rosacea descriptively, instead of using numbers.
The “typing” or classification of rosacea is often used in textbooks and in clinical trials, but in real life most rosacea patients do not fit clearly into one type. Plus, patients may suffer with different types or facets of rosacea at different times in life.
As I often inform patients, rosacea is something we are genetically predesigned to have, just like our hair color and eye color. We can reduce the appearance and symptoms of rosacea by treating the condition and avoiding triggers. At one point in time, rosacea was stigmatized to be the result of alcoholism, but this is not true.
Before we discuss the official types of rosacea, let me share how rosacea tends to present at different stages of life in my patients.
“The rosy cheeked kid” – These kids are easy to pick out. They have rosy cheeks, usually more on the lateral cheeks than the central cheeks or nose. Unlike normal flushing that comes and goes with exercise, overheating or embarrassment, these kids seemed to be rosy more than not. On these kids I try to recommend starting early with skin care products that do not irritate rosacea. Daily zinc sunscreen is a plus. Prescription treatment is limited to medications that slow down blood flow to the skin such as Rx Rhofade and Mirvaso. These topicals can be used daily or for special occasions. This can persist into teens and adulthood, and when it does, I often recommend ZO Rozatrol be applied topically every day. I have used this myself daily for years, and it really helps with redness control as well as antioxidants, oil control, and chemical exfoliation.
“The enlarging pink, red or purple nose on a middle aged or elderly man” -This was the classic WC Fields nose that made rosacea a recognizable medical condition. The official name for enlarging of the oil glands and supporting tissue causing enlargement and even a cauliflower texture to the nose is Rhinophyma. This phymatous change can be seen on other parts of the face and stages of life as well, most commonly on the medial cheeks of women. This makes the pore size and skin texture have a great contrast from the skin directly underneath the eyes. Use of topical retinoids is important in this type as early as possible. In advanced cases, only surgery can remove the excess growth of the skin on the nose.
“The pink face on adult males and females” – Unlike the lateral cheek flushing seen in kids. Adults tend to be diffusely red often with the whole face looking pink. This can also be strewn with visible blood vessels the diameter of a ink pen mark. The blood vessels may be pink or purple in appearance. This is really common in caucasian males and females. The topicals mentioned above, Mirvaso, Rhoade and Rozatrol can help, but Intense Pulsed Light (IPL) and vascular laser treatments are best for this type. In the office, we use IPL to treat the diffuse redness and fine blood vessels, and NdYag laser to treat the visible blood vessels. While a single treatment can make a huge difference in the visible blood vessels, unfortunately, repeated treatments 2-4 times a year are often required to maintain decreased redness.
“The 20-40 year old female breaking out around the mouth, nose and chin” – This can also be seen at younger ages, but usually is in adult women. There is irritation, pimples and often a rash like texture that concentrates on the lower face. The fancy name for this type is perioral dermatitis. We often treat with sulfur wash, topical metrogel or ivermectin, and oral antibiotics.
“The red and bumpy nose” – This is what people think of as far as classic rosacea. The nose is red and bumpy. The bumps sometimes have a head on them, sometimes not. This is most seen throughout adulthood. Depending on the level of severity, we treat with sulfur wash, topical metrogel or ivermectin, and oral antibiotics.
“Red irritated, gritty, dry eyes” – This type is called ocular rosacea and is increasingly recognized now by eye doctors. The standard treatment is oral antibiotics at times of flares, with a low dose oral antibiotic as maintenance. In recent years, eye doctors have begun doing IPL to treat ocular rosacea as well.
So now you can see why it isn’t as easy as giving patients a number. But for those who prefer a numbering system…
Type 1– Vasular Rosacea . This is where there is just excess redness or blood vessels. This would include the rosy cheeked kid and the red face.
Type 2 – Inflammatory or Papulopustular Rosacea . This is when there are bumps and pimples in additional to redness. This would include the red nose and perioral dermatitis described above.
Type 3– Phymatous Type – This is the big nose on an older man.
Type 4 – Ocular Rosacea
Hope this helps. If you are looking in the mirror and wondering if you have rosacea, we would be happy to discuss this at your visit. To learn more than you ever wanted to know about rosacea, read our Rosacea 101 post.
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