Causes, Risk Factors, and Triggers

Causes, Risk Factors, and Triggers


Rosacea is a frequent and persistent skin issue often seen on the face, particularly in those with fair skin. Symptoms vary with subtypes but may include redness, swelling, acne-type sores, tender skin, visible blood vessels, thick or dry skin, and/or eye irritation. These symptoms may appear and disappear, primarily affecting the nose, cheeks, and forehead. Rosacea is a complex condition with multiple possible causes and risk factors.

Although the exact cause of rosacea is unknown, researchers have identified genetic, environmental, microbial, immune, and vascular factors that can contribute to its development. Recognizing the contributing factors can help effectively manage the condition and minimize flare-ups. By identifying personal triggers and adopting a proactive skincare and lifestyle routine, those with rosacea can greatly enhance their quality of life.

Exposure to ultraviolet (UV) light—or sunlight—can activate specific channels in nerves and skin cells that release inflammatory mediators. These mediators can potentially trigger the onset of rosacea.

UV light exposure also causes vasodilation, a process that causes your blood vessels to widen, increasing blood flow to the skin’s surface. This makes your skin more susceptible to damage and irritation. 

In addition to UV exposure being a potential cause of rosacea, it is also a significant trigger. Prolonged exposure to the sun’s rays often results in rosacea flare-ups, characterized by redness, visible blood vessels, and a burning feeling on the face.

To manage their condition effectively, people with rosacea are advised to minimize sun exposure, wear broad-spectrum sunscreen daily, and wear protective clothing.

When the immune system detects a germ or allergen, it activates histamine, a chemical messenger, as part of a protective response. Histamine then triggers inflammation and vasodilation to help your body defend against potential threats. But sometimes, the immune system overreacts, causing the blood vessels to widen too much, leading to redness and inflammation. 

In addition, cathelicidin is a protein made by your body’s immune system and found in the skin. It helps protect the skin from germs and infection. However, how your body processes cathelicidin can affect whether you get rosacea. Instead of providing protection, the processing of cathelicidin can trigger and inflammatory response in your skin. This response can cause your immune system to overreact, triggering rosacea symptoms. 

Certain bacteria, like Bacillus oleronius, Staphylococcus epidermidis, and Bartonella quintana, are found at higher levels on the skin of individuals with rosacea.

Some evidence also suggests that people with rosacea might have more Helicobacter pylori (H. pylori) bacteria in their stomachs. However, not everyone with an H. pylori infection has or develops rosacea.

Mites are tiny organisms too small to see without a microscope. Demodex mites live on everyone’s skin and in your hair follicles and are typically harmless. However, they are found in larger amounts in those with papulopustular rosacea (PPR). It’s not clear if the mite causes rosacea or if rosacea causes an increase in mites. Researchers are also studying demodex mites’ role in other types of rosacea.

Vascular abnormalities refer to the excessive widening of both blood and lymphatic vessels in your skin, leading to noticeable symptoms such as flushing and persistent redness.

Blood vessels an important part of blood circulation, delivering essential nutrients and oxygen to your tissues and organs. Lymphatic vessels are responsible for transporting lymph fluid, which contains white blood cells and assists in eliminating waste and toxins from tissues. When these vessels become excessively widened, they disrupt the normal flow of blood and lymphatic fluid, contributing to the redness and inflammation seen in rosacea.

Neurovascular dysregulation interrupts the balance between nerves and blood vessels, causing excess vasodilation and redness.

Unlike vascular abnormalities, which are structural differences in blood vessels, nerve dysregulation specifically involves how nerves control blood flow. When these signals are impaired, blood vessels widen too much, leading to the persistent redness and flushing seen in rosacea.

Rosacea has subtypes that present with distinct symptoms. Known causes vary by subtype, but much is still unknown. Potential causes of each subtype include: 

  • Erythematotelangiectatic: Redness and flushing are likely due to problems with blood or lymphatic vessels, sunlight, or temperature changes.
  • Papulopustular: Redness and bumps associated with this subtype are similar to acne and likely due to an imbalance in microorganisms like Demodex mites.
  • Ocular: This type affects the eyes, causing dryness and itchiness. Experts are still determining the specific cause.
  • Granulomatous: This presents as firm, red, or yellowish bumps and is likely due to abnormal immune responses and inflammation.
  • Phymatous: This type causes skin thickening due to an overgrowth of specific tissues and glands. It is likely worsened by inflammation or genetics.

Rosacea often runs in families, suggesting a genetic link. Research notes that:

  • Up to 50% of those with rosacea have a family member with it.
  • It’s more common to inherit it from the maternal (mother’s) side.
  • About 15% of the connections were between siblings or cousins.
  • Around 62% of the connections were between generations, like great-grandparents and grandchildren.

Rosacea can affect anyone, but the following groups are more likely to develop it: 

  • Age: Adults between the ages of 30 and 50
  • Sex: Those assigned female at birth 
  • Ethnicity: Those with fair skin who sunburn easily, often from Celtic or Scandinavian ancestry

Certain groups, such as those with mild symptoms or limited access to healthcare, might not be adequately accounted for in rosacea data. 

Genetics, environmental factors, and individual susceptibility play significant roles in determining who is more likely to develop rosacea.

Smoking

The association between smoking cigarettes and rosacea is controversial. However, many studies note that smoking increases the risk of developing rosacea. It constricts blood vessels and reduces oxygen supply, leading to inflammation and skin damage, among other symptoms. Nicotine, a component of cigarettes, can trigger vasodilation and inflammation.

Smoking also weakens your immune system and disrupts skin barrier function, making your skin more vulnerable to rosacea.

Alcohol

Alcohol, especially in moderate to heavy amounts, can contribute to the development of phymatous rosacea. Consuming alcohol can widen your blood vessels, disrupt your immune system and skin barrier, and increase the development of inflammatory substances in your body like cytokines.

Wine (both white and red) and hard liquor are more likely to trigger rosacea than other types of alcohol.

Stress

Stress activates the nervous and immune systems, which can affect your skin and overall health. The stress hormone cortisol can make your skin red, itchy, and vulnerable to bacteria that cause rosacea. Stress can also make other skin concerns like acne, hair loss, eczema, and psoriasis more severe.

Other Conditions

The exact relationship between the following health conditions and rosacea is an ongoing research topic. However, they are often seen together, suggesting they share common underlying factors or pathways:

  • Allergies
  • Anxiety disorders
  • Obsessive-compulsive disorder (OCD)
  • Autoimmune diseases (like lupus)
  • Depression
  • Hypertension (high blood pressure)
  • Hormonal imbalances 
  • Metabolic disorders (like diabetes)
  • Neurological disorders (including migraines and Parkinson’s disease)
  • Digestive conditions
  • Respiratory illness

Medications

Long-term use of topical (on the skin) steroids on the face can lead to steroid-induced rosacea.  Topical steroids, or corticosteroids, are medications you apply to your skin to reduce inflammation, itching, and irritation from various skin conditions such as eczema. They suppress the immune response, reducing the release of inflammatory substances.

While the above risk factors increase your risk of someone getting rosacea, the following triggers can cause flare-ups for those who already have it:

  • Alcohol
  • Caffeine
  • Dairy products, spicy foods, vanilla, cinnamon, and histamine-rich foods (avocado, bananas, papaya, and pineapples)
  • Hot beverages
  • Niacin (vitamin B3) 
  • Formaldehyde
  • Harsh skin care products 
  • High-intensity exercise
  • Nicotine
  • Rough fabrics (like wool)
  • Stress
  • Sun exposure
  • Wind exposure
  • Vasodilating medications (used to widen blood vessels)

While the exact cause of rosacea is unknown, it is likely connected to genetic, environmental, microbial, immune, and vascular factors, each contributing more or less to different subtypes. Sun damage, disruptions in the immune system, Demodex mites, infections, blood vessel abnormalities, and nerve dysfunction can all contribute to rosacea development.

Rosacea is more common in people ages 30-50, people assigned female at birth, and those with fair skin. Smoking, drinking alcohol, stress, sun exposure, certain health conditions, and some medications likely increase your risk of developing rosacea.

If you suspect you have rosacea, it is important to consult a dermatologist for a proper diagnosis and tailored treatment plan.

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