Rosacea Subtypes

Pre Rosacea

Rosacea tends to be a progressive disorder that develops through a range of symptoms, often one stage developing ‘on top’ of the previous. However it is also known for people to have symptom of a stage of rosacea but without exhibiting an ‘earlier’ stage. If left untreated rosacea symptoms tend to get worse.

There is an often ignored stage of Pre- rosacea and there is likely to be over 4 million in the UK and Ireland and over 30 million in the United States. These people in general are prone to frequent episodes of facial flushing and blushing which can be easily triggered and can be noticeably prolonged (lasts for longer than the trigger is present). However facial redness is temporary and disappears after the causal trigger is over. For example, a change in temperature, either warmer or colder, during exercise, washing the face, being in a warm environment, or embarrassing situation, can all  trigger pre-rosacea flushes.

Most people don’t think too much about this other than they are prone to blushing but pre-rosacea flushing can be the first sign that rosacea is beginning. Treating at this early stage is a lot easier. This is done by taking steps to control triggers, avoid or protect against them (especially UV – all year round) and also improve the tolerance levels of your skin and blood vessels so you become more resistant to these triggers. If rosacea runs in your family or you suffer and see your child is exhibiting pre rosacea symptoms, take action immediately. They might not thank you for pestering them to wear at least a sun factor 30 all year round, but they will when they are in their 40s.

In the pre-rosacea stage, you are developing a sensitisation to triggers which leads to a basic functional change in the reactivity of facial blood vessels. This means blood vessels dilate more readily to a greater range of stimuli, open up wider, and stay open for longer periods of time than normal facial blood vessels. This basic difference is responsible for the frequent facial flushing. At this early stage, there are usually no signs of blood vessel wall damage.

Mild Rosacea

Mild rosacea is usually characterised by facial redness where the flush persists for an abnormal length of time (30 minutes or more) after the trigger has been removed. Many rosacea sufferers in this stage are often told they have a healthy glow.

However facial blood vessels are becoming even more reactive - dilating more easily than in pre-rosacea. This results in increased blood flow into the superficial layers of the facial skin and prolonged production of inflammatory chemicals which persist in the facial tissue. The blood vessels remain open for long periods of time, resulting in facial redness that persists for an extended period of time after the initial trigger is over. The inflammatory chemicals lead to some structural damage to facial blood vessels.

Moderate Rosacea

This stage of rosacea would include anyone where facial redness persisted for days or weeks and maybe described in some cases as semi-permanent particularly in the central areas of the face such as the nose and cheeks. Such people are often described as having a 'sunburned' or 'wind burned' look. Some swelling and burning sensations may also be felt especially in these central areas of the nose and cheeks. Also a significant number have outbreaks of inflammatory papules (red lumps), and pale watery looking pustules. In many, thread veins become apparent in the nasal and cheek areas where flushing is the worst.

The increased flushing frequency and intensity leads to blood vessels becoming damaged and dysfunctional causing permanent facial redness, often broken blood vessels, swelling, and inflammatory papules.

Blood Vessels can be in various stages of damage. Some are only mildly impaired and can still function normally and the body’s internal repair mechanisms can correct this damage. Where they are moderately damaged they cannot be easily self repairing, their functional ability is impaired and they tend to remain prone to hyper dilation for much of the time. Those that are severely damaged are permanently dilated (telangiectasia) and cannot be repaired and need to be removed and new ones encouraged. Such damaged blood vessels can merge together as the vessel walls break down and they become larger vessels and very visible.

Severe Rosacea

Some people develop the most severe stage of rosacea characterised by intense facial flushing, severe inflammation, swelling, facial pain, and debilitating burning sensations. On top of the inflammation can emerge crops of inflammatory papules and pustules.  Some exhibit rhinophyma (rino-fi-ma), a bulbous enlargement of the nose or general phyma (fi-ma) with raised areas of skin.

Sub-Types of Rosacea

Rosacea is categorised into 4 key subtypes although overlap is common.

Subtype 1: Erythematotelangiectatic Rosacea

Erythematotelangiectatic rosacea is mainly characterised by flushing and persistent central facial redness. The appearance of telangiectasia is common but not essential for a diagnosis of this subtype. Central facial oedema, stinging and burning sensations, and roughness may also occur. A history of flushing alone is common.

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Subtype 2: Papulopustular Rosacea

Papulopustular rosacea is characterised by persistent central facial redness with transient papules or pustules. The papulopustular subtype is often mistaken for acne vulgaris even by community doctors and nurses. Burning and stinging sensations may be reported. This subtype is often seen in combination with subtype 1, including the presence of telangiectasia which may be obscured by persistent redness, papules, or pustules.


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Subtype 3: Phymatous Rosacea

Phymatous rosacea includes thickening of the skin especially on and around the nose, and enlargement and is called. Rhinophyma which is the most common presentation, but phymatous rosacea may occur in other locations, including the chin, forehead, cheeks, and ears.

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Subtype 4: Ocular Rosacea

Involves the eyes which may be dry or watery, or have a blood shot appearance, be itchy like they have something permanently in them, experience recurrent sties, exhibit burning, swollen eyelids and maybe blurred vision with thread veins of the conjunctiva and eye lids. There is also a risk of potential vision loss from corneal damage and it is essential an eye specialist (ophthalmologist) becomes involved.

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Many patients experience characteristics of more than one subtype at the same time and those often develop in succession. It must be noted that it is entirely possible that, for example, you can have subtype 1 on its own, or even have subtype 2 and 4 at the same time.

While rosacea may or may not evolve from one subtype to another, each individual sign or symptom may progress from mild, through moderate to severe. Early diagnosis, treatment and protection are therefore highly recommended.

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