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If you’ve been diagnosed with rosacea, you’re likely feeling frustrated by conflicting information and uncertain about what lies ahead. This guide cuts through the confusion with practical insights developed over thirty years of specialised care.
Rosacea affects approximately 1 in 20 adults – about 1.3 million Australians – causing persistent facial redness and uncomfortable flare-ups. When it involves the eyes (over 50% of cases), it can seriously affect your vision and comfort. However, with proper understanding and management, we can often control symptoms entirely.
Understanding rosacea: more than just red cheeks
After thirty years treating eye conditions, I wanted to address the real concerns about rosacea that patients face daily. Most patients arrive having seen multiple practitioners, carrying conflicting advice that rarely addresses their specific situation.
Rosacea is a chronic inflammatory condition affecting the central face – your cheeks, nose, chin, and forehead. It involves genetic factors, environmental triggers, immune system responses, and increasingly, we’re learning about microscopic Demodex mites that naturally live on our skin.
The four types of rosacea
Erythematotelangiectatic rosacea (ETR)
- Persistent facial redness like a sunburn that won’t fade
- Visible spider veins on cheeks and nose
- Frequent flushing and burning sensations
Papulopustular rosacea (PPR)
- Red bumps and pus-filled pimples (no blackheads like acne)
- Persistent central facial redness
- Often confused with adult acne
Phymatous rosacea
- Thick, bumpy skin texture
- Most commonly affects the nose (rhinophyma)
- More common in men
Ocular rosacea
- Red, irritated eyes that may also be watery
- Gritty sensation – feeling like sand in the eyes
- Burning, especially at day’s end or upon waking
- Swollen, red eyelids with crusty discharge
- Blurry vision that fluctuates with blinking
- Eyelids stuck together in the morning
- Some patients have no symptoms despite measurable dry eye
The hidden world of Demodex mites
Our bodies host millions of microorganisms, including tiny mites called Demodex that live in hair follicles. While everyone has these mites, rosacea patients have 15-18 times more than healthy individuals.
Two types affect humans:
Demodex folliculorum: Lives in hair follicles and eyelash bases Demodex brevis: Lives in oil glands (elevated in rosacea)
The rosacea connection
These mites feed on skin oils. When they multiply excessively, they cause debris accumulation around eyelashes, leading to blepharitis and dry eyes. The real culprit may be Bacillus oleronius bacteria living on the mites, which triggers inflammation.
The vicious cycle: Inflammation promotes mite proliferation, which worsens inflammation – creating a self-perpetuating problem.
What causes rosacea?
Genetic predisposition: Family history significantly increases risk, especially in fair-skinned people of Northern European descent.
Immune system dysfunction: Overactive immune response creates inflammation from triggers that wouldn’t bother most people.
Vascular abnormalities: Facial blood vessels react more easily, eventually becoming permanently enlarged.
Common triggers:
- Sun exposure (most common)
- Hot showers
- Spicy foods and hot beverages
- Alcohol
- Stress
- Hot/cold weather
- Certain skincare products
Treatment approaches: what actually works
Skincare fundamentals
- Use gentle, fragrance-free cleansers
- Moisturise daily with sensitive skin products
- Apply broad-spectrum SPF 30+ sunscreen daily
- Avoid alcohol-based products and harsh scrubs
- Be careful to avoid the eyelids, as all skin products are very irritable if they enter the eyes.
Topical treatments
- Metronidazole gel: Reduces inflammation and targets Demodex
- Ivermectin cream (Soolantra): Specifically targets Demodex mites
- Azelaic acid: Reduces bumps while being gentle
- Brimonidine gel: Temporarily reduces redness
Oral medications
- Low-dose doxycycline: Works as anti-inflammatory, not antibiotic, needs to be used for months
- Oral Azithromycin: Used for up to 3 weeks
- Oral ivermectin: For severe cases with high Demodex populations
For ocular rosacea
- Proper lid hygiene: Use specialised products like Blephadex with tea tree oil (never homemade solutions). However, tea tree oil products must not be used long term (6 weeks maximum) as they are toxic to the eye.
- Cold compresses: 5-10 minutes twice daily can reduce inflammation
- Professional BlephEx treatment: Removes biofilm buildup for established cases
- Advanced dry eye technology: Early detection and prevention
Laser therapies
- Intense pulsed light (IPL): Reduces redness and may decrease Demodex
- Vascular lasers: Target dilated blood vessels
Managing your triggers
Keep a diary tracking foods, weather, stress, and skincare products alongside flare-ups. Sun protection is non-negotiable – UV exposure is the most common trigger.
Essential sun protection:
- Daily broad-spectrum SPF 30+ sunscreen
- Wide-brimmed hats
- Seek shade during 10 AM – 4 PM
The truth about rosacea
Myth: Caused by poor hygiene or alcoholism. Reality: Medical condition with genetic and environmental factors.
Myth: Just cosmetic. Reality: Can significantly impact quality of life; ocular rosacea threatens vision.
Myth: You’ll outgrow it. Reality: Chronic condition that worsens without treatment but is highly manageable.
The 5 key things about rosacea
1. Early treatment prevents progression
Rosacea worsens over time without intervention. Early treatment prevents permanent changes.
2. Demodex mites are key players
Papulopustular rosacea may be a chronic Demodex infection. Targeting these mites is often crucial for control.
3. Eye involvement is common and serious
Watch for eye symptoms and seek prompt treatment. Untreated ocular rosacea can threaten vision.
4. Treatment must be personalised
What works for others may not work for you. Effective management requires individualised approaches.
5. Prevention beats cure
Like dental hygiene preventing tooth decay, regular gentle skincare and trigger avoidance prevent flare-ups.
When to seek help
See a specialist for:
- Persistent facial redness lasting weeks
- Eye irritation, burning, or vision changes
- Bumps that don’t respond to over-the-counter treatments
- Emotional distress about appearance
Urgent eye symptoms:
- Sudden vision changes
- Severe eye pain
- Significant swelling around eyes
Looking forward
Research continues rapidly. New understanding of Demodex mites, laser advances, and targeted therapies offer hope for even better treatments.
The key is finding an experienced provider who understands rosacea’s complexity and can develop an effective, personalised plan.
Remember: Rosacea is manageable. With proper understanding, appropriate treatment, and lifestyle modifications, most people achieve significant improvement in symptoms and quality of life.