The disease course of rosacea is waxing and waning in nature, with patients often experiencing periods of remission and little or no symptoms followed by episodes of "flareups", where symptoms are exacerbated. For many individuals, rosacea progresses in stages, while for others, symptoms may progress in a nonsequential manner.
Before rosacea onset
The onset of rosacea may be preceded by episodic erythema (redness) that is triggered on exposure to various factors such as ultraviolet radiation, hot or cold temperature, stress, alcohol, hot drinks, or spicy food. Regular flushing and blushing can eventually cause permanent erythema across central regions of the face, as well as on the cheeks, chin, forehead and even the neck and chest.
Rosacea disease stages
The progression of rosacea is categorized into four main stages:
Stage 1 is characterized by the presence of persistent erythema, and spider veins across the cheeks, nose and forehead, along with a tendency to have allergic reactions to cosmetics, facial cleansers and sunscreens.
Stage 2 usually develops around one year after stage 1 and disease features typically include persistent and inflamed pus-filled bumps or papules, edema, redness, spider veins, and blocked pores.
Stage 3 is rarely seen among patients. Clinical features usually include a deeper redness of the skin along with the presence of papules, pustules, nodules, and granulomas. In addition, thickened and folded skin tissue may give rise to rhinophyma (particularly in men). The face becomes pitted, coarse, and edematous.
Among almost half of rosacea patients, there is involvement of the eye in disease progression. The patient experiences burning, stinging, and tearing along with a sensation of grit or sand in the eyes. There may be eye pain, photophobia, redness of the conjunctiva, swollen and inflamed eye lids (blepharitis), scaling around the eyes, and an intolerance for wearing contact lenses.
Eye involvement is independent of facial symptoms and may occur before facial redness does in some individuals. Over time, ocular rosacea can cause serious complications such as opacity of the cornea, scarring and even blindness.