Does your acne stick around, like an annoying nickname from high school, no matter how many treatments you try? Maybe it’s not acne at all. One chronic facial skin condition, rosacea, is often mistaken for acne vulgaris in skin of color. Though rosacea is mostly associated with people of European descent (think: Bill Clinton, W.C. Fields, and Princess Diana, three of the condition’s most famous faces), it can afflict people with darker skin tones as well. In fact, global estimates suggest that people with skin of color represent up to 10% of rosacea cases.
But many clinicians are only taught the symptoms of rosacea as they appear in white skin. “The dermatology textbooks used by residents and doctors don’t discuss this diagnosis as it affects patients of color,” says Amy McMichael, M.D., chair of the department of dermatology at Wake Forest School of Medicine in Wake Forest, North Carolina. Since rosacea often looks different in darker skin, your dermatologist may miss it, Dr. McMichael says.
What Is Rosacea Anyway?
This chronic, inflammatory skin condition has no known cause, though it’s possible it is sparked by an overactive immune response or sensitivity to skin organisms called Demodex mites (sounds gross, but we almost all have these usually harmless microscopic arachnids hiding out in our facial hair follicles). Genetics may play a role, too; if your mom or dad had rosacea, you’re more likely to get it as well.
The word you’ll hear the most when it comes to rosacea is “flare.” That’s because the condition is characterized by sudden disease events that are fiery in nature: red, burning, and blistering. One of the most common symptoms is a persistent, stinging facial redness (called erythema) that spreads over the cheeks, nose, chin, and forehead. People with fair skin might look like they are blushing or have a sunburn. These red flares are often, but not always, accompanied by small, red solid bumps or pus-filled pimples.
In darker skin, though, erythema may not look red at all. “The best way to diagnosis this disease in patients with skin of color is to closely observe a more violet-like color in the skin,” says Dr. McMichael.
Without the telltale sign of facial redness, rosacea’s accompanying bumps and pimples are often mistaken for “just acne” in people of color. So how can you tell the difference? There’s almost always a smoking gun when it comes to rosacea flare-ups, says Sara Harcharik Perkins, M.D., assistant professor at the department of dermatology at Yale School of Medicine in New Haven, Connecticut. Because rosacea makes the skin more sensitive in general, everyday stressors can cause a flare-up. Common triggers include sun, cold wind, heavy exercise, alcohol, spicy foods, heated beverages, and certain skin-care products. So, if you’ve noticed that your blemishes always pop up after you’ve, say, been to the beach, that’s an important clue that you might want to think beyond Clearasil for treatment, she says. Rosacea triggers are usually external, while those for acne are typically hormonal in nature (you might notice more acne breakouts during menstruation, for example).
Additionally, the American Academy of Dermatology advises people with skin of color to be on the lookout for these other possible symptoms:
- Your face feels warm (or it might even sting) all the time
- You have unidentified discoloration on your face
- You have dry patches of skin that appear swollen
- The skin on your forehead, nose, cheeks, and chin is rough, swollen, thickened, and malformed
- There are yellow or brown hardened bumps around your mouth and/or eyes
- You feel as if there is something gritty in your eyes or sensitivity to sunlight (ocular rosacea)
Why It’s Important
Rosacea can be much more serious than an acne outbreak or a “bad skin day.” Left undiagnosed and untreated, rosacea can progress to the development of excess skin tissue, resulting in thickened skin called “rhinophyma” and, possibly, the bulbous nose made famous by W.C. Fields. (Contrary to popular belief, a bulbous nose is not caused by drinking too much alcohol, although alcohol can exacerbate the condition.) These changes are not just cosmetic. Rhinophyma can cause blocked nasal passages and breathing difficulties, requiring surgical treatment.
In around half of rosacea patients of all skin colors, the disorder also affects the eyes, leading to ocular redness and irritation, swollen eyelids, styes (small, swollen lumps on the edge of the eyelids), and even corneal damage and loss of vision. If you’ve noticed any of the signs above, it’s important to contact a dermatologist right away. If you prefer a doctor of color, you can find one through the Skin of Color Society.
How to Treat Rosacea in Skin of Color
Unfortunately, rosacea has no cure. But you can successfully keep it under control and minimize flare-ups. For the most part, rosacea treatment is the same no matter what your skin tone: Your doctor may prescribe topical and/or oral antibiotics and anti-inflammatory medications and you’ll need to keep track of what triggers your flare-ups so that you can avoid them as much as possible. And since the sun is such a major rosacea flare trigger, you won’t want to skimp on daily sunscreen application.
There is one important difference in alleviating rosacea symptoms in skin of color, though. Vascular laser treatment, the use of lasers to target and collapse visible blood vessels near the surface of the skin, is common among patients with fair skin, but is generally not a good idea for others. “Lasers should rarely be used in patients with dark skin, as it can cause burns or irritation,” says Dr. McMichael. Pigmented skin tends to absorb about 40% more laser energy than nonpigmented skin, which makes it more susceptible to hyperpigmentation and scarring. So if your derm is gung-ho to try out laser treatment on your beautiful brown or black skin, it’s probably time to get a second opinion.