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Neurogenic Rosacea Fifth Subtype Variant Complex Nerve Trigger cause

olga-thelavart-o4PXAgfXCNw-unsplash Neurogenic Rosacea

Last updated 04/27/2022

The subject is the complex integumentary system (skin) and rosacea highly misunderstood disorder. I had come across a connection with rosacea and the nervous system before. It is referred to as neurogenic rosacea.

So, I decide to dig a bit further for Rosacea Awareness Month. Since rosacea as we understand it is still being researched. Therefore, misunderstood it shapes this subtype more difficult to diagnose.

When first seen it resembles ETR subtype one. But the neurologic symptoms are so much worse.

Rosacean Talonted Lex interviewed Doctor Alia Ahred (Psychodermatologist) on her site. Doctor Alia Ahred’s specialty is the psychosocial connection concerning skin conditions. Thus, goes to show rosacea is more than skin deep.

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What is Neurogenic Rosacea?

Neurogenic rosacea (AKA Neurogenic Inflammation) is considered a rare complex fifth subtype or variant of rosacea. However, it has been discussed since 2011. This subtype was brought about due to being somewhat resistant to usual rosacea treatments. Thus, several medications are tried with little improvement.

Neurogenic rosacea symptoms:

  • Stinging or burning pain exceeding physical appearance
  • Telangiectasia
  • Itch
  • Edema
  • Extreme redness
  • Intense psychological symptoms

It differs quite a bit from sensitive rosacea skin because of the neurogenic symptoms. There are few inflammatory papules and pustules as well as rhinophymatous transforms. Aloe vera, ice roller or fans can provide comfort to the inflamed skin.

Some studies have reported those with neurogenic rosacea having difficulty in daily and social activities. Their symptoms were pretty extreme. So, you can imagine the impact.

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What causes Neurogenic Rosacea?

The cause has a strong connection in the stimulation of sensory nerves resulting with rosacea triggers. In addition, the structure of your blood vessels in your skin and its immune response.

Erythema triggers start with these neural connections:

  • Sympathetic nervous system
  • Cranial nerve
  • Axon reflex
  • Sensory afferent responses

The face houses an array of nerves and fibers. In fact, your nervous system can carry inflammation. This is directly along with indirectly.

That is to say, it controls blood vessel diameter as well as blood flow. It is said that the characteristic flushing is raised due to the blood flow linked when we encounter our triggers.

Triggers can be grouped as:

  • Temperature and environment
  • Social and emotions
  • Medications and topical products
  • Diet
  • Over exertion like in physical activity
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Nerves and Rosacea Triggers

Temperature and Environment

A cold wind can change your skin temperature (for instance our skin may suffer frost bite). Wind can also cause irritation and lead to a response from your sensory afferent. In addition, it may dry out the epidermis layers. As a result, disruption in the skin barrier.

If the wind temperature causes a significant skin temperature change; it may worsen skin blood flow. Due to responses because of internal temperatures.

Concerning heat there is greater response of nerve, blood flow and sweating in those having rosacea. In short, this occurs in the sympathetic nervous system.

Social and Emotions

With mental stress versus embarrassment differences may be in the nerves responding. It's possible that rosacea symptoms are due partly to supraorbital nerve being more active or increased issues in perception. Your cranial nerves take part in cutaneous vasodilation through responses of axon and gustatory reflexes.

Gustatory reflex has to do with the salivary glands in your mouth. They are responsible for tasting, chewing and swallowing food. It is part of the sensory systems perception of taste and flavor.  In addition, it includes several cranial nerves.

Emotional triggers like stress can forge the sympathetic nervous system to release chemicals resulting with papules and pustules causing inflammation. That is to say dilation of blood vessels leading to flushing.

Contributing to these higher reflex responses us having rosacea can also have tweaked facial axon reflexes. Sensory nerves when activated can release local vasodilator agents.

These agents encourage keratinocytes (skin cells), sweat glands and mast cells to release in turn prostaglandins, Brady kinin and histamine. The strong vasodilators raise vascular permeability and cause edema.

Therefore, it is not acknowledged yet but possibly rosaceans release more of these vasodilators. Likewise, are more sensitized to these substances causing inflammation. Rosacea symptoms have many triggers that are stressors affecting the sympathetic nervous system. Studies suggest this dysfunction in rosacea.

Medications and Topical Products

You know of ingredients to avoid in products that trigger your rosacea. This is said to be due to skin irritation or an allergic reaction. Sensory afferent nerves (sense) our skin is irritated. As a result, the bump and flare-up of your skin is because usual allergic reaction is linked to axon reflex.

Another possibility the irritations cause higher blood flow in addition the skin barrier results with more transepithelial water loss and inflammation. This is another reason to hydrate.


A link exists with consumption of alcohol connected to small quantities of cutaneous vasodilation particularly of the face and periphery. The theory is due to the direct effect of ethanol on vascular smooth muscle. Could be rosaceans are more sensitive to this cutaneous vasodilation. Similarly, like hot drinks and spicy foods the ethanol encourages a gustatory (taste) flushing response.

Recent findings identify an oral cavity effect concerning hot drinks. It is suggested in this report that heat draining from your oral cavity enters the jugular vein heating the carotid-artery blood by another system.

Normally there is heat exchange with vessels but more so that extreme warm temperatures cause a reflex vasodilation. This is common with other gustatory reflexes. After that, heat stimulates warm sensory afferents possibly leading to a cranial-nerve reflex response. Not clear is the percentage with rosacea that have abnormal gustatory reflexes.

Concerning spicy foods capsaicin looks to be the culprit. Although other chemicals could be involved that are thought of as spicy. However, increase in skin blood flow was seen in the face after oral consumption of capsaicin.

A rosacea trigger of niacin (important vitamin AKA B3 in many foods) containing certain proteins can lead to flushing. Histamine and niacin both can make blood vessels dilate thus leading to rosacea flare ups.

Niacin is largely found in beef, fish, poultry, eggs, seafood, grains, beans, peas, nuts, seeds and soy products.

Physical Activity

There is more activity with the supraorbital sympathetic nerve if you have rosacea. It is unknown if this just affects the facial area. As a result, exaggerated flushing is the response and a common rosacea symptom. Furthermore, persistent redness, inflammation and telangiectasia could occur.

This increases changes in the vessels with diameters and their structural twist and turns. Because rosacea is also a vascular disorder that causes small blood vessels on the nose and cheek to swell.

Compare Trigeminal Neuralgia

The facial flushing due to trigeminal neuralgia should differ from NR. Trigeminal neuralgia can also contain flushing with pain sensation. But flushing with trigeminal neuralgia normally is because of the ophthalmic nerve location and its direction.

The pain is usually more extreme and could be experienced as stabbing, electric shock or shooting pains, compared to NR.

Compare Facial Erythromelalgia

Facial erythromelalgia is rare and occurs with a repeated skin rash that is painful. Other symptoms; swelling, warmth and burning. Similar to rosacea, warming makes it worse while cooling relieves it.

In some circumstances facial erythromelalgia had been misdiagnosed as rosacea or contact dermatitis. And patients actually had facial erythromelalgia that improved after taking aspirin, gabapentin and some serotonin re-uptake inhibitors.

Erythromelalgia and NR have common neurovascular pathology. Neuropathic symptoms like sensory abnormalities and itching are not easy to treat and may need to be approached differently.

In studies some symptoms of participants were not relieved by:

  • Oral doxycycline
  • Oral minocycline
  • Topical metronidazole
  • Topical calcineurin inhibitors

More clinical studies are required. But the following treatments were effective:

  • Gabapentin
  • Pregabalin
  • Tricyclic
  • Anti-depressants
  • Duloxetine
jerry-klein-FHBky0kJgG4-unsplashcloseup of red rose neurogenic rosacea

Why do Rosaceans have Flushing?

Why we flush is complicating. We have so many stressors that trigger this response. That is to say, this will take more studies but probably comes down to the individual.

These triggers that bring on the flushing start with our sympathetic, cranial, axon reflex or sensory afferent. Likewise related to heat and heightened activity.

It could possibly be linked to generations where more attention on the face was a part of communicating. In addition, the face contains more axon-reflex parts versus peripheral hairy and glabrous skin. As a result, higher sensitivity response in rosacea affected areas.

Wrapping it up

Neurologic rosacea is a fifth subtype or variant of rosacea the skin disorder. As with all rosacea types it needs more research to understand. It is also complex like our skin itself and has similar symptoms to other conditions.

Similar to other rosacea subtypes it has also been misdiagnosed. Neurologic rosacea has a link to our nervous system involving facial nerves. When we come into contact with our triggers this increases blood flow that causes the facial flushing.


Mary is the founder of All About Our Skin. Former esthetician and CPC. Enjoys researching skincare and has been studying our skin for the past fifteen years.

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