Rosacea Revisited

47

Rosacea’s more than a skincare topic to me; it’s a condition that I’ve lived with every day since I was a teenager. I remember blushing easily whenever I was embarrassed or angry. I hated that this condition showed my feelings to the world in a matter of seconds.  

Fast-forward a few years and working in the beauty industry, I made it my mission to learn about and understand rosacea. I then developed the tools to manage it. Through my openness on social media, I developed a community of women who experience the same thing, and it’s fascinating that there are so many of us out there.   

I chat with dermatologists Dr Vanessa Lapiner and Dr Ayesha Moolla about everything rosacea-related, and the good news is that there is light at the end of the red tunnel. It’s time for rosacea revisited.  

---

Identifying rosacea 

“Rosacea is a common skin condition, usually occurring on the face, which predominantly affects those with fair skin types, but it may affect all skin types in people aged 40 to 60 years old,” says Dr Lapiner.  

“It’s a chronic condition and, in any individual, the severity tends to fluctuate. Rosacea tends to affect the cheeks, forehead, chin, and nose. It is characterised by flushing, persistent redness caused by dilated blood vessels, small bumps and pus-filled spots, and skin sensitivity. There may also be uncomfortable inflammation of the surface of the eyes and eyelids.” 

Dr Lapiner’s tips for recognising sensitive, rosacea-prone skin:  

• Having fine, dilated veins on the nose, cheeks, and chin 
• Flushing when warm or consuming spicy foods or hot drinks 
• Red, irritated eyes 
• Sensitivity to new products 

Good to know: Acne is not the same thing. If you’re treating your rosacea with products targeting acne, you’ll end up making your rosacea worse. The main difference is that blackheads and whiteheads are prevalent with acne. If there are no clogged hair follicles, it isn’t acne. 

“Rosacea can also present with rough, dry, and scaly skin that often burns or stings,” says Dr Moolla. “Affected individuals may experience tightness and itchiness. Prolonged untreated rosacea can result in thickening of the skin, particularly affecting men more than women. This thickening typically occurs on the nose but can also appear on the chin, ears, and forehead. It is medically referred to as rhinophyma. 

Additionally, acne-like breakouts can also occur across all skin types with rosacea, and this manifests as papules and pustules. 

Furthermore, you may even experience a gritty sensation in your eyes, along with a feeling of dryness and itchiness. Other eye symptoms can include tearing, burning sensations, redness, soreness, light sensitivity, and a sensation of having something in your eyes. This is known as ocular rosacea.” 

Different types of rosacea 

“Dermatologists classify rosacea in terms of subtypes, since this impacts our choice of treatment: we treat papulopustular rosacea (treated with anti-inflammatory skincare actives/azelaic acid/topical ivermectin or metronidazole/oral antibiotics or isotretinoin) very differently to erythematotelangiectatic rosacea (where the focus is on physically impacting the blood vessels through vasoconstrictors like brominidine, botulinum toxin, or laser therapies). Phymatous rosacea requires resurfacing,” says Dr Lapiner.  

There are four distinct rosacea subtypes, namely:  

• Erythematotelangiectatic rosacea: Persistent redness and visible blood vessels.
• Papulopustular rosacea: Acne-like breakouts. 
• Phymatous rosacea: Thickened skin (often on the nose). 
• Ocular rosacea: Eye irritation and redness. 

Cause and effect 

“The exact cause of rosacea remains unclear, but recent scientific literature suggests that rosacea is linked to neurovascular dysregulation and inflammation,” says Dr Moolla. “This inflammation could explain the initial flushing that, with time, becomes more persistent, as well as the development of other symptoms such as acne-like lesions. The immune system activates specific cells that contribute to this inflammatory response. In individuals with rosacea, certain triggers may stimulate an immune response, leading to increased inflammation. 

“Cathelicidin is a protein in the immune system, and the body’s handling of this protein could influence an individual’s risk of developing rosacea. 

“Additionally, tiny mites called demodex inhabit nearly everyone’s skin and may contribute to rosacea. Studies have shown that these mites are more abundant in individuals with rosacea. This increased population of mites could provoke an immune response, leading to the inflammation typical of rosacea,” she adds.  

Demographics  

“Rosacea occurs in both women and men, with notable trends in age and gender. It is most commonly diagnosed in individuals aged 30 to 60, typically developing during adulthood, though it can appear earlier or later. Women are more likely than men to develop rosacea, particularly in their 30s and 40s. Men often experience more severe forms of rosacea and are at a higher risk for complications such as rhinophyma, which involves the thickening of the skin on the nose. In summary, while both genders can be affected by rosacea, women are diagnosed more frequently; however, men may face more severe manifestations of the condition,” says Dr Moolla. 

Triggers and lifestyle changes 

“Rosacea triggers are diverse, encompassing various environmental and lifestyle factors. Lifestyle changes are crucial in managing the condition and preventing flare-ups,” she notes.  

Dr Moolla suggests implementing the following in your daily routine:

• Apply broad-spectrum sunscreen daily with at least SPF 30, even on cloudy days, as UV rays can trigger flare-ups.  
• Wear a hat and sunglasses and choose shade when possible.  
• A gentle skincare routine is essential. (See Dr Lapiner’s skincare tips below under ‘Expert Advice’).
• Certain medications, particularly certain blood pressure treatments, have been known to trigger rosacea as well. Additionally, specific cosmetic, skincare, and hair care products can aggravate the condition, so be mindful of what you use.
• Temperature control plays a significant role as well; avoid extreme temperatures, both hot and cold. Hot showers or baths should be avoided. Using fans or air conditioning can help maintain a comfortable environment.
• Dietary modifications are also vital since certain foods like spicy dishes, hot drinks, and alcohol can trigger rosacea episodes. Avoid alcohol like white wine, red wine, and spirits.
• Avoid smoking.  
• Stress management techniques such as yoga, meditation, mindfulness, and relaxation are beneficial in reducing stress levels – another common trigger for rosacea. 
• Exercise is important, but focus on low-intensity activities to prevent excessive sweating or overheating. Avoid activities like running.
• Good sleep hygiene is crucial. Poor sleep can contribute to stress levels and worsen the condition.  

Genetically speaking 

“Rosacea appears to have a hereditary component, though its exact cause remains unclear,” says Dr Moolla. “Research indicates that genetics may play a role, as the condition often runs in families. Studies show higher rates of rosacea among individuals with a family history, suggesting an inherited predisposition.” 

Open season 

Rosacea can rear its head throughout the year, no matter the season. “Summer heat and UV exposure tend to worsen rosacea for many, while cold, dry winter air can also irritate the skin,” says Dr Lapiner. “This is why consistent care and seasonal adjustments to your skincare routine are essential.” 

A word on pregnancy 

“Pregnancy can worsen rosacea symptoms due to hormonal changes. Fluctuations in oestrogen and progesterone may increase skin inflammation and vascular reactivity, triggering or worsening rosacea,” says Dr Moolla. “Additionally, increased blood volume and vasodilation can lead to facial flushing, further aggravating the condition. Safe management strategies to take into consideration include avoiding known triggers and utilising pregnancy-safe treatments like azelaic acid. 

Is rosacea linked to cold sores?  

“There is no direct causal link between viral infections and rosacea, but some overlapping factors exist, such as immune response dysregulation and triggers that can worsen rosacea,” explains Dr Moolla.  

“While conditions like chickenpox, shingles, and cold sores do not directly cause rosacea, there are intriguing connections worth examining. Chickenpox and shingles are caused by the varicella zoster virus, which remains dormant in the body and can reactivate as shingles. Although this virus does not cause rosacea, some studies suggest that viral infections may trigger immune responses or inflammation that could exacerbate rosacea symptoms in individuals who are predisposed.  

“Cold sores, caused by HSV-1, do not directly cause rosacea either. Nonetheless, cold sores cause skin inflammation, and factors such as UV exposure or stress can reactivate cold sores while also worsening flare-ups of rosacea,” Dr Moolla explains. 

Expert advice 

“When you have rosacea, less is more,” says Dr Lapiner. “I teach my patients my root4 philosophy, which is: Uncomplicate. Elevate. Integrate.” 

1. UNCOMPLICATE 

Start simply with just three essentials: A cleanser, moisturiser, and sunscreen strategically formulated to cover all your skincare needs.  

2. ELEVATE 

Once you’ve established your “vanilla” skincare regimen, slowly try to advance your regimen through the addition of serums, facial oils, or masks, one at a time, focusing on the most critical ingredient you next want to incorporate into your regimen. Be strategic. If you want an antioxidant, for example, don’t go for an L-ascorbic acid, which is more likely to flare up your rosacea. Either look for a vitamin C derivative (ascorbyl glucoside is a nice gentle one) or look for other antioxidants (niacinamide, resveratrol, green tea are beneficial for rosacea while also providing antioxidant support). Use the same strategy with retinoids. Don’t go for tretinoin; try very low concentrations of retinol in a cream formulation or other alternatives such as granactive retinoids.  

3. INTEGRATE 

Harness the power of the gut-brain-skin axis to achieve optimal skin health and incorporate supplements to heal any underlying gut issues contributing to the vascular reactivity. Nutraceuticals that repair the gut lining (l-glutamine), fibre, and then probiotics are key. 

Rosacea treatment options 

“Rosacea treatment primarily aims to control symptoms and prevent flare-ups. The approach varies based on the severity of the condition and may involve several topical treatments. Metronidazole is a common first-line topical treatment that reduces inflammation and redness. Azelaic acid is another option that alleviates redness and inflammation. Topical ivermectin can also help decrease inflammation and skin lesions,” says Dr Moolla.  

“For oral medications, doxycycline is frequently prescribed for moderate to severe rosacea to manage inflammation. In severe cases resistant to other treatments, oral isotretinoin may be considered, particularly for prominent papulopustular rosacea. Procedures such as pulsed dye laser (PDL) therapy effectively reduce redness and visible blood vessels. 

“Other treatment options include brimonidine gel for the temporary reduction of redness through blood vessel constriction and sodium sulfacetamide in topical formulations for its anti-inflammatory and antimicrobial properties,” she adds. 

Skincare tips

Dr Lapiner recommends utilising these skincare tips if you have rosacea:

• Choose a cleanser with a minimalistic formula to prevent a reaction. The fewer ingredients in your cleanser, the better. Pick a milk cleanser to hydrate and nourish the skin rather than leaving it feeling stripped. It should contain no harsh surfactants like SLS or SLES. It’s a bonus if it actively targets redness.
• Avoid over-exfoliation. This may be damaging your skin barrier.
• Hydrate your skin sufficiently. Look for ingredients like glycerin, urea, panthenol, ceramides, squalane, and natural moisturising factor.
• Less is more. Pare down your skincare regimen to a few key products and choose products with short ingredient lists.
• Go fragrance-free. Fragrances in skincare products may cause irritation. 
• Use lukewarm water. Give the hot water a skip. 
• Look for ‘anti-inflammatory’ functional actives in your skincare products. Ingredients like aloe vera, niacinamide, oat, chamomile, bisabolol, turmeric, green tea, allantoin, liquorice root extracts (glycyrrhetinic acid shares some structure similarities to cortisone), Centella asiatica, colloidal oatmeal and blue tansy.
• Use SPF daily. Wear a good physical or mineral sunscreen (such as zinc oxide or titanium dioxide).  
• Try a concealer. A concealer with a green tint will counter the appearance of redness. 
• Patch-test new products. Test new skincare on the inner crease of your elbow twice daily for a week before trying it out on your face. If your skin feels calm, moisturised, and happy, then the product’s a winner.
• Slowly but surely. Phase in new products into your routine one at a time.
• Retinol 101. If you’re using a more active skincare function such as a retinoid, apply your moisturiser before and after your product.
• Chat to a professional. If the redness is persistent or still bothering you, see your dermatologist.
• Major laser. Lasers are very effective in lessening the appearance of fine, red veins. 

New findings 

“Rosacea management has done a 180-degree pivot from treating with antibiotics to treating with probiotics. Rosacea is the poster child for the mind-gut-skin connection. By maintaining a healthy gut bacterial balance, probiotics can reduce overall body inflammation that contributes to skin sensitivity and rosacea. Epidemiologic studies suggest that patients with rosacea have a higher prevalence of gastrointestinal disease (e.g. coeliac disease, H. pylori infection, small intestinal bacterial overgrowth [SIBO], inflammatory bowel disease such as Crohn’s, and irritable bowel syndrome) and report an improvement in rosacea following the successful treatment of SIBO. Since stress triggers intestinal permeability (so-called leaky gut), looking after your mental health is also vital,” says Dr Lapiner. 

“Phenotype-based classification has replaced the traditional subtype classification of rosacea. This new system emphasises observable signs and symptoms, enabling more personalised and effective treatment strategies,” adds Dr. Moolla.  

In conclusion 

Rosacea is one of the most complex topics within skincare. I’ve learned to accept my rosacea-prone skin and manage the condition by staying informed when it comes to triggers. If you’re in the same boat as me, please seek treatment options. There are effective solutions available.