Are you one of the 10% who suffers from a prolonged blush, spots that tend to occur in the middle of the face, rather than the t-zone? And do you find that your skin is often red and irritable, especially when it comes to trialling new skincare.
Well you might have rosacea. April is Rosacea Awareness Month so I wanted to go deep and discuss this common and distressing condition because there’s lots you can do to keep it in line, and reduce progression and I want you to have all the information you need to take charge of your skin.
Now, I’m prone to rosacea myself - my tendency for acne waned in my 30s and I began to notice different skin behaviour. A glass or red wine would make me red for a long time, as would spicy foods. And my skin tolerated skincare with a low pH less well than it used to. I also had to be more careful with my choice of sunscreen.
So some of these issues may be familiar to you. The good news is that with knowledge and good skincare choices, it's manageable and with a good strategy the anxiety around it becomes much less.
What are the different types of rosacea?
It's an incredibly common disorder, typically occurring between ages 30-60, affecting light skinned, light eyed individuals. But it can also affect darker skin tones where it presents greater diagnostic challenge.
Type 1 is known as erythematotelangiectatic rosacea or ETR and this is characterized by a prolonged flush and is often the first sign of the disease. Dilated capillaries or telangiectasia are also seen, leading to reddening of the skin.
Type 2 is perhaps the most recognisable and is termed papulopustular rosacea - it’s the form that gets mixed up with acne because you see red spots (papules) and white-headed spots (pustules) typically in the centre of the face, over the cheeks nose and chin.
Then we have type 3 or phymatous rosacea. This is most commonly seen in men and is characterized by firm, thickened areas overlying the redness zone, most commonly on the nose (rhinophyma) and it’s because the inflammatory process progresses to fibrosis.
Finally we have type 4 or ocular rosacea. Gritty, sore and red eyes are a common finding in as many as 40% of patients and may be associated with skin changes or may occur in isolation.
In practice, whilst we recognise these distinct subtypes, it’s common for them to overlap. One of the hallmarks of most individuals with rosacea whatever the sub-type is sensitive skin due to skin barrier dysfunction - stinging and burning are frequently experienced, especially in reaction to the elements, what you ingest and especially to certain types of skincare.
What triggers rosacea?
So many things. Let’s talk about the elements! Cold weather in winter steals away essential moisture from the skin and can aggravate the barrier dysfunction so a skiing trip may be very uncomfortable. Similarly UV exposure in summer can also wreak havoc. I think it’s fair to say that the in-between seasons are the kindest.
What you consume has an impact - common aggravants include alcohol, especially histamine releasing red wine. Spicy foods are frequently provocative so go easy on the hot sauce; and hot, caffeinated beverages may also trigger a flush.
I advise patients to pay close attention to the ambient temperature of their environment - overly hot baths, saunas, hot yoga or HIIT training are best avoided
What skincare is best for rosacea?
Think simple! Unfragranced is best. Extra care should be taken with cleansing - if you get cleansing wrong with rosacea, it's hard to get cleansing right. Gentle, non-foaming cleansers are best and I’d strongly advise sticking to a single cleanse. and avoid denatured alcohol and essential oils.
You may also be best with mineral spf such as Flawless Gossamer SPF, especially when disease is active.
How do I repair my skin barrier if I have rosacea?
Firstly don’t deplete it in the first place. Simplify cleansing is *so* important.
Use a moisturiser with barrier repair ingredients like ceramides and niacinamide. And avoid any skincare steps that will deplete it. Flawless Moisturiser has been formulated with 5% niacinamide but if you prefer a gel-textured hydrator, consider Flawless Moisturiser Light which is enriched with ceramides.
Of course, treating rosacea is a key aspect to restore your skin barrier. Inflamed skin does not retain water well so bringing that under control is vital.
Topicals in the toolkit
We have several options that are helpful.
Metronidazole Gel or Cream (on prescription). This has been around for a long time and its effective, however I find myself prescribing it less and less as we have more efficacious options available.
Ivermectin Cream (on prescription) This has been a great addition to the rosacea treatment armamentarium as it's in a Cetaphil Moisturiser base, so the texture is better than many of the formulations of old. It's also extremely helpful in active, inflamed papulopustular disease.
Azelaic Acid on prescription (15 and 20%) but it’s also now widely available over the counter, which is great news. Previously there were really very few options to rosacea sufferers over the counter so this is real progress. Anything from 5% to 20% can be helpful. It’s why I made a point of featuring this wonder ingredient in my Flawless Brightly and Nightly Serum. I find this the most helpful in the long-term maintenance of my rosacea patients.
Tetracyclines, in particular Doxycycline low-dose therapy for 6-12 weeks (sometimes longer)
In using oral antibiotics, we’re harnessing their anti-inflammatory action to reduce enzymes matrix metalloproteinase (MMP) activity, and downstream of this they reduce the overactivity of the innate immune system, lowering the level of a key molecule, our cathelicidins. They are not thought to work through their anti-microbial function.
How do I calm down a rosacea flare?
One of my favourite combinations is topical Ivermectin + a tetracycline. Their synergistic action works quickly; I then add in Azelaic Acid as things get less firey. Sometimes low dose Isotretinoin is needed but it’s benefits don’t persist once treatment is stopped (as they do in acne) so it’s used less often. In individuals who are severely affected by flushing, we can use drugs that target the unstable blood vessels, the alpha adrenergic receptor blockers although in practice I use these infrequently.
What should you not use on your face if you have rosacea?
I’d discourage the following:
- Double cleansing
- Toning - of any kind
- Most face masks
- Physical exfoliants
- Chemical sunscreens can cause issues
- I’d skip facials as a general rule - they offer little to benefit the rosacea sufferer and are high risk for triggering a flare.
It can be tricky managing rosacea alone. And certainly when it gets going, you’ll benefit from prescription products to help bring it under control. But a long-term maintenance strategy is also needed. I’m pleased to report, though, that once under control, my rosacea patients can usually go on to evolve their routine and target other concerns like premature ageing quite successfully and I’ll talk about that next week.
If you know someone who struggles with rosacea I’d LOVE for you to share this post!