Rosacea + Remedies
Rosacea is a chronic inflammatory skin condition with a global prevalence of 5%[1,2]. It’s actually the 5th most common dermatologist diagnosis, and is often misdiagnosed as adult acne[1]. In Canada, rosacea affects over 3 million people[2]. The condition usually has a later onset (symptoms start between 20-50 years), is more common between 30-60 years, and women seemingly are affected more than men[1,2,3]. Generally, rosacea involves variations of redness of the face, blushing easily, an acne-like appearance of the skin, or tiny swollen blood vessels (telangiectasias)[3]. It can also involve the eyes and nose[1,3].
Rosacea is associated with embarrassment and low self esteem, and up to 65% of patients with the condition reported symptoms of depression[4]. Rosacea can often feel worse than it looks, and it can be hard dealing with a condition that persists[2]. The good news is it's treatable, and controlling symptoms can improve both mental and emotional wellbeing[2].
Symptoms of Rosacea
Rosacea involves erythema (=redness) of skin on the forehead, cheeks, nose, and chin[1,3]. Major features include flushing, telangiectasia (=dilated capillaries that look like small red spidery clusters), and papules or pustules[1]. Minor features include swelling, dryness, and burning or stinging sensations[1]. In extreme cases, it can involve changes to the nose, caused by widening follicles, thickening skin, and enlarged glands[1].
Erythema (redness) and uneven skin
Telangiectasia (dilated capillaries)
Papulopustular rosacea
Rosacea Subtypes
There are 4 main subtypes of rosacea, but often symptoms can overlap between them:
Erythemato-telangiectatic - involves flushing, persistent redness of facial center, with or without telangiectasia (dilated capillaries)[4]. May also include swelling, stinging/burning, and skin roughness[2].
Papulopustular - involves persistent redness of facial center, with temporary papules/pustules that are often mistake for acne[2,4].
Phymatous - usually due to oil glands and connective tissue which cause skin to thicken and enlarge, becoming bumpy. Nose, chin, forehead, cheeks, or ears can be affected, but the most common area is the nose (called “rhynophyma”)[1,2].
Ocular - more than half of rosacea patients also have eye involvement, including foreign body sensation in the eye, burning, stinging, irritation, dryness, light sensitivity, blurred vision, and swelling around the eye[1,2,4]. Eye symptoms can even appear before skin symptoms[1].
Causes of Rosacea
Unfortunately, it still is not clear what causes rosacea, but it likely involves a number of different factors, such as genetics and environment, as well as specific triggers[1,2,4]. Dense sebaceous glands, nerve physiology, and vascular skin composition are being studied[4]. Scientists are investigating several potential biological pathways which involve dysregulation of innate and adaptive immune systems, but the specific way triggers may activate these pathways is still unclear[1]. There may also be predisposing factors or markers associated with rosacea, such as migraines, IBS, cardiovascular disease, and depression[1]. Family history or genetics may play a role, as rosacea tends to be more common in fair skin individuals of northern and eastern European descent (Irish, English, Scottish); however it can still develop in any skin type[1,2,4].
Rosacea Triggers
There are a number of potential triggers for rosacea, and it’s important to figure out what your triggers are to better manage your condition - keeping a journal will help you figure these out! Triggers can include sunlight, heat/hot weather (avoid hot baths, saunas), cold wind/weather (cover skin and moisturizer), spicy food, hot beverages/soup, caffeinated drinks, alcoholic drinks (especially red wine), certain comedogenic cosmetics, certain skincare products, dairy, or using alcohol or acetone-based products[1,2,4]. Intense exercise can cause overheating of the body, which can trigger flushing, so it’s important to stay cool while working out[2]. Emotional stress can also be a trigger, so sleeping well, deep breathing, healthy eating and exercise can help - while dehydration, skipping meals, and too much caffeine or sugar can increase stress levels[2,4]. Certain medications, such as calcium channel blockers, niacin, nicotinic acid, nitrates, sildenafil, and topical corticosteroids may also be involved with triggering rosacea[1]. However, always consult with your physician or pharmacist before stopping a medication.
Rosacea Treatment
Goals of rosacea therapy include identifying triggers and avoiding them, restoring a more even skin tone by reducing telangiectasias and controlling flushing/redness, managing any ocular symptoms, and reducing recurrence frequency and severity[1]. The following is a summary of treatment options that I hope you find helpful!
NON-PRESCRIPTION REMEDIES
General measures for helping with rosacea include avoiding triggers, using an appropriate skincare regimen, and applying proper sun protection. As well, there are certain procedures such as vascular laser/IPL, BBL, laser resurfacing, and electrosurgery that may help with certain types of rosacea, especially telangiectasia[1].
Skincare
Rosacea-prone skin is sensitive and dry, so stick with gentle products intended for sensitive skin[1,2]. The goal is to improve and maintain the permeability barrier of the stratum corneum and reduce sensitivity[2]. Avoid astringents, toners, and ingredients that may irritate such as camphor, menthol, alcohol, or acetone[1,4].
Cleansers: Use a mild, lipid-free, fragrance-free, non-abrasive, soap-free cleanser[1,4]. Aim for one that has a mildly acidic (non-alkaline) or neutral pH[4]. An example brand is Cetaphil. Use fingertips to gently cleanse, and pat skin dry[4].
Moisturizers: Look for a fragrance-free moisturizer with emollients and occlusives (for information on these ingredients, check out my dry skin blog post)[4]. Some features that improve dryness include lipid-free non-alkaline moisturizers (eg Cetaphil), ceramides (eg CeraVe), and polyhydroxy acid or PHA (eg Neostrata)[4].
SPF is a Must!
Everyone should be using SPF regularly, and it’s important for those with rosacea to protect damaged, irritated skin and to prevent flares. A broad-spectrum, SPF 30 (at least) should be used daily[1,4]. Specifically, look for sunscreen with either zinc oxide or titanium dioxide[4]. A product with dimethicone or simethicone may be better tolerated[4]. Wear a wide brimmed hat outside to protect your face, and try to avoid peak times in the sun from 11am-3pm[1,2].
Cosmetics
Extreme redness and inflammation can be difficult on self-esteem. If you prefer to camouflage it, green-tinted foundations are more effective in hiding the redness from rosacea[1,4]. Try to avoid makeup with fragrance, alcohol, and abrasive or irritating ingredients that may aggravate symptoms[2].
Eye Care
For ocular rosacea, good eyelid hygiene is key, which includes washing eyelids twice a day with baby shampoo (or diluted baby shampoo) and warm water[1]. Artificial tears (I usually suggest something preservative-free) can help with stinging/burning/dry eye symptoms[1]. A warm compress can also be soothing[4].
PRESCRIPTION REMEDIES
Prescription treatment for rosacea will depend on the type of rosacea present, severity, and what has been tried/worked in the past. It's important to realize that rosacea will generally not resolve on its own, and left untreated the condition can worsen[2]. Rosacea cannot be treated like acne can with OTC products, as self-treating with these non-prescription products may not help and even irritate the skin more[2].
Current options are listed in the two tables below for topical and oral treatments. In general, treatment is usually started with topical options for mild to moderate cases, with oral medication treatment reserved for more severe symptoms[4].
Topical Options [1,2,4]:
Medication (Brand Name) Category | Formulation + Typical Dosing | Helps With | How it Works | Tips |
Metronidazole (MetroGel, Metrocream, Metrolotion, Noritate) Antibiotic | Gel or cream Apply a thin film once or twice daily for 9 weeks, then as needed (can be used long-term) | Inflammatory lesions and redness | Improvement in about 4-6 weeks; may need 12 weeks to see large improvement Works by reducing oxidative stress which decreases redness and inflammation | Relapse may occur if stop Less irritating than azelaic acid Can use with oral doxycycline No significant difference in effect between strengths or vehicles |
Azelaic acid (Finacea) Dicarboxylic acid with antibacterial activity | Gel Apply twice daily | Inflammatory lesions and redness As effective as metronidazole, but may be less tolerated | Improvement in about 4-6 weeks Used for initial or maintenance therapy Works by inhibiting the creation of reactive oxygen species in white blood cells | Relapse may occur if stop Moisturizing before applying may help with irritation No difference in results between once or twice daily application |
Brimonidine (Onreltea, Mirvaso) Alpha-adrenergic receptor agonist | Gel Apply once daily | General facial redness | Shrinks dilated blood vessels ~ 30 mins. after applying. Effect can last up to 12 hrs. Works by promoting vasoconstriction (constricts blood vessels) | Discontinuation may result in rebound redness Wash hands immediately after applying **Cardiovascular effects may occur if ingested or applied to damaged skin!** |
Ivermectin (Rosiver, Soolantra) Acaricide | Cream Apply once daily | Inflammatory papules/pustules Decreases number of Demodex mites present | Works as an anti-inflammatory and on the Demodex mites (acaricide) | Benefits may continue after treatment stopped |
Cyclosporine (Restasis) Calcineurin inhibitorimmunosuppressant | Eye drop 1 drop each eye twice daily | Persistant or severe ocular rosacea | | Avoid touching tip of bottle to eyelids to keep sterile |
Oral Options [1,2,4]:
Medication (Brand Name) Category | Formulation + Typical Dosing | Helps With | How it Works | Tips |
Doxycycline (Apprilon, Oracea) Antibiotic | 40mg once daily x 12 weeks | Inflammatory papules/pustules Ocular rosacea | Used at a low, sub-antimicrobial dose for anti-inflammatory benefits and less risk of antibiotic resistance than higher dose; reassess after 3 months | Can use with topicals if response inadequate, or moderate-severe rosacea. Recurrence may occur after stopping Best absorbed on empty stomach Do not use if pregnant |
Isotretinoin (Accutane, Clarus, Epuris) Retinoid | Weight-based dosing Once daily x4-5 months | Inflammatory papules/pustules Usually only for refractory or severe cases unresponsive to antibiotics | Low dose used in treatment-resistant papules and pustules | Teratogenic! Do not use if chance of pregnancy - requires at least 2 types of contraception while on this. Many side effects |
Other Rx Options
Other medication options that have been used “off-label” with varying levels of evidence include calcineurin inhibitors (tacrolimus, pimecrolimus), clindamycin, benzoyl peroxide/clindamycin, permethrin, and retinoids (adapalene, tretinoin)[3]. When drugs are approved by the FDA or Health Canada, they are approved for treating certain conditions. Off-label means the drug has been approved for treating a certain condition, but is being used for another condition it was not approved to treat[3]. Using medication off-label generally occurs when the prescriber has deemed it medically appropriate for the patient, based on other factors (eg other options have failed).
Pregnancy and Rosacea
Some rosacea treatments should not be used in pregnancy and are even teratogenic, so if you are planning to conceive, please take note of the following and discuss with your physician:
STOP any oral retinoids (eg isotretinoin) at LEAST 1 MONTH prior to becoming pregnant; you must avoid getting pregnant for 1 month before starting therapy and 1 month after finishing therapy[1]. This is because isotretinoin is teratogenic (causes birth defects)[1].
STOP any tetracyclines (eg doxycycline) at LEAST 1 WEEK before attempting to conceive[1]. This class of medications is contraindicated in pregnancy, and can temporarily inhibit fetal bone development[1]. If exposure occurs in the 2nd or 3rd trimester, dental staining, enamel hypoplasia (weakened or no teeth enamel) in the baby, or liver toxicity in the mother can occur[1].
During pregnancy, topical treatments are preferred[1]. Azelaic acid has minimal absorption and is deemed safe; metronidazole absorption when used topically is also minimal and generally considered safe[1]. Similarly, azelaic acid and metronidazole both have low transfer to breast milk and are considered safe during breastfeeding[1]. Make sure to discuss your options with your physician and pharmacist!
Summary
Whew! There we go, rosacea in a nutshell. In summary, for inflammatory lesions and redness, a topical metronidzole or azelaic acid are generally used[4]. For general redness, topical brimonidine may be helpful[4]. Papulopustular rosacea may benefit from oral low-dose doxycycline, and phymatous rosacea is usually addressed with laser or light-based therapies[4]. Ocular rosacea may be helped with topical (cyclosporine) treatment or oral antibiotics[4]. If you stick with your physician’s treatment plan, your symptoms should start to improve in a few weeks!
References
Rivers, J.K. Rosacea. Canadian Pharmacists Association. Updated March 25, 2021. Retrieved 19April2021 from eCPS.
Canadian Dermatology Association. Rosacea. 2021. Retrieved 20April2021 from https://dermatology.ca/public-patients/skin/rosacea/.
UpToDate. Rosacea (Patient Education - Disease and Procedure). Updated March 3, 2021. Retrieved 19April2021 from Lexicomp online.
Oge, L.K, Muncie, H.L and Phillips-Savoy, A.R. Rosacea: Diagnosis and treatment. Am Fam Physician. 2015 Aug 1;92(3):187-196. Retrieved 20April2021 from https://www.aafp.org/afp/2015/0801/p187.html.
DISCLAIMER: The contents of this blog are for educational purposes and are not intended as medical advice. I enjoy researching but the information is general and not comprehensive. Please seek the advice of your healthcare provider (pharmacist/physician etc) with any questions you may have regarding your personal health. Never disregard professional medical advice or delay in seeking it because of something you have read online. Any mention of specific products or personal recommendations are my opinion and not to be taken as medical advice.
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