Best Skin Care Practices & Products for Rosacea

The skin of those with rosacea is exceptionally sensitive to various environmental, dietary, and facial products that can initiate or exacerbate rosacea symptoms. The sensitivity of the skin may be due to dysfunction of the epidermal barrier of the skin, as well as an overactive immune response. In some people, rosacea may be triggered by an exaggerated immune response to Demodex mites, which are part of the normal microbiota of human skin. The overall management of rosacea involves avoidance of environmental and dietary triggers and the appropriate selection of skin care products.

What is Rosacea?

Rosacea is a chronic inflammatory skin condition with the presence of central facial redness, flushing, inflammatory bumps, and telangiectasias (small visible blood vessels).^[1] Rosacea is also commonly associated with secondary features, such as burning and stinging, plaques, nodules, eye symptoms, phymatous reactions (skin thickening), swelling, and a dry skin appearance.^[1] Rosacea is actually an umbrella term used for multiple subtypes of rosacea that can have overlapping characteristics.

The main subclasses of rosacea include

• Erythematotelangiectatic rosacea
• Papulopustular rosacea
• Ocular rosacea
• Phymatous rosacea
• Granulomatous rosacea

Sensitive Skin

The most common subtype of rosacea is erythematotelangiectatic, followed by papulopustular. Erythematotelangiectatic rosacea is characterized by facial flushing, persistent redness, and visible small blood vessels (telangiectasia) on the cheeks, forehead, nose, or entire face.^[2] Similarly, papulopustular rosacea also presents with central facial redness, along with red and pus-filled bumps that come and go.^[2] These bumps are raised on the skin surface and can have a pus-filled center. Both of these subtypes of rosacea have been shown to have a poorly functioning skin barrier.^[3] This means that the skin cannot hold on to moisture normally. This decrease in facial hydration results in dryness and irritation, which can, in turn, make the skin even more sensitive.

Skin Care Products

Rosacea-prone skin has a compromised skin barrier function and is more susceptible to dryness, irritation, and skin sensitivity. Many ingredients in skin care products can cause irritation and make rosacea worse. Choosing the right rosacea-friendly products is an important factor in managing rosacea exacerbations. Cleansers and moisturizers should be selected to improve skin barrier function and reduce irritation and inflammation.

Facial cleansers

When it comes to washing the face, there are many different cleansing options. However, some are better than others when it comes to rosacea.

Soap Cleansers

Regular soap-based cleansers are created through a process called saponification, which is a chemical reaction that combines a fat molecule with an alkali molecule to create long chain fatty acid alkali salts.^[4] These soaps have a high pH, around 9 and 10, which is considered a basic or an alkali pH.^[5] The skin has a naturally acidic pH of 4-6.5.^[5] Cleansing the face with a regular soap-based product can increase in the skin’s natural pH to a less acidic environment. Consequently, when the skin becomes less acidic and more basic, this allows for overgrowth of bacteria and can cause damage to the lipids in the outer most layer of the skin, the stratum corneum.^[5] When this outer layer is damaged it can increase irritation, dryness, and sensitivity, especially in rosacea-prone skin.^[4]

Soap alternatives

Using cleansers with a pH that closely mimics the skin are better alternatives for those with rosacea to reduce the incidence of irritation and flares. These include syndets (synthetic detergents) and lipid-free cleansers. Syndets have a neutral or slightly acidic pH and are less irritating than soap.^[5] In comparison to soap, they do not cause destruction to the lipid layer of the skin.^[5] By preserving the lipid layer of the skin, it decreases dryness and irritation. Lipid-free cleansers, also known as “soap-free liquid cleansers”, are designed to clean the skin without soap formation and leaves behind a thin moisturizing layer on the skin.^[5] This is made possible by emollients (e.g., fatty alcohols), which facilitate the evaporation of the cleanser, and humectants (e.g., propylene glycol) which help to keep the skin moisturized.^[5] Both syndet cleansers and lipid-free cleansers are well suited for those with rosacea, as they are less irritating and help to maintain the moisture of the skin.

Antibacterial soap

Another type of cleanser is antibacterial soap, also known as combination bars (combars). This type of cleansing agent contains a combination of true soap and sydnets with an added antibacterial agent. Although antibacterial soaps may be helpful in initially improving rosacea, it can strip away the skins natural bacteria and cause an increase in dryness and sensitivity due to the soap component within the cleanser.^[4] Antibacterial soaps are generally not ideal for those with rosacea.^[1]

Moisturizers

Rosacea often involves a defective moisture barrier in the skin, as well as increased epidermal water loss, both of which can cause an increase in skin irritation and inflammation.^[7] Therefore, selecting a moisturizer for rosacea-prone skin is pivotal in symptom management. The basic function of a moisturizer is to provide hydration and a barrier for the outer layer of the skin, the stratum corneum. Common moisturizing agents are occlusives and humectants.

Occlusive ingredients for trapping the skin’s moisture

Occlusive agents prevent moisture loss by creating an oil or lipid barrier on the skin. This barrier inhibits evaporation of the skins natural moisture.^[4] There are many occlusive agents that can be found in moisturizers. The most effective agent is petrolatum which can reduce water loss by 98%, followed by other occlusive agents that can reduce water loss by 20-30%.^[4]

Humectant ingredients for hydrating the skin

Humectant moisturizers work by pulling water from the environment and dermis (the second layer of skin) to the epidermis (the top layer of the skin). This process increases skin hydration by attracting and holding water within the epidermis. There are both natural and synthetically derived humectants. Glycerin (glycerol) and hyaluronic acid are two of the most common and effective humectants.

Common facial irritants

A common misconception of rosacea skin is that if the skin is red, to remove the outer layer to eliminate the redness. This is an interesting theory and an incorrect solution. Rosacea-prone skin is naturally sensitive due to the impaired epidermal barrier and exaggerated inflammatory response. Using abrasive products or treatments such as microdermabrasion or chemical peels that could stimulate removal of the epidermis or irritate the outer layer of the skin could actually exacerbate rosacea flares.^[2,8]. In addition, many facial products can contain hidden ingredients that can make rosacea worse. In general, products that can cause stinging, burning or increased blood flow could exacerbate rosacea. Products containing alcohol can sting the face, and dry out the skin. Various oils may increase blood circulation which can contribute to the presence of facial flushing and redness. Fragrance is a common component in many facial products and is one of the biggest offenders in causing rosacea flares. Common procedures and irritants in products that should be avoided include:

• Microdermabrasion^[2]
• Chemical peels^[2]
• Topical retinoids^[8]
• Astringents or toners containing alcohol^[2] (e.g. Witch hazel)^[3]
• Methanol^[2,3]
• Peppermint oils^[2,3]
• Eucalyptus oil^[2,3]
• Clove oils^[2]
• Sodium lauryl sulfate^[4] (found in many soaps)
• Fragrance in cleansers and moisturizers^[3]

Lifestyle and Rosacea

While the underlying reasons for why rosacea occurs is still unknown, there are several triggers that have been shown to spark rosacea flares and increase skin irritation. One of the defining characteristics of rosacea is facial flushing, along with chronic erythema (redness) of the face. Flushing is a result of the dilation of blood vessels, which leads to increased blood flow to an area. This increase in blood flow causes the appearance of flushing and redness. In general, anything that can cause blood vessels to dilate can also cause a rosacea flare.^[8] Common triggers that cause vasodilation are:

• Alcohol consumption
• Spicy foods
• Exposure to extreme temperatures^[8]
• Hot beverages
• Strenuous exercise
• Sun exposure
• Emotions such as stress, anxiety, embarrassment

Quick Tips for Rosacea

• Opt for a syndet or lipid-free cleanser to decrease irritation and maintain pH balance. Sulfur-containing washes may be helpful.
• Reduce use of true soap and antibacterial soap cleansers that can alter the skins natural pH and damage the outer layer of the skin
• Moisturize with a humectant or an occlusive agent
• Identify and avoid rosacea triggers
• Wear broad-spectrum sunscreen of at least SPF 30 and reapply
• Consult a dermatologist if you are unsure about what products or procedures are safe for rosacea-prone skin.

A dermatologist may recommend a topical antibiotic gel or cream, or a low-dose oral antibiotic to decrease inflammation, especially if eye symptoms are present. For patients with difficult-to-treat rosacea, treatment may be aimed at treating Demodex mites.