Rosacea: The Curse of the Celts

Rosacea is a frustrating skin condition. Despite how long I’ve knowingly had the condition, I’ve struggled with it. Some days are good days, and some days are not so good. There’s rarely a single reason I can pinpoint for the bad days, and at times my skin can flare from occurrences so benign that they don’t even deserve a note.

This seems to be the universal problem with rosacea. It is confounding, chronic, and difficult to treat. There is no universal treatment, and for some, the recommended cures can turn into the cause.

Compounding that is the fact that rosacea frequently looks like other skin conditions, such as acne, and the prescriptions for acne can also aggravate the rosacea, undoing any benefits. To make matters worse, rosacea is frequently misdiagnosed and under-treated, leaving sufferers with worsening symptoms that are difficult to reverse.

My mom had always battled with it, and for decades she was misdiagnosed with acne. By the time she was properly diagnosed with rosacea (subtype 2), she had suffered from broken capillaries and flushing that was difficult to cover with make-up, as well as frustrating breakouts that did not respond to typical acne treatments.

Her story is one that is pretty common with rosacea-sufferers. It’s frustrating, painful, and sometimes just embarrassing.

As I was researching for this article, I uncovered so much that challenged my initial ideas around rosacea. It is without a doubt that skincare and lifestyle habits are the most important things for rosaceans, and hopefully, once you’re done with this post, you will be left with answers to some of the questions you started with.


The Curse of the Celts

Rosacea afflicts nearly 30-50% of the Caucasian population, particularly those of European descent. In one genome-wide study conducted in 22,952 individuals whose genomes were >97% European ancestry, they found that 2,618 individuals answered “yes” to whether they had been diagnosed with rosacea (roughly 9%). This was consistent with the population data of European countries, where the prevalence of rosacea has been reported as affecting upwards of 10% of the population¹. This link has earned it the nickname of “the Curse of the Celts.”

It is most common in women, but frequently the most severe in men. It also tends to run in families, and researchers have discovered two genetic variants that may be associated with the disorder.

According to the National Rosacea Society, nearly 90% of rosacea patients say the condition lowers their self-confidence and self-esteem, and 41% report it causing them to avoid public contact or social engagements. For patients with severe rosacea, nearly 88% said their condition negatively affected their professional interacts, and nearly 51% missed work due to the condition.²


The Subtypes of Rosacea, Defined

The National Rosacea Society Expert Committee has identified four major types of rosacea, though subtypes 1-2 are the primary major subtypes that can be accompanied by symptoms in subtypes 3-4.

The two primary subtypes of rosacea (1-2) are Erythematotelangiectatic Rosacea (ETR) and Papulopustular Rosacea (PPR). The common link between all types of rosacea is the constant blush or flush — called erythema — that remains present in the central portions of the face. It is the other symptoms, such as flushing, papules or pustules, ocular symptoms, phymatous changes, and telagiectasias, that determine the subtypes.

rosacea-forms

Subtype 1 ( Erythematotelangiectatic or ETR)

Facial-redness-cropped
Subtype 1 (ETR)

ETR presents as erythema with some visible blood vessels (telangiectasias). It has an abscense of papules, pustules, or nodules. ETR patients report a flush that lasts longer than 10 minutes, and usually involves the center-most part of the face, but can also involve the peripheral regions. The episodes can occur from emotional stress, spicy foods, hot baths and showers, hot weather, or with no cause at all. People with ETR frequently describe themselves as extremely sensitive and dry, sometimes accompanied by tightness, itching, and burning or stinging, even with topicals meant to soothe discomfort and redness.

Subtype 2 (Papulopustular or PPR)Bumps-and-pimples-cropped

Formerly “acne rosacea,” PPR presents with erythema (the common link between all types of rosacea) and can also display visible blood vessels. It is accompanied by papules and pustules, and sometimes swelling (edema) can occur, particularly in the cheeks. It can be dry, scaly, and even itchy, but not respond to heavy moisturizers or creams. A history of flushing and irritation from external stimuli can occur in PPR patients, but the symptoms are usually much milder than ETR patients and are generally less common. Due to the presence of papules and pustules, it is frequently misdiagnosed as rosacea, but generally responds very little to conventional acne treatments, and can sometimes worsen.

TABLE 1. Findings in patients with Subtype 2 Rosacea prior to treatment. ¹ n=patients
CHARACTERISTICS GROUP 1 (n=457) GROUP 2 (n=127) GROUP 3 (n=331)
Skin Dryness 65% 66% 69%
Scaling 51% 58% 57%
Itching 49% 51% 52%
Edema (Swelling) 36% 32% 38%
Burning 34% 33% 36%
Stinging 29% 34% 29%
Discomfort 17% 14% 21%

Patients with both ETR and PPR report hyper-reactivity to skin products (82% in a survey by the National Rosacea Society), even those meant for sensitive skin types, and UV (sun) exposure plays a large role in both conditions, but especially for patients with ETR.

rosacea-telangiectasia
Visible veining (telangiectasias)

Disruption of the skin barrier (the stratum corneum permeability barrier) plays a large part in rosacea, and all rosacean patients experience increased trans-epidermal water-loss (TEWL), particularly in the areas of the face most effected, such as the cheeks and along the sides of the nose. This disruption plays a large part in why rosacean skin is so hyper-reactive. In a study involving 7 ETR patients and 25 PPR patients, 100% of ETR patients responded positively to a “sting test” (discomfort, flush, stinging sensations) of 5% lactic acid, while 68% PPR patients responded potively. Only 19% of the control group responded in the same manner.

Subtype 3 (Phymatous)Skin-thickening-cropped

Subtype 3 is defined by thickening of the skin, enlarged pores, and surface nodules. It oten presents with bulbous nose (rhinophyma), lumpy, swollen areas (particularly in the cheeks). It can occur in women, but is most prevalent in men. In the past, it was confused for alcohol abuse (the “gin blossom”). In 50% of cases, it can cause irritated, bloodshot eyes, which is associated with subtype 4.

Subtype 4 (Ocular)

Ocular-Rosacea4
Ocular rosacea with PPR

The white part of the eye (sclera) has persistent burning, grittiness, dryness, discomfort, and visible blood vessels. Sties are common in sufferers of ocular rosacea. Inflammation of the eyelid is also common, and pink eye (conjunctivitis) can be recurring. Eye makeup can become painful and increase the symptoms.


Causes of Rosacea

There is a lot of debate around what causes rosacea, and nothing is for certain. Researchers have discovered two genetic variants that may be associated with the disorder, and fairly recent research suggests that the facial redness is likely the start of an “inflammatory continuum initiated by a combination of neurovascular dysregulation and the innate immune system.”² Beyond this, mites have also been considered a contributing factor to the condition (particularly the demodex folliculorum mite). While this mite is present on all people’s skin, it was found to be even more abundant in the facial skin of rosaceans.


Other Considerations

Rosacea is frequently accompanied by other conditions. In a study across 6 million people (nearly 83,500 with rosacea), aged 18 and above, researchers in Denmark found that people with rosacea seem to be at higher risk for dementia, particularly Alzheimer’s, compared to people without the disease³. It has also been linked to a progressive form of  hair loss in women.⁴  As if this isn’t bad enough, according to the National Rosacea Society, 26% of patients reported seborrheic dermatitis (SD) of the face, and 28% had SD of the scalp⁵.

Rosacea is also a highly inflammatory disease, and some patients may see mild to moderate improvement by adopting a healthier lifestyle that reduces inflammation in the body, such as eating probiotic rich foods (particularly ferments) and turmeric and ginger.

Smoking, drinking, and eating too much sugar can all cause inflammation in the body. Additionally, one study found that women taking birth control pills are at an increased risk of developing rosacea⁶.

Caring for Rosacea

The most important thing you can do if you have rosacea or think you have rosacea is visit a dermatologist, particularly one that specializes in rosacea (the National Rosacea Society has a physician finder to help get you started). There are many treatments that can create immense improvement. If you lack insurance and live in the US, Curology, an online dermatology service, is an option.

Beyond that, there is no magic bullet, but skincare (particularly cleansers, moisturizers, and sunscreen) seems to be the most important. Everyone’s skin is very different, and rosacean skin is especially individual.

TABLE 2. Skin care products and skin sensitivity in rosacea. Female respondents. n=patients
PRODUCT % (n=1,023)
Astringents and Toners 49.5%
Soap 40%
Makeup 29%
Perfume 27%
Moisturizers 25.5%
Hairspray 20%
Shampoo 12%
TABLE 3. Skin care products and skin sensitivity in rosacea. Male respondents. n=patients
PRODUCT % (n=1,023)
Soap 24%
Cologne 19%
Shaving lotion 24%
Sunscreen 13%
Shampoo 12%

Cleansers

One of the key parts to success when treating rosacea is the skincare routine you build for yourself, particularly gentle routines that do not further aggravate or inflame the skin. The cleanser is what you build the foundation of the rest of a skincare routine upon. I wrote a long post about cleansers that I encourage you to read, and indeed, all of the same rules apply.

Rosacean skin is particularly prone to being stripped, with “true” soaps (saponified soaps) being the worst, as they have a pH of 9 to 10. True soaps are excellent at removing dirt and debris, but in the process they strip the lipids of the skin, causing increased TWEL, dehydration, altered desquamation (shedding), and increased penetration of topically implied substances.

Syndet cleansers (or synthetic detergent cleansers) are usually less than 10% soap and have a more neutral to acidic pH (5.5 to 7), which makes them minimally stripping. They’re made from oils, fats, or petroleum, but are not processed like true soap. These are the gentle cleansers of old, before creamy cleansers were so widely available. These are recommended if you are unable to use creamy cleansers.

In one experiment on arm skin, the ultra-structural skin changes were monitored after washing with a true soap as well as a mild syndet bar. Electron microscopy revealed changes in the skin structure, including uplifting of cells and an increase in surface roughness after washing with true soap. In contrast, the syndet-washed skin had well-preserved proteins and lipids. Some examples of syndet cleansers recommended for rosacea:

Aveeno Moisturizing Bar

Ingredients: Oat Flour Avena Sativa, Cetearyl Alcohol, Stearic Acid, Sodium Cocoyl Isethionate, Water, Disodium Lauryl Sulfosuccinate, Glycerin, Hydrogenated Vegetable Oil, Titanium Dioxide, Citric Acid, Sodium Trideceth Sulfate, Hydrogenated Castor Oil.

Dove Sensitive Skin Unscented Beauty Bar

Ingredients: Sodium Lauroyl Isethionate, Stearic Acid, Sodium Tallowate, Sodium Palmitate, Lauric Acid, Sodium Isethionate, Water, Sodium Stearate, Cocamidopropyl Betaine, Sodium Cocoate, Sodium Palm Kernelate, Sodium Chloride, Tetrasodium EDTA, Tetrasodium Etidronate, Maltol, Titanium Dioxide (CI 77891).

Combination bars are another type of cleanser and are typically antibacterial soaps that are quite literally a combination of true soap, syndet, and antibacterial agent. This gives them a pH of 9 to 10. They are not recommended for rosacean skin due to their propensity to strip skin of essential flora.

Lipid-free cleansers are what most of us are familiar with. These are the liquid, creamy cleansers that cleanse without soap formations and are designed to leave moisture in the skin. They are some of the most studied cleansers with rosacean patients, and also some of the most recommended. Examples of lipid-free cleansers recommended for rosacea:

Aquanil

Ingredients: Water (Purified), Glycerin, Cetearyl Alcohol, Stearyl Alcohol, Benzyl Alcohol, Sodium Laureth Sulfate, Xanthan Gum.

CeraVe Hydrating Cleanser

Ingredients: Purified Water, Glycerin, Behentrimonium Methosulfate And Cetearyl Alcohol, Ceramide 3, Ceramide 6-II, Ceramide I, Hyaluronic Acid, Cholesterol, Polyoxyl,. 40 Stearate, Glyceryl Monostearate, Stearyl Alcohol, Polysorbate 20, Potassium Phosphate, Dipotassium Phosphate, Sodium Lauroyl Lactylate, Cetyl, Alcohol, Disodium EDTA, Phytosphingosine, Methylparaben, Propylparaben, Carbomer, Xanthan Gum.

Moisturizers

Hydration is integral to the function of skin in all people, but is very important in rosaceans, who have impaired skin barrier function and increased TEWL, regardless of subtype. I’ve written a full post about the classes of moisturizers, which you can find here.

Occlusive ingredients are very important for this reason. Examples include petrolatum, mineral oil, caprylic/capric triglycerides, silicones (such as dimethicone), lanolin, ceatyl alcohol, and stearyl alcohol. Unfortunately, while petrolatum can reduce water loss up to 98%¹, it can also diffuse into the intercellular lipid domain of the skin, interfering with barrier recovery. This may make it a poor choice for patients with ETR and PPR¹.

Note: This was new information to me and very surprising, as petrolatum is recommended for virtually all skin with impaired barrier function virtually everywhere in skincare communities, and I use it myself. I’ve done some additional digging and it seems like studies are mixed. There are a fair number of studies that cite that petrolatum products (specifically Vaseline) do not interfere with barrier recovery, while others dispute that occlusive-only coverings (such as Vaseline only as opposed to a product with petrolatum mixed in) are the problem, not petrolatum itself. 

Lanolin is also not recommended for rosaceans due to inducing allergic or irritant reactions. Another ingredient to look out for is propylene glycol, which can pose issues for hyper-sensitive skin, even in very low concentrations (<2%).

The benefits outweigh the downsides though, and rosaceans are encouraged to experiment with products until they find one that works.

While not inherently harmful, stearic acid and palmitic acid are some other ingredients commonly found in moisturizers that have the most potential to interact with skin lipids, and thus create reactions in rosacean skin.

Menthol, alcohol, acetone, sodium lauryl sulfate, benzalkonium chloride, benzyl alcohol, camphor, urea, and fragrance (parfum) are all common skin irritants for rosacea.

In general, rosaceans are encouraged to use products containing lipid-restoring ingredients, such as cholesterol and ceramides. Examples of recommended products:

CeraVe Daily Moisturizing Lotion

Ingredients: Purified Water, Glycerin, Caprylic/Capric Triglyceride, Behentrimonium Methosulfate and Cetearyl Alcohol, Ceteareth-20 and Cetearyl Alcohol, Ceramide 3, Ceramide 6-II, Ceramide 1, Hyaluronic Acid, Cholesterol, Dimethicone, Polysorbate 20, Polyglyceryl-3 Diisostearate, Potassium Phosphate, Dipotassium Phosphate, Sodium Lauroyl Lactylate, Cetyl Alcohol, Disodium EDTA, Phytosphingosine, Methylparaben, Propylparaben, Carbomer, Xanthan Gum

Paula’s Choice MOISTURE BOOST Hydrating Treatment Cream

Ingredients: Water (Aqua), Ethylhexyl Stearate (texture enhancer), Simmondsia Chinensis (Jojoba) Seed Oil (emollient plant oil), Butylene Glycol (texture enhancer), Glycerin (skin-replenishing ingredient), Petrolatum (emollient), Cetearyl Alcohol, Dipentaerythrityl Hexacaprylate/ Hexacaprate, Tridecyl Trimellitate (texture enhancers), Sodium Hyaluronate, Ceramide 3, Cholesterol (skin-replenishing ingredients),Tocopherol (Vitamin E/antioxidant) Squalane (emollient), Magnesium Ascorbyl Phosphate (stabilized Vitamin C/antioxidant), Dimethicone (texture enhancer), Niacinamide (Vitamin B3/skin-restoring ingredient) Polysorbate 60 (texture enhancer), Hydrolyzed Jojoba Protein, Hydrolyzed Wheat Protein (skin conditioning agents), Avena Sativa (Oat) Kernel Extract (soothing agent), Hydrogenated Lecithin (skin-restoring ingredient), Whey Protein (water-binding agent), Tridecyl Stearate, Neopentyl Glycol Dicaprylate/Dicaprate, Phenyl Trimethicone, Myristyl Myristate (texture enhancers), Linoleic Acid, Linolenic Acid, Decarboxy Carnosine HCI (skin-restoring ingredients), Hydroxyethyl Acrylate/Sodium Acryloyldimethyl Taurate Copolymer, Acrylates/C10-30 Alkyl Acrylate Crosspolymer (texture enhancers/water-binding agents),Cetearyl Glucoside, Cetyl Alcohol, Polyglyceryl-3 Beeswax (texture enhancers/emollients), Aminomethyl Propanol (pH-adjustor), Disodium EDTA (chelating agent), Benzoic Acid, Chlorphenesin, Sorbic Acid, Phenoxyethanol (all preservatives).

In short, avoid harsh skin care regimes that contain astringent (stripping) toners, abrasives (such as washclothes or cleansing tools like the Clarisonic), and sensory stimulants (menthol, camphor, and other things that “tingle”).

This proper care and grooming preps the skin for treatments. One study I read literally called it “priming the skin.” This is because once set into motion, the inflammatory reaction of rosacea is a domino effect that makes any topicals (either prescription treatments or basic skincare) even more challenging. Rosacean skin is incredibly delicate, and even once seemingly under control, the dominoes can begin to fall once you add products that were once too irritating.

For example, when I first began treating my rosacea, I could not use anything outside of my basic moisturizer. Years into treatment, I have begun to experiment. Every now and then though, I get cocky and try to introduce something to my routine too quickly after playing with harsher products, such as when I tried to use ialuset so shortly after using a BHA. My skin lit up and felt like it was on fire.

This is common with rosacea, and is called “status cosmeticus” (cosmetic intolerance syndrome).

Priming the skin — aka giving it time to rest and recover — mitigates the risk of this occurring.

When skin is this flared up, it is recommended to wait before applying even the most bland of moisturizers. In some cases, delaying up to 30 minutes may be necessary. This reduces risk of irritation. Once tolerability improves, you can reduce the wait time by 5 minutes per week until you are able to moisturize right after cleansing.

Sunscreens

Sun exposure plays a large part in the erythema of rosacea, particularly in ETR, and was cited as the number one trigger for redness and flushing by the NRS. For this reason, it is incredibly important to wear sunscreen or a hat daily. I’ve done a larger post on sunscreens that you can read here.

In general, zinc oxide sunscreens seem to do well with rosaceans due to the soothing effects of the zinc. Zinc oxide can be a bit drying though, so wear a moisturizer underneath if it feels uncomfortable.

Organic sunscreens (chemical filters) may cause stinging and irritation, particularly if the skin is more sensitized or irritable.

Prescription Topicals

Prescription topicals have become more and more common for treating rosacea, especially when considering the growing prevalence of antibiotic resistance (though some oral medications, like Oracea, have shown promise due to the lower prescribing level it is prescribed at, and is typically prescribed in combination with topicals for treating PPR).

Metronidazole

Metronidazole is known under the brand names MetroGel, MetroLotion, and MetroCream. It has been well-studied and has impressive results at killing some of the microbes that are considered responsible for rosacea.

Azelaic Acid

Approved by the FDA in 2002, azelaic acid (AzA, brand names Finacea and Azelex) is usually prescribed to treat mild to moderate ETR or PPR in concentrations of 15-20%. It is a dicarboxylic acid, and usually sits at a higher range of the pH scale (4.8-5). This is potentially what makes it less irritating.⁷ In one study, it was shown to be potentially as effective as metronidazole, but tolerated much better by patients.

It should also be noted that in another study involving AzA (15%), waiting until after moisturizing to apply AzA resulted in greater penetration of the AzA. This did not occur with all moisturizers however, and was only seen in moisturizers that lacked large amounts of occlusives.

It should also be noted that in a small study, gluconolactone (PHA) was shown to be helpful when combined with Azelaic Acid 15%.

Azelaic acid can be found in some over-the-counter products and in mixtures from Curology (US only, 4%+).

Oxymetazoline Hydrochloride

Oxymetazoline hydrochloride (brand name Rhofade) is an extremely new topical for treating the redness that is characteristic of rosacea. The mechanism of action is vasoconstriction — quite literally meaning it constricts the blood vessels involved in rosacea. You may recognize a different form of oxymetazoline from nasal sprays, such as Afrin.

Oxymetazoline hydrochloride was approved for topical use by the FDA in January 2017 and became available for prescription in May 2017. Unfortunately, it’s so new that I can’t find a ton of literature on it that wasn’t part of the initial literature and studies submitted to the FDA for approval.

However, according to the last study submitted by the parent company (Allergan) to the FDA for approval: “The FDA’s approval was based on data from two identical randomized, double-blind, parallel-group, vehicle-controlled studies involving a total of 885 patients with moderate or severe disease who were treated with oxymetazoline cream or vehicle. In study 1, the proportions of patients with reduced erythema at hours 3, 6, 9, and 12 on day 29 were 12%, 16%, 18%, and 15%, respectively, for oxymetazoline cream (n = 222) compared with 6%, 8%, 6%, and 6% for vehicle (n = 218). In study 2, the corresponding values were 14%, 13%, 16%, and 12% for oxymetazoline cream (n = 224) compared with 7%, 5%, 9%, and 6% for vehicle (n = 221).”¹¹

Brimonidine Gel

Approved by the FDA in 2013, Brimonidine gel (brand name Mirvaso) was one of the first topicals approved for vasoconstriction.

Unfortunately, it can cause severe rebound erythema if it does not do well with you.

Retinoids and Adapalene

For sufferers of PPR, tretinoin (such as brand names Renova and Retin-A) as well as adapalene (brand name Differin) may be an option. In a small study of 25 patients with mild to severe PPR who were treated with .05% tretinoin, 80% had complete or excellent resolution of their papules and pustules, with only one patient showing no improvement. In 40% of patients, it also resulted in a resolution of their visible blood vessels.¹² It is thought that tretinoin’s ability to suppress inflammation may be a factor in this.¹³

In some patients with rosacea, tretinoin may be very difficult to incorporate into their routine due to the irritation that tretinoin can cause. For these people, adapalene (Differin) may be a gentler option.

Other Combinations

Some doctors can also prescribe combination ingredients that may be more commonplace for acne sufferers, but can work in some PPR. These combinations usually include benzoyl peroxide (BP) and erythromycin.

Other Ingredients

Niacinamide

There have also been small studies that show the benefits of niacinamide in PPR⁸, though anecdotal evidence seems to be that the higher the percentage of niacinamide, the greater chance of reactivity. You can find niacinamide serums that are made to be added into products. Some examples:

The Ordinary Niacinamide 10% + Zinc 1%

Ingredients: Aqua (Water), Niacinamide, Pentylene Glycol, Zinc PCA, Dimethyl Isosorbide, Tamarindus Indica Seed Gum, Xanthan gum, Isoceteth-20, Ethoxydiglycol, Phenoxyethanol, Chlorphenesin.

Paula’s Choice 10% Niacinamide Booster

Ingredients: Water (Aqua), Niacinamide (vitamin B3, skin-restoring ), Acetyl Glucosamine (skin replenishing/antioxidant), Ascorbyl Glucoside (vitamin C/antioxidant), Butylene Glycol (hydration), Phospholipids (skin replenishing), Sodium Hyaluronate (hydration/skin replenishing), Allantoin (skin-soothing), Boerhavia Diffusa Root Extract (skin-soothing), Glycerin (hydration/skin replenishing), Dipotassium Glycyrrhizate (skin-soothing), Glycyrrhiza Glabra Root Extract (licorice extract/skin-soothing), Ubiquinone (antioxidant), Epigallocatechin Gallate (antioxidant), Beta-Glucan (skin-soothing/antioxidant), Panthenol (skin replenishing), Carnosine (antioxidant), Genistein (antioxidant), Citric Acid (pH balancing), Sodium Citrate (pH balancing), Sodium Hydroxide (pH balancing), Xanthan Gum (texture-enhancing), Disodium EDTA (stabilizer), Ethylhexylglycerin (preservative), Phenoxyethanol (preservative).

Vitamin C

In my experience, vitamin C – a powerful antioxidant – may also prove to be tricky for rosaceans. I’ve never been able to successfully use vitamin C for long periods on my skin, though some rosaceans may find success with it.

There are many derivatives of vitamin C. Refer to table 5 below.

TABLE 5. Derivatives of Vitamin C
Sodium Ascorbyl Phosphate
THD
Ascorbyl Glucoside
Magnesium Ascorbyl Phosphate
Ethylated L-Ascorbic Acid
L-Ascorbic Acid

L-Ascrobic Acid (L-AA) and Ethylated L-Ascorbic Acid (EL-AA) are the most irritating forms of vitamin C. Magnesium Ascorbyl Phosphate is typically considered the most gentle and recommended for sensitive skin types.

Salicylic Acid

Salicylic acid (BHA) is usually recommended to rosaceans over AHA due to it’s anti-inflammatory properties (it is related to asprin and both are salicylates). This means that it can reduce redness and swelling. Conclusive evidence of it’s efficacy with rosacea is lacking, but it can work for some. When shopping for a product, you’ll want to find a BHA product without alcohol or menthol.

Natural Oils

In anecdotal cases, natural plant oil can benefit rosacean skin, particularly rosacean skin that is troubled by many moisturizer ingredients.

In my case, I do better with oils that are high in linoleic acid and low in oleic acid. Knowing how your skin does with one oil may guide you in choosing the next. Refer to table 6 below for more information on linoleic vs oleic content in common oils.

TABLE 6. Linoleic vs Oleic Content in Common Skincare Oils
OIL LINOLEIC % OLEIC %
Mineral Oil 0 0
Grapeseed 73 16
Flaxseed 67 20
Sunflower 62 25
Hemp 55 11
Rosehip 48 14
Sesame 42 42
Rice Bran 39 43
Argan 37 43
Apricot Oil 29 58
Sweet Almond 24 62
Hazelnut 12 79
Neem 10 40
Olive 10 70
Coconut 2 60
Jojoba 0 10

Licorice

Licorice root and licorice extract are both considered skin brighteners due to their ability to inhibit or slow melanin synthesis, but it can also be very soothing and anti-inflammatory.

Green Tea

Green tea (Camellia Sinensis Polyphenol) is an increasingly common anti-inflammatory and soothing ingredient. It stars in many anti-inflammatory serums and moisturizers, such as the Replenix Power of Three products.

Snail Mucin Extract

Collected from happy snails (snails are not harmed for the collection of their mucus and are usually fed diets of organic greens), purified snail mucus is more common in Asian beauty products, but has already shown promise for wound healing and may have anti-inflammatory properties for some people. It is the star in many KBeauty favorites, such as CosRX Snail Mucin Extract. Not all rosaceans respond to snail mucin extract, but some (particularly with PPR) find it to be nearly magical.

Propolis

Another rising star in the Asian beauty world, propolis or “bee glue” is a mixture of bee saliva and beeswax. It can be very soothing and similarly to honey, anti-bacterial.

Aloe Vera

Aloe is renown for its ability to soothe and heal. It is found (at least in part) in every post-sun product you can get your hands on, and may have been recommended to you by a family member to slather on a wound, directly out of the stem of the plant. It can be extremely soothing to both ETR and PPR rosacea. It also may contain some humectant (water-binding) qualities and helps with wound healing.

Tranexamic Acid

While I do not know much about tranexamic acid, in a small study of 30 rosacean patients over two weeks, involving 3% tranexamic acid, it was shown to improve the skin barrier.⁹ According to Paula’s Choice ingredient dictionary, tranexamic acid is a “synthetic amino acid that functions as a skin-conditioning agent and astringent. Research has shown that amounts of 3% can work as well as gold standard skin-lightening ingredient hydroquinone for discolorations; however, hydroquinone has considerably more research attesting to its effectiveness. Other research has looked at skin improvements from tranexamic acid via administration by microneedling.”¹⁰ It seems to be more common in Asian beauty products, such as UNT EX WHITE LASERWAVE (also contains mandelic acid, a mild hydroxy acid).

Hydroxy Acids (Glycolic, Lactic, Mandelic)

Hydroxy acids are tricky for rosacea. In virtually every study I read, lactic acid preparations in 5-10% were used for sting tests in rosaceans (from above: In a study involving 7 ETR patients and 25 PPR patients, 100% of ETR patients responded positively to a “sting test” (discomfort, flush, stinging sensations) of 5% lactic acid, while 68% PPR patients responded potively. Only 19% of the control group responded in the same manner). The permeability barrier dysfunction, characterized by an increase in TWEL, is an integral feature of rosacea and would explain why hydroxy acids are so tricky for rosaceans.

Mandelic acid seems to be the acid of choice for most rosaceans who can use hydroxy acid at all, but only once skin has stabilized over the course of a couple of months and not immediately following other treatments. If you find that you cannot use hydroxy acids at all without redness and discomfort, you are not the only one.


Laser and Light Treatments

While it is one of the more expensive ways to treat rosacea, it can be highly effective and very helpful for stubborn cases.

The most common laser and light treatments for rosacea are pulsed dye lasers (PDL) and light-emitting devices (IPL or Intense Pulsed Light), though CO2 lasers are used for thickened skin.

While not a laser, IPL helps to break down the structures in the skin that cause redness. The output is broad spectrum, and can be modified.

PDL is more intense, and aims light at blood vessels beneath the skin. This light is then converted to heat, absorbed by abnormal vessels, which destroys the vessels without damaging the surrounding skin. This can cause bruising, and is usually recommended for severe cases.


Hopefully this post has been helpful to many people. Do you have rosacea? Let me know what has helped you in the comments below!

Sources

  1. A Guide to the Ingredients and Potential Benefits of Over-the-Counter Cleansers and Moisturizers for Rosacea Patients
  2. NRS – All About Rosacea
  3. Alzheimer’s risk higher in people with rosacea
  4. Study Finds Potential Link between Hair Loss and Rosacea
  5. NRS – Seborrheic Dermatitis
  6. Reproductive and hormonal factors and risk of rosacea in US women
  7. Disruption of the transmembrane pH gradient–a possible mechanism for the antibacterial action of azelaic acid in Propionibacterium acnes and Staphylococcus epidermidis
  8. Cosmeceuticals and rosacea: which ones are worth your time
  9. Topical tranexamic acid improves the permeability barrier in rosacea
  10. Tranexamic acid
  11. Drug and Device News – Mar 2017
  12. Topical tretinoin resolves inflammatory symptoms in rosacea, in small study
  13. Topical tretinoin for rosacea: a preliminary report

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Game developer by day. Real-life gremlin. Amateur photographer. Mental health advocate. Skincare lover and science devotee. In 2011, I began a journey into skincare that became a life-long passion. I've written numerous articles on reddit.com on skincare and helped hundreds of people as they begin their own journey into a better understanding of their skin. I am an advocate for science-based skincare, and want to help others achieve their goals of better skin.

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