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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.

Rosacea: The Curse of the CeltsRosacea: The Curse of the Celts

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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Blackheads on the Nose: Are they “sebaceous filaments”?

When you hang out in skincare communities as much as I do, you eventually see lots of questions about totally normal skin features, such as the one I want to talk about today: the blackheads on your nose. These are frequently described as “sebaceous filaments,” though this is not a medical condition or diagnosis and only gained popularity in the 2000s through skincare boards and communities. It is also important to note that they are not oil glands (sebaceous glands), which are deep in the dermis and excrete sebum along the hair follicle, which finds it’s way to the surface of the skin.

Cosmetic chemist KindofStephen notes:

The term sebaceous filament likely originates from around 1912 by French dermatologist Sabouraud quoted in the Journal of Cutaneous Diseases Including Syphilis where it is quoted as “seborrhoeal filaments” and presumably translated to sebaceous filament.

It’s then referenced 12 years later as sebaceous filaments in a paper by Rulison in the Archives of Dermatology and Syphilology.

These of course are looking at seborrhoel or sebaceous filaments of the scalp, but a German paper published in 1976 under Follikel-Filamente examined ones found in the skin. Sebaceous filament was then mentioned by David Whiting in his 1979 review on acne, before making its way into a book by Plewig and Kligman in 1993.

In many textbooks microcomedone, impactions, follicular casts, follicular filaments or just the contents of the infundibulum (the pore opening above the sebaceous gland) are also used to describe them.

If you do a Google Scholar search for the term “Sebaceous Filament” you only get about 15 hits, a University of Toronto literature search only returns 7.

While they are not explicitly comedones, they are usually found in places rich in microcomedones, which can turn into open comedones (or blackheads). Perhaps the most common location for them is the nose, chin, and forehead, where people tend to feel the most self-conscious due to the central location. They frequently appear as an open pore with oil enveloping a vellus hair (the fine, baby hair all over our body that appears during puberty). When extracted, cylindrical tubes of sebum are expressed, which contain all of the makeup of your hair follicles – sebum, dead skin cells, bacteria, microflora, and sometimes the small vellus hair.

The primary difference between these “sebaceous filaments” and blackheads is that they are not inflammatory in nature, are typically uniform in size, and don’t extract as a hard plug or “grain.” On some people, they can appear larger, while on others they may be smaller.

Morning Session-071.jpg

No one is ever this close to your nose.

These openings never quite go away, though they can appear smaller or lighter.

 

 

Regardless of what you want to call them, many people are uncomfortable with this feature of the skin. If you’re bothered by their appearance, here are some guidelines to follow to do just that:

  • Try a BHA. Paula’s Choice 2% BHA Liquid is my weapon of choice, as it is oil-soluble and can break down sebum sitting inside of our pores, effectively “cleaning them out.” Adjust this as needed — some people need AHAs instead of BHAs, and some people can tolerate much higher percentages of AHA on areas like their nose than the rest of the skin. It is okay to apply products to only one area of your skin. I do this all of the time with my actives, since my rosacea makes my skin a lot more sensitive in some places as opposed to others.
  • For a quick fix, try a clay mask. If you have an event coming up, try a mild clay mask to soak up some of the sebum on your skin. Depending on the strength of the mask (Aztec Indian Clay Mask is very, very strong and can actually be a bit uncomfortable to wear), do this up to a night before so your nose isn’t red before the big event. I recommend being careful with clay masks if your skin is very sensitive, such as people with rosacea or dehydrated skin.
  • Keep pore strip usage to a minimum. While frequently recommended against due to the idea that they can “stretch the pore, making it larger,” there is no scientific literature that confirms that this occurs. Instead, make sure you keep usage to a minimum – KindofStephen recommends only once a week – and that your skin is in top shape before use. This means avoiding use shortly after introducing an AHA or retinoid into your routine, or scrubbing your skin or masking.
  • Try a moisturizer with urea and/or HA. Many people have good luck with low percentage urea moisturizers and HA serums, finding that they reduce the size and appearance of the filaments. I recommend several in my dehydrated skin post.
  • Gently massage your oiliest areas a little longer with cleanser at night. I always spend a couple extra seconds gently working cleanser into my oily areas, like my nose, chin, and forehead.
  • Breathe. No one is looking at your nose when they talk to you, nor are they as close to your skin as you’re probably getting when you’re staring at yourself in front of a mirror. If you’re feeling worried, stand back 3 – 6 feet from a mirror. This is how close most people will be to you.

 


Sources:

  1. Sebaceous filaments
  2. Why your dermatologist or that sales person may not know what a ‘sebaceous filament’ is
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Evaluating Your Routine: Hydroxy Acids

When I was younger, I spent almost every waking moment browsing skincare communities. Most posts in those communities boils down to routine help, selfies, or general questions, but sometimes, skincare routines in popular media come up. One such routine was displayed in the film American Psycho with Christian Bale. You can do a quick Google search and find numerous articles, blog posts, and videos about Patrick Bateman’s infamous daily routine and people who’ve tried to follow it.

bateman.gif

In the film, Patrick Bateman — a man with deep, anti-social behaviors — details his morning routine:

“I live in the American Gardens Building on W. 81st Street on the 11th floor. My name is Patrick Bateman. I’m 27 years old. I believe in taking care of myself and a balanced diet and rigorous exercise routine.

“In the morning if my face is a little puffy I’ll put on an ice pack while doing stomach crunches. I can do 1000 now.

“After I remove the ice pack I use a deep pore cleanser lotion. In the shower I use a water activated gel cleanser, then a honey almond body scrub, and on the face an exfoliating gel scrub. Then I apply an herb-mint facial mask which I leave on for 10 minutes while I prepare the rest of my routine. I always use an after shave lotion with little or no alcohol, because alcohol dries your face out and makes you look older. Then moisturizer, then an anti-aging eye balm followed by a final moisturizing protective lotion.”

Showing the audience this routine reveals to us how much emphasis Bateman puts on his outwards appearance — a central theme to the film.

Most people care deeply about their appearance, whether they’re following a Bateman-esc routine or trimming their brows. After all, glowing skin is typically a sign of health.

Bateman’s routine puts particular emphasis on a youthful appearance, with multiple scrubs, peels, and moisturizers; and indeed it is exfoliation and skin-cell turnover that keeps your skin looking younger and healthier, but how do we get there from here? What should a good exfoliation routine look like? Where do you even start?

In this post, I’ll be breaking down some of the things that can keep us looking younger: AHAs, BHAs, and LHAs.


Introduction to Hydroxy Acids

You may remember from my post on moisturizers that skin cells (keratinocytes) begin deep in the stratum basale — the deepest layer of the epidermis — and work their way upwards, flattening out, hardening, dying, and eventually flaking away.

Stratum+corneum,+top+layer+of+skin,+graph

However, some skin cells are not quite as good at this as others. They will build up, stick together, or get “stuck” in the pores (hair and oil gland openings) of skin. Hydroxy acids are what is called an “active” skincare ingredient — basically something that performs an action on the skin. In this case, rejuvenation and exfoliation. They are largely found in botanical sources, which is why they are frequently referred to as fruit acids, and are divided up based upon the hydroxyl groups on their molecular structures. Hydroxy acids posses the ability to separate skin cells from the stratum corneum, which can be hugely beneficial to skin diseases that are characterized by a build up of dead skin (or hyperkeratosis), such as acne. Many also have the ability to stimulate the growth of collagen in the deeper layers of the skin, resulting in the reduction of fine lines over time.[1][2][3][4][7]

If you want to think of it in a more simple way, hydroxy acids are solutions that break down the “glue” that holds skin cells together (not the skin cells themselves), but like with anything that performs an action on the skin, this can be very irritating. Whether or not it is irritating to you depends on your needs and the formulations as well as the concentrations of the exfoliants you pick.


AHAs

The term AHA is short for “Alpha Hydroxy Acid.” It is the most common of the chemical exfoliants you can find. They’re usually associated with creating glowing, youthful skin due to their ability to exfoliate away the upper layers of the stratum corneum so effectively.

They work best around a pH of 3.5, which allows for better absorption. The higher the pH, the lower the amount of acid that is absorbed by the skin. To demonstrate this, one study compared the effects of glycolic and lactic acid on the skin when applied at different pH values. At a pH of 3, the total absorption of a 5% glycolic acid cream in 24 hours was 27%. When increasing the pH value to 7, that absorption tanked to a mere 3.5%. Similarly, 5% lactic acid had a total absorption of 30% over 24 hours at a pH of 3, which dropped to 10% when the pH was boosted to a value of 7. [5]

They are water-soluble, meaning that they work best directly on clean, dry skin. Some even have humectant properties, allowing them to draw moisture into the upper layers of the skin.

All AHAs create photo-sensitization — or sensitivity to the sun — due to their ability to exfoliate the stratum corneum.

AHAs are also generally not recommended for rosacean or eczema-prone skin, as they can worsen the inflammation that is common in these conditions. Additionally, avoid using AHAs in combination with other forms of exfoliation (such as physical scrubbing) or prescription topicals given to you by your dermatologist, especially tretinoin/Retin-A.

There are multiple types of AHAs, and they come in various forms, differentiated by molecular size and source. The most common types of AHAs are glycolic, mandelic, and lactic.

Glycolic

The most common form of AHA is glycolic, and it’s found in nearly every AHA product you can find these days. It has a small molecular structure, meaning it can penetrate the upper layers of the skin more easily and quickly, but it is also the most irritating due to these properties. It’s usually found in products in concentrations of 8-10%. Some examples of popular products with glycolic acid:

Paula’s Choice 8% AHA Gel – Recommended

Water (Aqua), Glycolic Acid (alpha hydroxy acid/exfoliant), Sodium Hydroxide (pH adjuster), Chamomilla Recutita Matricaria Flower Extract (chamomile/skin-soothing), Aloe Barbadensis Leaf Juice (hydration), Camellia Oleifera Leaf Extract (green tea/antioxidant/skin-soothing), Sodium Hyaluronate (skin replenishing), Panthenol (hydration), Sodium PCA (skin replenishing), Propylene Glycol (hydration), Butylene Glycol (hydration), Hydroxyethylcellulose (texture-enhancing), Polyquaternium-10 (texture-enhancing), Phenoxyethanol (preservative), Sodium Benzoate (preservative).

Pixi Glow Tonic

Aqua, Aloe Barbadensis Leaf Juice, Hamamelis Virginiana (Witch Hazel) Leaf Extract, Aesculus Hippocastanum (Horse Chestnut) Seed Extract, Glycolic Acid, Ammonium Glycolate, Glycerin, Butylene Glycol, Hexylene Glycol (and) Fructose (and) Glucose (and) Sucrose (and) Urea (and) Dextrin (and) Alanine (and) Glutamic Acid (and) Aspartic Acid (and) Hexyl Nicotinate, Panax Ginseng Root Extract, Phenoxyethanol, Sodium Benzoate, Biotin, Polysorbate 20.

Nip + Fab Glycolic Fix Daily Cleansing Pads

Aqua (Water), Glycerin, Glycolic Acid, Polysorbate 20, Sodium Hydroxide, PEG-12 Dimethicone, Hamamelis Virginiana (Witch Hazel) Water, Phenoxyethanol, Benzyl Alcohol, Alcohol Denat. (SD Alcohol 40-B), Disodium EDTA, Globularia Alypum (Blue Daisy) Extract, Panthenol, Lactic Acid, Parfum, Limonene, Ethylhexylglycerin, Dehydroacetic Acid, Sodium Hyaluronate, Linalool, Geraniol, Citral.

CosRX AHA 7 Whitehead Power Liquid

Pyrus Malus (Apple) Fruit Water, Butylene Glycol, Glycolic Acid, Niacinamide, Sodium Hydroxide, 1,2-Hexanediol, Panthenol, Sodium Hyaluronate, Xanthan Gum, Ethyl Hexanediol.

Lactic Acid

Lactic acid is the second most common of all AHAs, and can be frequently found hanging out in the ingredients with other AHAs or BHAs , though it is a fine exfoliator on its own. It has a larger molecule than glycolic, making it slower to act and less irritating — ideal for more sensitive skin. It is usually derived from milk, and has the best humectant properties out of all of the acids. Some examples of popular products with lactic acid:

Sunday Riley Good Genes All-In-One Lactic Acid Treatment

Opuntia Tuna Fruit (Prickly Pear) Extract, Agave Tequilana Leaf (Blue Agave) Extract, Cypripedium Pubescens (Lady’s Slipper Orchid) Extract, Opuntia Vulgaris (Cactus) Extract, Aloe Barbadensis Leaf Extract & Saccharomyses Cerevisiae (Yeast) Extract, Lactic Acid, Caprylic/Capric Triglyceride, Butylene Glycol, Squalane, Cyclomethicone, Dimethicone, Ppg-12/Smdi Copolymer, Stearic Acid, Cetearyl Alcohol And Ceteareth20, Glyceryl Stearate And Peg-100 Stearate, Arnica Montana (Flower) Extract, Peg-75 Meadowfoam Oil, Glycyrrhiza Glabra (Licorice) Root Extract, Cymbopogon Schoenanthus (Lemongrass) Oil, Triethanolamine, Xantham Gum, Phenoxyethanol, Steareth-20, Dmdm Hydantoin.

The Ordinary Lactic Acid 10% + HA

Aqua (Water), Lactic Acid, Glycerin, Pentylene Glycol, Arginine, Potassium Citrate, Triethanolamine, Sodium Hyaluronate Crosspolymer, Tasmannia Lanceolata Fruit/Leaf Extract, Acacia Senegal Gum, Xanthan Gum, Trisodium Ethylenediamine Disuccinate, PPG-26-Buteth-26, Ethyl 2,2-Dimethylhydrocinnamal, PEG-40 Hydrogenated Castor Oil, Ethylhexylglycerin, 1,2-Hexanediol, Caprylyl Glycol.

AmLactin 12% Alpha-Hydroxy Therapy Daily Moisturizing Body Lotion – Recommended (for body)

Water, Lactic Acid, Light Mineral Oil, Glyceryl Stearate, PEG 100 Stearate, Propylene Glycol, Glycerin, Magnesium Aluminum Silicate, Laureth 4, Polyoxyl 40 Stearate, Cetyl Alcohol, Methylparaben, Propylparaben, Methylcellulose.

Mandelic Acid

Mandelic acid has only just begun to appear on the scene, though it has been around for awhile. It is one of the best choices for very sensitive skin, and great for acne-prone skin due to its anti-bacterial and anti-microbial nature. It is derived from almonds and has moderate humectant properties, floating somewhere between glycolic and lactic. An example of a popular product with mandelic acid:

Stratia Skin Soft Touch AHA with 10% Mandelic Acid – Recommended

Water (Aqua), Mandelic Acid, Propylene Glycol, Polyacrylate Crosspolymer-6, Panthenol, Aloe Barbadensis Leaf Juice, Matricaria Recutita (Chamomile) Flower Extract, Glycerin, Sodium Hyaluronate, Allantoin, Sodium Hydroxide, Diazolidinyl Urea, Iodopropynyl Butylcarbamate.

There are also plenty of products that combine several alpha hydroxy acids together, such as:

Drunk Elephant TLC Framboos Glycolic Night Serum

Water, Glycolic Acid, Butylene Glycol, Glycerin, Sodium Hydroxide, Salicylic Acid, Lactic Acid, Citric Acid, Vitis Vinifera (Grape) Juice Extract, Aloe Barbadensis Leaf Juice, Opuntia Ficus-Indica Extract, Aesculus Hippocastanum (Horse Chestnut) Seed Extract, Camellia Sinensis Leaf Extract, Rubus Idaeus (Raspberry) Fruit Extract, Saccharomyces Cerevisiae Extract, Buddleja Davidii Meristem Cell Culture, Sclerocarya Birrea Seed Oil, Sodium Hyaluronate Crosspolymer, Allantoin, Hydroxyethylcellulose, Galactoarabinan, Propanediol, Disodium EDTA, Xanthan Gum, Hexylene Glycol, Phenoxyethanol, Caprylyl Glycol, Ethylhexylglycerin, Sodium Nitrate, Potassium Sorbate, Pentylene Glycol, Sodium Benzoate.

Dr. Dennis Gross Skincare Alpha Beta Extra Strength Daily Peel

Water (Aqua), Alcohol Denat., Glycolic Acid, Potassium Hydroxide, Hamamelis Virginiana (Witch Hazel) Leaf Extract, Salicylic Acid, Polysorbate 20, Lactic Acid, Mandelic Acid, Malic Acid, Citric Acid, Salix Alba (Willow) Bark Extract, Menthyl Lactate, Camellia Sinensis Leaf Extract, Achillea Millefolium Extract, Chamomilla Recutita (Matricaria) Flower Extract, Soy Isoflavones, Copper PCA, Zinc PCA, Disodium EDTA, Fragrance (Parfum), Sodium Benzoate.


BHAs

BHA is short for “Beta Hydroxy Acid.” These acids are slightly more complex than AHAs due to their oil-solubility. They are able to penetrate not just the skin, like AHAs, but also the pores of the skin. This is what makes them an ideal choice for acne-prones, who tend to have lipid-rich sebaceous glands.

BHAs work best around pH values of 3, and in concentrations of 1-2%. They’re frequently found with AHAs, but can be found in formulations without the addition of other hydroxy acids.

BHAs are not as photo-sensitizing as AHAs [6], but it is still frequently recommended that you wear a sunscreen when using any hydroxy acid.

There are two major types of BHAs: salicylic acid and lipohydroxy acid.

Salicylic Acid

When discussing BHAs, the ingredient that is usually being discussed is salicylic acid, which is derived from salicin — the same stuff in asprin. Due to this origin, salicylic acid should be avoided if you have an asprin allergy.

Salicylic acid has no humectant properties, and can cause drying of the skin. Though if formulated correctly, this can largely be avoided which can make BHA a much more effective acne treatment for some than harsher, more drying topicals such as benzoyl peroxide.

It can also be soothing to some skin types, such as rosacean skin or acne skin, and is pretty well-tolerated overall.

Some examples of popular products with salicylic acid:

Paula’s Choice 2% BHA Liquid  – Recommended

Water (Aqua), Methylpropanediol (hydration), Butylene Glycol (hydration), Salicylic Acid (beta hydroxy acid/exfoliant), Polysorbate 20 (stabilizer), Camellia Oleifera Leaf Extract (green tea/skin calming/antioxidant), Sodium Hydroxide (pH balancer), Tetrasodium EDTA (stabilizer).

Stridex Triple Action Pads, Alcohol Free (Red Box)

Salicylic acid 2.0%, Ammonium lauryl sulfate, ammonium xylenesulfonate, citric acid, DMDM hydantoin, fragrance, menthol, PPG-5-Ceteth-20, purified water, simethicone, sodium borate, tetrasodium EDTA.

Lipohydroxy Acid

Lipohydroxy acid is a derivative of salicylic acid, with unique properties. It has a higher molecular weight and an added fatty chain, making it more lipophilic (oil loving) than its parent SA.

First developed by L’Oreal in the 1980s, it penetrates the skin less easily due to it’s lipophilic properties. This slower penetration means that it breaks down the glue of the skin cells slower, but it is still unclear whether or not this results in less irritation.

Like other hydroxy acids, LHA thins the stratum corneum, but has dermal thickening properties. In one study, it was shown to be as effective as tretinoin, due to it’s stimulation of structural skin proteins and lipids. [7]

It is excellent for acne skin due to it’s lipophilic nature, and in one study, showed a decrease of 85% in follicular plugs over 14 days. [8]

It is only available in products made by L’Oreal, so it is difficult to get your hands on a wide variety. Some examples:

SkinCeuticals LHA Cleansing Gel

aqua / water / eau, coco-betaine, propylene glycol, peg-120 methyl glucose dioleate, sorbitol, glycerin, glycolic acid, triethanolamine, sodium laureth sulfate, sodium chloride, disteareth-100 ipdi, phenoxyethanol, salicylic acid, capryloyl salicylic acid, menthol, methylparaben, disodium edta, steareth-100.

La Roche-Posay Effaclar Duo

Water, Isostearyl Alcohol, Glycerin, Pentylene Glycol, Silica, Carbomer, Capryloyl Salicylic Acid, Potassium Hydroxide, Tocopheryl Acetate, Acrylates/c10-30 Alkyl Acrylate Crosspolymer, Disodium EDTA, Epilobium Angustioflium Flower/leaf/stem Extract.

SkinCeuticals LHA Toner

Water / Eau, Alcohol Denat., Glycolic Acid, Sodium Hydroxide, Capryloyl Salicylic Acid, Salicylic Acid.


All Together Now

  • If you’re sensitive, avoid AHA and BHA used together. Multiple hydroxy acids in one product increase your likelihood of a reaction. It’s better to start low and slow when introducing skin to a hydroxy acid.
  • Lower concentrations for beginners. If you’ve never used a hydroxy acid, go for lower concentrations, such as 1% BHA (Paula’s Choice makes a 1% variety of BHA) and 4-5% glycolic acid. If your skin is sensitive and generally reactive, look for larger molecules, like lactic or mandelic acid.
  • If you’re oily-skinned, rosacean, or acne-prone, try BHA. I cannot understate enough how great BHA is. It is generally soothing and can break through oils on the skin, making it ideal for acne.
  • Do not use physical exfoliation like scrubs, towels, or a Clarisonic when using a chemical exfoliant. Your stratum corneum thins when using a chemical exfoliant, so you shouldn’t need to be physically scrubbing your skin, which can just create irritation.
  • Use hydroxy acids infrequently. Unlike Patrick Bateman, most people do not need daily exfoliation. Use a hydroxy acid two to three times a week. Tweak this based on how your skin reacts.
  • Back off if you’re breaking out. Skin irritation can occur with hydroxy acids, usually in the form of breakouts. If this occurs, discontinue use until your skin clears. Re-introduce the product slowly and use fewer days per week. If the reaction re-occurs, discontinue use entirely.
  • Use a sunscreen during the day. Except for salicylic acid, hydroxy acids thin the stratum corneum and photo-sensitize the skin. You must use a sunscreen during the day to prevent damage and sunburn.
  • Be careful when using BP/retinol/retinoids with AHAs/BHAs if you are very sensitive. If you’re very sensitive with conditions such as rosacea or eczema, be cautious when using other actives in addition to AHAs/BHAs. This can be too much for some skin.
  • Use at night. As I said above, hydroxy acids photo-sensitize you. Use them at night for this reason.
  • Use hydroxy acids as close to the skin as possible. Applying any skin “active” right after you cleanse is ideal. This ensures it is as close to the skin as possible, and does not need to penetrate any additional products to work.

Sources

  1. Effects of alpha-hydroxy acids on photoaged skin: a pilot clinical, histologic, and ultrastructural study.
  2. A review of skin ageing and its medical therapy
  3. Epidermal and dermal effects of topical lactic acid
  4. Glycolic Acid Treatment Increases Type I Collagen mRNA and Hyaluronic Acid Content of Human Skin
  5. Labmuffin – Why does pH matter for AHAs and BHAs
  6. The effects of topically applied glycolic acid and salicylic acid on ultraviolet radiation-induced erythema, DNA damage and sunburn cell formation in human skin
  7. The Use of Lipohydroxy Acid in Skin Care and Acne Treatment
  8. Comedolysis by a lipohydroxyacid formulation in acne-prone subjects.
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