Treating Rosacea

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Rosacea is a mysterious skin disorder. For most people it first appears as a blush across the cheeks that either comes and goes or sticks around. After a while, the flushing becomes more persistent and intense, with noticeable spider-like capillaries accompanied by bumps that look like, but aren't, acne. Extreme sensitivity and flaking round out this not-so-pretty picture.

More than 14 million people are thought to have rosacea, and all of them are struggling to find solutions to this annoying skin disorder. Treating rosacea isn't easy, but following the steps we present will get you closer to the beautiful, calm skin you want. First, let's discuss what causes rosacea, and then, most important, we'll tell you how to treat rosacea.
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What Is Rosacea?

Rosacea is a chronic, inflammatory skin condition characterized by patches of red and sometimes bumpy skin on the face. You'll notice a persistent, pink to red flush over the nose and cheeks, and the skin becomes sensitive, often reacting strongly to internal or external changes in temperature. For example, an increase in temperature from stress or exercise or from a hot bowl of soup, or a decrease in temperature from a cold wind outdoors can mean misery for those with rosacea.

Left untreated, rosacea eventually gets worse, until, for some people, there is almost constant inflammation and red to bluish purple surface capillaries across most of the face. In addition, the skin's sensitivity goes off the charts, reacting to almost anything that touches it. Skin can be oily or dry, with persistent flaking. Acne-like bumps that aren't really acne may be present, too, leading some doctors to describe the condition as acne rosacea.

Although there's no known cure for rosacea, there are things you can do to get it under control so it's not a constant source of frustration and discomfort.

What Causes Rosacea

One of the main reasons there have been problems finding a cure for rosacea is that no one knows, or at everyone doesn't agree on, exactly what causes it. Many researchers think there's a genetic component to the development of rosacea. Others believe that elevated levels of an inflammatory peptide called cathelicidin or high levels of an enzyme known as KLK5 in the skin's uppermost layers play a role.

Another theory is that a mite commonly found on human skin, Demodex folliculorum, triggers the inflammation that leads to rosacea. Research has shown that those with rosacea tend to have a finer layer of superficial blood vessels in their facial skin, and these vessels are hypersensitive to internal and external factors.

Last, some researchers believe that those with rosacea have a much thinner, more delicate surface barrier. Think of the skin's layers like the layers of an onion: On rosacea skin, the barrier is akin to the onion's paper-thin skin; on skin without rosacea, there are more layers (literally, thicker skin) offering enhanced barrier protection.

Regardless of the cause, there are plenty of factors that can make rosacea worse! Basically, anything that causes a rush of blood to the face is an issue. All of these are triggers:

  • Sun exposure
  • Wind
  • Hot climates
  • Heavy or strenuous exercise
  • Emotional stress
  • Certain cosmetic ingredients
  • Topical steroid creams and other topical medications that can thin the skin
  • Spicy foods, alcohol, and caffeine (especially from hot beverages like coffee)

That's quite the line-up—and it's not even the entire list! Although some triggers are more obvious than others, it's hard to state with certainty exactly what will spark a rosacea flare-up—even something that seems extra gentle could cause an issue. Now that's frustrating!

Who Gets Rosacea

Rosacea is a condition that shows up in adults, usually between the ages of 30 and 60. It affects all segments of the population, but is most common in people with fair skin tones, especially those who tend to blush easily. In fact, it's thought to affect as much as 30 to 50 percent of the Caucasian population! Women are diagnosed with rosacea more frequently than men, but men tend to experience more severe symptoms, such as a swollen, distended nose area and more broken capillaries.

There's More Than One Type of Rosacea

Making rosacea even trickier to address is that it doesn't manifest itself in just one way: There is more than one type of rosacea! In its earliest stages, rosacea can be so subtle and fleeting that many people don't even know they have it. They tend to think they just have an uneven skin tone instead of an actual skin disorder. However, the sooner you catch and treat rosacea, the easier it will be to get it under control and stop its progression! From subtle beginnings to more advanced cases, here are the four different types of rosacea:

  • Erythematotelangiectatic: This long and hard-to-pronounce name is the most basic type of rosacea. It's characterized by flushing and persistent redness, often in a butterfly pattern on a person's nose, cheeks, forehead, and chin. Blood vessels under the skin may also be visible, and often are referred to as broken capillaries or spider veins. The affected skin may feel warmer than the surrounding skin, and often reacts strongly to stimuli.
  • Papulopustular: This form includes bumps and pimple-like eruptions in addition to redness, with some of the bumps becoming infected with acne-causing bacteria. This is what people mean when they say they have acne rosacea.
  • Phymatous: Most common in men, this type of rosacea involves a thickening of the skin and hyper-growth of facial blood vessels, which can result in a bulbous nose from the excess growth of tissue in this area (legendary comedian W. C. Fields, famous for his large nose, had this disfiguring type of rosacea).
  • Ocular: This type of rosacea affects the eyes. Symptoms include dry eyes, tearing and burning, a sensation of the eyes feeling gritty, swollen eyelids, recurring sties—and even potential vision loss. Ocular rosacea often exists with another type of rosacea, so you're battling skin symptoms plus itchy, irritated eyes.

Skin Care for Rosacea

Because rosacea is an unpredictable skin disorder, with just about anything setting it off or creating extreme sensitivity, it is critical to assemble the gentlest skin-care routine possible so as not to aggravate matters. All skin-care products should be fragrance- and dye-free. "Fragrance-free" means avoiding fragrant plant oils, too, which surprisingly, and disturbingly, often show up in products for sensitive skin. For example, lavender oil is a definite no-no!

First things first: Use sunscreen! UV exposure makes rosacea worse, so be sure to apply daily a sunscreen with SPF 15 or higher to keep those damaging rays from harming your delicate skin.

Check the labels when you're picking out a sunscreen: You should be using sun protection whose active ingredients are only titanium dioxide and/or zinc oxide. These mineral sunscreens are gentle and are the least likely to cause a stinging or burning sensation, both of which can worsen the redness you're trying to minimize.

Familiarize yourself with ingredients that can be irritants, including alcohol (SD- or denatured), menthol, mint, citrus, lavender, and any fragrant plants. For a comprehensive step-by-step skin-care routine for rosacea, check out our article Skin Care for Rosacea.

Prescription Treatments for Rosacea

Because rosacea is a chronic condition with no known cure, you'll need to see a doctor to get it under control; in most cases, skin care alone isn't enough. A good dermatologist should know the latest treatments and techniques for dealing with rosacea, and can properly diagnose what type you have. Among the variety of medical treatments available for rosacea are:

  • Oral antibiotics like tetracycline or doxycycline (brand name: Oracea), which can relieve acne-like pustules and inflammation.
  • Topical antibiotics, including metronidazole, which has been shown to be effective in killing Demodex folliculorum and other microbes that may play a role in rosacea. MetroCream, MetroGel, and MetroLotion contain this active ingredient.
  • Prescription-strength azelaic acid (brand name: Finacea), which can help reduce lesions and bumps.
  • Mirvaso Gel is a prescription product from the Galderma brand (of Cetaphil fame). It is FDA-approved for treating persistent redness from rosacea. Although how this drug works isn't exactly clear, researchers believe it constricts blood vessels, with results lasting up to 12 hours. Its chemical name is brimonidine, and, like all topical medications, it has side effects to discuss with your doctor, particularly if you have circulatory system issues.
  • Salicylic acid, also known as beta hydroxy acid (BHA), which has anti-inflammatory properties and can also gently exfoliate rosacea-affected, breakout-prone skin. BHA products are available over-the-counter.
  • Beta blockers (prescribed in pill form, and often used to treat heart conditions) have been shown in some studies to reduce rosacea redness.
  • Isotretinoin (first marketed as the anti-acne drug Accutane) can help combat the pustules seen in papulopustular rosacea, although this oral medication typically is a last resort due to its many serious side effects.

Light-Based Treatments for Rosacea

Some of the best and most effective treatments for rosacea involve using light to target the blood vessels that cause the "red mask" and broken capillaries of rosacea. Special lasers or intense pulsed light (IPL) machines target capillaries and diffuse redness in the upper layers of the skin. These light-based treatments cause the walls of blood vessels to heat up, which damages them, causing them to be absorbed by the body as part of its natural defense.

The catch? Repeated treatments (typically 4–6 spaced a few weeks apart) are required for the redness to disappear completely, and most people will need a maintenance treatment at least once per year. These light-based treatments aren't cheap—they can cost as much as $300 to $700 per treatment, and medical insurance often doesn't cover it (check with your health insurance provider).

Despite the need for repeat treatments and the expense involved, light-based treatments can make a remarkable difference in keeping rosacea and its symptoms under wraps, often for extended periods of time.

Redness Be Gone!

Although there is no simple, works-for-everyone solution for those with rosacea, you can take action and control its most telltale symptoms. Even though it might look like you're blushing, rosacea is nothing to be embarrassed about. Through trial and error, rosacea can be brought under control. If you have rosacea, see your dermatologist for medical treatments, and keep your skin-care routine gentle, gentle, gentle! Check out our step-by-step skin care for rosacea here.

Sources: Journal of Drugs in Dermatology, June 2013, pages 650-656; Future Microbiology, February 2013, pages 209–222; Skin Therapy Letter, December 2012, pages 1–4; British Journal of Dermatology, November 2012, pages 1042–1047, and February 2012, pages 279–287; The Australasian Journal of Dermatology, September 2012, ePublication; Journal of Drugs in Dermatology, July 2012, pages 838–844; Annals of Dermatology, May 2012, pages 126–135; Journal of Psychosomatic Research, February 2012, pages 153–158; Duodecim, volume 128, issue 22, 2012, pages 2327–2335; Journal of Investigative Dermatology, Symposium Proceedings, December 2011, pages 16–23; Annals of Dermatology and Venereology, November 2011, Supplement, pages S184–S191 and S219–S222; Cutis, August 2011, pages 67–72; Cosmetic Dermatology, 2nd Edition, McGraw Hill Medical, 2009, Chapter 16; Journal of Cosmetic and Laser Therapy, 1999, volume 1, no. 2, pages 95–100; and www.rosacea.org.

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About the Experts

Paula Begoun is the best-selling author of 20 books on skin care and makeup. She is known worldwide as the Cosmetics Cop and creator of Paula's Choice. Paula's expertise has led to hundreds of appearances on national and international television including:

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The Paula's Choice Research Team is dedicated to helping you find the absolute best products for your skin, using research-based criteria to review beauty products from an honest, balanced perspective. Each member of the team was personally trained by Paula herself.

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