Over 14 million Americans live with rosacea, which has no cure and no definitive cause. While even people who have rosacea may think it just causes blushing more frequently, this is actually a very complex skin condition that can worsen with severe symptoms over time. While it can’t be completely eliminated, researchers and doctors have found several factors that worsen or trigger it, as well as treatments to minimize symptoms.
What is rosacea?
As mentioned above, rosacea is a skin condition that roughly four to five percent of the American population suffers from. It is chronic, and occurs in cycles where it can be present for weeks or even months before disappearing for a period of time, and then returning. It can be identified by frequent reddened skin, usually only affecting the face, but also can bring on more uncomfortable, and even painful, symptoms.
Often, rosacea appears as small, red, pus-filled bumps or persistent redness across the center of the face. Small blood vessels on your nose and cheeks often swell and become visible during flare-ups. However, it can be easily misidentified as other skin conditions such as acne or eczema, partially due to the different subcategories of the disease.
Types of rosacea
The four main forms of rosacea are erythematotelangiectatic rosacea, which is the most common and what most people think of when they think of rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea. All four have slightly different symptoms and treatments, but a person can also be diagnosed with multiple types of rosacea, further complicating diagnosis and treatment.
Erythematotelangiectatic Rosacea (ETR)
ETR is the form of rosacea that most people are familiar with. This type causes blushing or redness across the nose and cheeks, but it can also appear on the forehead, scalp, chin, and neck if allowed to worsen without treatment. Less common symptoms of ETR include warmth or tingling in the affected areas or the skin getting dry and scaly. By not treating it, not only will symptoms escalate, but time between cycles will decrease and length of flare-ups will increase.
Also called “acne rosacea”, this type not only causes redness and visible blood vessels, but also brings pimples and acne-like symptoms, hence its name. It won’t cause blackheads and whiteheads (common indications of regular acne), but it usually results in large, painful blemishes called papules and pustules. These develop and exist deep in the skin, making it difficult to remove or get rid of, especially quickly. The papules can also be accompanied by abnormally oily or abnormally dry patches of skin.
Usually occurring on and around the nose, this also starts with redness and visible blood vessels, but additionally causes a buildup and thickening of skin, starting with small plaques. As it progresses, the skin can resemble scar tissue and is bumpy and tough. With cases that are left untreated, the skin can build up to the point where the nose is noticeably bulbous and protruding. This is the least common form of rosacea but unlike papulopustular rosacea, this condition is more common in men than women.
Ocular rosacea, meaning related to the eyes, primarily causes inflammation and redness around the eyes and eyelids. This can lead to additional bumps, swelling, and redness of the eyes, which will cause burning and watering. In certain cases, symptoms may also include photosensitivity and blurred vision. Due to these broad characteristics that are shared by other issues (including hay fever), it can be difficult to diagnose properly, even by a dermatologist. If someone has these symptoms in addition to other rosacea symptoms such as the redness and visible blood vessels, it is more likely that this is ocular rosacea rather than allergies or dry eyes. It may best be treated by an ophthalmologists.
Rosacea triggers & causes
Now that we know what to look for, we should discuss what could be causing or provoking the rosacea. While it’s true that there isn’t a conclusive decision as to what actually causes or “gives” someone rosacea, there are numerous factors that trigger a cycle or worsen flare-ups. We covered common triggers of facial redness in depth here, but we will also give an overview of what to keep an eye out for, and avoid for, rosacea.
Unbalanced skin microbiome
The first key to healthy skin, whether in controlling rosacea or other skin conditions such as eczema or acne, is a balanced skin microbiome. It’s a complex topic, but the basics are that the surface of your skin is home to bacteria, some that are good and helpful and some that are bad and can be harmful if not kept in check.
If your skin microbiome becomes unbalanced, it creates an environment for bad bacteria to take over and worsen conditions like rosacea. By stabilizing it with something that works to restore the microbiome, it can also bring your skin health under control.
Indirectly related to the skin microbiome and your skin’s health are environmental components that impact your body. These can be external factors like sun exposure and heat, internal factors like stress, or foods that you eat containing ingredients that worsen redness. Foods and drinks known to do this include spicy food, dairy, alcohol, and cinnamaldehyde, which is in cinnamon, chocolate, and citrus.
These external factors all impact how your skin reacts to perceived threats and can also disrupt your skin microbiome’s bacteria. We’ll address avoiding these triggers in the treatments section, but keep in mind that there are nearly endless environmental factors that can affect different people's skin differently. This area of potential causes should be discussed with a doctor to determine how to go about testing and identifying your triggers without accidentally causing a serious reaction.
Harsh skincare products
Similar to several environmental factors like heat and sun exposure, harsh skincare products contain ingredients that dry out and irritate your skin. By looking through the products you use and eliminating those that have irritating ingredients, you might be surprised by the improvements you see over time. Harsh products often “overclean” and strip the skin of its microbiome and its natural barriers that help fend off redness and environmental pathogens. Things like preservatives and fragrances can be harmful, so using products without them can be beneficial to your skin, rosacea or not.
The term skin mites can sound scary and make your skin crawl, but everyone has them on their skin and they’re totally normal. In particular, Demodex folliculorum are the types of mites connected to rosacea. Usually these mites are completely harmless and don’t cause any issues as they live in hair follicles, especially around the face.
However, people with rosacea have been found to have higher concentrations of this microorganism. Unfortunately, researchers aren’t sure whether they are a cause of the inflammation, or an effect of it. Either way, this is another reason to balance your skin microbiome and not let them get out of hand.
Genetics almost certainly play a role in why rosacea appears in some but not others. Someone in a family that has a history of it is more likely to develop it themselves, and researchers at Stanford found two particular areas of the genome that can be linked to rosacea. In addition to that, certain demographic groups are more susceptible to the disease, including females, those with fair skin, hair, and eyes, and those between 30 and 50 years old.
Rosacea treatment options
While rosacea doesn’t have a cure, it can be treated in various ways. Below we will talk through treatment options, both those that are stronger and usually reserved for more extreme cases, as well as those that are simpler and don’t require prescriptions. Certain forms of rosacea are treated differently (especially ocular rosacea), but usually through use of antibiotics, or other prescriptions. Unfortunately, these carry a risk of worrisome side effects.
The most basic treatment is to avoid the things that cause flare-ups or worsen existing redness. With so many factors capable of influencing our skin and everyone’s skin being different, it can be difficult to not only list everything that could be a component, but to even know where to start. As mentioned in the section about environmental causes, discussing with a doctor what they think should be the starting point and timeline for evaluating should be your first step. A medical professional will also be better-equipped to identify what things are most likely to be affecting you through your diet, skincare routine, daily schedule, and more.
Ocular rosacea is different from the other forms due to its proximity to the eyes and how sensitive they are. Because of this, it’s unsurprising that eye drops are often prescribed to treat the redness and irritation. While dermatologists usually are the experts on rosacea, an eye specialist might have to be consulted for treatments like eye drops, and may prescribe blephamide, a steroid and antibiotic eye drop. Warm compresses also help soothe the effects of ocular rosacea, and are a common pair with eye drops.
Prescription rosacea cream
For the other forms of rosacea, creams with azelaic acid, or other ingredients may be prescribed by a doctor. Usage will depend on the cream and the situation, but application will likely be once or twice per day to reduce inflammation and discoloration. However, topical treatments can often take 3 to 6 weeks to see improvement. If using a topical steroid cream, be careful of withdrawal when reducing use of it, as this can make the skin become hypersensitive and redder.
Another cream that might be an option is one that reduces blood flow by constricting blood vessels in the cheeks and face. This has the effect of reducing and sudden redness and flushing associated with most forms of mild rosacea. Be wary of reactions upon discontinuing this.
Antibiotic treatment of rosacea can fall under either topical or oral, with some overlap between topical antibiotics and prescription creams discussed in the previous section. Oral treatments include tetracycline, minocycline, and erythromycin and may produce results faster than topical options. These are also used commonly with ocular rosacea because of the limitations of creams around the eyes.
Antibiotics are powerful but can also lead to severe side effects and should be carefully considered only after topical treatment and trigger avoidance options haven’t worked. Side effects may include rashes, vomiting, abdominal pain, light sensitivity, aches and pains, and more.
This is another oral medication but is not an antibiotic. It’s a powerful drug that’s used to treat severe or resistant outbreaks of acne or rosacea by essentially preventing the skin from producing oil.
This is an option that should only be considered if everything else doesn’t work, as it can cause serious birth defects if the patient is pregnant or plans on becoming pregnant. Side effects of isotretinoin can also include behavioral changes, depression, vomiting, joint pain, and more.
Light or laser treatment is an option for rosacea treatment that would follow if any topical or oral medications are not not reducing symptoms. This therapy uses intense pulses of light to shrink the size of blood vessels in your face to bring inflammation, itchiness, and irritation back to manageable levels.
Laser therapy will usually not permanently reduce symptoms however, and can be needed on a recurring basis to not only reduce blood vessel size, but to remove buildup of skin from phymatous rosacea as well.
Similar to laser therapy to reduce skin buildup or thickness from phymatous rosacea, surgery may also be a consideration to get this done. A cosmetic surgeon would be required for this procedure rather than a dermatologist and the procedure usually involves removing excess skin and reshaping the surface of it.
With surgery, other treatment options may be used in conjunction so that the progress made doesn’t reverse, letting the rosacea worsen again. Often, the patient will be given medication that is more for maintenance and upkeep of the skin rather than the purpose of clearing it.
Balancing your skin microbiome
One way of maintaining and ensuring the health of your skin is by balancing and protecting your skin’s microbiome. As mentioned in the section about causes of rosacea, this will create a healthier environment where good bacteria can keep bad ones in check.
There are two primary ways to keep the skin microbiome healthy – by restoring stability if it’s become unbalanced, and then by supporting and maintaining that balance. Products with a protein like Gladskin’s Microbalance® can help calm skin prone to rosacea using this tactic. It does this by helping the good bacteria and microbes restore balance and prevent bad bacteria from overwhelming the good. This also provides a solution that doesn’t have side effects like dryness and sun sensitivity so you’re not swapping one skin issue with another.
Once that balance has been restored, upkeep is necessary to prevent future outbreaks. This is where both avoiding harsh skincare products that strip the skin microbiome and using gentle products that maintain it are essential.
Rosacea can be kept in check
Rosacea is a skin condition that can vary wildly in terms of how manageable it is and how much impact it can have on your life. With a better understanding of it and your treatment options, you should now be able to decide whether it’s something mild enough where more basic and accessible treatments will do or whether you need to visit a specialist. No matter what your situation with rosacea is, there is help out there and rosacea can be kept in check so you can live a happier, healthier life.
At Gladskin, we’ve often found that people who suffer from rosacea-prone skin turn to us once they’ve realized all the common lines of defense (i.e. antibiotics and prescription creams) come with a lot of baggage, and aren’t always that effective. Whether you’re experiencing facial redness for the first time or you’ve been battling it for years, Gladskin offers a solution that won’t trade out one issue for another (think dryness, hyper-sensitivity, etc.) due to harsh and harmful ingredients.