Updated: Sep 28, 2022
Rosacea is a common condition, and unfortunately chronic for about ten percent of people with fair skin. It is generally more common in women over the age of 30 years and may look like flushing and redness in the center of the face, or it may be more acne-like #papules and pustules in the middle of the face, or even small blood vessels. Some individuals find these symptoms around their eyes, with itching and even irritation of the eyes themselves and others suffer more symptoms specific to their nose, even a thickening of the skin which is called #rhinophyma. These latter symptoms are more common to men and when they do occur in men, they are typically more significant. Unfortunately, some suffer some or all of these symptoms but more often, all who suffer with #rosacea really struggle with sensitive skin and have stinging and burning with many personal care products.
Rosacea lowers self-confidence and self-esteem in about 70 percent of people with the condition and one study found 41 percent of individuals with rosacea avoid public contact or cancer social engagements. Another study found that those with rosacea have higher incidences of embarrassment, social anxiety, depression, and decreased quality of life compared to the rest of the population. Rosacea is more than just a red face.
The cause is not well understood and unfortunately, there isn't thought to be a cure. The initial outbreak seems to originate from the skin not respond or recovering well from some level of trauma, whether bacterial or even sun exposure. Higher levels of inflammation occurs in these individuals and in response to the trauma, as their immune systems create more vessels which increases blood flow and subsequently the pinkness we see. In most people, rosacea tends to get better for a while and then gets worse again, or flares up. Rosacea may get much worse of time as well, if untreated.
There is also potential that symptoms are related to an inflammatory reaction to Demodex folliculorum, a mite found in most people, but present in higher numbers on the skin of people who have rosacea. Dysfunction of cutaneous blood vessels, also related to the immune and inflammatory reactivity, is yet another potential. One study found small bowel overgrowth (#SIBO) to be the underlying cause of rosacea, and treatment with antibiotics resulted in significant improvement or clearance of the rosacea symptoms (Parodi, Paolino, Greco, et al, 2008).
The potential triggers for rosacea flares include sun exposure, extreme temperature exposure, rapid changes in temperature, exercise, spicy foods, hot beverages or foods, alcohol, irritation from topical skin care products, emotional states - especially anger, rage, or embarrassment - and some medications such as beta-blockers and niacin.
Management and Resolution
It's important to minimize flares of rosacea because repeated flares results in more aggressive inflammatory responses. There are a number of triggers, but each individual is unique. Some respond to one, while others react to many or even an uncommon trigger that can be hard to identify. With my own clients, I ask that they keep a symptom journal of when and where they find reactions and what substances or activities they have exposed themselves. Once a flare is triggered, using a cool mist or compress on the skin can minimize the inflammation and ultimately, the flushing. Conventional treatment for rosacea is most effective for the pimples and bumps; however, addressing the underlying inflammation and triggers is key to resolution.
Antibiotics (metronidazole), often by mouth initially and then topical (#MetroGel) is commonly prescribed. It may take about two months before your skin starts to look better though. At this point the oral dose is reduced or transitioned to the topical gel or cream. Overall length of antibiotic treatment is unique to the individual. Rhinophyma may require surgery with a fine electric needle or laser to remove the enlarged blood vessels.
Sensitive skin is common to those with rosacea so a gentle skin care regimen is important. Washing with warm water in a circular motion with the fingertips, using only gentle pH-balanced cleansers or soapless cleansers are encouraged. Once the face is dry, a gentle, non-alkaline moisturizer can be applied to the skin. Ceramide-containing moisturizers may be particularly helpful. Harsh soaps and abrasive cleansing will likely worsen symptoms. Our skin care program can help you understand how to best manage your skin to show off your best glow.
Minimizing exposure to chemicals that may irritate the skin is an important part of managing rosacea. Common potential irritants are often acetone, alcohol, propylene glycol, alpha-hydroxy acids, sodium lauryl sulfate, benzalkonium chloride, formaldehyde releasers, menthol, benzyl alcohol, camphor, urea, pyrrolidone carboxylic acid, lanolin, and fragrances. Wearing sunscreen may be necessary for those with a sun exposure trigger, especially one formulated for people with sensitive skin or for babies.
Healthy dietary choices are certainly important for optimal health, but there is no quick fix. Our practice utilizes special testing for identifying sensitivities to food, chemicals, and dyes. This can go a long way towards minimizing over reactions to your various exposures, and it is very individualized. Our practice has seen sensitivities to paprika, coconut, onions, and apples - all sorts of things one would not guess where diary, eggs, and wheat were not an inflammatory trigger. These may never have been identified without our specialty testing, but often for clients with rosacea, will then transition to an anti-inflammatory diet taking into account the new information we learned with the original testing. The Mediterranean diet is another diet that can well support reducing inflammation. Research supports eating a plant-based diet low in processed foods to support a healthy gut microflora.
Although the diets above are the guide, consider implementing more berries into your diet. All berries, including raspberries, blackberries, and blueberries are high in antioxidants called flavonoids which contribute to anti-inflammatory effects by reducing free-radical damage to cells. The darker the berry, the better. This is true too of all vegetables and fruits. Aim for at least a cup a day.
Garlic is another excellent addition to your daily diet when working against inflammation. In addition to its antibacterial, antiviral, and antioxidant properties, garlic also contains a sulfuric compound called allicin, which offers an anti-inflammatory effect. The finer you chop it, the more allicin is released.
Turmeric is an excellent anti-inflammatory spice, part of the ginger family and a traditional component of Indian food. Curcumin gives turmeric its bright yellow color and when combined with black pepper, the turmeric has even more bioavailability. You can either try traditional recipes with turmeric or add it to recipes you are already making and see what you think. Ginger is a bit more tame and also works to halt the body's production of cytokines (proteins that trigger chronic inflammation). Ginger has long been used to ease the stomach and to help regulate the blood sugar.
Leafy green veggies such as kale, Swiss chard, collard greens, arugula, and spinach are rich in antioxidants that restore cellular health, as well as anti-inflammatory flavonoids. They also offer important vitamins and minerals like vitamins A, C, and K, as well as potassium. Swiss chard, in particular, is packed with antioxidants that can help protect your brain against oxidative stress caused by free-radical damage. Again, the darker the shade, the more nutritious they are.
Cinnamon sprinkled on your food can help regulate blood sugars, improve memory, and even balance your monthly cycle but it also offers a high concentration of anti-inflammatory and antioxidant compounds which help protect the body from oxidative stress, fight infections, and repair tissue damage.
Coconut oil has long been touted for its wide-ranging health and medicinal benefits. This oil is a bit easier for the body to metabolize making it a great resource for energy and also a potent weight-loss tool. It also contains lauric acid, which when digested, helps fight off harmful bacteria, viruses, and fungi in the body. Coconut oil is a superfood and one of the best anti-inflammatory foods available.
Chia seeds are tiny, but mighty and full of the perfect ratio of omega-3 to omega-6 fatty acids. They are full of fiber and protein, and excellent for reducing inflammation as well as cholesterol, and lowering the blood pressure. We add chia seeds to our overnight oats.
Broccoli is one of my daughter's favorite foods. They are high in minerals like potassium and magnesium. It also has sulforaphane which lowers oxidative stress and reduces inflammation. Try it in soup, pesto, coleslaw, stir-fry, salad, or just steam it. The options are endless.
Bone broth is full of body-boosting minerals, including calcium, magnesium, and phosphorous, as well as glucosamine, which helps protect joints and strengthen bones. It is also full of collagen, which helps skin remain plump and firm - the glue that holds us together. Sip on a warm cup in the morning, or use it as a soup base or to cook your favorite grains, like quinoa or even rice.
Nuts are yet another option offering high levels of omega-3 fatty acids, which help keep the heart, brain, eyes, and even breasts happy. The fiber they offer can help reduce weight and of course, they too are anti-inflammatory. Snack on homemade trail mix, add some almond butter to smoothies, or sprinkle some nuts on top of a salad or entree dish.
One more option is to add beets as they offer an amino acid called betaine, which help protect the body from environmental stressors. The phytonutrients found in beets, which make them so bright in color, have also been shown to have cancer-fighting properties. And, beetroot juice has been shown to help increase blood flow to the brain.
Omega-3 fatty acids have been shown to decrease the production of inflammatory compounds. Ideally, omega-3-fatty acids would come from foods such as fatty fish (salmon, tuna, herring, mackerel, and sardines), flaxseeds, and walnuts. When that is not possible, supplements can be helpful. The omega-3s found in flax are not as potent in terms of anti-inflammatory effects as those in fish oil. Suggested dosing for the flax oil is 1 tablespoon for every 100 pounds of body weight per day, or a tablespoon or two of flaxseed daily, or a gram or two of fish oil capsules twice daily. Aim to eat three ounces of fatty fish twice each week.
Probiotics aren't specifically supported in the literature for rosacea, but the correlation of small intestinal bacterial overgrowth with symptoms of rosacea certainly suggest that supporting a healthier gut microflora is a wise move. Hopefully more research will be invested into the future to help clarify specific doses and strains that are most likely to be effective, as we already know diet choices make an impact.
Otherwise, avoid over-the-counter topical steroids although this may be tempting as they can offer temporary relief, but they can also easily worsen symptoms long-term with rebound symptoms after the steroids are ultimately discontinued. In enough time, topical steroids can cause thinning of the skin so not only should these be monitored by your clinicians, but they should only be used on a short-term basis.
Green tea is an antioxidant and anti-inflammatory, and it appears to have UV-protective effects as well, making it a good and safe choice for topical treatment of rosacea (Pazyar, Feily, & Kazerouni, 2012). Either 2 percent green tea extract or 2 percent EGCG can be added to a topical base by a compounding pharmacy. Increasingly, there are over-the-counter products available with the appropriate concentration of green tea extract.
Nicotinamide is a form of vitamin B3 and has been found to have anti-inflammatory and anti-sebum properties. It also stabilizes the epidermal barrier and helps increase moisture content of the epidermis (Emer, Waldorf, & Berson, 2011). Preparations of 4 to 5 percent are helpful in treating blemishes and are often particularly helpful in treating papulopustular rosacea.
Mind-Body Therapies & Somatic Healing
Our practice is very dedicated to #somatic healing as part of our wellness plans and management of dis-ease from a functional and integrative mindset. While there are not specific studies specific to mind-body approaches and rosacea that I am aware, we know they are significant for emotional regulation. These types of approaches may be particularly helpful for individuals who have clear emotional triggers for their symptoms. We have a program for those with anxiety and depression, and a separate program for those who are ready to embrace somatic healing.
Emer, J., Waldorf, H., & Berson, D. (2011). Botanicals and anti-inflammatories: natural ingredients for rosacea. Semin Cutan Med Surg, 30(3), 148-155. doi: 10.1016/j.sder.2011.05.007
Parodi, A., Paolino, S., Greco, A., et al. (2008). Small intestinal bacterial overgrowth in rosacea: Clinical effectiveness of its eradication. Clinical Gastroenterology & Hepatology, 6(7), 759-764. doi: 10.1016/j.cgh.2008.02.054
Pazyar, N., Feily, A., & Kazerouni, A. (2012). Green tea in dermatology. Skinmed, 10(6), 352-355.