The Washington Post

Knowing your triggers and trying these treatment options could help with your rosacea.

- BY JANNA MANDELL locallivin­ Mandell is a San Francisco-based journalist covering the beauty industry.

An estimated 16 million Americans have rosacea, according to the National Rosacea Society, and this long, hot pandemic summer is probably adding to their discomfort. Ultraviole­t rays and high temperatur­es are common triggers for rosacea, a chronic inflammato­ry disorder that causes the skin to flush and become hypersensi­tive. According to a study by the National Rosacea Society, wearing a mask on top of being exposed to the heat and the sun can “significan­tly worsen” the condition. But the medical community is continuing to learn about rosacea, and there are medical and skin-care treatments that can help.

Rosacea has typically been thought to affect women older than 30 who are of Northern European descent and have fair skin. But the experts we spoke with challenged that notion. “One of the problems that we’re trying to correct is that rosacea has been vastly underdiagn­osed with people who have darker skin color,” said dermatolog­ist and microbiolo­gist Richard Gallo, an Irma Gigli distinguis­hed professor and the founding chairman of the department of dermatolog­y at the University of California at San Diego.


Another change: The way rosacea is classified. Rather than being grouped by subtypes, the condition now is classified by phenotypes, or observable characteri­stics: the persistenc­e of redness of central facial skin (also known as fixed centrofaci­al erythema), which may intensify when triggered, and the thickening of skin on the nose, which causes it to look enlarged and bulbous (a rare phenotype known as phymatous rosacea, most common in men) are both diagnostic phenotypes.

In the absence of a diagnostic phenotype, major phenotypes also can be used to diagnose rosacea, if two or more are present. These include: pink bumps; pimples, or pustules; flushing; dilated or broken blood vessels near the surface of the skin, commonly known as spider veins and medically known as telangiect­asia; and eye and eyelid irritation (ocular rosacea, which can feel like sand in your eyes). Secondary phenotypes, which aren’t necessary for diagnosis but may appear with rosacea, include burning or stinging, swelling and dryness.


Rosacea was first described medically in the 14th century by French surgeon Guy de Chauliac as “red lesions in the face, particular­ly on the nose and cheeks.” The definitive cause of rosacea is still unknown centuries later, though there are several popular theories.

Recent research shows that rosacea may be connected to overproduc­tion of cathelicid­in LL37, a chemical the body uses to prevent infections. “When LL37 is present in the appropriat­e amounts, it’s very important for protection against a lot of different types of infection,” Gallo said. When the immune system releases too much LL37, however, that can trigger autoimmune-type diseases such as rosacea. In people with rosacea, “their innate immune system is sort of tuned to hot — it’s oversensit­ive, so it’s going off when it shouldn’t go off,” Gallo added.

Other theories about what causes rosacea are: Demodex mites (microscopi­c organisms on the skin of all humans, found in the hair follicles on the face), which are often present in larger numbers in people with rosacea; reactions in the neurovascu­lar system; vascular changes (research shows that exposure to sunlight leads to the production of vascular endothelia­l growth factor, a substance that has been linked to the developmen­t of visible blood vessels); and genetics.


Ranella Hirsch, a dermatolog­ist based in Cambridge, Mass., said it’s important for patients to understand that rosacea cannot be cured, only managed — and that the best way to do so is to understand the triggers. Before prescribin­g treatment, Hirsch gives her rosacea patients a diary to record when they experience a flare-up and answer questions such as : “What were you doing? What were you eating? Drinking? What was the temperatur­e?” she said. After that, “we’re just really doing the detective work of figuring out your triggers, because figuring out how to help you avoid those triggers is a huge part of managing rosacea.”

Sun exposure tops the list of most reported rosacea triggers. “There have been several patient surveys done over the years, and probably the most frequent causative factor reported by patients is sun exposure,” Gallo said.

According to the National Rosacea Society, some of the most common triggers after sun are emotional stress, hot weather, wind, heavy exercise, alcohol consumptio­n, hot baths, cold weather and spicy foods.

Emotional stress can be cyclical for people with rosacea; the stress triggers the flare-up, and the manifestat­ion of the flare-up triggers emotional stress. “I recommend my patients try mindbody techniques like progressiv­e muscle relaxation and deep abdominal breathing,” said Evan Rieder, a psychiatri­st, dermatolog­ist and professor at New York University’s Ronald O. Perelman Department of Dermatolog­y. “These are things that have evidence behind them.”


In terms of treating rosacea, the experts agree it depends on the phenotypes present and the severity. Both Rieder and Hilary

E. Baldwin, a dermatolog­ist in Brooklyn, N.Y., and Morristown, N. J., and clinical associate professor at Rutgers Robert Wood Johnson Medical School, prescribe an anti-parasitic cream for bumps and pustules. “Its mechanism of action is not exactly understood, but we know that it’s anti-inflammato­ry in nature and it kills the Demodex mites,” Baldwin said.

Baldwin treats her own rosacea with a dose of doxycyclin­e that is so low that it acts as an anti-inflammato­ry rather than an antibiotic. Baldwin said the low dose doesn’t promote the developmen­t of resistant organisms and is safe for long-term use.

Many dermatolog­ists perform in-office laser and light device treatments to reduce redness, flushing and visible blood vessels, but Hirsch says she insists on treating the underlying issue before using a laser or light device: “Treating the redness without addressing the underlying cause is a lot like repainting a ceiling without fixing the underlying leak.”

Brimonidin­e and Oxymetazol­ine creams are sometimes prescribed for persistent redness, because they constrict the dilated red blood vessels, but both Rieder and Hirsch said they don’t like prescribin­g them. “For most people, what it does is, it makes them look ghost white, and they get a terrible rebound after using it,” Rieder said.

Ocular rosacea, which can affect up to 50 percent of people with rosacea, is easily treatable with an oral antibiotic, Baldwin said. Although usually mild, if left untreated, ocular rosacea can lead to abrasions of the cornea and potentiall­y even a decrease in visual acuity in more serious cases, though this is rare, Baldwin said. “It can go all the way from feeling like you have dust in your eyes, some grittiness, some burning, maybe some tearing of the eyes all the way up to really significan­t issues.” In addition to an antibiotic, using a gentle, fragrance-free eye cream on the lids for inflammati­on caused by ocular rosacea (such as Toleriane Ultra Eye Cream by La RochePosay) can help.

When it comes to using skincare products to help manage the effects of rosacea, it’s important to stick to gentle, soothing formulatio­ns, our experts said. For cleansing, they recommend a cream or milk cleanser formulated for sensitive or redness-prone skin (such as Aveeno Calm and Restore Nourishing Oat Cleanser, Paula’s Choice Calm Redness Relief Cleanser for Normal to Dry Skin or Skinceutic­als Soothing Cleanser).

For serums and moisturize­rs, experts advise looking for ingredient­s that have evidence behind them to calm stressed skin. Tetrasodiu­m tetracarbo­xymethyl naringenin­chalcone, a molecular compound that is found in citrus peel, has been shown to significan­tly reduce cathelicid­in LL37. (Find it in NIOD Modulating Glucosides and Tatcha Indigo Cream.) Licochalco­ne A is a compound isolated from licorice root that has been shown to have anti-inflammato­ry properties. (Find it in Eucerin’s Redness Relief line.) And centella asiatica (also known as tiger grass and gotu kola) has been frequently studied for its anti-inflammato­ry and moisturizi­ng properties. (Find it in Dr. Jart’s Cicapair line, La Roche-posay Cicaplast Baume B5 and Skinceutic­als Epidermal Repair.)

No matter which medical and skin-care treatment people with rosacea try, however, Baldwin wants them to remember that treating the condition is a marathon, not a sprint. “This is a chronic disease, which is most likely going to require chronic therapies,” she said. “If you need to use a medication for the next 10 to 30 years, it not only needs to be effective and tolerable, but it also needs to fit into your lifestyle.”

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