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 mind-body 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 extremely 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 Roche-Posay) can help.
When it comes to using skin-care 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.”
Mandell is a San Francisco-based journalist covering the beauty industry.