Rosacea – The Ultimate Guide

Rosacea is a chronic inflammatory skin disease in adults that usually presents on the facial skin. It is characterized by recurrent flushing, redness, pimples, pustules, and dilated blood vessels (telangiectasia) on the nose, chin, cheeks, and forehead and rarely by thickened skin.

50 to 75% of patients with rosacea have eye involvement with symptoms including dryness, redness, tearing, tingling or burning sensation, light sensitivity, foreign-body sensation, and blurred vision. In addition to the skin and eye symptoms, rosacea can cause embarrassment, anxiety, and depression and can have a significant impact on the quality of life. Although usually limited to the skin, an association of rosacea with systemic comorbidities such as neurologic diseases, inflammatory bowel disease, and cardiovascular diseases has been reported.

• Genetics

• Allergies

• Immune reaction

• Ultraviolet (UV) exposure

• Helicobacter pylori and Demodex mites (organisms with reported association with rosacea)

• Environmental factors like weather changes

• Neurovascular dysregulation, and

• Additional vascular endothelial growth factor (VEGF) in those with the disease are some causes.

Finding your trigger can also help to keep the rosacea at bay:

• Foods like: liver, yogurt, sour cream, cheese (except cottage cheese), chocolate, vanilla, soy sauce, yeast extract (bread is ok), vinegar, eggplant, avocados, spinach, broad-leaf beans, and pods, including lima, navy, or pea, citrus fruits, tomatoes, bananas, red plums, raisins or figs, spicy and thermally hot foods, and foods high in histamine could cause rosacea.

• Beverages like: alcohol, especially red wine, beer, bourbon, gin, vodka, or champagne, and hot drinks, including hot cider, hot chocolate, coffee, or tea could cause rosacea.

• Emotional influences like stress and anxiety.

• Skin care products like cosmetics and hair sprays, especially those containing alcohol, witch hazel, or fragrances could cause rosacea. Hydro-alcoholic or acetone substances should also be avoided.

• Temperature-related: saunas, hot baths, simple overheating, exercising, and excessively warm environments.

• Weather: sun, strong winds, cold, and humidity.

• Drugs: vasodilators and topical steroids.

• Medical conditions: frequent flushing, menopause, chronic cough, and caffeine withdrawal syndrome.

1. Subtype 1: Erythematotelangiectatic rosacea
2. Subtype 2: Papulopustular rosacea
3. Subtype 3: Phymatous rosacea
4. Subtype 4: Ocular rosacea

The subtypes are not mutually exclusive. Patients can present with features of multiple subtypes, and the predominant features and areas of involvement can change over time.

Rare forms of rosacea include:

1. Lupoid or Granulomatous Rosacea
2. Rosacea Fulminans (Pyoderma Faciale)

It takes a doctor (and typically a specialist like a dermatologist or an ophthalmologist) to properly diagnose rosacea.

There are several skin disorders that might present with symptoms that appear very similar to rosacea, some of which are uncommon but might be potentially serious. Only a professional can tell the difference.

Rosacea can be tough to diagnose, even for professionals and especially if the symptoms don’t look like obvious rosacea. Sometimes it can be a matter of monitoring symptoms over time and ruling out other conditions first before deciding upon a diagnosis of rosacea. It may take multiple visits, and trying various treatments.

Some conditions might not only appear similar to rosacea but sometimes might even appear along with rosacea:

• Seborrheic dermatitis 
• Contact dermatitis
• Lupus erythematosus 
• Steroid-induced rosacea 
• Photodermatitis
• Keratosis pilaris

The presence of either of these signs may be diagnostic of rosacea:

• Persistent redness or erythema in the central face (nose, cheeks, forehead, chin)
• Skin thickening

Patients with two or more of the following facial symptoms may have rosacea:

• Flushing
• Papules as well as pustules
• Eye irritation and other ocular manifestations

Rosacea patients may also have one or more of the following symptoms, but they are not considered diagnostic unless accompanied by the above signs:

• Dry skin
• A sensation of skin burning
• Swelling

A skincare routine cannot resolve rosacea by itself, but it can help in managing it. Newly diagnosed patients will have to reevaluate their routine to eliminate harsh products that might worsen symptoms of rosacea.

It’s generally recommended for those with rosacea to choose products free from fragrance, parabens, and sulfates formulated for sensitive skin. Establishing a simple routine can be helpful at first, slowly adding additional products over time to more easily identify products that may be causing problems.

Note: your skincare routine should be as minimal as possible.

A gentle, soap-free facial cleanser formulated for sensitive skin can help clean away dirt and excess oil without over-drying the skin, helping the skin to repair the skin barrier.

Once or twice a day cleansing is enough as cleansing too frequently can lead to unnecessary stripping and dryness. Or, you can just use plain old lukewarm or cool water to cleanse your skin. If tap water irritates your skin, then you can use filtered water.

If you have trouble choosing cleansers, look for the words “gentle” or “hydrating” on the products.

A moisturizer is really important if you have rosacea as it will prevent dryness and inflammation. It can be applied after washing the face, and some find repeated applications throughout the day might be helpful depending on the circumstances. Moisturizers that contain ingredients like hyaluronic acid, azelaic acid, and niacinamide can help with rosacea.

Many also find that applying moisturizer over damp skin helps seal in that additional moisture.

Sun exposure is a very common rosacea trigger. Protection from the sun is very important for rosacea patients because many rosacea medications can cause increased sun sensitivity.

A broad-spectrum sunscreen with an SPF rating of 30+ is typically recommended for rosacea.

Mineral sunscreens are better to use for rosacea than chemical sunscreens as they contain ingredients like titanium oxide and zinc oxide that sit on top of the skin and physically block or reflect UV rays. Chemical sunscreens get absorbed into the skin and can cause irritation along with inflammation for rosacea sufferers.

Moisturizers along with sunscreen can also help if you have rosacea.

Products: mineral sunscreens for rosacea

Mineral makeup will be a better option if you have rosacea and try to use makeup as minimally as possible.

You can also use sunscreens that have makeup in them.

• Topical steroids such as hydrocortisone
• Fragrances 
• Alcohol in skincare 
• Exfoliators or exfoliating the skin too much. Try to avoid the use of chemical exfoliators like BHAs or AHAs.
• Essential oils might be irritating for people with rosacea, so it is better to avoid them.
• Sensory stimulants like camphor, menthol, alcohol, and acetone can be irritating and/or drying.

Topical medications are among the first things prescribed to rosacea patients, especially in milder cases. Many of these drugs may make the user more photo-sensitive, so it is very important to apply sunscreen when outside. Below are some common FDA-approved topical treatments:

• Metronidazole: (many brand names Metrocream, Metrogel, Noritate, and Flagyl) is an antibiotic that also works as an anti-inflammatory and has been shown to reduce erythema, papules, and pustules.

• Azelaic acid: (brand name Finacea) has anti-inflammatory, anti-keratinizing, and antibacterial effects. It is also available in lower concentrations in some cosmeceutical products.

• Ivermectin: (brand names Soolantra and Rosiver) is believed to have anti-parasitic and anti-inflammatory effects and can reduce Demodex mites. It is prescribed for papulopustular rosacea.

• Retinoids: such as tretinoin and adapalene have also had some clinical success, but the data is still limited.

• Brimonidine: (brand names Mirvaso and Onreltea) can reduce redness by restricting blood vessels in the skin. After application, the drug reduces the redness for a period of time. While it can be effective for many, after losing effect the face may become redder than before application in what is informally known as the “rebound effect.”

• Oxymetazoline: (brand name Rhofade) can reduce erythema through direct cutaneous vasoconstriction. Users may experience the “rebound effect.”

• Topical Minocycline Foam 1.5%: (brand name Zilxi) is a tetracycline-class antibiotic that is prescribed topically and orally for the treatment of rosacea that is also sometimes prescribed orally for rosacea.

• Other creams: Epsolay cream.

Many of the following drugs may make the user more photo-sensitive, so sunscreen use and avoiding unnecessary exposure to sunlight can be especially important. These drugs may be used in combination with topical therapies.

• Doxycycline is a tetracycline-class antibiotic often prescribed for rosacea in sub-antimicrobial (too low for the treatment of acute infection) doses. It has anti-inflammatory properties that can be helpful for rosacea even at such low doses, though higher doses can be used at first to help establish initial control. It is most often prescribed as a generic. 

• Oracea is a combination 30mg immediate release and 10mg sustained release low-dose formulation of doxycycline that has been approved to specifically help rosacea patients and reduce side effects of doxycycline.

• Minocycline is another tetracycline-class antibiotic with anti-inflammatory properties too.

• Isotretinoin (brand name Accutane) is a derivative of Vitamin A that is most often prescribed for patients with severe acne, but may be prescribed in lower doses for treating papulopustular rosacea.

• Baby shampoos: can also help with type 1 or type 2 rosacea and a lot of people have had success with it. Johnson’s baby shampoo should be a good one to use.

• Tea tree oil: is the most common oil used to treat rosacea because of its ability to kill Demodex mites.

• Salicylic acid: has anti-inflammatory, anti-acne, and mild exfoliating properties that might help milder cases of rosacea; however it might cause flareups, so its efficacy varies from person to person.

• Niacinamide (also known as nicotinamide) either topically or orally may reduce redness and help with acne.

• Zinc oxide: may help with rosacea. Diaper rash creams like Boudreaux’s Butt Paste contain zinc oxide and can help to reduce rosacea.

• Azelaic acid + Metronidazole + Ivermectin (15%-1%-1%): this is a prescription medicine you can get from a website called apostrophe and is another treatment you can try using.

• Biologics: like secukinumab and erenumab can help.

• Sulfur: has antibacterial, anti-microbial, and anti-keratolytic properties that might be helpful for rosacea. Some patients have success using sulfur creams, soaps, and lotions. Prosacea is a sulfur-containing product and has worked for some people.

• Hypochlorous Acid: studies show that hypochlorous acid can effectively kill the nymph form of the Demodex mites and Bacillus oleronius. It can also kill the Staphylococcus aureus bacteria that live on the eyelids and that are found inside the Demodex gut. In addition, HOCl also neutralizes the inflammatory toxins released by both mites and bacteria. It is completely non-toxic and non-irritating. 

• Other medicines: like elidel, protopic, prednisone, dapsone, benzyl benzoate solution, permethrin cream, crotamiton cream, selenium sulfide wash, ornidazole, and encapsulated benzoyl peroxide cream, B244 topical spray, omiganan topical gel, DMT210 5% topical gel, and hydroxychloroquine can help with rosacea.

Azithromycin, erythromycin, and clarithromycin are considered to be safe in pregnant women with mild-severe inflammatory rosacea.

You can try dieting and see if your rosacea goes down. Note that dieting can work only for some people. You can take probiotics, prebiotics, vitamins, or minerals along with trying out diets like keto or low-carb diets, and cutting out gluten, dairy, spicy foods, eggs, sugar, cinnamon and other similar spices, citrus fruits, nuts, caffeine, and alcohol can help.

Vascular lasers or intense pulsed light can help to reduce background redness, erythema and telangiectasia but may not reduce the frequency of flushing episodes. For now, evidence is still emerging and most to all of these treatments are not yet FDA-approved for rosacea, so many insurance plans and healthcare systems still regard them as cosmetic procedures and they aren’t often covered. More research is still needed before they might become more widely adopted for use in treating rosacea, and a dermatologist can help determine what treatments might be helpful for you, and if you’re ready for them.

Laser and light therapy devices currently FDA-cleared for the treatment of rosacea symptoms include:

• Candela Vbeam Prima pulsed-dye laser: telangiectasia and rosacea.
• Candela Nordlys Ellipse IPL, Frax 1550nm, NdYAG 1064nm: telangiectasia, rosacea, diffuse redness
• Candela elos Plus: telangiectasia, rosacea
• Cutera excel V+ laser: telangiectasia, rosacea
• Cynosure Icon Aesthetic Platform 2940nm, 1540nm, 1440nm, 1064nm: telangiectasia

In case of pain association, an analgesic therapy with, for instance, lidocaine gel (4%) or polidocanol cream in mild cases and antiphlogistics, anti-depressants, or anticonvulsants in more severe cases may be helpful.

Treatment for flushing and erythema may involve oral drugs with vasoconstriction properties including adrenergic antagonists including mirtazapine, propranolol, or carvedilol. These are used at low doses to avoid adverse effects such as hypotension, somnolence, fatigue and bronchospasm.

If you tried Soolantra (ivermectin) and had great results with it, but were not afford it for a second time, then you can try using horse paste/gel. Many horse paste/gel contains ivermectin that can treat rosacea.

Some brands include:

• DURVET ivermectin injection for cattle and swine 1,87% with apple flavour
• EQVALAN paste 1.87% ivermectin

Note: make sure to consult a doctor before using horse paste or any form of ivermectin that is not FDA-approved. Also do conduct a patch test first before applying it on your whole face.

No, you shouldn’t pop rosacea bumps or acne as it will only make things worse. Rosacea looks like acne but it isn’t, it is caused by broken blood vessels but also depends on the type of rosacea.

It is least likely that Demodex would cause tinnitus. Itching in the ears would be a more common symptom and there could be redness in and around the canal. There can also be discharge since hair follicles are located in the outer part of the canal.

Tinnitus would be the last symptom as it can have a vast number of causes. In most cases, the cause remains unknown.

At times it can be slight aberrations in the hair cell functioning that can cause tinnitus. However, in most cases, it is not harmful and might simply go away by habituation and masking.