Rosacea Treatment: The Complete Guide

According to the National Rosacea Society, as many as 16 million people suffer from some form of rosacea in the United States alone. With so much of the population affected by the condition, it is no wonder that so many researchers, pharmaceutical companies, and doctors are looking for solutions that will not just control rosacea, but cure it completely.  If you have just been diagnosed with the skin condition, or you just want to learn more about rosacea treatment, then you have come to the right place. 

For our quick overview on rosacea: click here

Introduction

Rosacea, by definition, is a disorder that primarily affects the facial skin by way of phases of flare-ups and remissions. Typically, the first signs of rosacea will appear around age 30; they will first show up as central facial redness and around the eyes, which is associated with a number of systemic disorders. These symptoms may come and go without worsening for some time. However, if the rosacea is left untreated, it will worsen over time, and eventually lead to:

• Visible Blood Vessels
• Bumps or Pimples 
• Swollen, Bumpy or Excessive Tissue of the Nose
• Dry or Irritated, Bloodshot Eyes

Generally speaking, rosacea can affect anyone, no matter their race, gender, or nationality. However, people who have fair skin who tend to flush easily will be at the greatest risk. Additionally, more women are diagnosed with rosacea than men. Find our article on rosacea in people of Asian, African, and Hispanic Heritage. to learn more about how rosacea can affect patients based on ethnic background.

Although there is no known cure for rosacea, most people notice the progression of symptoms can be halted and flare-ups managed through identification and avoidance of triggers combined with gentle rosacea skincare, and medical treatment(s). Awareness and intervention can improve the quality of life significantly for rosacea patients. It is important to consult your doctor to discuss medical rosacea treatment options, to gain an understanding of your rosacea triggers, and to explore rosacea skincare routines that can help.

Rosacea Symptoms

Some people who begin to develop rosacea have no idea that they have the condition at all. However, by understanding the symptoms, it is easier to recognize the issue. There are different types of the condition - which we will discuss later - but the basic symptoms include:

• Flushing – May appear as blushing or unspecified facial redness.
• Persistent Redness – May look like a chronic sunburn.
• Bumps and Pimples – May appear pus-filled and will appear along with redness as well as burning or stinging.
• Visible Blood Vessels – May appear as enlarged capillaries just under the skin.
• Eye Irritation – May happen with rosacea.
• Burning or Stinging – May occur along with itching, tightness, and redness.
• Dry Skin – Facial skin may be rough and dry.
• Rarely Facial Swelling – Could appear with other signs or independently.

Rosacea commonly appears on the face, but signs of it can form on the chest, scalp, eyes, ears, and neck as well.

As mentioned, there are different types of rosacea. We will discuss the four subtypes individually and discuss the rosacea treatments available for each.

Rosacea Basics

To put it in the most basic terms, rosacea is an inflammation that comes back again and again. Essentially, someone who has this chronic disease will relapse from time to time while going through weeks, months or even years without a single symptom. There is no cure at this time, but this guide sets out to focus on the ways in which each form of rosacea can be treated. More importantly, we set out to provide those living with rosacea, different pathways to minimizing the disruptive symptoms associated with this condition.

Types of Rosacea

The four subtypes of rosacea, which we will discuss in detail later, include the following:

Subtype 1: Facial redness (Erythematotelangiectatic Rosacea) – This type is characterized by flushing, redness, and the appearance of visible blood vessels.

Subtype 2: Bumps and Pimples (Papulopustular Rosacea) – This form is characterized by central facial redness and bumps or pimples forming.

Subtype 3: Enlargement of the Nose (Phymatous Rosacea) – This type is characterized by thickening and enlargement of the skin and facial tissues, primarily the nose along with bumps and pimples. 

Subtype 4: Eye Irritation (Ocular Rosacea)  – This type affects the eye, resulting in dry eyes, excessive tearing, burning eyes, swollen eyelids, vision loss, recurrence of sties, and corneal damage. (NRS)

While these are considered different subtypes of the condition, it is very common for patients to have an overlap of more than one subtype at any time. This has given rise to the new classification by National Rosacea Society Expert Committee (2017).

General Measures to Avoid Outbreaks

The beginning of rosacea treatment simply starts with knowing how you can avoid outbreaks. While these measures will not take away your risk of outbreak completely, they can minimize it a great deal. So, knowing what causes rosacea to flare up and then avoiding those triggers can go a long way toward not letting the condition rule your life.

In a way, how much rosacea will be a problem for you can depend on what you do. By learning to avoid flare-ups and your own triggers, you will be able to minimize how often you have issues with the condition. That, of course, doesn’t mean you will always be able to avoid flare-ups. Sometimes, they happen for seemingly no reason at all. However, it does mean you can minimize them.

Flushing

This is, by far, the most common symptom of rosacea. It appears in all subtypes and can be a frustrating problem for rosacea patients. Some experts even believe that chronic flushing will eventually contribute to other rosacea symptoms. Flushing can be triggered by certain activities, including:

• Exposure to Extreme Temperatures
• Exposure to Sunlight
• Drinking Alcohol
• Eating Spicy Foods
• Becoming Very Stressed
• Exercising
• Taking Certain Medications
• Having Hot Flashes Associated with Menopause

Each patient can have different triggers and different levels of these triggers as well. For example, you may flush very badly when exposed to sunlight, but someone else with rosacea may not. It’s a good idea to start logging when you experience flushing, the severity of your symptoms, and what caused it. This will help you create a clearer picture of your own triggers.

Click here for more information on diet and rosacea.

There are certain medications that can help suppress or reduce flushing, including antidepressants, beta-blockers, gabapentin, clonidine, and topical brimonidine or oxymetazoline. Some experts recommend the use of intense pulsed light or lasers and photodynamic therapy, but the results are variable.

Skincare

In order to manage Rosacea, a good skincare regimen will be key in helping to avoid the dry, rough, and scaly symptoms of rosacea. Using gentle skincare measures and avoiding anything harsh that could further aggravate the skin are good fundamental guidelines to follow.

The following tips are critical to creating an effective rosacea skincare system: 

• Regular Cleansing – It is vital to use only gentle measures to cleanse your skin. This includes using lukewarm water, only the fingertips, and non-soap cleansers such as beauty bars and mild liquid cleansers.
• Avoiding Harsh Topical Products – A variety of different skin products are simply too harsh for patients with rosacea, including exfoliating agents, toners, and astringents. You should also avoid manual exfoliation with sponges or rough cloths.

Using the right type of skincare will ensure that you do not make the symptoms of your rosacea worse. If formulated correctly, some topical skincare products can even lessen the risk of symptoms and flare-ups.

Rosacea skin is sensitive skin and facial irritation can be caused or exacerbated by skincare products themselves. Thus, gentle hypoallergenic skincare that avoids irritation is an important factor in the management of rosacea. Furthermore, gentle skincare can help to build and maintain the barrier function of the skin, helping to prevent bacterial overgrowth and improving overall skin health.

The barrier function of the skin has two components: the stratum corneum and the acid mantle. The stratum corneum is the outermost layer of cells on the skin. These cells are dead but form a cohesive barrier that is important in preventing infection and UV damage. The acid mantle is a very fine, slightly acidic (between pH 4.5 and 6.2) film on the surface of the skin secreted by the sebaceous glands, which acts as a barrier to bacteria, viruses, and other potential contaminants.

Gentle, hypoallergenic skincare for rosacea should include a mild cleanser, and gentle serum and a moisturizer. Avoid products containing allergens such as dyes, fragrances, and formaldehyde-releasing agents. Also, chemicals that strip the acid mantle or stratum corneum such as alcohol-based toners, mechanical/chemical exfoliants, and retinol should be avoided.  

If you are suffering from Rosacea make sure to give Dr. Rivers' 15-day free sample kit a try. Developed specifically for his patients to reduce redness, flushing and irritation, the free sample kit will last long enough to make sure Riversol works for you.  

Sun Protection

Because exposure to sunlight is a very common trigger for rosacea symptoms, using sun protection is a must. Not only does the warmth of the sunlight cause flushing flares, but the exposure to ultraviolet radiation can cause changes beneath the skin that worsen rosacea.

The best option for anyone with rosacea is to use a broad-spectrum sunblock of at least SPF 30 or higher. Additionally, it is a good idea to use sun-protective clothing and to avoid the midday sun.

The best sunblock to use when you have rosacea will be one that incorporates a cream or lotion base because the alcohol can further irritate the skin.

Cosmetic Camouflage

When rosacea symptoms appear, one option is to cover the problem with cosmetics. Red patches and flushing can often be covered well enough that others will not notice.

For women, it is best to start with a green-tinted concealer and finish with a  foundation.

For men, it is best to use a green-tinted facial powder to reduce the redness.

When choosing makeup, it is best to look for products that do not contain oil and specifically say on the label that they are non-comedogenic. Also, check products for alcohol, peppermint, menthol, clove oil, eucalyptus oil, salicylic acid, and hazel oil all of which may aggravate your rosacea. 

Now that we have covered the basics of rosacea, and how you can take steps to avoid flare-ups, we will go over each of the subtypes with information on treatment for each as well.

Everything You Need to Know About Subtype 1 Rosacea: Erythematotelangiectatic

Often referred to simply as ETR, this is the most common subtype to show symptoms of rosacea. This type will show:

• Flushing and redness, especially at the center of the face
• Enlarged capillary blood vessels that are visible primarily on the cheeks and nose.
• Skin that becomes swollen
• Sensitive skin that stings and burns
• Skin that appears dry, rough, and scaly

Remember, you may not see all of the above-mentioned symptoms at once. Some people only develop one or two at a time. However, symptoms typically worsen over time. For example, if you are experiencing redness and flushing and your rosacea is left untreated, you will likely develop the remaining symptoms over time.

Subtype 1 Rosacea Treatment

The core purpose of treatment for this subtype of rosacea is to reduce skin sensitivity and flushing. Usually, people only show mild symptoms, which can be managed well with basic treatment. However, if basic treatment is not effective against more severe forms of this type, then pulsed light, lasers, and medications may be used.

Laser and Intense Pulsed Light (IPL) Devices

If avoiding triggers does not have a noticeable impact on your symptoms, we recommend moving to second-line interventions. This will include light-based treatments and medications.

• Laser and Intense Pulsed Light – This treatment can be used to treat vascular lesions associated with ETR. This treatment will allow the damaged vessels to be sealed.
• Medications – Some medications may help to reduce the symptoms of rosacea.

Again, none of these interventions completely eliminate the signs of rosacea, and they only help fight the symptoms.

Medications

As mentioned, medications have proven to be most effective at managing the symptoms of rosacea. There are several different types used to manage ETR specifically.

• Topical Brimonidine and Oxymetazoline – These medications have proven to be of benefit in managing ETR rosacea. There have been scientific trials to show these drugs help to reduce the redness associated with rosacea. There are generally well tolerated even by sensitive skin and have proven to remain safe and effective even for long-term use.

Side effects of this treatment include contact dermatitis, flushing, burning sensations, and rebound redness.

If you are taking high blood pressure medication, cardiac medication, depressants of your central nervous system (monoamine oxidase inhibitors), then you should discuss your options with your doctor before using brimonidine.

• Topical Retinoids – Some studies have found that these medications can relieve the redness and flushing associated with ETR.
• Topical Calcineurin Inhibitors – There have been reports that these medications can be effective.

The main line of defence against rosacea flare-ups of this type are lifestyle factors and changes. Avoiding direct sunlight or using a strong broad-spectrum sunblock is a must, metronidazole or azelaic acid may also be able to suppress some of the inflammation. Additionally, using gentle facial cleansers and avoiding harsh chemicals in cosmetics is critical to improving or eliminating the symptoms of rosacea.

If lifestyle changes are not enough to manage the rosacea, then medications or laser / IPL therapy can be used as well. However, your doctor will determine the best course of treatment depending on the severity of your condition and how it has responded to previous treatments.

Everything You Need to Know About Subtype 2 Rosacea: Papulopustular

The next subtype of rosacea is papulopustular, which is often referred to simply as acne rosacea. Symptoms associated with this type include:

• Central facial redness associated with acne-like pimples

• Excessively oily skin

• Visible dilated blood vessels

As with type 1, patients with this type of rosacea may also flush frequently. This type is so commonly mistaken for acne that many people go for years without knowing that they have it.

Subtype 2 Rosacea Treatment

If you have a moderate form of this condition, then there is a good chance it can be successfully managed with topical medications. However, in more severe cases, antibiotics must be used and laser therapy may be considered.

Mild to Moderate Disease

As mentioned, oral medications and IPL / laser therapy are used in most cases of mild to moderate forms of rosacea because they are capable of controlling the symptoms to a satisfactory level. Oftentimes, even non-medicated topical skincare is sufficient to control mild rosacea symptoms. If non-medicated skincare is insufficient, many topical medications can provide relief:

• Metronidazole – This medication is an antimicrobial, and anti-inflammatory agent. At this time, reviews have not determined how this medication works to improve rosacea. Usually, the topical medications will be used either once or twice a day and it is generally very well tolerated. However, some people may experience stinging, dryness, or irritation.
• Azelaic Acid – This is a lotion that is used in either 15% or 20% concentrations. Several studies have looked into the use of azelaic acid as a treatment for acne rosacea. As a general rule, it takes about 12 to 15 weeks of use before a patient will see very good results.

There are some side effects that come along with this medication, including itching, burning, and stinging. Usually, the symptoms are mild. However, in about 1% of the patients, the symptoms become chronic.

Two studies have shown that ivermectin is quite effective in treating acne rosacea. Overall, this topical medication is well tolerated by most people.

• Sulfacetamide – Sulfur – This is a topical agent available in many different forms, including lotions, creams, cleansing pads, cleansers and foams. It usually comes in a form of 10% sulfacetamide and is even used in sunscreens. At this time, we do not know why this medication works against acne rosacea. However, trials have been completed showing that a sunscreen with these ingredients is superior to any other option.
• Antimicrobials – This includes benzoyl peroxide and clindamycin. These topical treatments have been studied and found to be somewhat effective in treating rosacea. However, these compounds can be irritating to the skin for rosacea patients.
• Retinoids – A 12-week study looked at this treatment and found that the use of retinoids is, in fact, effective at reducing inflammatory lesions and skin damage associated with rosacea. However, retinoids may be irritating to the skin and should be used carefully.

Moderate to Severe Disease

If you have a more severe form of rosacea, then topical medications just may not be enough to manage it. As a result, oral antibiotics can be used as well as certain types of laser therapies.

Tetracyclines

These antibiotics have proven to be the best studied and most effective treatments for more severe acne rosacea. These include tetracycline, doxycycline, and minocycline. They have already been in use for treating rosacea for years. The medications can be helpful due to their anti-inflammatory properties.

Tetracycline is usually given in a dose between 500 to1000 mg per day.

Experts are trying to determine if very small doses of the medications can be beneficial in lessening the effects of the rosacea on a larger scale. At present, the only clinically proven drug to do so is low-dose, 40mg sustained-release doxycycline given once daily.

However, most doctors use a short-term treatment of higher doses of these antibiotics. The purpose of this is to decrease the inflammation quickly and get it under control. Then, after the inflammation has been managed, it is possible to stop the medications and move to topical therapies like azelaic acid or metronidazole.

Patients who are being helped with topical treatments may have breakthrough flare-ups of the lesions and this means the short-term use of higher dosage medications will be needed to handle the flare-ups quickly. Studies have shown that using an oral antibiotic in addition to a topical treatment will do the best to handle severe forms of acne rosacea.

There are a few other oral antibiotics occasionally used to treat this condition, including clarithromycin, azithromycin, erythromycin, and metronidazole. However, these medications have only been studied at a very minor level, so it is unclear how effective they will be in the long run. Oral metronidazole is the most common medication used to treat rosacea in Europe at a level of 200 mg twice a day. If you are using this type of treatment, then you should avoid alcohol altogether as there can be severe reactions between the two.

Refractory Disease

Some people with severe forms of rosacea do not respond to oral antibiotics or topical medications. In those cases, oral isotretinoin is used when nothing else seems to be working. It is used as a last-ditch effort simply because it comes along with a variety of different adverse effects as well. 

Studies continue to show that higher doses are not any more effective than lower dose medication in rosacea. Remember, there are significant warnings associated with isotretinoin including the need to avoid pregnancy while using the drug, and for a month after isotretinoin is discontinued. High doses of this drug usually come with more significant adverse effects, so they are not used as often.

Laser and Intense Pulsed Light

Intense Pulsed Light and Vascular Laser therapy have been of benefit in treating papulopustular rosacea, but these results have been variable. 

All rosacea treatments require some form of maintenance therapy. Again, rosacea can't be cured and therefore long-term management is necessary. Sub-antimicrobial doses of antibiotics are used commonly for long-term maintenance. It is important to discuss treatment options with your physician before making any decisions.

Everything You Need to Know About Subtype 3 Rosacea: Phymatous

An Old Man and His Grandson, c. 1490 by Domenico Ghirlandaio. Showing subtype 3 rosacea. 

Phymatous rosacea causes irregular overgrowths on the face, especially the nose. It can also affect the cheeks, ears, and chin. Very rarely it can include:

• Thickening skin
• Skin that looks bumpy and red
• Thickening nose and nostrils

Because this type of rosacea may progress, leading to more and more obvious symptoms, treatment depends on what stage the disease is diagnosed and treated at. 

Early Cases

There is no quality treatment for the early stages of phymatous rosacea. However, some experts feel that the use of isotretinoin can be helpful. It can be administered at 0.3 up to 1 mg/kg per day for a course of 12 to 28 weeks. This may help initially, but it is uncertain how long the benefits of the treatment will last. Usually, a patient will have to wait until the rosacea and thickening of the skin has gotten worse so that further treatments can be used to deal with the outward signs of the condition.

Advanced Cases

When the disease reaches advanced stages and the skin has become thickened, then surgical intervention is needed. Your doctor may choose to use debulking or recontouring to remove tissue that has been changed or distorted. Infrared lasers or carbon dioxide lasers can be used depending on the actual condition.

Additionally, there are a few different types of debulking surgical methods that can be used, including dermabrasion, scalpel excision, electrosurgery, and erbium, or carbon dioxide lasers. Your doctor will determine the best one based on the extent of your condition.

Of course, laser therapies and surgical intervention for phymatous rosacea do come along with some side effects that you will need to consider, including the possibility of scarring, hyperpigmentation, and hypopigmentation. However, if the rosacea is in the most advanced form, these interventions may be the only option available.

Again, even surgical intervention does not cure the rosacea. It is a way of lessening the effects, though. Additionally, these treatments are a way of reducing the build-up of excess tissue in the skin. As a result, symptoms can be addressed, providing a better quality of life.

Everything you need to know about subtype 4 rosacea: Ocular

As you may have guessed by the name, ocular rosacea affects the eyes, specifically. This subtype may affect up to 50% of individuals with rosacea and tend to appear in adults between the ages of 30 and 50. Usually, the first sign of this form is redness of the eyes, either alone or in combination with facial skin involvement. Symptoms include:

• Dry eyes

• Burning and stinging in the eyes

• Itchy eyes

• Feeling as if something is in the eye 

• Sensitivity to light

• Blurred vision

• Redness of the skin

• Dilated blood vessels in the whites of the eyes

• Red, swollen eyelids

• Excessive tearing (Mayo Clinic)

Treatment of minor ocular rosacea includes lid scrubs and warm compresses to stimulate the gland so that it will begin functioning properly again. Topical antibiotics may be used to handle any minor inflammation of the eyelid.  In more severe cases of this form of rosacea, a course of tetracyclines is often used. Topical anti-inflammatories such as cyclosporine, can be used to manage significant eye inflammation.

Ocular rosacea can be worsened by certain lifestyle choices and environmental factors, including:

• Wind

• Hot and spicy foods

• Alcohol consumption

• Sunlight

• Temperature extremes

• Anxiety, stress, anger, and embarrassment

• Hot baths

• Saunas

• Cortisone creams

These factors can cause any type of rosacea to worsen. So, it is best to determine triggers for flare-ups and then avoid them when at all possible.

If ocular rosacea is left untreated, it can lead to eyelid inflammation, infections, corneal complications, and rarely vision loss.

Special Cases

In addition to the four subtypes of rosacea outlined above, there are always unique cases that do not appear in the way you would expect. Remember, these cases are very rare and will likely not affect you.

Granulomatous Rosacea

This is a form of rosacea, that varies from the typical signs and symptoms. Instead of appearing as pimples or redness, it appears as yellow-brown or red-brown papules situated in the central portion of the face. With this type of condition, you may not see any other signs or symptoms of rosacea, like redness or flushing.

Because this is a uncommon condition, the best treatment has not been defined. Usually, dermatologists will first take a skin biopsy to confirm the diagnosis, and then may treat this disorder as they would for papulopustular rosacea.

Treatments that have proven to be most successful include:

• Oral Isotretinoin
• Oral Dapsone
• Topical Pimecrolimus
• Intense Pulsed Light Therapy

Because this is a rare condition, it is usually handled on a case by case basis. If by chance, you develop this form of rosacea, then your dermatologist will determine the best way to proceed.

Conclusion

Rosacea is a very common condition that affects at least 5% of the population. In some cases, the symptoms are so mild that all you need to do to manage them is avoid your trigger factors. However, for many people the symptoms are severe enough that medicated treatment will be needed.

Whether you are having a rosacea flare-up or not, it is vital that you always use proper skincare to help manage rosacea and reduce the frequency of flare-ups. Removing harsh or abrasive ingredients from your skincare regimen is of paramount importance. Seek skincare products that are safe, well-tolerated, and effective for your skin.

If you do have rosacea flare-ups, see your physician in order to determine the best treatment method to get your skin back to normal as soon as possible.

Resources

1. http://journals.sagepub.com/doi/pdf/10.1177/1203475416650427
2. http://journals.sagepub.com/doi/pdf/10.1177/1755738012467183
3. http://www.rosacea.org/patients/allaboutrosacea.php
4. http://www.huffingtonpost.com/2013/10/21/rosacea-concealing-treating_n_4135215.html
5. http://www.healthline.com/health/skin/rosacea#RiskFactors3
6. http://www.mayoclinic.org/diseases-conditions/ocular-rosacea/basics/symptoms/con-20035058
7. http://journals.sagepub.com/doi/pdf/10.5301/ejo.5000103
8. http://www.rosaceafacts.com/rosacea-types-treatment.aspx
9. http://www.niams.nih.gov/health_info/rosacea/rosacea_ff.asp
10.  https://www.karger.com/Article/Abstract/249218
11. http://journals.sagepub.com/doi/pdf/10.1177/875512250902500604
12.  http://journals.sagepub.com/doi/pdf/10.1177/014107689709000308
13. National Rosacea Society Expert Committee - Rosacea Classifications

1. Introduction
2. Rosacea Symptoms
3. Rosacea Basics
4. Types of Rosacea
5. General Measures You Can Take to Avoid Outbreaks
6. Everything You Need to Know About Subtype 1 (Erythematotelangiectatic) Rosacea Treatment
7. Everything You Need to Know About Subtype 2 (Papulopustular) Rosacea Treatment
8. Everything You Need to Know About Subtype 3 (Phymatous) Rosacea Treatment
9. Everything You Need to Know About Subtype 4 (Ocular) Rosacea Treatment
10. Special Cases
11. Conclusion