Understanding Rosacea - Symptoms, Types, Triggers & Treatment
By Cynthia Bailey MD.
Understanding rosacea is important if you are one of the many millions of people blessed with the condition. The good news is that if you have rosacea, it is possible to have rosacea AND have an attractive and healthy complexion. You just need the best skin care routine and to make some diet and lifestyle changes.
What is rosacea?
Rosacea is a facial rash that starts in adulthood and is a common cause of ‘adult acne’. Anybody can develop rosacea, but Caucasian people are most likely to be affected, especially those with Celtic or Northern European ancestry.
It’s a chronic condition that continues to confound scientists. While we don’t know the cause or have a cure for rosacea, we do have treatments and advice to help control the symptoms.
I’ve answered some of the most common questions about rosacea below. I have also developed diet and lifestyle recommendations that I find helpful in supporting the control of this otherwise frustrating skin problem. These can be found in my Rosacea Guide.
Signs you may have rosacea
If you think you suffer from rosacea, there are three main skin symptoms you may notice. You don’t have to suffer from all three of these to qualify for the diagnosis of rosacea.
The skin signs of rosacea include:
1. Facial pimples
2. 'Broken' facial capillaries that are prone to flush and blush
3. Enlargement of solitary oil glands called sebaceous hyperplasia papules (not always accompanied by increased skin oil).
Are there different types of rosacea?
You will read elsewhere that there are four types of rosacea (which I described in detail in my rosacea eBook).
In my dermatologist's opinion, the four types or rosacea really can be distilled down to two basic complexion types for helping you understand how to create the best skin care routine to control your complexion:
- Highly sensitive, and
- Fairly tolerant.
You need to know which of these two complexion types you fit best in order to find the right skin care products.
The sensitive skin type of rosacea is called the erythematotelangiectatic type. It’s sometimes called subtype 1 rosacea.
The more tolerant skin type of rosacea is the papulopustular type. It’s sometimes called subtype 2 rosacea.
There can be overlap between the two rosacea complexion types, but try to decide which of these your complexion most closely resembles.
The different features between these two rosacea skin types are the following:
Skin changes of erythematotelangiectatic (type 1) rosacea
- The skin is very sensitive and easily irritated by normal to harsh products, environmental climates etc.
- Skin flushing, and blushing often stings
- The skin is fine textured with scale and roughness to the touch and visible fine broken capillaries.
- Red pimples are often small
- These changes may be very dramatic or quite subtle
Skin changes of papulopustular (type 2) rosacea
- This is the more classic type of rosacea with skin that may be sebaceous, oily, red, thick and swollen
- Large pores are often present
- Pimples are often large and very red
- Broken capillaries are visible
- Skin is often not sensitive
- Flushing may or may not sting
Because skin sensitivity differs in these two rosacea skin types, it’s important to decide if you have type 1 or 2 rosacea before you try any new products. This is important! If you are still uncertain, please download my free rosacea eBook with photos and more information. - Dermatologist Dr. Cynthia BaileyIs there anything else I need to know about rosacea before I buy skin care products?
Yes, there is one additional important point to think about.
People who have rosacea often have facial seborrheic dermatitis (aka dandruff) too.
Both rosacea and seborrhea cause sensitive red facial skin, and both respond to some of the same treatments. Stubborn flare-ups of either of these two conditions may call for different approaches.
Here is how to tell if you have seborrheic dermatitis along with your rosacea:
Rosacea often involves the “apples” of the cheeks, mid forehead, chin and nose.
- Seborrheic dermatitis of the face often involves the furrows of the face and hairy areas. It causes redness and a flakey scale in the eyebrows, the furrow along the sides and crease of the nose and along the sides of the chin. Facial seborrhea may be accompanied by dandruff (redness and/or dry scaly flakes) on your scalp.
If you think you may also have seborrheic dermatitis on your face, then using products that treat both conditions will work best to control your complexion. I will explain this below.
What’s the best skin care treatment routine to control rosacea?
Soothing skin care products are the best for rosacea. You’ll want to use ingredients that calm inflammation, because rosacea is an inflammatory skin problem -- not a type of acne.
It’s important to understand that most rosacea-prone complexions have abnormally-sensitive facial skin due to compromised skin barrier strength.
This means that any irritating products or treatments (such as anti-aging or acne treatments) may not be tolerated if you have sensitive skin from rosacea.
Control your rosacea from the 4 essential steps for a Complete Skin Care Routine:
Create your complete skin care routine by layering products that help your skin so that it can heal.
I've created a skin care kit to address all the key steps with my Rosacea Therapy Kit. This kit gives you the best Complete Rosacea Skin Care Routine to control rosacea.
To help you understand how to build a rosacea skin care routine, here is how I do it:
CLEANSE your rosacea-prone complexion carefully. Cleansers can be irritating and trigger rosacea flare-ups. It’s best to use cleansers that are non-irritating and not overly drying unless you have extremely oily papulopustular rosacea. Avoid scrubbing or exfoliation until the rosacea is under control. My tips for selecting the best cleansers for rosacea are as follows:
- I avoid harsh cleansers, except for only the oiliest papulopustular rosacea.
- I find that people with rosacea do best with a type of cleansers called synthetic detergent cleansers (Syndets). These are pH balanced. My top choice is my Extremely Gentle Foaming Facial Cleanser (which is what I use), VaniCream Cleansing Bar is another excellent choice and can be used on the entire body. Other alternatives include Neutrogena Ultra Gentle Cleanser, Tolariane Cleanser and Aquanil Cleanser. A natural alternative is my Naturally Best Bar Soap. All naturally made soaps will not be pH balanced.
- I often alternate the gentle synthetic cleanser in the morning with a medicated cleanser at night or vise versa. Medicated cleansers are a simple way to deliver treating ingredients to the skin. My favorite medicated cleansers for my rosacea skin care routines are:
- Calming Zinc Soap fortified 2% pyrithione zinc (also addresses seborrheic dermatitis)
- Prescription Sodium Sulfacetamide/Sulfur cleanser (a sulfa antibiotic and sulfur combination)
- Very rarely, oily skin suffering from papulopustular rosacea responds nicely to benzoyl peroxide foaming cleansers such as my Foaming Benzoyl Peroxide Acne Treatment Cleanser.
- For excessive facial scale and engorged/clogged pores I have my patients VERY GENTLY try a Exfoliating Facial Sponge , BUT I wait until their skin’s sensitivity and signs of rosacea are controlled. That’s because when the skin has an active flare-up of rosacea, it may not tolerate even gentle exfoliation and scrubbing. Thus, I only try this when a person’s rosacea is in remission and I always recommend that they are cautious at first.
- I generally avoid facial toners for all but the oiliest rosacea complexions. If I do use them I stick with alcohol free/gentle products only such as my Naturally Hydrating Pore Minimizing Rose Tone.
CORRECT rosacea complexion problems by using products that help heal rosacea.
The best products for rosacea skin care include:
High concentration green tea antioxidant and caffeine combination products. Every rosacea patient in my practice uses Green Tea Antioxidant Skin Therapy Cream fortified with resveratrol because it works so well.
Why is a pharmaceutical-grade, stable and high concentration green tea product so helpful for rosacea?
- Studies have shown that skin suffering from rosacea is depleted of antioxidants. These two products contain highly concentrated levels of the active and soothing green tea antioxidants. When combined with caffeine the green tea polyphenol antioxidants are even more anti-inflammatory.
Facial dandruff often occurs with rosacea and needs to be treated too. The Calming Zinc Bar Soap and Green Tea Antioxidant Skin Therapy are the two most useful daily products to control facial seborrhea. They are available together in my Redness Relief Kit. I also sometimes add clotrimazole cream (an OTC antifungal cream) twice a day applied after the Green Tea Antioxidant Skin Therapy until facial dandruff is controlled.
- Benzoyl peroxide (such as my Benzoyl Peroxide Acne Treatment 2.5% Cream) and/or salicylic acid (such as Paula’s Choice 2% BHA Gel) are helpful for classic papulopustular oily rosacea complexions. These products can be applied once or twice a day after the Green Tea Antioxidant Skin Therapy. They are not tolerated by most people with the sensitive skin/erythematotelangiectatic type of rosacea.
- There are prescription FDA-approved medicines and “off label” skin care treatments that dermatologists use to treat rosacea. These need to be worked into any skin care routine by your treating physician. I typically have patients apply medicated treatments after the Green Tea Antioxidant Therapy product but before their moisturizers or sunscreens. Some of the FDA-approved products include metronidazole cream or gel (Metrogel), sodium sulfacetamide and sulfur lotion, and azelaic acid products (such as Finacea). In addition, when one of my rosacea patients is struggling with a lot of very red and pussy pimples or irritated and rough skin then we may choose to try to reduce the population of skin demodex mites in the pores with a prescription medicine called Soolantra. I have also used generic permethrin cream to do this though it is an 'off label' use of the prescription medication. Use of any prescription medicine must be guided by the treating physician.
HYDRATE your skin to help heal sensitive skin from rosacea. Barrier strength of rosacea prone skin is weakened. Help it heal by keeping your skin optimally hydrated. Your moisturizer should ‘dial in’ the moisture your skin needs. Parts of your face may be drier than others. If so, use a richer moisturizer on dryer areas and a lighter one on oily areas.
- For a rosacea skin care routine, be safe and choose only non-irritating moisturizers whose function is only to hydrate. That means no AHAs, BHAs, vitamin C etc. Look for a product that feels good and keeps your skin from feeling dry. Good ingredients to look for are oils, glycerin, hyaluronic acid and ceramides. I prefer that people with rosacea keep product ingredients simple in their moisturizers to lower the risk of accidentally using a product with something that irritates their rosacea.
- Moisturizer should be selected based on skin type with heavier/richer/oil-containing products for drier skin and lighter texture or oil-free products for oily skin. Many good products exist and are easy to find. Popular product lines that I like include Aveeno, Oil of Olay, Neutrogena, Clinique, Kiehls, Dr. Hauschka and others. I build skin care routines for my patients using my products that I know well. These include:
My favorite product for oily skin: Daily Moisturizing Face Cream for Oily to Normal Skin.
- My favorite products for drier skin:
- Daily Moisturizing Face Cream for Dry to Normal Skin
- Natural Face, Hand and Body Lotion
- Instantly Luminous Multi-Action Serum. This is the only product I ever apply before the Green Tea Therapy products. It binds water like non-other and can augment your moisturizing cream to plump skin and sooth irritation. It is ideal for dehydrated skin and crepey skin.
- People with oily papulopustular rosacea may not want to use a moisturizer. Non-oil hydrating ingredients such as hyaluronic acid in the Instantly Luminous Multi-Action Serum may help increase skin moisture without leaving much (if any) product feel on the skin. The Green Tea Antioxidant Skin Therapy is loaded with hyaluronic acid and may provide sufficient hydration for oily skin. Instantly Luminous Serum binds water without adding oil. Where additional hydration is needed, I recommend my Daily Moisturizing Face Cream for Oily Skin
PROTECT rosacea-prone skin from UV light. This is really important because UV can trigger rosacea, especially the erythematotelangiectatic type. This means that daily sun protection is important for helping to control your rosacea 365 days a year.
I find that physical/mineral sunscreens work better for my rosacea patients. I don’t recommend chemical sunscreens. Physical/mineral sunscreens contain zinc oxide or titanium dioxide. I recommend that people with rosacea minimize or avoid the chemical sunscreen ingredients because they may sting and irritate rosacea prone skin. Plus, the chemical sunscreens also generate a slight amount of heat as they block UV rays and heat can aggravate rosacea.
It’s my opinion that zinc oxide is a better mineral sunscreen than titanium dioxide. I recommend mineral sunscreen with zinc oxide listed at 5% or higher as an active ingredient. I am very particular about sunscreens because not all products perform equally well. In addition, the chemical/non-mineral sunscreen active ingredients are variably irritating depending on a product’s particular formulation. Based on my patient’s experience, I have a short list of products that I recommend for rosacea prone skin. Like moisturizers, I recommending matching your sunscreen to your skin type. These are the most popular products we use in my practice:
Sunscreen tinted to soften complexion flaws such as redness from rosacea
Sheer Strength Pure Physical SPF 50+ Sunscreen. Ideal for all complexion types. A light weight formula that is also an excellent makeup primer.
Untinted sunscreens for rosacea
- Sheer Strength Pure Physical Spray SPF 50+ Sunscreen. An invisible and ultra-light texture product that is excellent for hairy skin and all complexion types. Water resistant for up to 40 minutes.
- Sheer Strength Pure Physical Invisible SPF 50+ Sunscreen
What’s the best makeup to use if you have rosacea?
Pure mineral makeup powder is tolerated best due to its ingredient simplicity. Makeup, if you use it, goes on top of your other skin care products. Mineral makeup also provides additional sun protection when applied on top of sunscreen.
There are many good brands of mineral makeup including Jane Iredale, Bare Minerals, Bareescentuals, and most of the major cosmetic brands have powdered mineral makeup.
My Pressed and Baked Mineral Powders and Loose Mineral Makeup Blush are elegant, natural and ideal for rosacea-prone skin, plus, they provide long lasting coverage with a fine natural finish. My mineral makeup is well-priced and high quality.
What’s the best way to begin a rosacea skin care treatment routine?
- Think about what products and procedures you have tried before. What have you tolerated or not tolerated? Use this history as a guide.
- When in doubt, start cautiously with non-irritating products and treat only a small area of your rosacea prone skin to see how your skin responds.
What skin care products can irritate rosacea and make it worse?
Commonly irritating products include many acne products, some anti-aging products and a variety of other products including those considered “natural”.
Acne products with ingredients such as salicylic acid, benzoyl peroxide, glycolic acid, ethyl alcohol or acetone can be overly drying and irritating to sensitive skin.
Anti-aging products made with AHAs (also called alpha hydroxyl acids including glycolic acid and lactic acid among others), BHAs (most notably salicylic acid), vitamin C, retinol and prescription retinoids such as tretinoin (Retin A and Renova) can all be irritating and drying, thus pose a risk to rosacea prone skin.
Botanical products, such as those with tea tree oil or rosemary may also irritate sensitive rosacea skin.
Having rosacea doesn’t mean you can’t ever use these types of products, but it means that you have to be cautious and patient and ‘sneak up’ on your skin with them. This means:
- Testing them on a small part of your skin for several weeks
- Trying them only when your rosacea is controlled
- Choosing lower strengths and/or starting with less frequent applications.
If your rosacea flares back up for any reason, you have to stop using anything even slightly irritating, and go back to a gentle, rosacea-healing skin care routine until your skin calms down.
IF you think your skin will tolerate it, consider re-trying a potentially irritating product, but using it less frequently and on the less sensitive parts of your face. Remember, a serious flare up of rosacea can leave lasting marks on your skin.
Bottom line: whether your rosacea is active or in remission, your skin is still sensitive and has a more porous barrier strength than normal skin. That’s why you need carefully-selected skin care products to prevent rosacea flare-ups.
Is it safe to use cortisone creams on your face to “treat” rosacea?
Cortisone creams should only be used under the supervision of a qualified dermatologist. Even then, it’s still not entirely “safe,” as cortisones can cause lasting side effects on your skin.
In my dermatology practice, I only use non-halogenated topical cortisone steroid creams as a last resort for short-term control of facial inflammation (such as over-the-counter hydrocortisone cream).
It’s important to note that halogenated steroids will aggravate rosacea. Steroid creams can also thin your skin and damage your eyes. Your dermatologist will know what this means and should be the one to prescribe and supervise any cortisone use on your face.
Are you overwhelmed with your complexion and the intricacies of rosacea-prone skin? Try my Rosacea Therapy Kit for a good skin care routine that's been proven successful by my many thousands of rosacea patients. Just start with the Calming Zinc once a day alternating with the Extremely Gentle Cleanser. Apply the Green Tea and Daily Face Cream twice a day and use the Sunscreen choice that best fits your skin type every day - that's it. See how it goes. You can add more later once you see how your complexion responds. This is what I use on my own tricky rosacea-prone face.