Rosacea Treatment Strategies: From Scientifically-Proven Remedies to Skin Care and More

Rosacea is a chronic skin condition affecting the central facial area. The persistent redness, prominent blood vessels and skin bumps can cause social anxiety. Some patients develop visual problems because it can also affect the eyes.

Science has yet to find a cure for this condition, but all hope is not lost. Current rosacea treatment strategies help control flare episodes and remove stubborn lesions effectively.

In this article, we talk about rosacea therapeutic options and what you can do to prolong symptom-free periods.

What Is Rosacea?

Rosacea is a lifelong condition manifesting primarily in the mid-facial areas—the nose, cheeks, forehead and chin. Its most common symptoms are flushing, branching or broken facial blood vessels, and inflammatory lesions called “papules” and “pustules.”

Papules are small, typically red bumps that do not contain pus. They become pustules when pus builds up from within.

Men with rosacea are prone to phyma formation, a condition marked by disfiguring skin thickening and pore dilation in the nose, chin, forehead and eyelids. Women may also develop phymas, but hormonal differences soften the skin changes.

About half of patients have eye involvement. Skin dryness, facial swelling and stinging pain may also occur.

The condition can affect any skin type. However, it is more easily detectable in people with fair skin as they tend to have more striking symptoms. Rosacea can present as early as childhood but more commonly manifests after age 30.

Rosacea is not life-threatening by itself. However, it is linked to conditions like inflammatory bowel disease, Alzheimer’s disease, cardiovascular disease and type 1 diabetes mellitus because of its inflammatory nature.

How Do You Get Rosacea?

The cause of rosacea is unclear, but susceptible individuals are thought to have the following:

• Immune system dysregulation
• Heightened reactivity of the facial blood vessels, making them prone to inflammation and damage
• Abnormalities in skin connective tissue composition, leading to skin barrier defects and blood vessel wall weakening and dilation
• Hair follicle and oil gland structural defects aggravated by inflammation
• Hypersensitivity to specific microbial species, which is thought to be linked to eye symptoms and papule and pustule formation

Rosacea flare-ups usually have triggers. The most frequent ones are the following:

• Extremes of temperature
• Excessive sun exposure
• Wind
• Hot beverages
• Vigorous exercise
• Spicy food
• Alcohol
• Emotional stress
• Harsh beauty products
• Menopausal flushing
• Some medications
• Dairy products
• Other environmental irritants

Part of the management of rosacea is to avoid known triggers.

What Are the Subtypes of Rosacea, and Why Does It Help to Know?

To guide treatment decisions, the National Rosacea Society (NRS) Expert Committee classified the condition into four subtypes and one variant.

Erythematotelangiectatic Rosacea

The following symptoms are predominant in this subtype:

• Facial erythema or redness 
• Spider veins and broken blood vessels, known medically as “telangiectasias”
• Central facial swelling
• A burning or stinging sensation in the involved areas
• Skin roughness and scaliness

Swelling and ruddiness are due to blood vessel dilation. Correcting this problem eliminates the symptoms.

Papulopustular Rosacea

As the name suggests, papules and pustules are the primary skin manifestations of this subtype. Central facial redness and telangiectasias are also typically present, though less pronounced. Burning pain occurs but less commonly.

Antimicrobials help with inflammation and possible infection. Topical treatment or lasers are used on visible blood vessels.

Phymatous Rosacea

Phymas are predominant in this condition. Mild skin thickening and pore dilation may be treated initially with topical medications. Unresponsive and disfiguring lesions are best managed by dermatologic surgery.

Ocular Rosacea

Aside from facial skin manifestations, people with ocular rosacea experience symptoms of eye damage. Inflammation and telangiectasias are evident on the eyelids. The eyes may also be inflamed. Light sensitivity, eye dryness, corneal injury and visual changes are common.

Skin treatments are the same as in the other subtypes. Eyelid cleansing, artificial tears, warm compresses and ophthalmic medications help improve the eye symptoms. Ocular rosacea patients may be referred to an ophthalmologist for co-management. 

Granulomatous Rosacea

This is the only rosacea variant recognized by the NRS. Patients have firm, red and yellow-brown bumps on the cheeks and around the eyes and lips. It is the most challenging to treat, but lasers, phototherapy and medications can alleviate the symptoms.

The above classification scheme is old but remains useful in many parts of the world. Nevertheless, it has limitations.

For example, some individuals manifest a number of symptoms that make them unfit for just one subtype. So the NRS recently recommended that rosacea treatment be based on phenotype—the actual combination of symptoms—rather than subtype.

Rosacea symptoms are classified as either mild, moderate or severe.

How Is Rosacea Diagnosed?

Physicians diagnose rosacea based on the history of the symptoms and the patient’s physical examination.

Central facial redness and phyma are the most telling of rosacea symptoms, and either one is usually enough to clinch the diagnosis.

Without the above “diagnostic features,” two or more of the following “major symptoms” help identify this condition:

• Flushing
• Papules and pustules
• Telangiectasias
• Eye changes

The above symptoms may be accompanied by “minor manifestations,” notably burning or stinging sensation of the mid-facial skin, facial swelling and skin dryness.

No confirmatory tests are necessary unless the lesions or combination of symptoms is unusual. Acne, skin infection and lupus are some conditions that must be distinguished from rosacea.

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Overview of Rosacea Treatments

How Do Doctors Treat Rosacea?

The list of scientifically-proven rosacea therapies keeps growing every year. You and your doctor will choose based on your symptoms, the severity of your lesions, your perception of your condition and each treatment’s side effect potential. 

Medical Treatments

Medications correct the processes causing your symptoms, not specific lesions. Topical medications are the first line of therapy for mild rosacea because of their low side effect risk.

For facial redness, FDA-approved topical brimonidine and oxymetazoline are prescribed. They normalize blood vessel size, reducing erythema and swelling.

Oral clonidine, oral carvedilol, and Botox injection have the same effect, so they are off-label alternatives. Menopausal flushing may be relieved with hormone replacement therapy.

For papules and pustules, topical antimicrobials with anti-inflammatory properties are given.

The first-line drugs in this group are metronidazole, azelaic acid and ivermectin. Alternatives are topical minocycline, benzoyl peroxide, sodium sulfacetamide, clindamycin and erythromycin.

For moderate to severe inflammation or if unresponsive to topical therapy, your doctor may prescribe low-dose oral doxycycline. Isotretinoin, a retinoid, may also be given orally. Retinoids have anti-inflammatory action.

For phyma, the topical retinoid tretinoin may be considered in the early stages for its anti-inflammatory effect and ability to normalize skin cell growth. If the condition does not improve, oral doxycycline, minocycline or isotretinoin may be given before exploring surgical treatments.

For eye symptoms, the first-line remedies are topical azithromycin, an antibiotic, and the topical immunosuppressants cyclosporine and tacrolimus. Oral antibiotics such as doxycycline and azithromycin are prescribed if the symptoms do not improve with topical medications. 

For treatment-resistant skin or eye inflammation, an injectable immunosuppressant like secukinumab is the last resort.

Surgical Treatments

In contrast to medications, dermatologic surgery targets specific lesions or structures. Your dermatologist will recommend them if you don’t respond to medications.

To remove aberrant blood vessels causing skin redness, intense pulsed light and blood vessel lasers like the Vbeam are appropriate.

For severe phymas, your dermatologist may perform an ablative procedure to shave off excess tissue and reshape deformed areas. The most highly recommended are CO2 or erbium laser treatment, electrosurgery and radiofrequency.

Intense pulsed light therapy may also be applied to the eyelids to stimulate their oil glands, preventing eye dryness in ocular rosacea patients.

Is There Room for Complementary and Alternative Remedies in Rosacea Treatment?

Few clinical trials support the use of complementary and alternative medicine in managing rosacea. However, patients have reported symptom improvement after using the following natural substances: 

• Aloe vera
• Ascorbic acid
• Coffeeberry
• Feverfew
• Green tea
• Niacinamide
• Oatmeal
• Soy

Studies among non-rosacea patients show that these substances combat inflammation and enhance the skin barrier function when applied topically. 

“Manual therapy” has also been reported to help improve facial swelling. You may do this by pressing your fingers in a sweeping motion toward the jawlines. This pushes the leaked fluids in the direction of the neck’s bigger lymph vessels.

Field experts believe that the scantiness of scientific data does not mean that these treatments are ineffective. If you’re considering holistic remedies, talk to your doctor if you can use them alongside clinical trial-backed treatments.

Most rosacea patients present with a combination of symptoms, warranting combined therapies. Standard combination regimens for rosacea are proven safe and are often synergistic—they can speed up symptom remission in people with severe rosacea.

What Can You Expect During the Rosacea Treatment Process?

The rosacea treatment experience differs for everybody. But think of it as a three-phase process.

Before Treatment

It all starts when you consult a medical professional for your condition. Your provider will talk to you about your symptoms, especially the ones that bother you the most, and inquire about your medical history. They will then do a physical examination and look for evidence that will help them diagnose rosacea.

As previously mentioned, your clinical history and physical examination are enough to help identify the condition. However, a confirmatory test may be necessary when the combination of your symptoms points to a different medical problem.

If the provider is certain that you have rosacea, they will give you a personalized treatment plan at the end of the session. Your therapy could be medical or surgical, depending on your symptoms and risk factors. 

If your specialist prescribes a surgical procedure, they will give you advice on how to prepare for it.

Generally, you must avoid substances and activities that may complicate the treatment or delay your recovery. Examples are blood thinners, smoking and alcohol.

If you are cold sore-prone, they may prescribe an antiviral medication, which you should start days before your session. If you’re already on retinoid treatment, they may recommend stopping it months before laser therapy. Retinoids can make your skin light-sensitive, increasing the risk of laser burns. It may take a while to recover from their side effects.

If you have another health condition, you may need medical clearance before surgery or starting certain oral medications. You will be advised to avoid flare triggers regardless of the kind of therapy prescribed.

Read our article on the dermatology visit to learn how you can prepare for yours.

During Treatment

If your doctor prescribes a medical treatment, you should use it as instructed. Stop the drug and seek medical help immediately for intolerable side effects. Otherwise, schedule a follow-up visit if you complete the treatment course.

If you agree to have a rosacea procedure, expect it to be done in an outpatient setting. Local anesthesia or skin cooling will be used to make the treatment painless. You will be awake or mildly sedated throughout the session, depending on the kind of procedure and the extent of your lesions.

Rosacea procedures generally take about an hour. You may have someone accompany you to the clinic and assist you when you go home.

After Treatment

The post-treatment phase also depends on the kind of therapy you received.

If you completed a medical treatment course, you might be prescribed a maintenance skin care regimen. Your doctor will remind you to avoid rosacea triggers and follow up when necessary.

The length of medical treatment depends on your response. Patients who improve after several weeks are kept on the same regimen for six months. If that doesn’t happen, your doctor may recommend combining medications or surgical therapy.

On the other hand, if you have undergone surgery, you will be given aftercare instructions. Recovery can take a week or two, depending on the procedure and your health status. Seek medical help right away for unwanted side effects.

Once the treated skin heals, you will observe continuous improvement for several months and up to a year due to enhanced collagen production and remodeling. You must avoid relapse triggers and take good care of your skin to ensure excellent, long-lasting results.

You may read our CO2 laser resurfacing and intense pulsed light therapy recovery guides to know more about these topics. 

Rosacea is a complex skin condition that can frustrate patients if treated inappropriately. So it’s best to entrust your therapy in the hands of a board-certified dermatologist, as dermatologists are the true skin disease experts. 

What Skin Care Regimen Is Best for Rosacea?

People with rosacea generally have sensitive skin. Extra care is a must to avoid flare-ups. We recommend the following:

Cleansing

Cleanse your face twice daily using a mild cleanser. Avoid rubbing your skin vigorously or washing more than necessary. These can deplete your skin of protective lipids and proteins and weaken the barrier surface.

Non-soap and anti-inflammatory cleansers are good for the skin of patients with rosacea. However, most of them contain sulfur, so they are contraindicated in people with sulfa allergy. 

Skin Vitamins

Antioxidant-containing cosmeceuticals help fight inflammation. Niacinamide, green tea, resveratrol and vitamin C are examples.

Moisturizing

Dry skin is irritation-prone, so it’s best to avoid skin drying if you have rosacea. Aloe vera and ceramides are excellent moisturizers for rosacea patients. Aloe vera is both an anti-inflammatory and a water attractant. Ceramides enhance your skin’s barrier function.

Sun Protection

A water-resistant, broad-spectrum sunblock with an SPF of 30 or greater is recommended. Rosacea patients tolerate metal oxide formulations better than carbon-based types.

Green-Tinted Makeup

If you want to conceal facial redness with makeup, choose a green-tinted one specially formulated for sensitive skin.

Things to Avoid

Do not use skin care products containing abrasive particles, hydroxy acids, alcohol, and astringents, as they can irritate your skin.

You do not have to figure out your skin care regimen by yourself. A highly experienced, board-certified dermatologist can help you determine the best home treatments for you.

Will Lifestyle Changes Help Clear Rosacea Symptoms?

Yes, lifestyle modifications can help your symptoms. 

The first is trigger avoidance. Our list above includes only the most common rosacea triggers. But others not on the list may also cause flare-ups. So keep a diary of your symptoms, identify the possible triggers and modify your routine accordingly.

The second is good skin care, as discussed previously.

Other than avoiding foods that can cause flares, no dietary changes are particularly helpful in the management of rosacea. However, people with ocular rosacea may benefit from eating more omega-3 fatty acid-rich foods like fatty fish and walnuts. Omega-3 fatty acids help relieve eye dryness and have anti-inflammatory properties.

How Important Are Stress Management and Emotional Support in Rosacea Treatment?

Rosacea symptoms can make you feel anxious or down. But remember that this condition can worsen with emotional stress. Stress management can help your symptoms more than you think.

The first thing you can do is practice relaxation techniques. Do yoga and meditation. Challenge your negative thoughts as you meditate.

Second, join a rosacea support group. There, you can learn from others’ treatment experiences and how they cope with their symptoms.

Third, expand your social activities. Stay in the company of people who encourage you and share your interests. 

Fourth, if your symptoms are causing overwhelming distress, seek counseling. You don’t ever have to go through this journey alone.

Can Rosacea Be Cured?

Rosacea currently has no cure. However, scientific advancements continue to expand the arsenal of effective and safe treatments for its symptoms.

Why Is It Important to See a Dermatologist for Rosacea Treatment?

Seeing a board-certified dermatologist for your rosacea therapy gives you the best possible chance for a quick recovery and longer remission. With their deep understanding of this condition, you can rest assured that:

• Your condition is properly diagnosed.
• You’re being given the right treatments at the right doses.
• You get only excellent cosmetic results from dermatologic procedures, which are their specialty.
• You avoid unwanted costs from potentially unsafe or futile therapies.

When you trust a board-certified dermatologist for your rosacea treatments, you put yourself in the most capable hands to handle the problem.

Finding Your Best Rosacea Treatment Option

Rosacea is a multifactorial condition manifesting primarily in the central facial region. Its most prominent manifestations are skin redness, telangiectasias, papules and pustules. Many patients also develop eye symptoms and phymas in the nose and other areas of the face.

The condition currently has no cure. However, various treatments are available for shortening flares and prolonging remissions. Besides scientifically-proven therapies, good skin care and trigger avoidance are also critical in symptom management.

To help you choose the best rosacea treatment option, trust only a board-certified dermatologist. Only dermatologists are the real experts in this skin condition.

Get Rid of Facial Redness with the Help of LA’s Top Rosacea Specialists

Rosacea affects the most noticeable parts of the face. So when you flare up, you want to clear the symptoms fast. But that’s not always possible unless you’re working with a real skin disease expert.

At BHSkin Dermatology, our rosacea specialists have helped many people manage their symptoms successfully. Come visit us at our Glendale or Encino clinic for a face-to-face consultation or use our telederm portal for an online checkup.

Book your appointment today!

Author: Don Mehrabi

Don Mehrabi, MD, FAAD, is LA’s leading board-certified dermatologist who treats patients, builds the BHSkin clinics, and raises three kids. This blog builds on medical studies combined with Dr. Mehrabi's first-hand experiences from practicing in Encino-Tarzana, Glendale, and online