Evidence of Barrier Deficiency in Rosacea and the Importance of Integrating OTC Skincare Products into Treatment Regimens

April 2021 | Volume 20 | Issue 4 | Original Article | 384 | Copyright © April 2021

Published online March 16, 2021

Hilary Baldwin MD,a Andrew F. Alexis MD MPH,B Anneke Andriessen PhD,c Diane S. Berson MD FAAD,d Patricia Farris MD FAAD,e Julie Harper MD,f Edward Lain MD FAAD,g Shari Marchbein MD,h Linda Stein Gold MD,i Jerry Tan MD FRCPCj

aAcne Treatment & Research Center, Brooklyn, NY
bIcahn School of Medicine at Mount Sinai, New York, NY
cRadboud UMC Nijmegen, Andriessen Consultants, Malden, The Netherlands
dCornell University Weill Medical College, Weill Cornell Medical Center, Dermatology, New York, NY
eTulane University School of Medicine, New Orleans, LA; Sanova Dermatology, Metairie, LA
fThe Dermatology and Skin Care Center of Birmingham, Birmingham, AL
gSanova Dermatology, Austin TX; Austin Institute for Clinical Research, Austin, TX
hNYU School of Medicine, New York, NY
iHenry Ford Health System, Detroit, MI
jRoyal College of Physicians and Surgeons of Canada; Schulich School of Medicine and Dentistry, Department of Medicine, Western University, Windsor, ON, Canada; Windsor Clinical Research Inc; The Healthy Image Centre, Windsor, ON, Canada

These data point to a barrier dysfunction in rosacea, although the etiology and pathomechanisms are ill-defined. It is believed that the impaired epidermal barrier facilitates the entry of irritants and allergens, causing hypersensitivity to exogenous stimuli, vasodilation, and inflammation. This promotes the development of a cycle of disease and periodic exacerbations. What is unknown is the chicken/egg conundrum: does an initial barrier defect trigger the derangements in vascular and immune system function that we call rosacea? Or does the inflammatory storm and vascular dysregulation elicit a barrier dysfunction? Or, to muddy the waters further, does genetic predisposition lead to the simultaneous development of neurovascular and immune dysregulation, both of which may contribute to barrier dysfunction?

Regardless of its origin, clinically, the disturbed barrier often translates into a situation where patients are too irritated to permit the use of the medications and products that would otherwise result in clinical improvement.

Integration of OTC Skincare Products into a Rosacea Regimen
The panel determined that addressing barrier repair early in the treatment phase, continuing such care through acute treatment, and the maintenance phase is paramount in rosacea management.

The panel explored recent guidelines and algorithms for rosacea management to provide a basis for OTC recommendations.2,6,32-35 We considered that selected treatment might need to take into account patient phenotype (eg, transient and persistent erythema, papules and pustules, flushing, ocular disease, prominent symptomatology, telangiectasia, and phyma), personal circumstances, preferences, cost, and availability of treatment.2,6,8,32-35

Prescription Treatment for Rosacea
Guidelines recommend that persistent erythema be treated with topical brimonidine or topical oxymetazoline.2,6,32,33,35,36 Patients with both erythema and telangiectasia may benefit from laser and intense pulsed light therapy.2,6,32,33,35,36

FDA-approved therapy for the papules and pustules of rosacea includes oral doxycycline 40 mg modified-release (MR), topical azelaic acid, topical metronidazole, topical ivermectin, and most recently, topical minocycline foam. Although isotretinoin is not FDA approved for this indication, it is effective for most aspects of recalcitrant disease and phymas.2,6,32,33,35,36 Further treatment options for the papules and pustules of rosacea include antibiotic doses of doxycycline and minocycline, although antibiotic resistance concerns preclude long-term use.2,6,32,33,35,36 Ocular rosacea may benefit from oral omega-3 fatty acids and responds to topical ivermectin, doxycycline 40 mg MR, and tetracycline-class antibiotics.2,6,32,33,35,36 Since patients often present with heterogeneous phenotypes, combination treatment may be necessary.32,35,36

OTC Skincare Products for Rosacea
Skin barrier function includes physical, chemical, and immunological barriers to the ingress of noxious environmental toxins.37 Additionally, skin pH plays an important role in the barrier function. Normal barrier function is dependent on the complex interplay of stratum corneum pH and exogenous and endogenous processes.31,37 Lipid processing and formation of lamellar structures require an acidic skin pH. Further, elevated skin pH may delay barrier recovery and facilitate skin barrier breakdown.31,38,39 This is particularly well documented in AD, but also rosacea.40 Normalizing pH using acidic topical skincare products contributes to skin barrier repair, normalization of the microbiome, and the reduction of inflammation.40

Skincare considerations in rosacea include cleansers, moisturizers and UV protection.32,33 Guidelines recommend skincare with gentle cleansers and moisturizers to relieve/ prevent dry skin, improve irritation symptoms, and restore skin barrier function.2,6,32,33,35,36

The global ROSacea COnsensus (ROSCO) guidelines emphasize the importance of skincare as part of rosacea's treatment and maintenance approach.2 According to the guidelines, skincare should include a gentle cleanser, avoidance of topically applied triggers, use of a moisturizer containing humectants and barrier lipids such as ceramides or hyaluronic acid, and a sunscreen.2,7,31 Camouflage products may be used to reduce the visibility of the disorder. Although avoidance of environmental stimuli (sun, cold, hot), emotional stimuli (stress and anxiety), physiological stimuli (alcohol, caffeine, spicy foods, strenuous exercise) is thought to prevent flares and reduce symptoms, achieving these goals is difficult and often patient adherence may be impractical.33

Skin cleansers
An effective and safe skin cleanser aims to remove pollutants, debris, and harmful bacteria from the skin without disrupting or removing the beneficial lipids, proteins, and normal flora that contribute to the skin barrier's integrity and function.31,37,39,41,42 Physiological stratum corneum pH is acidic (4–6), while the body's internal pH is neutral to slightly alkaline (~7.4).31,40 Imbalance in the skin surface pH can inhibit lipid processing and can lead to dysbiosis, which is recognized as an associated factor in inflammatory dermatoses.31,38,41 Cleansers with an elevated pH can damage the stratum corneum or strip it of essential components, such as lipids, proteins, and natural moisturizing factor (NMF).31,38,41

Considerations for choosing the ideal cleanser for rosacea-prone skin involves inclusion as well as omission of key ingredients.