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

Ingredients that may induce skin irritation, such as alcohol, acetone, benzyl alcohol, propylene glycol, butylene glycol, and acids (alpha, beta-hydroxyacids) should be avoided.39 Surfactants are an integral component of cleansers but may be a source of irritation. They are amphiphilic molecules with a hydrophobic, water-insoluble tail and a hydrophilic, watersoluble head and thus can adsorb at the interface of water and oil.39 They can be anionic, cationic, amphoteric, or non-ionic Anionic agents such as sodium lauryl sulfate or quaternary ammonium can induce skin irritation.31,38,41 The use of abrasive cleaners may damage the stratum corneum, compromising the skin barrier's permeability, exacerbating rosacea.41 Lastly, cleansers containing antimicrobial agents such as some combars should be avoided due to their high pH (10–12) and propensity to cause cutaneous dysbiosis.41

Non-greasy, oil-free liquid cleansers and syndet (synthetic detergent) cleansers have a near physiologic pH (4–7) and do not contain true soap.41 Both are helpful for skin that is prone to irritation and dryness (Table 3).7,31,38,41 These gentle cleansers support skin barrier repair, decrease inflammation, accelerate pH recovery, and support the skin's antimicrobial defense.31,41

The addition of hydrating agents to cleansers can provide both hygiene and moisturization. An example discussed by the panel is a ceramide and hyaluronic acid-containing cleanser with a near-physiological pH of 5.5. In addition to providing hydration, the product utilizes a technology (Multi Vesicular Emulsion), which releases the moisturizing ingredients slowly over time, providing long-term hydration.24,42

Patient behavior modification must also be considered. Patients should be advised to discard all cleansing brushes and scrubs, to avoid vigorous cleansing, and to wash the face using a gentle motion with the fingertips.6 Avoiding hot or cold water may decrease irritation and avoid triggering flushing and irritating the already sensitive skin.7,39,41

The past decade has seen considerable advances in the understanding of moisturizers and barrier maintenance and repair. Effective moisturizers can restore and maintain skin barrier function, enhance skin hydration, and reduce the likelihood of skin irritation.2,6,7,32-35,42 Moisturizers are composed of humectant, occlusive, and emollient ingredients that attract water, seal in moisture, and smooth and soften the skin.4 Increased knowledge of skin barrier function has led to the development of moisturizers containing physiologic lipids such as ceramides, which may help replace the deficient lipids in inflammatory skin disorders characterized by skin barrier impairment.31,33,41-43 In the treatment of rosacea-prone skin, moisturizers relieve dry skin, reduce symptoms (pruritus, stinging, burning) improve skin texture, and reduce erythema.

As such, they can be helpful as monotherapy or as adjuncts to rosacea prescription therapies.2,6,8,32-35 An ideal moisturizer for rosacea patients would be safe, effective, affordable, and fragrance- and sensitizing agent-free. Preferably, the product would be pleasant to use with a look, smell, and feel that it invites consistent use. OTC skin care product choice may differ between gender, skin type, and skin condition, and the clinician is urged to consider patient preference.43

There are many types of OTC moisturizers available to recommend to our rosacea patients. However, robust comparative studies are scarce.44 Most of the information comes from open-label studies, case reports, or small case series and studies that combine biophysical measurements (corneometry and trans-epidermal water loss) with clinical assessment.42,44,45

A multicenter, open-label study (N=102) showed that a skincare regimen consisting of a mild cleanser and moisturizer could help maintain skin barrier integrity and reduce rosacea symptoms.45 Two small clinical studies evaluated a tinted daily SPF‐30 facial moisturizer used for dry skin or as part of the skincare regimen for rosacea patients.46 The first assessed the improved barrier function in twenty-one healthy women with dry skin. After a single moisturizer application, an increase of electrical capacitance and a significant decrease in TEWL was observed at 2-, 4-, and 8-hour assessments compared to baseline.46 In the second study, the efficacy and tolerability of a once-daily moisturizer used for twenty-two days in thirtythree females with mild-to-moderate rosacea and non-transient erythema were evaluated. The study revealed that skin redness improved after day one compared to baseline. Both image analysis and chromameter readings showed that redness was significantly lower on the day 22 assessment than baseline.46 Further, patients reported that the product was well tolerated and noted a reduction of skin dryness at three days, one and three-week evaluation.46

The evaluation of barrier function in multiple inflammatory skin conditions has shown that ceramide levels are decreased in atopic dermatitis, acne vulgaris, psoriasis, and ichthyosis.17-20 Although presumed, ceramide abnormalities have not been evaluated in rosacea patients. Nevertheless, the use of ceramidecontaining moisturizers and cleansers plus moisturizer has been shown to improve symptoms and disease severity in atopic and psoriatic patients.26 Most recently, Draelos 2020 showed that the use of a ceramide-containing moisturizing cream on dry lower leg skin of 49 women resulted in an 11% increase in total ceramide content, a 14% increase in free fatty acids, and an 11% increase in cholesterol.24 Most importantly, this increase in ceramide content was still demonstrable after 48 hours. Specifically, microvesicular technology mentioned previously traps ingredients into layers which dissolves slowly over a sustained period.42 The reduction of symptoms in many