A Chinese study on 999 rosacea cases compared to 1010 skinhealthy controls showed a positive correlation with rosacea for a high frequency of cleansing (more than once daily) (OR = 1.450) and the use of a large number of cleansers (> 5 pieces/year) (OR = 1.612).40
Significant risk factors also included the deep cleansing habits, overuse of a cleansing tool (more than four times/week) (OR 2.179), oil control and exfoliating behaviors via daily used products (OR 2.435), facial mask (OR 1.459), and projects in beauty salons (OR 2.688).40
Daily use of exfoliating products presented a positive correlation with the progression of the symptoms from flushing to erythema (OR = 2.01), papules and pustules (OR = 2.28), and telangiectasis (OR = 2.14).40 The researchers concluded that excessive cleansing habits were substantial risk factors for the incidence and progression of rosacea in the Chinese population studied.40
Appropriate skincare includes gentle facial cleansing once or twice a day with a near physiologic pH (4-7) synthetic cleanser (Table 2) and application of moisturizers, similar in composition to the skin's lipids.23,34-37 The use of gentle skincare products with a near-physiological skin pH may improve skin barrier repair and reduce inflammation.34-37 Rosacea patients often have dry facial skin that can exacerbate symptoms. Using gentle cleansers and frequent application of quality moisturizers can promote or maintain stratum corneal barrier function, enhance skin hydration, and reduce the likelihood of skin irritation.23 Skincare should also be used as adjuvants to other rosacea therapies.23,32-34
Moisturizers used for rosacea-affected skin are preferably rich in ceramides, hyaluronic acid, glycerin, niacinamide, free fatty acids, and without alpha-hydroxy acids.41-45
A split-face design study on 102 patients with mild to moderate papulopustular rosacea evaluated skin condition after cleansing with a gentle facial cleanser.44 The study participants applied azelaic gel 15% to both sides of the face. They then used the provided ceramide containing moisturizer (Cerave) or a moisturizing cream (Cetaphil) to the right side of the face only. Self-reported scores for stinging, burning, tingling, and itching on each side of the face twice daily for seven days were recorded in a diary. On day seven, the self-reported cumulative symptom score showed a significant reduction for the cleansing regimen with moisturizer (P=.008) compared to baseline, however not for the regimen without moisturizer use.44
A percutaneous penetration study on human skin applying the ceramides-containing moisturizer before or after azelaic acid gel 15% did not affect the skin absorption profile of the azelaic acid gel. The multivesicular emulsion ceramide-containing moisturizing lotion enhanced penetration of the azelaic acid gel when applied before the drug to human skin.44
Barrier damage in papulopustular rosacea has been shown to be similar to atopic dermatitis.28 Ceramide-containing cleansers and moisturizers have been successfully used in various inflammatory skin conditions such as atopic dermatitis, acne, and xerosis and may offer benefits to rosacea patients.45-48
Between 61% and 81% of patients with rosacea reported sun exposure as a contributory factor.23,42 The ROSacea COnsensus (ROSCO) guidelines stress that skincare regimens should include using sunscreen with an SPF ≥30.23 Moisturizers with a sun protection factor may be practical for use in rosacea-prone skin.42 Further oral photoprotection can be considered using polypodium leucotomos or nicotinamide.49,50
Significant risk factors also included the deep cleansing habits, overuse of a cleansing tool (more than four times/week) (OR 2.179), oil control and exfoliating behaviors via daily used products (OR 2.435), facial mask (OR 1.459), and projects in beauty salons (OR 2.688).40
Daily use of exfoliating products presented a positive correlation with the progression of the symptoms from flushing to erythema (OR = 2.01), papules and pustules (OR = 2.28), and telangiectasis (OR = 2.14).40 The researchers concluded that excessive cleansing habits were substantial risk factors for the incidence and progression of rosacea in the Chinese population studied.40
Appropriate skincare includes gentle facial cleansing once or twice a day with a near physiologic pH (4-7) synthetic cleanser (Table 2) and application of moisturizers, similar in composition to the skin's lipids.23,34-37 The use of gentle skincare products with a near-physiological skin pH may improve skin barrier repair and reduce inflammation.34-37 Rosacea patients often have dry facial skin that can exacerbate symptoms. Using gentle cleansers and frequent application of quality moisturizers can promote or maintain stratum corneal barrier function, enhance skin hydration, and reduce the likelihood of skin irritation.23 Skincare should also be used as adjuvants to other rosacea therapies.23,32-34
Moisturizers used for rosacea-affected skin are preferably rich in ceramides, hyaluronic acid, glycerin, niacinamide, free fatty acids, and without alpha-hydroxy acids.41-45
A split-face design study on 102 patients with mild to moderate papulopustular rosacea evaluated skin condition after cleansing with a gentle facial cleanser.44 The study participants applied azelaic gel 15% to both sides of the face. They then used the provided ceramide containing moisturizer (Cerave) or a moisturizing cream (Cetaphil) to the right side of the face only. Self-reported scores for stinging, burning, tingling, and itching on each side of the face twice daily for seven days were recorded in a diary. On day seven, the self-reported cumulative symptom score showed a significant reduction for the cleansing regimen with moisturizer (P=.008) compared to baseline, however not for the regimen without moisturizer use.44
A percutaneous penetration study on human skin applying the ceramides-containing moisturizer before or after azelaic acid gel 15% did not affect the skin absorption profile of the azelaic acid gel. The multivesicular emulsion ceramide-containing moisturizing lotion enhanced penetration of the azelaic acid gel when applied before the drug to human skin.44
Barrier damage in papulopustular rosacea has been shown to be similar to atopic dermatitis.28 Ceramide-containing cleansers and moisturizers have been successfully used in various inflammatory skin conditions such as atopic dermatitis, acne, and xerosis and may offer benefits to rosacea patients.45-48
Between 61% and 81% of patients with rosacea reported sun exposure as a contributory factor.23,42 The ROSacea COnsensus (ROSCO) guidelines stress that skincare regimens should include using sunscreen with an SPF ≥30.23 Moisturizers with a sun protection factor may be practical for use in rosacea-prone skin.42 Further oral photoprotection can be considered using polypodium leucotomos or nicotinamide.49,50
CONCLUSION
There are limited data on rosacea in SOC, but the condition is not rare in this population. In addition, a history of skin sensitivity should raise the index of suspicion of rosacea in SOC populations. Prescription medications combined with gentle cleansers, moisturizers, and sunscreen may support successful rosacea therapy; however, skincare's role and beneficial ingredients for rosacea require more studies.
Increasing SOC subjects in clinical trial trials and increasing resident/physician dermatology education on rosacea in SOC are two critical steps towards increasing awareness of rosacea in SOC.
Increasing SOC subjects in clinical trial trials and increasing resident/physician dermatology education on rosacea in SOC are two critical steps towards increasing awareness of rosacea in SOC.
DISCLOSURES
The authors disclosed receipt of an unrestricted educational grant from CeraVe International for support with the research of this work. The authors also received consultancy fees for their work on this project.
All authors participated in the steps of the project, selection of the literature, review of the manuscript, and agreed with the content.
All authors participated in the steps of the project, selection of the literature, review of the manuscript, and agreed with the content.
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2. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: the 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148–155.
3. Tan J, Berg M. Rosacea: current state of epidemiology. J Am Acad Dermatol. 2013;69(6) Suppl 1:S27–S35.
4. Fitzpatrick TB. The validity and practicality of sun reactive skin types I through VI. Arch Dermatol. 1988; 124(6):869-871.
5. Al-Dabagh A, Davis SA, McMichael AJ, Feldman SR. Rosacea in skin of color: not a rare diagnosis. Dermatol Online J. 2014;20(10) pii: 13030/qt1mv9r0ss.
6. Alexis AF, Callender VD, Baldwin HE, et al. Global epidemiology and clinical spectrum of rosacea, highlighting skin of color: Review and clinical practice. J Am Acad Dermatol. 2019;80:1722-9.
