Supplement Article: Skin Barrier Deficiency in Rosacea: An Algorithm Integrating OTC Skincare Products Into Treatment Regimens

skin lipids, and reduces microbial diversity, which is explicitly damaging for rosacea patients.⁶

Moisturizers
Quality moisturizers contain humectants to attract water and occlusives that form a barrier that retains water by preventing TEWL.^{6,12,15,32,43-45} Moisturizers containing lipids such as ceramides, cholesterol, and free fatty acids further help to restore the skin barrier function and maintain its integrity.^{6,15,32,43-45}

Alpha hydrox acid (AHA) containing products can change the skin microbiome and surface pH and result in irritation.^{6,15,32,43-45} Good skincare helps to improve stratum corneum hydration, reduce TEWL, and maintain skin softness and elasticity.⁶ Challenges to implementing a skincare regimen include complex regimens and applications viewed as a "chore," personal preferences, socioeconomic factors, and cost (Box 3).^6,51

Sun protection measures and products
UV radiation exposure is an important trigger for rosacea in mary patients.^1,2,4

Guidelines recommend, and the panel agreed, that sun avoidance and sunscreen with a sun protection factor (SPF) of at least 30 are necessary for rosacea patients.^{2,6,30,32,37-42} Sunscreens are part of a complete program for sun protection that includes protective clothing and sun avoidance. ^{2,6,30,32,37-42} Sunscreens can be classified as UVB filters, UVA1, UVA2 filters, or physical blockers.^46-49 Most currently available sunscreen formulations aim to cover both UVA and UVB spectra. Physical blockers, including zinc oxide, are effective in UVA and UVB ranges as they reflect or refract UV radiation.^46-48 A ceramide-containing sunscreen and moisturizer routine protects against UV-induced skin surface barrier changes by preventing erythema and hyperpigmentation, improving skin hydration, and maintaining normal superficial skin cells morphology and turnover.⁴⁹

Many dermatologists recommend daily sunscreen of SPF 30 or higher, especially for sun-exposed areas, 15 minutes before sun exposure and every 2 hours after that (Box 4).

Treatment and Maintenance of the Main Phenotype
This section of the algorithm defines three areas of main concern, 1) erythema, 2) telangiectasia, and 3) papules and or pustules. Patients with rosacea usually present with a spectrum of findings.^6,31 To effectively target the disease, there is a need to treat all of the individual anomalies in each patient.^6,30-33 Erythema and telangiectasia are often cited by patients as being the most bothersome signs.^6,30-33 Other findings, such as central facial edema, stinging, and burning, are equally bothersome.^6,30-33

Evaluation of prescription medications was outside the scope of this work. Prescription treatments and maintenance appear in the algorithm as recommended in current guidelines and consensus papers and described in the USCRO review by the advisors (Table 1).^{2,6,30-32,37-42}

Guidelines recommend that persistent erythema be treated with topical brimonidine or topical oxymetazoline.^{2,6,31-32,37-43} Patients with both erythema and telangiectasia may benefit from laser and intense pulsed light therapy; however, laser may not be suitable for richly pigmented skin types.⁵ 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, topical minocycline foam, and, most recently, microencapsulated benzoyl peroxide.⁶ Although isotretinoin is not FDA approved for this indication, it is effective for recalcitrant disease and phymas. ^{2,6,30-32,37-43} Further treatment options for the papules and pustules of rosacea include antibiotic doses of doxycycline, minocycline, and sarecycline, although antibiotic resistance concerns preclude long-term use.^{2,6,30-32,37-43,54} Prescription medications combined with formulated gentle cleansers, moisturizers, and sunscreen support successful rosacea therapy; however, specific beneficial ingredients for rosacea are not well defined and require more studies.^6,45,50,51

The USCRO evidence-based clinical treatment and maintenance algorithm combines prescription medications with gentle cleansers and moisturizers for rosacea phenotypes. Addressing facial skin barrier repair early in the treatment phase, continuing such care through acute treatment, and maintenance is paramount in rosacea management.

The authors disclosed receipt of an unrestricted educational grant from CeraVe USA for support with this work's research. The authors also received consultancy fees for their work on this project. All authors contributed to the development and review of this work and agreed with the content.