Mini Series Part 2
Rosacea prone skins may react to extrinsic or intrinsic stimuli that would not usually trigger an immune response in healthy skins, and these stimuli that worsen the condition can vary between individuals. Treatment must start with identifying and avoiding individual triggers, the most important being avoidance of ultraviolet radiation from environmental exposure, as it is considered a common trigger which causes inflammation in all rosacea subtypes.
UVR exposure contributes to vascular changes and a dysregulation of the innate immune response, with studies suggesting that UVR may initiate the condition in genetically-prone people, as well as contributing to flare-ups. UVR exposure damages keratinocytes leading to an increase in reactive oxidative species (ROS), an increased degradation of collagen by MMP’s and an upregulation of the antimicrobial protein cathelicidin as part of the innate immune response. UV damage also contributes to an impaired barrier function through an increased alkaline pH, increased trans-epidermal water loss and reduced stratum corneum hydration levels, intensifying the immune response and exacerbating the typical presentation of erythema and telangiectasia.
Physical and environmental factors such as heat, humidity, hot weather, wind, intense cold, strenuous exercise, use of saunas and hot baths, consumption of spicy foods, hot beverages and alcohol which raise body temperature may trigger a flare up. In particular, red wine has a vasodilatory effect, contributing to the typical presentation of phymatous rosacea: enlarged sebaceous glands, thickened skin, inflammatory lesions and telangiectasia on the nose.
Further evidence suggests a dysregulated microbiome comprising bacteria or Demodex mites may trigger an innate immune response, so the promotion of a healthy varied diet is important. Some cosmetic and skincare products may be comedogenic and therefore worsen the condition, such as those containing alcohol, witch hazel or fragrances. Intrinsic factors such as emotional stress and anxiety, or physiological actions of hormones may also contribute to rosacea severity. It is suggested that a high Glycemic Index diet, from foods high in histamine, citrus foods or dairy products may exacerbate the presentation of rosacea. Smokers have an increased risk of developing the erythematotelangiectatic (ETR) rosacea subtype. Chemical triggers including nicotine, acetones and other toxic components often found in tobacco smoke contribute to the visible effects of an erythematous skin. Nicotine causes vasoconstriction of the skin’s microcirculation, one of the detrimental effects of smoking on the skin in particular, making it a risk factor for the development of rosacea. Of course, the negative effect of smoking on all other body systems is well documented, and should then be avoided. Medications such as topical steroids, niacin and beta blockers may act as trigger factors. To assist in identifying potential triggers, individuals could keep a journal of lifestyle and activities, diet and medications, for example, so they know what to avoid. TREATMENTS
The condition of Rosacea often presents as a combination of the various features of the subtypes; therefore, a combination of therapies may be used to optimise treatment results. Treatment should be personalised to take into account patient preference, symptoms and presentation, severity of the condition and individual trigger factors. Inflammatory targets in rosacea skins can be repressed by more than one treatment or intervention, another benefit of combination therapy. Darker Fitzpatrick skin types must also consider longer wavelengths and lower fluence when treating with laser to avoid post inflammatory hyperpigmentation. Dermal Clinicians will assess the current manifestations their client presents with, devise treatment plans through a thorough consultation including medical history, advise on appropriate skin care and will reassess regularly with their clients throughout the course of treatment. Treatment options include topical preparations, oral or systemic medications and laser or light-based modalities, with systemic medication and physical modalities often combined to produce best results. Although it is beyond the scope of a Dermal Clinician to prescribe medication, they can inform clients of the drugs available to treat rosacea, and play a vital role in supporting clients during treatment and afterward with maintenance of results. The clinician’s role includes managing the client’s expectations for the timeline of long-term improvement, based on the client’s own goals.
Steps in treatment include controlling and clearing inflammatory lesions such as papules and pustules through medications such as tetracycline and isotretinoin, and long-term suppression of erythema, inflammation and visible vessels using laser/IPL modalities. Laser/light-based treatments will produce the best results for treating the vascular abnormalities (telangiectasia) of Rosacea, and the patient may need 1-4 sessions. Energy from the laser wavelength is absorbed by the chromophore haemoglobin, enabling the treatment of vascular lesions in the skin, as topical and systemic medications will not be effective in treating telangiectasia. Patient education regarding the relapsing nature of rosacea, gentle skincare, topical and systemic medications and physical modalities make up an effective and comprehensive management program for the treatment of cutaneous rosacea. Subtypes including phymatous and ocular rosacea require medical interventions, however a Dermal Clinician can possibly assist with laser treatments in conjunction with medical specialists, in the maintenance phase of treatment. The Global Rosacea Consensus panel (ROSCO) recommends treatment options for inflamed phymatous rosacea including surgical excision (electrocoagulation), dermabrasion, Pulsed Dye laser, IPL and Carbon dioxide laser ablation.
Treatment for ocular rosacea requires referral to an Ophthalmologist. Skincare A clinician-designed skincare routine is a vital component of rosacea management to improve and maintain barrier function, and optimize results from other treatments. Skincare is important both in skin priming prior to treatments, and is also restorative post treatment. Skincare ingredients which assist in the management of rosacea include peptides, vitamin A (retinoids), vitamin C (L-ascorbic acid), Vitamin E (tocopherol), vitamin B3 (niacinamide) vitamin B5 (panthenol), and allantoin. Dermal Clinicians are invaluable in providing clients with the most effective skincare products and education as to their best use, in order to improve skin integrity and alleviate rosacea symptoms. Retinoids (vitamin A derivatives) assist in desquamation, encourage cellular turnover, upregulate the synthesis of collagen, enhance angiogenesis providing greater tissue oxygenation, and regulate immune responses. Through these and many other long-term beneficial clinical effects, retinoids are advisable in daily skincare routines and are also able to accelerate post procedural wound healing in rosacea treatment. While retinoids will produce desirable clinical results, it is important to consider the most appropriate formulation that will not irritate or cause further sensitivity. Niacinamide improves epidermal strength and barrier function, important in barrier-impaired rosacea skins, and L-Ascorbic Acid and tocopherol work synergistically as powerful antioxidants to improve skin defence and aid wound healing. Morning skincare routine:
Basic skin cleanser (pH balanced, non-foaming, non-alkaline, fragrance free e.g. Cetaphil)
Emollient moisturiser (silicone based)
SPF 50+ broad spectrum UVA/UVB Physical Sunblock (zinc oxide)
Antioxidant serum (Vitamins C and E)
Evening skincare routine:
Basic skin cleanser
Retinoid Antioxidant serum (used only at night at retinols are photosensitizing)
Emollient moisturizer (restorative and occlusive)
Topical Agents (prescribed by a Doctor)
Ivermectin – anti-parasitic drug which reduces inflammatory lesions and is useful in maintenance
Brimonidine – vasoconstrictor topical gel to treat persistent erythema
Oxymetazoline - topical alpha-adrenergic agonist and vasoconstrictor
Intradermal botulinum toxin A injections - for flushing and erythema
Azelaic acid - anti-inflammatory, reduces papular and pustular lesions
Benzoyl peroxide
Dapsone
Permethrin
Clindamycin
Erythromycin
Beta blockers – Carvedilol (reduces redness) Antihypertensive drugs
Retinoids – anti-inflammatory
Metronidazole – scavenges free radicals and inhibits ROS production
Oral Medications (Doctor prescribed)
Tetracycline - inhibits inflammatory mediators
Doxycycline – downregulates many inflammatory mediators in the inflammatory rosacea cascade
Minocycline
Low dose Isotretinoin (retinoids) however there are common side effects of dry skin and eyes due to the drug’s effects on the pilosebaceous unit. It is contraindicated in pregnancy.
Zinc sulphate – reduces inflammatory lesions
Azithromycin
Clarithromycin
Modalities available to Dermal Clinicians
Dual frequency ultrasound – reduces erythema and trans-epidermal water loss and improves barrier function
Fractional microneedling Radiofrequency
Pulsed dye laser (595nm) treats diffuse redness
IPL (560nm) is safe and effective to target haemoglobin
Dual wavelength 775nm alexandrite/ 1064nm neodymium: yttrium-aluminum (Nd: YAG)
1064nm Nd: YAG laser is the best choice for Fitzpatrick skin types IV-VI to minimize the risk of post inflammatory hyperpigmentation.)
Frequency-doubled potassium titanyl phosphate (KTP) laser 532nm
Non ablative fractional resurfacing laser
Gel based AHA peel
BHA peels for acne rosacea
Ongoing Management
Sun protection (broad spectrum) at all times, or avoidance of exposure where possible.
Use of physical zinc oxide sunscreen is preferable.
Avoid stimulants, and patient-specific triggers (keep face cool)
Use water based make up (avoid oil based)
Use concealers to cover redness (low allergenic, mineral make up)
Avoid skincare products containing alcohol and astringents, or abrasive exfoliants
Avoid chemical sunscreens if sensitivity occur
Avoid corticosteroids
Use basic daily skin care to improve barrier function
Seek advice from a Dermatologist if necessary
Seek Counselling if necessary, taking into account the debilitating nature of the condition
Avoid aggressive exfoliation or abrasive skin lightening ingredients
Mineral makeup is well tolerated and will help to conceal redness
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