Everything you need to know if rosacea is leaving you red-faced

There’s no greater comedy in this world than domestic cats whose contempt for humans is paralleled by their dependence on them to be fed and have a clean litter box. A close second is rosacea-prone skin that needs TLC and barrier-nourishing ingredients, but will also scream and turn red at first contact with face cream. 

Humans are the only animals that blush. Some spend thousands on pots of pigment to bring us that ‘youthful’ pop of colour. If rosy cheeks were a sign of wellness, then people with rosacea are in the pink of health. But in truth, rosacea is a chronic inflammatory skin condition with persistent redness around the centre of the face caused by visibly dilated blood vessels, pustules that look like acne, swelling, an incredibly irritated and impaired skin barrier.

We’re not strangers to skin flushing and redness. After one too many experiments with skincare products. A day out in the sun without any sun protection. Failed pimple popping that has left behind an angry mess on your cheek. Rina aunty’s mutton curry that’s so spicy it turns you into a sweaty tomato but you can’t help take another bite. But these eventually fade and subside.

“While the exact cause of rosacea is yet to be completely clarified, several factors play an important role. An overactive immune system, heredity factors, environmental factors, stress or a combination of all these may lead to rosacea,” says Dr Mikki Singh, head dermatologist, Bodycraft skin clinic.

Rosacea symptoms can manifest in a variety of ways, according to Dr Janet Alexander Castelino, the founder at DermaZeal clinic. “For some, it manifests as prolonged red flushing of the face with a few small visible blood vessels, while for others, it’s red bumps (that resemble pimples) against a background of redness. Rosacea can manifest itself as redness of the eyes (ocular rosacea) with flakes across the eyelashes in a few rare cases (known as conical dandruff). Phymatous rosacea is a kind of rosacea in which the nose, chin, ears, or forehead become enlarged and bulbous.”

Dr Niketa Sonavane further breaks it down into four types. “Medically, rosacea is classified into four types according to the area involved, the severity of symptoms and visible skin changes. Type one mainly involves facial redness and broken capillaries. Type two has acne-like breakouts. Type three has thickening and swelling of the nose. Type four involves the eyes with vision abnormalities.”

The experts agree that it’s a skin condition that’s more common for people with Caucasian or paler skin type. But it can affect anyone in varying degrees of severity, irrespective of skin tone.

It’s believed that only 4% of people with ‘Asian and African’ skin types deal with rosacea. Dr Shoma Ratthee feels the number could be a lot higher, but it’s difficult to diagnose in people with brown skin. “Treatment plans and observations have largely been euro-centric. Practitioners go by what they’ve learnt in training, but many conditions present themselves differently on brown skin. We need to open up our thinking and pay more attention to what our client is saying,” adds Dr Shoma Ratthee. 

If you’ve been trying to figure out if your skin is having an acne breakout, rosacea flare-up or simply annoyed at your mixing and matching exfoliating serums, the experts suggest tracking your symptoms carefully. Pay attention to the things that can trigger rosacea and see if your experience lines up. Rosacea is a medical condition that isn’t curable but can be well managed with topical treatments, in-clinic cosmetic treatments and select skincare ingredients.

The rosacea triggers

So was it the spicy food, one too many glasses of red wine or a day out in the sun? Our experts say it could be either or a combination of them all that is triggering your rosacea flare-up. 

They recommend you avoid harsh exfoliation, especially physical scrubs. “UV radiation (UVA and UVB), spicy foods, hot beverages, and vigorous scrubbing or rubbing of the face are the most typical triggers,” says Castelino. 

Look at the back of your skincare package, there could be hidden triggers in the ingredient list that are causing you to go red and itch. Ingredients like drying alcohol, sodium lauryl sulfate and propylene glycol can be useful if you have oily skin, but for rosacea-prone skin, it becomes too drying and hampers the skin barrier that’s already struggling to hold itself together. ‘Tingling’ and ‘cooling’ agents like peppermint, menthol, clove and eucalyptus should also be avoided.

Ratthee says that skincare products with a high amount of fragrance and essential oils can be irritating for people with rosacea. “However, everyone’s skin reacts to fragrance differently. I would avoid very fragrant products and stay on the safe side. But if one out of 3 products you use happen to have some fragrance, then you don’t need to throw it away either. If it’s working for you, stick to it.” More brands are becoming cognisant of the possible irritation that fragrances can cause and are creating alternatives. 

Castelino adds that for some people, even exercise can be a trigger. Stress is also a trigger for flares and to combat that many advise exercise as a stress-reduction technique that gives you a boost of happy hormones. Dr Tsippora Shainhouse believes that for long-term rosacea management, incorporating exercise is beneficial even if it “causes some temporary flushing due to the acute vasodilation.”

If it’s getting too much for you, you may want to skip the high-intensity (HIIT) workouts. HIIT rapidly (but temporarily) increases blood flow and heart rate which can cause a lot of flushing and make “the skin appear redder in patients who already have vasodilation associated with rosacea,” according to Shainhouse. Keep cool and try not to let your body get overheated by sipping cold water, keeping a mist handy to spray your face intermittently and layering clothing that you can remove as and when needed. You could opt for moderately intense workouts and mix that in with strength training to make sure you’re getting all the mental and physical benefits of working out.

The treatments for rosacea

Topical treatment

Simplicity is the mantra that the experts want you to adopt when it comes to skincare. A dermatologist’s evaluation can determine the severity of your condition and the treatment course you need to take. Singh and Castelino say that you may be prescribed oral antibiotics and medicated products like topical metronidazole and azelaic acid.

Azelaic acid is a championed ingredient for treating rosacea. Anti-microbial and anti-inflammatory, it works at decreasing the swelling and redness of the skin. It’s a very mild skin exfoliator as well that’s safe for sensitive rosacea-prone skin. As a medication, you may be prescribed a gel at 15%-20% strength that should be used under the guidance of a doctor. But it’s also becoming a popular ingredient in cosmetics with lower strengths and derivatives that are as effective, though they may take longer to show results.

Niacinamide is another ingredient our experts recommend. It can work as an antioxidant, anti-bacterial and anti-inflammatory. But with niacinamide, you want to start with a low concentration that’s worked into your skincare routine slowly.

Niacinamide can boost skin barrier function by increasing ceramide production, according to Dr Sam Bunting, which aids in the skin’s ability to retain water and protect itself.

Proper skin barrier function and health is what you want to focus on when it comes to building your rosacea-friendly skincare routine. That involves picking gentle, non-foaming face washes and cleansers, and making sure you’re moisturising well to prevent your skin from losing water and getting dry patches that a lot of people with rosacea struggle with. Focus on face creams with ceramides and occlusive that will keep all the goodness trapped in.

Most importantly, perhaps, is sun protection. “Nothing you put on, no medicine or serum will matter if you’re not protecting your skin from the sun. Not wearing sunscreen will undo any progress you make,” says Ratthee.

Singh says that physical sunscreens with ingredients like zinc and titanium dioxide are well suited for rosacea-prone skin. However, these do tend to leave behind a white cast on the face. Looking like Casper the ghost works only one day in the year, for the rest, you can look for tinted sunscreens to match your skin tone.

What to cut from your plates

Like with all things hair, scalp and skin, it’s not just what we apply topically but what we put in our body that matters. More than what you should be eating, experts say to keep track of the things you should be cutting out instead.

Hot beverages

Unfortunately, we’re talking about your morning dose of caffeine. It’s not so much the caffeine itself, but the temperature of the drink that can make you flush. Try switching your hot chai and coffee for iced versions. Tepid tea sounds like a nightmare, we get it, but try it as a process of elimination for a week or so to see if your rosacea reacts in any different way.

Alcohol

Everyone has a different tolerance to alcohol and flushing, so you will have to see what your limits are. What triggers you may not trigger a flare-up in another, but red wine has been cited as the most common culprit, followed by white wine, then beer.

“Keep a limit on the number of drinks. Alternate it with glasses of water and if you feel like having a drink or two, have it on the rocks rather than warm or at room temperature. The slight chill can help curb flares,” says Ratthee. Alcohol is also high in histamines. While they’re produced naturally in the body, a high histamine level can cause itchiness, rashes, hives and more.

Hot spices

What’s Indian food without our spices? Sadly, when it comes to rosacea management in the long run, you’re going to want to tone down the intensity of spice in your food. Put away the laal mirch powder, tone down the black pepper and especially the cinnamon. Cinnamaldehyde is the compound that gives cinnamon its flavour but it can also cause vasodilation, increasing the appearance of redness of the skin. It’s not just cinnamon either, but cinnamaldehyde is present in tomatoes, citrus fruits and, sadly, chocolate.

Dairy

Speaking of chocolate, you may want to break up with dairy as well. It’s a great source of vitamin D and calcium, but dairy could potentially be inflammatory (though this is still being studied and debated). Ratthee suggests doing a trial elimination for a few days to see how you respond to it. “Some people react negatively to dairy. Some feel it makes their acne worse as well. It’s all about seeing how your body reacts to the presence or lack of certain foods and finding a diet that works best for you.”