One word- cautiously. Rosacea patients have extra-sensitive skin. This means you can not afford to ‘try’ things out, because chances are you will get a reaction. As a rule you consider the use of calming lotions & anti-inflammatory topicals. Consider-

• Niacinamide 5-10% in a good formulation. Vitamin B3 can reduce inflammation, redness as well as improve your skin’s barrier function.
• Azelaic acid 10-20%, azelaic acid can reduce inflammation, acne, calm sensitive skin as well as reduce pigmentation. It is relatively gentle on the skin.
• Botanicals such as green tea can reduce inflammation & protect skin from UV induced damage.
• Tocopherol or vitamin E is a fat soluble, banal skin care vitamin. It is a powerful antioxidant that does not irritate skin.
• Skin care acids are double edge topicals, on one hand they can be useful to decrease inflammation (very low dose salicylic acid – around 0.5 to 2%). BHA can also reduce scale formation in cases of rosacea seb dermatitis overlap, however AHAs such as glycolic acid can be pro-inflammatory. If in doubt, test patch.

You may be better off under the guidance of a skincare professional or a medical dermatologist if you have uber sensitive skin. If in doubt, use a low concentration on a area in front or one ear *2 by 1 cm ‘spot test’. If your skin reacts you most likely would have an irritant reaction. True skin allergies are rare, but can be investigated with patch testing. 

Skin inflammation from rosacea makes pores appear larger. This is most commonly seen on the cheeks, forehead, & nose. Treat the inflammation, & stimulate collagen to support the pores means no more enlarged pores. A few pointers-

• Niacinamide 10% is anti-inflammatory. Use up to twice a day on affected areas. Formulations really do matter. Aspect Dr, The Formulated, Medik 8
• Azelaic acid 10-20% is anti-inflammatory. Use up to twice a day. Azclear is a good, cost effective brand.
• Botanicals can help, aloe vera reported as an anti-inflammatory.
• A medical dermatologist can prescribe anti-inflammatories to reduce flare ups.
• Enlarged pores can be treated with lasers & light based systems, these include vascular, fractional & pico laser as well as thermomechanical systems like Tixel. Consult my nurses @cliniccutis for more information.

Most skin care experts recommend mineral makeup. This formulation is talc & paraben free. Some make up colours include a tiny bit of green as this colour spectrum can potentially hide the red from rosacea.

For colour matching & coverage, you are best advised to see a good make up artist for tips and tricks, over a dermatologist.

For eye make up, consider extra-gentle routines. Eyes are sensitive to begin with, and if yours have signs and symptoms of ocular rosacea, it’s especially important to be extra careful. Select products designed for sensitive eyes that have been ophthalmologist tested — preferably allergy- tested, fragrance-free formulas may be ideal. Mascara and eyeliner should be easy to apply and remove without pulling or tugging on the eyes. Look for mascara formulas that can be gently removed by simply rinsing with warm water. Mineral powder eye shadow may be the perfect choice for eyes susceptible to rosacea symptoms. Neutral colors, both in shadow and eye pencils, may also be less irritating than strong jewel tones since they have less pigment.

Retinol can be tolerated in some patients with rosacea. As a rule you should consider a good low dose formulation of retinol (over retinoic acid or retinaldehyde). Murad makes good, low irritant formulations. The Ordinary is not a good choice in the context of rosacea or if you have sensitive skin.

1. Consider initiating treatment when your rosacea cycle is not as inflamed.
2. Start off every second night
3. Apply a moisturizer 30 minutes before retinol
4. Start with a 0.5% formulation
5. If you have sensitive skin, skip a day…or a week
6. Increase as tolerated
7. If you have inflammation, use niacinamide or azelaic acid to reduce redness
8. Increase your concentration to 1.0% after 3-4 months
9. Listen to your skin, if required give retinoids a break
10. Be guided by your dermatologist, they may give you a very short course of anti-inflammatories to get you back on track

With correct & cautious use, retinol can be used intermittently by most rosacea patients. Should you require guidance please see my clinical staff at Clinic Cutis. The same applies for prescription retinoids such as Retreive. In this context, skin irritation is much more common, hence why you should start with retinols. 

*Disclaimer: My work in the context of rosacea is eneritey procedural, namely I employ vascular lasers for recalcitrant inflammatory or telangiectatic rosacea, or ablative lasers for the management of end stage phyma.

Dermatologists will often prescribe medications to help control rosacea that does not improve with conventional medications & lifestyle changes. These include-

Topical creams, gels and lotions. Rozex is one of the most commonly prescribed gels. This has metronidazole, whilst Finacea is azelaic acid. Other creams include Soolantra or ivermectin topically. This targets mites called Demodex that live on the skin. Other topicals include brimonidine & sulfur based compounded creams. Another solution contains sodium sulfacetamide, sulphur, & salicylic acid. This can be used as a face wash. Short contact, short term pulsed cs or anti-inflammatories can be combined with other creams.

Tablets including doxycycline, EES, tetracyclines, lymecin, & oral isotretinoin. These work by modulation of inflammation. Micro-Botox or botulinum toxin can be considered in recalcitrant cases.

Flushing and blushing can be treated with beta-blockers including propranolol or alpha adrenergics. Mirvasso or brimonidine topical can be effective in the extreme minority of patients.

It is important to approach skin care analytically with thought, precision & purpose. This is especially important for rosacea patients as the majority of strong anti-aging products like retinoids, ascorbic acid & skincare acids can flare up rosacea.

As suggested, start with a good formulation of Niacinamide, then add an active every 2 to 3 months as tolerated. The next can be retinol at 0.5%. You can even dilute this with half a pea application of retinol on one finger tip & moisturizer on the other. This can give you an approximate dilution of 0.25%.

Lasers & light based rejuvenation procedures are preferred over chemical peels purely because light can reduce inflammation, while peels (even enzyme peels) have the potential to flare up rosacea patients. Here are a few sensible skin rejuvenation produces to consider in rosacea patients-

• Laser Genesis with the LP Nd Yag Vascular Laser: this can reduce redness & at the same time reduce skin sensitivity & burning. Over time it builds collagen, reduces pore sizing.
• Vascular 595 VBeam Perfecta/Prima; the go to laser if you have rosacea. This can also improve skin texture with continued use (3-6 sessions)
• 1927 Diode lasers such as Clear And Brilliant can rejuvenate your skin with minimal risks of flare ups.
• Pico Toning
• Dermal Toning
• Tixel; is a thermomechanical device that is relatively new. It can treat wrinkles, pores as well as recalcitrant rosacea (often in combination with BTX)
• Aquagold Nano with BTX; for refractory rosacea

Rosacea is an adjustment disorder. You will adjust to this. The more analytical you are, the faster you will figure it out.

Every case is different, you will have a very own blueprint of flare factors, skin irritants, & exacerbating factors. The flipside is that you will have a unique set of plans to calm your skin down. This can include foods, de-stressing, topicals, orals, & even laser treatments.

The way you figure it out is like detective work, the more meticulous you are, the more you pay attention to the smaller details, the more accurate your mapping. This way you can understand what flares up your condition, & conversely what works to calm it down.

Keeping a simple rosacea diary, food diary & sequence of recording of events based upon observations & photographic documentation will help.

When you add, subtract or alter things, do it step by step. For example, don’t change your entire skin care range at the same time. Alter one small aspect, a cleaner for example. This gives you a better analytical profile of changes.

Discuss options with your medical dermatologist. If you are after a directed skin care & rejuvenation program, book an appointment with my nurses at Clinic Cutis. They will guide you as to product use, lasers, & rejuvenation procedures.

Disclaimer: My work is entirely procedural, I do not do skincare consultations, nor do I practice medical dermatology. In the context of rosacea, my skill sets are with lasers including vascular lasers for refractory rosacea & ablative treatment of end-stage rhinophyma. My colleagues can assist with medical management.