We all know what rosacea is. Red skin with visible blood vessels and the occasional feeling of tightness and itchiness. But did you know there are a few different types of rosacea? Me, neither. But now I know. And will explain every type so you can understand them better.
So first things first.
What is rosacea
Rosacea is a chronic inflammatory skin condition that most often affects the cheeks, forehead, nose and chin and is estimated to affect up to 15% of specific populations. Groups of capillaries close to the surface of the skin become dilated, resulting in blotchy red areas with minor bumps and sometimes pimples.
The redness can come and go, but eventually, it becomes permanent, and in more severe cases, there might be some swelling of the facial skin. It can occur at any age, but most often, it will affect adults with fair skin between ages 30 and 50. It is more common in women than men, although symptoms are usually worse in men.
There is no known cause for rosacea, but it’s related to genetics, hot flashes in menopausal women, alcoholism, gastrointestinal disorders, or vitamin deficiency. There is no cure for rosacea, but there are ways to minimize symptoms.
Types of Rosacea
There are 4 types of rosacea:
- subtype 1 – erythematotelangiectatic rosacea; usually appearing as facial redness, flushing, and visible capillaries
- subtype 2 – papulopustular (or acne) rosacea; is associated with acne-like breakouts and is most common in middle-aged women
- subtype 3 – rhinophyma; a rare form that usually affects men and can cause thickening of the skin on the nose
- subtype 4 – ocular rosacea; centred around the eye area
Erythematotelangiectatic rosacea
Erythematotelangiectatic rosacea is the most common type of rosacea. Its characteristic is persistent redness on the face. Blood vessels can be visible, and there might be flushing. In the beginning, redness can flare up, but it usually goes away until another flare-up. If we don’t treat rosacea, it can become permanent and spread to larger areas. Some people might even have redness on their scalp and neck. Also, there might sometimes be tingling, stinging or a sensation of warmth in the affected areas.
Signs of Erythematotelangiectatic (ER) rosacea:
- redness
- visibly broken blood vessels
- flushing
- tingling and stinging
- warm sensation in the skin
- dry, scaly skin
Papulopustular (or acne) rosacea
Often mistaken for acne, this type of rosacea is characterized by acne-like bumps on the skin. They are called papules or pustules and are rooted deep in the skin. These blemishes are filled with pus and can become swollen. Unfortunately, they are usually quite painful, and at the time of a severe flare-up, there can be even up to 40 blemishes at once covering areas of cheeks, chin and forehead. These blemishes are accompanied by redness and flushing. But, unlike acne, which shows up in the teen years, this condition usually affects middle-aged women. People affected by papulopustular rosacea can develop skin sensitivity, and the areas affected by acne can become oily, whereas other areas can have dry, scaly patches.
Signs of papulopustular rosacea:
- acne-like blemishes
- redness
- broken blood vessels
- sensitive skin
- oily skin
- raised patches of skin
Phymatous Rosacea
This type of rosacea is very rare and affects men more often than women. It causes the skin to thicken and become bumpy, and individuals with this condition describe such tissue as scar tissue. When the skin starts to thicken, it builds up around the nose area, making the nose bulbous and enlarged. Alongside that, the blood vessels can become visible and the surrounding skin red. Improper or non-existent treatment of other types of rosacea can lead to this most severe type.
Signs of phymatous rosacea:
- thickened skin on the nose
- bumpy skin
- redness
- large pores
- broken blood vessels
Ocular Rosacea
As you can guess, this type of rosacea affects the eyes. It is often misdiagnosed as an eye problem rather than a skin problem making it hard to treat accordingly. The eyes are bloodshot, there is inflammation both inside and around the eyes, and there might be bumps on eyelids similar to styes. People with ocular rosacea describe the feeling in the eyes as having dirt or dust stuck in the eyes. There might be stinging, watery eyes and sensitivity.
Signs of ocular rosacea:
- visibly broken blood vessels in the eyes
- bumps on the eyelids
- eyes are sensitive to the light
- dry, irritated, watery eyes
- a feeling of dirt/dust in the eyes
- swelling of the skin around the eyes
Rosacea triggers
There can be a plethora of triggers, and they are different for everyone.
They include:
- eating spicy food
- drinking tea or coffee
- eating foods containing cinnamaldehyde, such as tomatoes, cinnamon, chocolate, citrus fruit
- alcohol
- stress
- hard physical activity
- intestinal bacteria Helicobacter Pylori
- skin mite called Demodex
- sunlight
- extreme heat or cold
Diagnosing Rosacea
If you think you might have rosacea, the best thing to do would be to visit your dermatologist. They can diagnose your rosacea by visually examining your skin. Next, dermatologists will also evaluate your symptoms and possible triggers to correctly diagnose which type of rosacea you have. They will ask you which symptom occurred first and when it occurred. Finally, they will ask how frequently they happen and if you noticed any connection between the appearance of symptoms and possible triggers.
The best thing you can do before your dermatologist appointment is to keep a diary of all your symptoms. That can help the dermatologist get a clear picture of what is happening and when.
Once you get your diagnosis, the dermatologist will prescribe a treatment that can be topical or oral, depending on the severity of the rosacea.
Treatment
Firstly, it’s worth mentioning that there is no cure for rosacea as it can not be cured. But it can be managed. And that’s where topical and oral treatments come into play.
In the beginning, a dermatologist might prescribe both topical and oral treatment to reduce and calm the flare-up. Oral medications can reduce inflammation and blemishes and can reduce redness. And topical products such as creams and gels work similarly in reducing redness and blemishes.
Topical treatment
There are a few types of active ingredients doctors recommend for rosacea.
They usually include the following:
- antibiotics
- azelaic acid
- retinoids
- brimonidine
They all have a similar effect in the way that they work on reducing facial redness, but obviously, your doctor will prescribe what he thinks is best for your skin.
Azelaic acid and retinoids are available as over-the-counter products, whereas antibiotics and brimonidine are prescriptions only. That being said, retinoids and azelaic acid are in much lower concentrations when they are bought over the counter. What your doctor prescribes you will be of much higher concentration and is available only via prescription.
I will write a bit more about azelaic acid and retinoids as they are available over the counter, and I have more knowledge about them than the other two.
Azelaic acid
Azelaic acid is known to reduce the redness and blemishes caused by rosacea. It is a naturally found acid in grains such as barley, rye and wheat. It has antimicrobial and anti-inflammatory properties making it a fantastic ingredient for treating rosacea and blemishes. Azelaic acid products you can buy OTC are usually under 10% concentration, and the ones that are prescription-only are usually 15%-20%.
You can try the OTC products first, but you would need about 3 to 4 months to see a difference. But prescription products might work within a few weeks.
As with any acid, wearing SPF is very important when using azelaic acid. Also, SPF is essential for those suffering from rosacea, so there isn’t any reason not to wear sunscreen.
Retinoids
Retinoids are known to be a star ingredient for anti-ageing. But they can also help with rosacea-caused blemishes. They exfoliate the skin, and by doing so, they can help clear the pores that might be clogged and inflamed due to rosacea. By clearing the pores, retinoids reduce blemishes and can also reduce redness.
As rosacea skin is sensitive, I would recommend a 3-2-1 method of introducing retinoids into your skincare.
If you don’t know, the 3-2-1 method means using retinoids every third night for the first three weeks, then every second night for two weeks and then every night after that. This method will give your skin a chance to get familiar with retinoids and will hopefully prevent any unwanted side effects from happening.
Usual side effects are peeling of the skin, red skin, dryness and sensitivity, and it is obvious why we want to avoid that in people with rosacea. If you experience any of those symptoms, stop using retinoids and focus on hydration and repairing the skin for a few days until it’s back to normal. Once back to normal, start slowly again with the 3-2-1 method.
Oral treatment
Oral treatment can work well for those that don’t find topical medication helpful. These medications are usually prescribed to treat blemishes such as whiteheads. If you get a prescription for oral treatment, it’s important to follow the doctor’s instructions on how to take the medication.
Treatments that are usually prescribed orally are:
- antibiotics
- isotretinoin
Skincare for rosacea
Even though rosacea is not curable, it is manageable. And to manage it and keep the symptoms at bay, we have to be careful what we put on our faces. Due to the sensitivity that comes with rosacea, we have to avoid harsh ingredients such as alcohol denat, strong acids (AHAs or BHAs) and perfumes or fragrances.
We know what a typical skincare routine consists of:
- cleansing
- hydrating
- moisturising
- SPF
Cleansing rosacea skin
To start the day, we will choose a gentle cleanser that contains soothing ingredients. And it doesn’t have any harsh and drying ingredients. We will look to avoid alcohol denat, mineral oils, perfumes and essential oils. Always look at the ingredient list that isn’t too long. On the other hand, ingredients that are welcome in cleansers are soothing ingredients such as oats, glycerin, dexpanthenol, and propolis.
In the evenings, we will do a double cleanse. I wrote about it here: Double cleansing – why is it so important?
Essentially, it is a method where you first melt your makeup and dirt with an oil-based cleanser. Afterwards, you go in with a foaming cleanser to remove that oil and melted makeup.
The first product should be a gentle oil cleanser. Choose a product without a lot of essential oils and perfumes. It can even be your blend of oils. I used to use a blend of almond and castor oil (ratio 2:1), and it worked great for me.
The second cleanser can be the same one you use in the morning.
Here are some good options for the first cleanser (oil/balm/lotion):
And here are examples of good second cleanse/morning cleanse options:
I have tried a few different cleansers so I’m going to leave my reviews here: La Roche-Posay Toleriane Softening Foaming Gel Wash Review, Review: Apivita Cleansing Creamy Foam
Hydrating rosacea skin
We hydrate with toners and serums. Once again, look for products with gentle, soothing ingredients. Those include:
- niacinamide
- glycerin
- hyaluronic acid
- chamomile extract
- allantoin
- squalane
- antioxidants
Serums with those ingredients can work on repairing and strengthening blood capillaries. Also, they can soothe the skin and reduce redness. Because of that, serums are a great place to invest a bit more money in your skincare.
Some of the good options:
Here is my review for La Roche Posay Dermallergo Serum: La Roche Posay Dermallergo Serum Review
Moisturising rosacea skin
Moisturisers go after serums to lock in the moisture. They can be an essential step for those with rosacea, particularly if the skin is dry. Look for ingredients such as:
- shea butter
- glycerin
- ceramides
In case your skin is oily, you can skip this step or look for fluids instead of creams. Be careful if your skin is prone to breakouts, as some moisturisers, particularly ones for rosacea skin, can be very heavy and block your pores. For example, I know that shea butter clogs my pores and causes breakouts on my skin. Because of that, I avoid that ingredient and choose lighter formulations. Everyone is different, so it will take some time to find appropriate products for you.
Product options:
SPF for rosacea skin
Lastly, protecting the skin from the sun. Sun can be one of the triggers for rosacea skin, and it’s very important to always protect your skin. Look for mineral SPFs rather than chemical ones. Mineral SPF tends to be more gentle on the skin and is a better option for sensitive skin. Zinc oxide and titanium dioxide (mineral filters) can have a calming and restorative effect.
Also, sunscreen can have other nourishing ingredients, such as:
- niacinamide
- ceramides
- fatty acids
- panthenol
To emphasize, sunscreen is non-negotiable. Not just for rosacea skin but for every skin. There are hundreds of different formulations on the market, and I’m sure you can find one that suits you. Don’t skip the SPF.
Sunscreen recommendations:
What to avoid
I have already mentioned the triggers for rosacea. Everyone is different, and not all those things will be your triggers. But, over time, you will be able to pinpoint your triggers, and you will learn to avoid those things. For me, those are alcohol, strenuous exercise and spicy food, so I try to avoid those things.
For the most part, it’s best to avoid:
- direct sunlight
- drinking alcohol
- skincare gadgets that are too harsh on the skin
- strong retinoids and acids
- alcohol denat in skincare
- perfumes in skincare
- spicy foods
- tea or coffee
- too hot or too cold water
Conclusion
To summarise, rosacea is a skin condition that is not curable. But with proper care, it can be managed, and a person can go without flare-ups for months, if not years. But to manage it, you need to understand what your skin needs and what it doesn’t like. And to do that is only through trial and error. It will take time to find an appropriate product, but you will find them.
To repeat, if you think you might have rosacea, the best thing to do is to go to a doctor. A doctor will be able to diagnose your skin condition properly and give you the treatment you need. In the meantime, you can avoid your triggers and choose more gentle and protective skincare. But proper diagnosis is the key.
