Dr. Teo Wan Lin is the host of a beauty podcast- Dermatologist Talks: Science of Beauty, which covers the latest in skincare active ingredients, dermatology news and beauty technology. Listen to her podcast here.
In this Conscious Beauty blog series which ties in with the launch of my podcast- Dermatologist Talks: Science of Beauty- I will be sharing about skincare tips in common dermatological conditions. Do you suffer from facial redness or flushing? Facial erythema can be caused by acne, rosacea, eczema and even autoimmune diseases like lupus. Most commonly, facial redness is due to rosacea. It is a disorder where the skin’s blood vessels are abnormally active leading to persistent skin inflammation. This article will focus on dermatologist rosacea skincare tips, medical therapies, as well as the role that a rosacea skincare routine has to play in treatment.
Rosacea Symptoms, Signs and Diagnosis
Rosacea is a dermatological condition characterised by the tendency of one’s skin to become flushed or red. This can happen in the presence of certain triggers or when the disease is advanced, it may present as persistent redness. It is a condition affecting many in Singapore. It can also be fully treated by a dermatologist.
How does the skin look like? Firstly, there is persistent flushing, which presents as redness on the face. In skin of color, the redness may not be obvious. However the individual over time develops skin textural changes, which can become disfiguring. Irregular skin texture, enlarged pores and eventual skin thickening are medium to long term complications of untreated rosacea.
In general, onset of the skin inflammation occurs when one is between 30 to 50 and tends to affect fair skinned individuals from a Celtic or Scandinavian ancestry. It is also seen commonly in Chinese people in Singapore.
Rosacea is diagnosed visually, examining the skin around the nose and eyes, and from asking more questions. Before giving you a diagnosis, your dermatologist would have to rule out other medical conditions that can look like rosacea. Medical tests can help to rule out conditions like lupus and allergic skin reactions.
- Family history: It is more likely for you to get rosacea if you have a family member who also has rosacea. It is possible that people inherit the gene for rosacea.
- Immune system: Research has found that many people who have acne-like rosacea, or papulopustular rosacea, react to a bacterium called bacillus oleronius. This reaction causes their immune system to overreact.
- Intestinal bug: H Pylori is a bug that causes infections in the intestine. This bug is also common in those with rosacea. There is a hypothesis about the Helicobacter pylori bacteria colonizing the gut of rosacea patients, which explains why treatment with metronidazole can be effective in treatment.
- Skin mite: Demodex is a mite that lives around the nose and cheek areas on the skin. This is where rosacea often appears. Studies have found that people with rosacea have large numbers of this mite on their skin.
- Processing of protein: The protein cathelicidin usually protects the skin from infection. How the body processes this protein may determine whether a person gets rosacea.
Topical treatment can include brimonidine, metronidazole and azelaic acid. However, these have irritating side effects.There is increasing evidence to support the use of cosmeceuticals, which do not have side effects, for the adjunct treatment of rosacea. At TWL Specialist Skin & Laser Centre, our dermatologist uses cosmeceuticals for the treatment of mild to moderate rosacea, in combination with oral treatment where necessary. Anti-inflammatory oral antibiotics may be required for papulopustular subtypes i.e. tetracycline, erythromycin, to reduce skin inflammation. In severe papulopustular variants, isotretinoin may be required. Light therapies and lasers may be of value as adjunct treatments.
Rosacea Skincare Tip #1 Respect the Skin Barrier When Cleansing and Moisturising
We’re going to talk about the role of the skin barrier in rosacea.
The skin barrier is best thought of as the physical “wall” that separates the external and our internal cell environment. An intact skin barrier protects from external allergens and environmental damage. An individual with rosacea may have associated eczema, making face redness worse. This can be pre-existing childhood eczema or due to external factors such as harsh drying skincare.
When you suffer from a dermatological condition like rosacea, it is important to have it treated by an accredited skin specialist. Your rosacea skincare routine affects skin barrier function. When it is intact, there is less inflammation and facial redness will improve.
In your rosacea skincare routine, gentle cleansers are recommended. For foaming cleansers-these can be amino- acid based or formulated with lower SLS (sodium laureth sulfate) content. SLS- free cleansers usually contain alternatives like ammonium-laureth sulfate. Laureth sulfates can all strip the skin of moisture. SLS-alternative foaming cleansers can be natural emulsifiers, such as soy-based or honey. Medical-grade honey is purified and retains bioactive properties. It is a broad-spectrum anti-microbial. It inhibits bacteria, fungi and also moisturises the skin.
The function of gentle cleansers for rosacea can be two-fold. First by emulsifying the dirt, oil and grime in a lather which is then rinsed off. Second, the best cleanser leaves a beneficial residual effect on skin. It continues to act after the cleanser is washed off. This is possible with medical-grade honey cleansers that have a natural humectant property, trapping water under the skin’s surface. This reduces trans-epidermal water loss (TEWL).
If you wear makeup, double-cleansing is recommended. The type of cleanser to remove makeup has to effectively dissolve oil-soluble makeup pigments. An oil cleanser or a oil-in-water cleanser (usually formulated as a milk cleanser) will be gentler on your skin then a micellar formulation.
Rosacea Cleansing Tips Explained by a Dermatologist
Gentle skincare is key. The goal of a rosacea skincare routine is to maintain integrity of skin barrier while avoiding agents that cause inflammation/flushing. Non-soap cleansers with synthetic detergents (pH 4.0-6.5) are better tolerated than traditional soaps (pH >6.5). Avoid harsh topicals such as toners, exfoliating agents and astringents. In erythematotelangiectatic rosacea and facial erythema (flushing), telangiectasia, eczema-like features such as skin sensitivity (burning or stinging sensation), dryness and scaling can be present. The redness can also affect other areas e.g. scalp, ears, neck and chest.
Repair the skin barrier while undergoing rosacea treatment. Facial redness can be caused or worsened due to facial eczema. If you have itch, swelling and skin flaking, you may have dermatitis, which can co-exist with other dermatological conditions.
The Best Type of Moisturiser for Sensitive Skin
Moisturisers in your rosacea skincare routine should target barrier repair. The best moisturiser for sensitive skin and rosacea is one with ceramides. Ceramide-dominant moisturisers with an optimal lipid ratio help to replenish dehydrated skin. The gold standard moisturiser is formulated as a Prescription Emollient Device with additional anti-inflammatory ingredients. Hyaluronic acid and polyglutamic acid are additional hydrating molecules that do not leave a greasy feel in a tropical climate like Singapore. Polyglutamic acid is more effective than hyaluronic acid in attracting water molecules, but can be more expensive.
Rosacea Skincare Tip #2 Anti-Oxidants Target Inflammation
Inflammation occurs in rosacea. In papulopustular rosacea, inflammatory papules and pustules are present in addition to persistent face redness. Phymatous rosacea is a subtype of rosacea that shows thickened and coarse skin. Enlarged pores (dilated hair follicles on facial skin) may be a sign of rosacea, due to tissue overgrowth. Irregular skin texture can be due to nodules. These changes can get worse as one ages. Cosmeceutical skincare containing anti-oxidants fight inflammation in a healthy skincare regimen.
Importantly, skin inflammation in rosacea should be treated medically. This is because the end stage of persistent inflammation is a condition known as rhinophyma. Rhinophyma is disfiguring and surgical methods, including fractional CO2 laser resurfacing, may be required treatment when the disease is advanced.
Dermocosmetics are the latest development in cosmetic dermatology. There is evidence supporting botanical anti-inflammatories in skincare formulations.
As a rosacea skincare tip, active ingredients such as Gingko Biiloba, Camellia Sinensis, Aloe Vera, and Allantoin are beneficial in treatment. Gingko Biloba works for redness because of active terpenoids. Gingko reduces blood vessel hyperactivity through its anti-inflammatory effect. Polyphenols are powerful antioxidants that fight free radicals. Green tea known as camellia sinensis is a source of polyphenols that are anti-inflammatory. It has been shown to reduce UVB-induced inflammation. Bioactives in aloe vera include aloin, aloe emodin, aletinic acid, choline and choline salicylate which are anti-inflammatory. It can also balance the skin microbiome. Allantoin is a derivative of glyoxylic acid from the comfrey plant. It is a humectant and attracts moisture, restoring barrier function in patients with facial redness.
Common Misdiagnoses of Rosacea
Acne rosacea is the commonest subtype seen in dermatologist offices. It commonly occurs over the nose, forehead, cheeks and chin. An accredited dermatologist will be able to correctly diagnose, based on clinical examination, as well as symptoms derived from history taking. It mimics acne and can be mistaken for pimples. It is also possible for early rosacea to be misdiagnosed as facial eczema coexisting with acne, because of the background redness. The papule-pustular variant can appear with acne-like bumps, cysts, or nodules. The facial redness is due to visible blood vessels, also known as telangiectasia.
The flushing and skin swelling can look like sensitive skin or eczema. It also mimics the enlarged pores of oily skin-types, when in fact the thickened skin is due to rosacea. Flaking, redness and red bumps around the mouth can be due to perioral dermatitis. It can affect the eyes, resulting in blepharitis, where one develops red and irritated eyes. This can be confused with findings of ocular rosacea- dryness, irritation and a foreign body sensation. Other dermatological conditions that can mimic rosacea include seborrheic dermatitis, lupus erythematosus, polycythaemia rubra vera and carcinoid syndrome which are less common. Steroid-induced acne may be a consideration if there is a history of using steroid creams on the face.
Rosacea Skincare Tip #3 Sunprotection
While it has multifactorial origins, lifestyle factors affect rosacea significantly. Sun exposure, consumption of alcohol, emotions, spicy foods, medications, menopausal hot flushes, exercise and stress can trigger flare ups.
Sun protection is an essential component of a rosacea skincare routine. It is critical in treatment of all facial redness which is photosensitive. The cheeks are the most affected. As it is now covered by a face mask in a post-COVID19 world, sunblock may not be a practical measure of photoprotection. I have suggested in my research paper on maskne that UPF50+ biofunctional textiles be used as primary photoprotection with a face mask design. This means there is no need for reapplication.
However, as a rosace skincare tip, sunblock can also cause facial stinging in rosacea patients. A UPF50+ textile provides maximum broad spectrum UV-protection without any risk of skin irritation. For uncovered areas like the forehead, neck and upper chest, a broad-spectrum sunscreen is necessary. To prevent stinging, look for a sunscreen that is dermatologist-recommended. Also, UV-blocking ingredients such as titanium oxide and zinc oxide function as physical blockers are less sensitising. Look for additional protective ingredients such as dimethicone, cyclomethicone to prevent irritation from sunscreen ingredients.
Dermatologist’s Tip: Top Rosacea triggers
Various environmental or lifestyle factors can exacerbate rosacea. Heat, sunlight, stress, hot or cold weather, exercise, alcohol, spicy foods and certain skin care products. Emotions can also increase the frequency of disease flares. To reduce flushing after encounter with stimuli, applying cool compresses and transferring to cool environments may be helpful. Cold therapy can be harnessed for its anti-inflammatory effects.
Rosacea Skincare Tip #4 Cosmetic camouflage
The use of cosmetic products such as green colour correcting concealers can help. Cosmetic camouflage is a recognised intervention as part of rosacea treatment. Green-tinted concealers or foundation helps to camouflage facial redness. This can be followed by a flesh-coloured facial foundation to achieve a natural look. I develop a line of color-correcting concealers in my skincare makeup line that helps with concealing.
Dermatologist’s Tip: Best Concealer for Rosacea? It’s Green
Based on color science, green neutralises red, a color on the opposite end of the colour wheel. Cosmetic camouflage is an important part of rosacea treatment. It can alleviate psychosocial distress. Patients suffer significant embarrassment from episodes of facial redness. This perpetuates a cycle that makes the chronic condition more stressful.
Rosacea Skincare Tip #5 A daily skincare ritual can help with your skin and also boost your mood
Stress is a major trigger factor for rosacea. Some scientific ways to reduce psychological stress include cognitive reframing and mindfulness activities. Adopting a daily skincare ritual is beneficial mentally and physically for rosacea treatment. We have discussed the essential steps in a skincare regimen for sensitive, reactive skin. This maintains a healthy skin barrier, restores the skin microbiome and provides anti-oxidants to help protect. However, the additional value of a daily skincare ritual is that it improves psychological well being.
Self-care is a concept that allows the mind to re-charge together with the body. As a rosacea skincare tip, having a bed-time ritual for example, is healthy for sleep hygiene. Starting your work day with a ritual, can make you more productive. I created the 360 Conscious Mask Bar as a complete self-care concept with anti-inflammatory benefits for rosacea, sensitive/reactive skin patients. Cold therapy/ cryotherapy can be relaxing and soothing both physically and psychologically.
Conscious Beauty by Dr.TWL Dermaceuticals stars model-actress Sara Malakul Lane, international burlesque performer Sukki Singapora and dermatologist at TWL Specialist Skin & Laser Centre Dr. Teo Wan Lin. Feminine beauty as a modern tale told by the girls themselves, through the lens of fashion model-turned photographer Sabrina Sikora.
E-book version only. 100% of proceeds received from CONSCIOUS BEAUTY will go to charitable causes supported by Dr.TWL Dermaceuticals – Action for AIDS Singapore and the United Nations World Food Programme. Available on Amazon Kindle, and the Dr. TWL Dermaceuticals website.
“Your healing journey towards beauty, begins with your consciousness of the inner world,” Dr. Teo Wan Lin
Dr. Teo Wan Lin is an accredited dermatologist practising at TWL Specialist Skin & Laser Centre. An expert in dermocosmetics for skin diseases, the skin microbiome and biofunctional textiles, her work has been published in top dermatology journals. Her additional research interest is in the brain-skin connection which emphasises psychological wellbeing in sufferers of chronic skin disorders. In her journey of helping dermatology patients for over a decade in practice, she strongly believes that true beauty has to begin from the inside rather than from the external.Tags: Rosacea, Skincare