Optimizing Skin Care in Rosacea Management

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The Dermatologist recently met with Hilary Baldwin, MD, to discuss the significance of gentle cleansing, moisturization, and sunscreen use in alleviating rosacea symptoms and enhancing treatment outcomes. In this interview, Dr Baldwin identifies skin care product ingredients that may exacerbate rosacea and provides valuable insights into selecting suitable products. Additionally, she details the role of the National Rosacea Society’s (NRS) Seal of Acceptance program in guiding patients toward skin-friendly choices and shares recommendations for sun exposure management. Throughout the conversation, Dr Baldwin underscores the vital role of dermatologists in educating patients about skin care practices and raising awareness about rosacea.

The Dermatologist: Why is proper skin care emphasized as an integral part of rosacea treatment, and how does it complement medical therapy?

Dr Baldwin: Rosacea is fundamentally a barrier disruption disorder. We see a decrease in hydration; an increase in transepidermal water loss; itchy, burning, stingy skin; and an increase in the possibility of allergic reactions. And we know that with adequate skin care, we can make a patient’s rosacea better even without a pharmacologic therapy. Bad skin care, such as excessive washing and using scrubs or exfoliants, can make rosacea worse. Additionally, the use of good moisturizers can make the skin feel so much better that the patient can tolerate a medication they might not have been able to tolerate before. Moisturization especially, but also good cleansing and the use of quality sunscreens, is crucial for every patient with rosacea. Patients should use a mild cleanser and avoid using washcloths and exfoliating brushes. I also suggest to my patients that they only cleanse their face once a day because every time we wash our face, we dry it out further.

The Dermatologist: Can you elaborate on some of the specific ingredients commonly found in skin care products and cosmetics that may exacerbate rosacea symptoms, as highlighted in a recent NRS survey?

Dr Baldwin: The survey asked 885 participants whether they experienced skin care products or hair care products that made their skin feel irritated or made their rosacea worse, and more than 82% said yes. They were asked about specific ingredients; alcohol was at the top along with witch hazel, both things that dry out the skin. And then the things that make products smell minty, such as peppermint, eucalyptus, and menthol, which are all drying agents. Fragrances were on the list, too, which are one of the most common allergens in skin care products for people with any kind of skin. We want our patients to avoid products with these ingredients.

The Dermatologist: What are the key recommendations for patients with rosacea when selecting skin care products?

Dr Baldwin: We must tell our patients that the bottom line is to avoid what bothers them and use what feels good. I suggest to my patients that they start off with a good quality product intended for sensitive skin, if not rosacea prone skin, made by a reputable company. Then we will move on from there. Clearly, we want them to avoid acids and exfoliants. We would like them to use a moisturizer that has quality ingredients, including an occlusive, an emollient, and a humectant to draw the water in, and ingredients that we know help repair the skin barrier, such as ceramides and natural moisturizing factors, as well as niacinamide, which is a soothing agent.

The Dermatologist: Could you discuss the significance of the NRS Seal of Acceptance program in helping patients with rosacea identify suitable skin care and cosmetic products?

Dr Baldwin: The NRS has asked several dermatologists who specialize in both rosacea and skin care to evaluate the safety of products that have applied to receive the Seal of Acceptance. We are looking at irritation; patch testing results, including human repeat insult patch testing where we are trying to make the patient allergic to the product and failing; and patient satisfaction. The Seal of Acceptance program is in its infancy, so there are maybe 10 items on the list right now, but that does not mean other products out there are not acceptable, it just means they have not yet gone through the rigorous evaluation of the panelists. The aim is to increase patients’ likelihood of picking a product that has been found to be particularly helpful in those with sensitive skin.

The Dermatologist: How does sun exposure influence the development of flushing and redness in rosacea, and what sunscreen recommendations should patients follow?

Dr Baldwin: The NRS has repeatedly asked patients to weigh in on what seems to cause their rosacea to be exacerbated, and heat and sun are both always at the top of the list of triggers for patients. Heat makes sense because rosacea is already a problem associated with increased redness and vasodilation at the skin’s surface. Heat is going to cause those blood vessels to dilate even more and increase the redness that we see. Heat is also a trigger for the vanilloid receptors, which we know are overexpressed in the skin of patients with rosacea. When triggered, this causes an increase in pain and itch because substance P and calcitonin gene-related protein have all increased, resulting in the symptoms that we see from sun and heat exposure. Additionally, ultraviolet light itself increases angiogenesis, atelectasis, fibrosis, and inflammation. So, we have both a short-term issue of vasodilation and a worsening of redness, as well as a more long-term issue with ultraviolet exposure specifically. We have a lot of data on how heat and ultraviolet light cause a problem in rosacea, but there are less data showing that sunscreens mitigate this problem.

We always recommend sunscreens with an SPF of at least 30. Frequently, we call for the use of mineral sunscreens, which usually contain fewer chemicals and may be more tolerable for our patients with rosacea, or perhaps a sunscreen with a tint in it so it not only protects against the sun but also gives a little bit of a benefit in reducing the redness of the skin. Also, the sunscreen should not be too thick or heavy. The problem with mineral sunscreens is that they tend to be chalky and white, and they are hard to remove. If a patient is struggling to remove it and must scrub to do so, it is not a great idea for somebody with sensitive skin and rosacea. Sometimes a water-based formulation is easier to remove and may be more beneficial to the patient. Again, it is a bit of trial and error to find a sunscreen that gives good coverage, maybe with a tint, and good protection from the sun, but can also be removed relatively easily.

The Dermatologist: What role do dermatologists play in educating patients about proper skin care and guiding them in selecting appropriate therapies for managing rosacea?

Dr Baldwin: First and foremost, we need to make sure that no visit for rosacea is complete until we have discussed cleansing, moisturizing, and sunscreen. Time can get tight with visits sometimes, but we must educate our patients on skin care. We also want to be educating patients who clearly have rosacea but have not come in for that. On occasion, patients will come in for other issues, such as warts, eczema, or psoriasis, and they have a very red face or pimples on their face and it is incumbent on us to point out, gently of course, that they also have a skin disease of the face, which can be treated and deserves to be treated. I also think it is important to ensure that we educate the public in general. So many of us are adept at social media. Dermatologists’ voices need to be part of the information that is out there on the internet so we are sharing appropriate, quality information for patients as opposed to the sometimes silly things you can see on TikTok, which may be misleading patients and perhaps causing problems.

The Dermatologist: Could you share some insights on the public education activities conducted by the NRS during Rosacea Awareness Month, and how can health care professionals contribute to raising awareness about the condition?

Dr Baldwin: If you go to the NRS website at rosacea.org, you will find outreach concepts, such as the myths and facts about rosacea. For example, one myth is that things like alcohol consumption or a poor diet are what makes people red. Another is that rosacea is really acne or that it is caused by having poor hygiene and you just need to wash your face more. The NRS provides information about the disease entity, how to cope with it, and how to treat it. The website is also a place to sign up for surveys. The more participants with rosacea we have taking these surveys, the more sensitive, specific, and valid the results are, so we will have a better understanding in the future of what makes our patients with rosacea tick.