Rosacea is a chronic inflammatory skin disorder mainly affecting the face. It is characterized by redness of the cheeks, nose, chin, and forehead, with fine red lines due to broken or dilated blood vessels. Rosacea often manifests in recurring episodes of flushing, acne-like bumps and pustules, and sometimes severe skin damage with thickening, swelling, and nodules.^1,2 Rosacea can also cause inflammation, redness, and small blood vessel damage in the eyelids and superficial eye tissues.²

About 5.5% of the world’s population is affected by rosacea, and most are fair-skinned adults between 45 and 60 years old.³ Rosacea may be underdiagnosed in those with darker skin tones since its symptoms are less noticeable on pigmented skin.^2,4

Because it affects the face, individuals with rosacea often experience diminished social and psychological well-being, decreased quality of life, and mental health problems like anxiety and depression.²

Fortunately, a number of dietary and lifestyle changes can help manage rosacea. These include:

• Avoiding triggers like alcohol; spicy food; hot drinks; exposure to sun, heat, or cold; and stress
• Having a daily skin care routine using gentle cleansers and moisturizers
• Eating a diet that supports a heathy gut microbiome
• Getting good sleep

In addition, several nutrient supplements, including gamma-linolenic acid, zinc, and a combination of vitamin C, zinc, selenium, and rutin, as well as topical products with nicotinamide (a form of vitamin B3), chrysanthemum, and licorice extract have been found to be beneficial in clinical trials in rosacea patients.

The main symptom of rosacea is persistent redness (erythema) of the cheeks, nose, chin, and forehead. Most people with rosacea also experience episodes of more intense redness or flushing related to specific triggers (eg, exposure to sunlight or eating spicy food). Pink to red thread-like skin markings caused by dilation and breakage of superficial blood vessels (telangiectasia, sometimes called “spider veins”) are another common feature of rosacea. Burning and stinging of rosacea-affected skin is also common. Small red bumps called papules and pimple-like pustules frequently occur. Less frequently, chronic rosacea-related skin thickening, nodules or benign tumors, and swelling or enlargement (phymatous changes) develop. Phymatous changes usually occur on the nose and are more common in men.^1,2,5

Figure 1: A close-up view on the face of a young Caucasian lady, suffering from a severe case of rosacea, with facial redness and dilated blood vessels of the eyelids, nose, and cheeks. Credit: Sruilk, Shutterstock.

Rosacea can also involve the eyes, a condition known as ocular rosacea. Symptoms of ocular rosacea can include eye dryness, burning, stinging or itching; a sensation of a foreign body in the eye; and, light-sensitivity.^2,5 In addition, inflammation, vascular dilation, and nodules on the conjunctiva, eyelids, and cornea may occur and can potentially compromise vision.²

Rosacea was originally classified into four subtypes based on symptom patterns^6,7:

• The erythematotelangiectatic subtype includes redness (erythema), flushing, and/or telangiectasia. This is the most common type of rosacea, affecting approximately 57% of rosacea patients.
• The papulopustular subtype, which includes papules and pustules, occurs in about 43% of rosacea patients. This subtype frequently overlaps with the erythematotelangiectatic subtype.
• The phymatous subtype is marked by phymatous skin changes (eg, skin thickening and nodules), often of the nose. Phymatous rosacea is the least common subtype, affecting about 7% of rosacea patients, and frequently overlaps with the erythematotelangiectasic and/or papulopustular subtypes.
• The ocular subtype involves the eyes and eyelids. This subtype affects about 11% of rosacea patients. Most, but not all, patients with ocular rosacea have skin symptoms characteristic of the other subtypes at some point in the course of their condition. It is not uncommon for ocular rosacea to be misdiagnosed due to its similarity to other eye conditions. A delay in accurate diagnosis and treatment can lead to long-term vision impairment.⁸

More recent understanding suggests the symptoms of rosacea are part of an inflammatory continuum, and various combinations of symptoms can be expressed by an individual patient over the course of the condition.⁹ Nevertheless, the older subtype model and terminology are still useful for clinical interpretation and treatment decision-making.

Multiple interrelated factors likely contribute to rosacea, including:

• Genetic susceptibility²
• Immune dysregulation, with increased inflammatory signaling and increased numbers and activation of mast cells (immune cells that produce histamine)²
• Abnormal nerve-blood vessel interactions, frequently triggered by stimuli such as temperature change, exercise, sunlight, spicy food, alcohol, and stress^2,10
• Imbalanced facial skin microbiome, with increased presence of Demodex species (ie, microscopic parasitic mites that live in human hair follicles as members of the normal skin microbial community)^2,10,11

Rosacea is diagnosed based on clinical presentation. According to diagnostic recommendations of the National Rosacea Society, a diagnosis of rosacea requires the presence of either^2,9:

1. persistent redness (erythema) of the central face with periodic worsening due to triggering circumstances, or
2. the presence of phymatous changes such as skin thickening, surface irregularity, nodules, and enlargement.

Alternatively, a diagnosis can be confirmed if any two of the following major features are present^2,9:

1. flushing or redness that comes and goes;
2. inflammatory papules (bumps) and pustules (pimples);
3. telangiectasia (broken or dilated blood vessels at the skin surface); and,
4. inflammation and telangiectasia of the eyes or eyelids.

The presence of burning, stinging, dryness, and edema of the facial skin lend support, but are not sufficient alone, for a rosacea diagnosis.^2,9

Oral/Systemic Supplements

Gamma-linolenic acid. Gamma-linolenic acid (GLA) is derived from the essential omega-6 fatty acid found in plant oils, linoleic acid. Some by-products of GLA metabolism have anti-inflammatory effects. While GLA can be made in the body from linoleic acid, certain plant oils contain significant amounts of GLA, such as evening primrose oil, borage oil, and blackcurrant seed oil. Taking GLA-rich oils has been reported to protect against skin infections, reduce skin inflammation and allergies, and slow skin aging.²¹ In a randomized placebo-controlled trial in 31 people with rosacea being treated with minocycline (Minocin), the addition of 320 mg GLA twice daily for eight weeks resulted in greater improvement in skin hydration, higher likelihood of achieving treatment success, and better patient satisfaction.²² Clinical trials in patients with other types of inflammatory skin disorders suggest GLA-rich oil supplementation may have positive effects on skin health, improving skin barrier function and skin hydration and reducing symptoms in those with atopic dermatitis and acne.²³ Evening primrose oil was also found to decrease isotretinoin-induced skin dryness, without reducing its therapeutic effect, in acne patients.²⁴

Zinc. Zinc is an important nutrient for skin health with antioxidant and anti-inflammatory properties. Clinical evidence indicates its potential role in treating inflammatory skin disorders as well as skin infections and wounds.^25,26 In one placebo-controlled crossover trial that included 25 rosacea patients, 100 mg zinc sulfate (providing 23 mg of elemental zinc) three times daily for three months resulted in decreased rosacea severity.²⁷ However, a randomized placebo-controlled trial in 44 rosacea patients found no effect from 220 mg of zinc sulfate (providing 50 mg elemental zinc) twice daily after three months.²⁸ A combination providing 25 mg zinc along with 750 mg nicotinamide, 1.5 mg of copper, and 500 mcg folic acid was found to improve patient-reported skin symptoms in an eight-week preliminary trial that included 198 subjects with rosacea or acne.²⁹

Vitamin C. Vitamin C is a free radical scavenger that supports healthy skin structure by preventing collagen breakdown and stimulating collagen production.³⁰ It also protects sun-exposed skin from radiation damage, especially when combined with vitamin E.³¹ A report on a placebo-controlled clinical trial indicated 9 of 12 rosacea patients treated with a 5% vitamin C cream had measurable improvement in facial redness.³² In another trial, two to three months of treatment with a daily oral supplement providing 200 mg vitamin C as well as 10 mg zinc, 100 mcg selenium, and 400 mg rutin (a flavonoid that may reduce capillary fragility³³ and inflammation related to histamine)^34,35 was compared to standard medical therapy in 30 rosacea patients. The supplement group had greater reductions in facial redness at the end of the treatment period and fewer recurrences during 12 months of follow-up.³⁶

Omega-3 fatty acids. Omega-3 fatty acids, such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) found in fish oil, are metabolized into anti-inflammatory compounds in the body. EPA and DHA have been shown to reduce inflammatory immune activity and swelling in the skin, and a compound derived from EPA called Resolvin E1 had been found to improve regulation of skin immune cells.^23,37 Clinical evidence suggests EPA and DHA are useful in the treatment of inflammatory skin conditions such as acne, atopic dermatitis, and psoriasis.^38,39 In one randomized controlled trial that included 130 rosacea patients with ocular symptoms (specifically dry eyes), treatment with 180 mg EPA and 120 mg DHA twice daily for six months led to greater improvements in subjective and objective measures of dry eye compared with placebo (olive oil).^40,41

Palmitoylethanolamide. Palmitoylethanolamide (PEA) is an endocannabinoid (ie, a molecule made in the body that can activate cannabinoid receptors found throughout the nervous system). PEA not only directly stimulates cannabinoid receptors but also enhances activation of these receptors by other endocannabinoids.⁴²

Endocannabinoids can inhibit inflammatory signaling, and PEA in particular stabilizes mast cells and reduces histamine release.⁴² Since inflammation and histamine are underlying contributors to rosacea, PEA has potential therapeutic value in this condition. Oral (systemic) PEA preparations are available for veterinary use and have been shown to effectively relieve dermatitis in dogs.⁴³ While no human studies have been completed to specifically examine the effectiveness of oral PEA for rosacea, its robust record of safe systemic use in the context of other inflammatory conditions make it a reasonable option to try.

Topical application of PEA appears promising as well. Topical use of PEA has been shown to reduce itching in patients with various types of dermatitis.^42,44 In addition, PEA and other topical endocannabinoids have been shown to reduce skin dryness, redness, scaling, plaque formation, and pain, and promote skin healing.⁴² In preclinical research, topical PEA has even been shown to reduce redness and DNA damage in skin cells exposed to ultraviolet light (simulating sunlight).⁴⁵

Melatonin. Melatonin, a neurohormone produced by the pineal gland in the brain, is known to regulate sleep-wake cycles, other circadian rhythms, and neurologic and hormonal functions. It has also been shown to decrease inflammatory signaling and lower oxidative stress, and clinical research suggests melatonin has beneficial effects in a wide range of chronic metabolic and inflammatory disorders, including neurological and skin diseases.^46,47 Evidence suggests melatonin may be useful in treating rosacea partly by reducing inflammation and normalizing nerve-blood vessel interactions. A study in mice found melatonin injections improved rosacea-like skin lesions.⁴⁶ In a small clinical study, researchers found that blood levels of melatonin were reduced in perimenopausal women with rosacea and menopause-related symptoms compared with women with rosacea but without menopausal symptoms.⁴⁸ These findings suggest that low melatonin blood levels may be a common feature in women who experience rosacea and menopausal symptoms.

Topical Agents

Vitamin A. Vitamin A (retinol) is a fat-soluble vitamin stored in the liver and skin cells. Vitamin A derivatives, known as retinoids, have important functions in skin, such as strengthening the skin structure and barrier function; supporting antimicrobial protection; and regulating immune activity, pigmentation, sebaceous gland function, cell division and metabolism, and skin growth and thickening.^31,49,50 Retinaldehyde is a natural retinoid that may be helpful in treating rosacea. In an uncontrolled clinical trial in 23 women with rosacea, use of a topical 0.05% retinaldehyde cream once daily for six months led to modest improvement in rosacea-related facial redness and telangiectasia in 75% of participants.⁵¹

Synthetic isomers (structural variations) of retinoids are part of standard care for papulopustular rosacea. They include all-trans retinoic acid (tretinoin, Retin-A) and 13-cis-retinoic acid (isotretinoin, Accutane) and are only available by prescription.⁵⁰ Synthetic retinoids have well-known adverse side effects including skin dryness, irritation, redness, and peeling.^50,52 In addition, oral retinoids can cause dryness of the lips, mouth, nose, and eyes.⁵² Over-the-counter vitamin A and topicals made with natural retinoids have milder side effects than synthetic retinoids, but are also less likely to have beneficial effects.⁵⁰ If you are considering using a retinol product, talk to a board-certified dermatologist to decide if it is a good option for your skin. Also, it is important to note that synthetic retinoids, as well as high-dose vitamin A, may cause birth defects and should not be used orally or topically during pregnancy.^50,52,53

Nicotinamide. Nicotinamide (a form of vitamin B3), also known as niacinamide, is needed for numerous metabolic reactions in the body and has been used historically to treat rosacea.⁵⁴ A controlled trial in 50 rosacea patients found treatment with a nicotinamide-containing facial moisturizer twice daily for four weeks improved skin barrier function and rosacea symptoms.⁵⁵ An uncontrolled trial found a topical gel containing methylnicotinamide (a form of nicotinamide) applied twice daily for four weeks led to reduced rosacea symptoms in 26 of 34 cases.⁵⁶ A petrolatum-based ointment with 1% NADH (the reduced form of nicotinamide adenine dinucleotide, another nicotinamide derivative) was reported to help with rosacea.⁵⁷ It is important to note that taking large oral doses of vitamin B3 in the form niacin can cause facial flushing and may trigger rosacea symptoms.⁵⁸

Tea tree oil. Tea tree oil has broad antimicrobial activity and has been shown to be effective against Demodex mites. In one laboratory study that used skin samples from rosacea patients, a 25% tea tree oil solution was as effective as a standard 5% topical permethrin formulation at clearing Demodex folliculorum.⁵⁹ A topical preparation containing an active compound from tea tree oil, terpinen-4-ol, used twice per day on the face and eyelids, was reported to fully eradicate Demodex after four months and alleviate all rosacea symptoms in a woman with ocular rosacea that had persisted five years despite standard therapies.⁶⁰ In a clinical trial in which 47 subjects with papulopustular rosacea treated one side of their face with a tea tree oil-enhanced 2.5% permethrin gel and the other with placebo twice daily for 12 weeks, tea tree oil plus permethrin was more effective at reducing mite count on the skin and improving rosacea symptoms.⁶¹

Chrysanthellum indicum. Chrysanthellum indicum, a medicinal plant commonly called African wild daisy, is reported to have been used traditionally to treat conditions such as inflammation, infections, migraine, and various skin disorders.⁶² Chrysanthellum extracts have demonstrated antibacterial activity against several intestinal pathogens.⁶² It also appears to have blood vessel-constricting effects and may be useful in topical formulations for rosacea.^63,64 In a randomized placebo-controlled trial that included 246 patients with moderate rosacea, a cream containing 1% chrysanthellum, applied twice daily for 12 weeks, reduced facial redness and overall rosacea severity compared with placebo.⁶⁵

Silymarin. Silymarin is a mixture of polyphenols extracted from milk thistle (Silybum marianum) with strong anti-inflammatory, free radical-scavenging, and antitoxic effects.⁶⁶ In an uncontrolled trial, twice daily use of a silybum-containing topical cream for 12 weeks reduced facial redness in 29 of 32 participants.⁶⁷ Methylsulfonylmethane, or MSM, is a naturally-occurring sulfur-rich compound that also has anti-inflammatory and antioxidant effects, and supports detoxification pathways in the liver.⁶⁸ In a randomized controlled trial, 46 participants with rosacea-related facial redness and telangiectasia received either topical treatment with silymarin plus MSM or placebo for one month. Those who received silymarin plus MSM had greater improvement in facial redness, papules, itching, and skin hydration.⁶⁹

Licorice. Licorice extracts have long been used to treat peptic ulcer and other digestive conditions that have been associated with rosacea.⁷⁰ Several studies show licorice has antibacterial activity against H. pylori.^71-73 H. pylori infection is a major causative factor in peptic ulcer disease, gastritis, and gastric cancer, and has been correlated with rosacea in some studies.^74-76 Furthermore, rosacea patients with H. pylori infection have been reported to experience improvement in skin symptoms after medical treatment targeting H. pylori.^75,77

Clinical trials evaluating oral licorice extracts in rosacea treatment have not yet been performed. Topical products containing the licorice flavonoid licochalcone A have shown promising results, despite their inability to impact H. pylori infection. An uncontrolled trial in 32 participants with mild-to-moderate rosacea found a skincare regimen using three topical products (cleanser, daytime cream with sunscreen, and night cream) containing licochalcone A daily for eight weeks improved redness, skin texture, and telangiectasia.⁷⁸ A similar eight-week skincare regimen using licochalcone A-containing products was also shown to reduce facial redness in an uncontrolled study with 62 subjects described as having mild-to-moderate facial redness.⁷⁹

Quassia. Quassia (Quassia africana) is a medicinal herb indigenous to Africa that has antiparasitic properties.⁸⁰ In an uncontrolled trial with 30 participants, a topical 4% quassia gel, used daily for six weeks, led to improvement in rosacea symptoms such as flushing, redness, papules, pustules, and telangiectasia. The degree of improvement was reported to be comparable to that seen with metronidazole or azelaic acid.⁸¹

Other Herbal Therapies

A number of other herbal therapies have been suggested to have a possible role in rosacea treatment. Herbs and herbal extracts with well-described anti-inflammatory, vascular-stabilizing, antimicrobial, and microbiome-balancing effects may have anti-rosacea benefits, including^82,83:

• Curcumin (from turmeric, Curcuma longa)
• Green tea (Camellia sinensis)
• Resveratrol (from red grapes, red wine, and peanuts)
• Feverfew (Tanacetum parthenium)
• Chamomile (Matricaria recutita)
• Lavender (Lavendula angustifolia)
• Oat (Avena sativa)

In one randomized controlled trial, 30 subjects with rosacea received twice-daily treatment with 2,000 mg of turmeric, an Ayuvedic multi-herb combination containing turmeric, anantamul (Hemidesmus indicus), manjistha (Rubia cordifolia), neem (Azadirachta indica), gotu kola (Centella asiatica), guduchi (Tinospora cordifolia), bhumyamalaki (Phyllanthus amarus), amalaki (Phyllanthus emblica), and licorice (Glycyrrhiza glabra), or placebo for four weeks. Those who received the multi-herb combination had a 40% reduction in facial redness, while no change was observed in either those receiving turmeric alone or placebo.⁸⁴

For more information about balancing the gut microbiome, please see Life Extension’s Maintaining a Healthy Microbiome protocol.

The skin is closely connected to the digestive system through the gut-skin axis, and imbalances in the gut microbiome may link skin disorders like rosacea to digestive, cardiovascular, and metabolic diseases.^85,86 Consuming foods that improve gut microbiome health can contribute to more healthy immune regulation and has been shown to be beneficial in individuals with inflammatory skin problems such as atopic dermatitis and acne, and is likely to benefit those with rosacea as well.^86,87 High consumption of plant foods rich in prebiotic fibers, antioxidants, and other phytochemicals is closely associated with microbiome health.^87,88 In addition, cultured and fermented foods like sauerkraut, miso, kefir, and yogurt can favorably influence the balance of healthy bacteria and may support balanced immune function in the skin and throughout the body.^87,89,90

The oils from cold water fish like herring and salmon are high in omega-3 fatty acids and have been found to modulate skin immunity and reduce inflammation.^41,91 On the other hand, a diet high in fatty meat, lard, and fried food was correlated with increased risk of rosacea in one study.⁹²

Certain specific foods often trigger flare-ups in people with rosacea.⁴¹ While not all people with rosacea react to the same foods, certain food groups have been reported to be especially likely to aggravate symptoms, including:

• Alcoholic drinks. The most commonly reported rosacea trigger is alcohol, in particular, wine (especially red) and spirits. Some studies have also found alcohol consumption was associated with increased risk of rosacea.⁴¹
• Spicy foods. Many people with rosacea report aggravation of symptoms like flushing, stinging, and burning after eating foods containing hot spices such as hot sauces, cayenne pepper, and other hot peppers.⁴¹
• Cinnamaldehyde-containing foods. Cinnamon, chocolate, tomatoes, and citrus all contain cinnamaldehyde and have been reported to cause rosacea flares.⁴¹
• High-histamine foods. Although the relationship between histamine in food and rosacea symptoms is uncertain, an estimated 1% of people in the United States have histamine intolerance, which can lead to tissue swelling, blood vessel dilation, and skin barrier dysfunction.^41,93 While a formal diagnosis of histamine intolerance may be relatively uncommon, given the low-risk associated with eliminating high-histamine foods, someone whose rosacea has persisted despite other treatment strategies may find it worthwhile to try a low-histamine diet. Many foods, including some that may be therapeutic for other reasons, contain histamine or can slow histamine breakdown. Foods that raise histamine levels may need to be avoided by those with rosacea who have been diagnosed with histamine intolerance, including⁹⁴:

  Aged cheeses Processed meats Seafood Pork Egg whites Wheat germ Sauerkraut and other fermented foods Spinach Eggplant

  Tomatoes Citrus fruits Papaya Strawberries Avocado Nuts Chocolate Vinegars Wine and other alcoholic drinks

• Hot drinks. Drinking hot beverages has been reported to be a trigger for rosacea flare-ups. Interestingly, drinking caffeinated coffee was correlated with lower risk of rosacea in one observational study that included 82,737 female subjects.⁹⁵ This may be related to caffeine’s ability to stimulate blood vessel constriction; however, intake of other caffeine sources such as black tea, cola, and chocolate were not correlated with rosacea risk.^41,95

Individuals with rosacea have been found to have impaired skin barrier function, a condition more often associated with atopic dermatitis (another inflammatory skin disorder).^96,97 This means rosacea-affected skin is prone to water loss and sensitivity to irritants.⁹⁸ Therefore, routine skin care for rosacea patients includes gentle cleansing, the use of moisturizers, and sun protection to minimize irritation of sensitive skin and aggravation of skin inflammation.^97,99 Facial washing should be performed with a light touch using lukewarm (not hot) water and no brushes, scrubs, exfoliating granules, astringents, toners, or other mechanical or chemical irritants. In addition, skin care products should be soap-free, fragrance-free, and slightly acidic, reflecting the skin’s natural acidic pH.^97,98

Avoiding known triggers may help with the management of flare-ups. Temperature changes, exposure to heat or cold, exercise, ultraviolet radiation (mainly from sun exposure), spicy food, and alcoholic beverages are among the more common triggers of rosacea flare-ups.^99,100

Stress management is often practiced by, and thought to help, those coping with rosacea.^101,102 Psycho-emotional stress and rosacea may have a bidirectional relationship, such that each worsens the other.¹⁰³ Some evidence suggests rosacea-affected skin is highly reactive to stress signaling, which can lead to increased vascular dilation and skin flushing.¹⁰⁴

Similarly, poor sleep quality was found to be more prevalent in rosacea patients than healthy subjects, and the severity of rosacea was correlated with the degree of sleep disturbance.¹⁰⁵ Obstructive sleep apnea, a sleep disorder characterized by repeated episodes of partial or complete airway obstruction during sleep and closely linked to cardiovascular and metabolic diseases, has also been associated with rosacea.¹⁹ Poor sleep may aggravate rosacea by increasing stress and inflammatory signaling, and possibly disrupting skin microbiome balance and impairing skin barrier function.^106,107

Medical treatments for rosacea are chosen based on the specific symptoms present. Combination therapy is often used to manage rosacea with multiple components.^2,108

Erythema

Either topical brimonidine (Mirvaso) or oxymetazoline (Rhofade) can be used to treat persistent redness. These medications work by constricting superficial blood vessels and appear to have similar effectiveness. Brimonidine has been noted to cause rebound redness several hours after use in about 20% of users. While oxymetazoline use is less likely to cause rebound symptoms, it can worsen inflammatory skin symptoms.^108,109

Telangiectasia

Laser therapy and intense pulsed light therapy are treatment options for helping to eradicate visible broken and dilated blood vessels. They may also be used to remove thickened skin and reduce persistent redness. Possible adverse side effects of laser- and light-based therapies include skin itching, tightness, bruising, pain, and possibly scarring, as well as temporary skin discoloration.^108,110 While light and laser treatments require multiple sessions in order to be effective, their results can last for years.¹⁰⁸

Flushing

Flushing is best prevented by trigger avoidance. Oral medications that constrict blood vessels have shown some benefit in reducing flushing. These include the beta-blockers propranolol (Inderal) and carvedilol (Coreg), which block certain adrenaline receptors, as well as the antidepressant mirtazapine (Remeron), which blocks another type of adrenaline receptor.¹⁰⁸

Papules and Pustules

The following medications are approved for treating rosacea-related papules and pustules²:

• Topical azelaic acid (Finacea), which is classified as a dicarboxylic acid, improves rosacea by reducing skin swelling and redness. Because it kills bacteria and reduces production of keratin, it is also used to treat acne.¹¹¹
• Topical ivermectin (Sklice) is an antiparasitic medication that has been shown to reduce rosacea’s papules and pustules by decreasing the presence of skin mites in the Demodex family, as well as suppressing inflammation.¹⁰⁸
• Topical metronidazole (Metrogel) has antibacterial and antiparasitic effects, but is thought to reduce rosacea papules and pustules through anti-inflammatory mechanisms.^112,113 Some evidence indicates metronidazole is not as effective as ivermectin or azelaic acid.⁹⁹
• Topical minocycline (Zilxi) is an antibiotic with anti-inflammatory effects. It also reduces production of tissue-damaging free radicals and may help constrict superficial blood vessels.²
• Oral doxycycline is a member of the tetracycline family of antibiotics. It also has antiparasitic activity, but is thought to benefit rosacea patients by reducing inflammation and constricting superficial blood vessels.¹¹³ It is mainly used in combination with topical therapies to manage severe papulopustular rosacea.¹⁰⁸

These therapies may take four to six weeks or even longer to bring about noticeable improvement.¹¹⁴ The main adverse side effects of topical medications for rosacea are skin itching, dryness, burning, stinging, and irritation.¹¹⁵ Common adverse side effects of doxycycline include digestive upset and diarrhea, sensitivity to sunlight, and skin rashes.¹¹⁶

Other topical medications sometimes used to treat rosacea papules and pustules include¹⁰⁸:

• Sulfacetamide sodium and sulfur (eg, Sumaxin), an antimicrobial and anti-inflammatory combination that helps thin the skin surface^117,118
• Tacrolimus (Protopic) and pimecrolimus (Elidel), calcineurin inhibitors that suppress inflammation¹¹⁹
• Tretinoin , adapalene (Differin), and other retinoids that promote normal turnover of superficial skin cells and clearing of pustules⁵⁰
• Permethrin (Nix), an antiparasitic
• Microencapsulated benzoyl peroxide (Epsolay, topical cream), an antibacterial agent used to treat acne.

Alternative oral medications include other antibiotics like azithromycin (Zithromax) and minocycline, and the retinoid isotretinoin.^2,99 Importantly, retinoids are well known to cause birth defects and their use during pregnancy is strictly contraindicated.⁵⁰ Reproductive-age women should be counseled about the need for regular and proper use of birth control when using this medication.

Phymatous Changes

Laser- and light-based therapies may be helpful in the early stages of phymatous changes for skin resurfacing, reducing redness, and decreasing edema. Oral doxycycline or isotretinoin may also be recommended.⁹⁹ For more advanced phymatous changes (eg, rhinophyma), surgical techniques may be used to remove damaged tissue and reconstruct functionally and aesthetically acceptable nasal structure.¹²⁰

Ocular Symptoms

In patients with ocular rosacea, eyedrops containing cyclosporine, an immunosuppressant that reduces inflammation, are generally used.⁹⁹ Topical agents described above may be helpful in those with symptoms affecting the eyelids.¹⁰⁸ In addition, a combination of topical ivermectin and oral doxycycline has been found to improve severe ocular rosacea symptoms.² Note that medications should only be applied near the eyes under the guidance of a qualified healthcare provider. Not all topical medications are appropriate for use near the eyes.

Novel Treatments

A number of new agents are under investigation for their potential role in treating papulopustular rosacea. These include²:

• Secukinumab (Cosentyx) (oral), a monoclonal antibody that blocks the action of an inflammatory cytokine.
• Erenumab (Aimovig) (subcutaneous injection), a monoclonal antibody that inhibits nerve signaling involved in vasodilation.
• B244 (topical spray), a bacterium (Nitrosomonas eutropha) with antimicrobial, anti-inflammatory, and vascular-stabilizing effects.
• Omiganan (topical gel), an antimicrobial peptide.
• Rifaximin (Xifaxan), an oral antibiotic used to treat SIBO, IBS, and traveler’s diarrhea.
• DMT210 (topical gel), an anti-inflammatory agent thought to reduce production of inflammatory cytokines. DMT210 eyedrops are also being developed to study their effects on ocular rosacea.
• Hydroxychloroquine (Plaquenil, oral), an antimalarial, immune-modulating, and anti-inflammatory drug. Although hydroxychloroquine has shown promise in rosacea patients, its potential usefulness is limited by its ability to cause severe, irreversible retinopathy that can lead to permanent vision loss.^2,121
• Cromolyn sodium (topical), a mast cell stabilizer that inhibits release of histamine.¹²²

What is rosacea?

Rosacea is a chronic inflammatory skin condition causing redness and other changes to the skin of the face, usually on the cheeks and nose.¹

What does rosacea do to your skin?

Skin inflammation caused by rosacea can cause redness and, over time, can lead to bumps and pimples, enlargement or breakage of tiny blood vessels in the skin, and skin thickening.¹

What are the root causes of rosacea?

Rosacea has multiple overlapping causes. Genetics, immune sensitivity, abnormal signaling between nerves and blood vessels, and increased presence of a type of microscopic skin mites may all contribute to rosacea.²

Which diseases are associated with rosacea?

Many people with rosacea also have digestive problems such as gastroesophageal reflux disorder (GERD) or irritable bowel syndrome (IBS).¹² Rosacea is also reported to be more common in people with other systemic health problems, including heart disease, obesity, type 2 diabetes, neurologic diseases, anxiety and depression, autoimmune conditions, sleep apnea, hypothyroidism, and migraines.^13,16,19,20

What causes rosacea flare-ups?

Flushing can be triggered by stress, temperature changes, exercise, sunlight, alcoholic drinks, hot drinks, and spicy foods.² Other foods like those high in histamine or cinnamaldehyde have been reported to trigger flushing in certain individuals.⁴¹

Could someone with oily skin develop rosacea?

People with oily, dry, and mixed skin types appear to be more likely than those with neutral skin to have a high presence of the microscopic skin mites linked to rosacea.¹²³ However, people with any skin type can develop rosacea.¹²⁴

How can rosacea symptoms be relieved?

Many people with rosacea manage their symptoms through a daily routine of therapeutic skin cleansing and moisturizing, avoiding triggers, and using topical or oral medications that decrease skin redness or reduce skin mite concentrations when needed.¹⁰⁰ A number of natural therapies, such as gamma-linolenic acid (GLA), zinc, and certain herbal extracts may also help improve skin health and reduce rosacea symptoms.^{22,26,125,126}

How is rosacea different from sensitive skin?

Rosacea is a chronic and distinct skin disorder in which long-term skin inflammation and disruption of the skin microbiome lead to persistent or recurring symptoms. Sensitive skin is a frequent symptom of rosacea, but has other possible causes.^2,98

What supplements are good for rosacea?

Gamma-linolenic acid (GLA), zinc, and herbal supplements like green tea and licorice extracts are examples of supplements that may improve skin health and reduce rosacea symptoms.^{22,26,125,126}

What supplements should be avoided with rosacea?

Cinnamon- and cinnamon oil-containing supplements may trigger flushing in some individuals with rosacea.⁴¹ High-dose niacin (a form of vitamin B3) can cause flushing that could be confused with or aggravate rosacea.⁵⁸

What skincare ingredients are bad for rosacea?

People with rosacea generally have sensitive skin and should avoid skincare products containing soaps, fragrances, astringents, toners, or abrasive particles. Examples of ingredients to avoid include alcohol, acetone, benzyl alcohol, propylene glycol, butylene glycol, alpha- and beta-hydroxy acids, sodium lauryl sulfate, and quaternary ammonium.⁹⁷

Can someone with rosacea use retinol?

Natural and synthetic retinoids (vitamin A derivatives), though not retinol (vitamin A) itself, are often used to treat rosacea. High doses of vitamin A, as well as other retinoids, are not safe in pregnancy.⁵²