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What You Need To Know

Nearly 14 million Americans have rosacea, a common but little-known inflammatory skin condition characterized by dilation of the blood vessels in the face. Rosacea is often misdiagnosed as acne or discoid or systemic lupus erythematosus (SLE). It usually occurs on the cheeks, nose, central forehead and chin, and can also occur on the upper back and upper chest. If you were to look at the skin of someone with rosacea under a microscope, it would show swelling, dilated blood vessels, and, where red bumps known as papules are present, you would see collections of white blood cells.

People with rosacea often experience periods of remission and exacerbation. As with acne, rosacea flare-ups often occur the week before a woman’s period, perhaps because the body is working to rid itself of impurities at that time.

Because of its acne-like effects on personal appearance, rosacea can cause significant psychological and social problems in people who do not know what to do about it. Surveys performed by the National Rosacea Society showed that nearly 70 percent of people with rosacea have lower self-confidence and self-esteem, and 41 percent reported that it had caused them to avoid public contact or cancel social engagements. Among those with severe symptoms, nearly 70 percent said the disorder had adversely affected their professional interactions, and nearly 30 percent said they had even missed work because of their condition.

Rosacea affects both men and women, but occurs more often in women after the age of 30 and is most commonly diagnosed in women in their 40s and 50s. Rosacea almost always worsens when women are under significant emotional stress. Given our culture, it is not surprising that more women than men get rosacea at mid-life. It is most common in women with fair skin, because fair skin is often more reactive, but rosacea has also been diagnosed in Asian and African American women.

Many experts believe that early diagnosis and conventional treatment are key to managing rosacea. While I have seen people with rosacea who fare much better with self-treatments and a holistic approach that includes behavior modification, it is usually a good idea to know what you are dealing with first. That way you can avoid irritating products and other triggers.

Listen To Your Body

The diagnostic criteria indicative of rosacea1 include the presence of one or more of the following:

  1. Flushing (transient erythema), redness on the cheeks, nose, chin or forehead. This may appear similar to a blush or sunburn. One potential cause is flushing due to the large amount of blood rushing through the vessels quickly. Redness tends to become worse over time and can be accompanied by stinging or burning sensations as well as swelling. Persistent redness (non-transient erythema) occurs later.
  2. Telangiectasia, or small, visible blood vessels on the face. These enlarged blood vessels look like thin red lines. They usually appear on the cheeks and nose. They can be hidden by redness, but are visible when the redness disappears.
  3. Papules, which look like bumps, and pustules, if they are filled with pus. These are not like the bumps you get from acne, in that they do not contain the blackheads or whiteheads.
  4. Watery or irritated eyes. Sometimes rosacea patients report feeling like something is in their eyes. They may feel dry or swollen. People with rosacea tend to get styes. In severe cases, some vision loss can occur. Another quite common symptom is redness of eyelids, often misdiagnosed as an infection and mistakenly treated thus.
  5. Rhinophyma, or enlarged nose. Severe cases of rhinophyma cause the nose to swell from excess tissue and knobby bumps. It is more common in men, probably because men do not seek treatment early for their other symptoms. This is what W. C. Fields had. Former president Bill Clinton also suffers from it.

What Causes This

While the causes are unknown, there are several theories behind the cause of rosacea. One theory is that the disease may be a subcomponent of a more generalized vascular disease, as indicated by the tendency of rosacea sufferers to flush. Another theory suggests that changes in normal skin bacteria or infection of the stomach by Helicobacter pylori may be involved. Various other unproven theories indicate that microscopic skin mites (Demodex spp.), fungi, malfunction of the connective tissue under the skin, and emotions could all be potential causes. Allergies may also play a role, as allergies can cause flushing, which frequently triggers rosacea symptoms.

Some of the most common rosacea triggers include the following factors:

  • Weather/Temperature: Sun, wind, cold, humidity, heat, saunas, hot baths, overheating, overly warm environments.
  • Foods: Liver, yogurt, sour cream, cheese, chocolate, vanilla, soy sauce, yeast extract, vinegar, eggplant, avocados, spinach, broad leaf beans and pods (lima, navy or pea), citrus fruits, tomatoes, bananas, red plums, raisins, figs, spicy foods, thermally hot foods, and foods high in histamine may all be triggers.
  • Beverages: Alcohol (especially red wine, beer, bourbon, gin, vodka and champagne); hot drinks (cider, coffee, tea, chocolate).
  • Physical Exertion: Exercise, heavy lifting jobs.
  • Drugs: Vasodilators, topical steroids.
  • Medical Conditions: Frequent flushing, chronic cough, caffeine withdrawal.
  • Skin Care Products: Cosmetics and hairsprays containing alcohol, witch hazel, fragrance, hydro-alcoholic or acetone substances; or any product noted to cause redness or stinging.
  • Emotional Influences: Stress, anxiety, and emotions such as excitement, embarrassment, or shame that are held too long or experienced too frequently (causing the body’s normal blushing response to go too far).
  • Other: Hot flashes related to menopause.

In addition, the prolonged estrogen dominance that can often occur during perimenopause seems to increase the severity of rosacea breakouts.

Healing Alternatives

There are many widely used conventional treatments for rosacea. The standard treatment for rosacea includes both oral and topical medications that are anti-inflammatory (antibiotics—such as tetracycline, minocycline, doxycycline or erythromycin—or accutane) and a topical anti-inflammatory (such as a metronidazole-based product). The treatment is generally followed for four to six months until the rosacea is under control, and after that topical treatment is continued. However, this treatment will not make the redness go away or reduce the appearance of dilated blood vessels, and I do not recommend taking antibiotics over the long haul because taking them for so many months can result in an imbalance of normal bowel flora. (That’s why I always recommend taking a probiotic like acidophilus when you take antibiotics.) And often the antibiotics don’t help anyway because there’s no evidence that rosacea is caused by abnormal skin bacteria.

Dermatologists also often recommend the use of steroids in the form of cortisone creams, to reduce inflammation and white cell accumulation in the papules. Again, I do not like to recommend using steroids for any length of time. In fact, there can actually be a rebound effect. Discontinuing use of a steroid cream can often result in a flare-up known as steroid-induced acneiform eruption. This can occur as an inflammatory response in anyone who uses corticosteriods for a long period of time, not just people with rosacea.

Some dermatologists prescribe birth control pills to reduce breakouts. Anxiolytic drugs are sometimes used as well, including Valium and Ativan, to prevent blushing. These drugs, however, can be highly addictive and do not teach you to use your inner resources to change your body’s responses.

There is currently a push among dermatologists to use vascular lasers and intense light and laser therapy to treat persistent redness caused by rosacea. Both of these treatments destroy the dilated blood vessels. Multiple treatments are necessary to achieve the best results and maintenance treatments are recommended for long-term success. One especially promising treatment is a special laser treatment known s the Photoderm VL-Flashlamp. This detailed three-step laser process treats microvessels located directly beneath the epidermis, removing the superficial blood vessel types that are such a problem with rosacea.

For rhinophyma, surgery is generally necessary to successfully treat the changes that can become permanent. Dermatologists suggest electrosurgery, using a small electric needle, laser surgery, or dermabrasion to sculpt the area around the nose.

Spiritual and Holistic Options

People with rosacea are often advised to steer clear of their triggers. Common triggers include over-exposure to sun, extreme exercise, hot, humid air or very hot showers, some topical acne medications such as retinoic acid or other vitamin A derivatives, alpha hydroxy products, spicy foods, alcohol, spinach, chocolate, and caffeine.

But individual triggers for rosacea can vary from person to person. And each person’s own triggers can vary from time to time as well, making it difficult to control rosacea flare-ups. That’s why it can be a good idea to keep a journal, where you can monitor your triggers. In a survey by the National Rosacea Society of 1,221 rosacea sufferers, 96 percent of those who believed they had identified personal trigger factors said avoiding those factors had reduced their flare-ups. If you keep a journal, make sure to keep an accurate account of the date and the various factors, including weather, foods and products, as well as the condition of your skin and any therapies you use on a daily basis. You may also want to note how you feel. Did you experience any emotional stress? Did you have a particularly grueling workout at the gym? Once you establish a trigger, try to eliminate it. If eliminating it minimizes your flare-ups, then you should probably avoid it.

Cellular inflammation aggravates rosacea, so it’s also helpful to follow an insulin-normalizing diet (eliminating starches and sugars and eating lots of fresh fruits and vegetables loaded with inflammation-fighting antioxidants).

The emotional and psychological profiles of people with rosacea show that they are typically perfectionists with strong desires to please. Someone with rosacea may also have a strong disposition toward excessive feelings of shame or guilt.2  One of my readers with rosacea was a lawyer and often blushed in court. She recognized that one of her triggers was the fear of making a mistake in public. In an effort to avoid the blushing, she would practice her arguments endlessly to perfection. In her effort to control her blushing intellectually by being meticulously prepared, her blushing nonetheless worsened, and she began to blush even before speaking in court.

If my description of the psychological profile of a person with rosacea made you feel guilt, shame or even anger, make note of it. The next time you feel any of these emotions, try the following approach:

  1. Take a deep, full breath. We often stop breathing when we feel an emotion strongly.
  2. Close your eyes.
  3. Try to identify where in your body you are feeling the emotion.
  4. Describe what you are feeling.
  5. Do not judge your feeling. Simply allow yourself to feel it fully, exactly as it is.
  6. Keep breathing and start moving around while you are doing this. Movement while breathing will help you to move emotion through.

Here’s what you will probably notice: The minute you allow yourself to feel an emotion fully, it goes away. You can use this technique any time you feel a difficult emotion.

You may also want to practice the following affirmation in front of a mirror out loud: "I accept myself unconditionally right now." If it helps, try placing your hand over your heart, as though it were the heart of a precious child. This can facilitate the ability to perceive yourself as worthy of self-love. Do this every morning and every night for a month and you will see a change in your self-deprecating thoughts.

Some women report that supplementing their diets with betaine hydrochloride, which increases stomach acidity, helps rosacea. This supplement is available in natural food stores. If you take it, make sure you take it with food. Otherwise it creates a sensation like heartburn. The usual dose is 500–1,000 mg with meals.

Because people with rosacea often have sensitive, reactive skin, they must also often modify their approach to cleansing and bathing. Adopting a personal care routine that soothes and calms your skin while helping it heal is often an ongoing process for people with rosacea. Using very gentle products and avoiding the latest trends that could irritate your skin are a must. However, if you do make changes to your current routine, be sure not to introduce too many new products at once. In addition, keep track of the products you use (along with any major dietary factors) in your journal, and note any reaction you may have. Here are my suggestions:

  • Cleansing Your Face: It is best to use a gentle cleanser that is nonabrasive. Use your fingertips to spread the cleanser. Avoid using rough washcloths or sponges. Splash your face with lukewarm water to remove dirt and cleanser. Blot your face dry with a soft towel. Allow your face to rest for a moment before applying any other products. Also, stay away from toners that have alcohol or other drying ingredients.
  • Use Toners Carefully: It’s generally a good idea to stay away from toners that contain alcohol or other drying ingredients. (See triggers.)
  • Moisturize Your Skin: It may be tempting to try some of the many products on the market today claiming to make your skin look younger and firmer. But stay away from anything that burns, stings or causes redness (including alpha-hydroxy acids and topical retinoids). In general, select fragrance-free products and avoid products that contain benzoyl peroxide, hydrocortisone, alcohol, witch hazel, menthol, peppermint, eucalyptus oil or clove oil. When applying your moisturizer, make sure that your face is dry and that the skin is calm. If you apply medication to your skin, do so before you moisturize and let it soak in completely before moisturizing.

It’s also helpful to use skin care products that are self-preserving (without parabens or other irritants) and contain antioxidants (which may help reduce inflammation). You can also try Orlane B21, Dermalogica, and Decleor aromatherapy products, which are gentle enough for most sensitive skin types.

  • Use a Sunscreen: Make sure that your sunscreen does not contain any of the irritating ingredients I mentioned above. An SPF of 15 or higher year-round is generally a good idea for people with rosacea. If necessary, use a formula developed for children to avoid irritation. You may also want to wear a sun hat with a brim during the hottest part of the day and limit your exposure to sun during the summer months.
  • Exfoliate Very Carefully: It is not a good idea to use abrasive products on sensitive skin or skin with rosacea. If you get facials, you should ask your facialist to avoid using steam and abrasive products. Try not to over-exfoliate. (Also avoid dermabrasion and laser resurfacing for the same reason.)
  • Take Supplements: A good multivitamin–mineral supplement can help support your skin. Additional vitamin E, DHA (docosahexænoic acid), and a calcium-magnesium supplement may also help some people with rosacea. Watch that you do not get too much niacin, which can cause flushing.

In addition, try natural progesterone cream during the last two weeks of your cycle to help correct estrogen dominance.

Don’t expect overnight results Six to eight weeks or more may transpire before restorative changes become noticeable, but by then, the benefits of taking good care of yourself should make a marked difference, not just in how your skin looks, but in how you feel about yourself—from the inside out.

Learn More | Recommended Reading or Resources
  1. Wilkin, J., Dahl, M., Detmar, M., Drake, L., Feinstein, A., Odom, R., & Powell, F. (2002). Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J. Am. Acad. Dermatol., 46 (4), 584-587.
  2. Engels, W. D. (1982). Dermatological disorders: Psychosomatic illness review (No. 4 in the series). Psychosomatics, 23 (12), 1209-1219; Bick, E. (1968). Experience of the skin in early object relations. International J. Psychoanalysis, 49, 484-486; Kaplan, H. I, & Sadock, B. J. (eds.) (1989). Comprehensive textbook of psychiatry (5th ed., 1221). Philadelphia: Lippincott, Williams & Wilkins.
Last updated: August 28, 2012