Rosacea patients form a subset of sensitive skin, making the selection of skin care products and cosmetics problematic. Ingredients that typically cause little difficulty in the average patient can cause severe stinging and burning in the rosacea patient. Sometimes the adverse reaction can be invisible, more typically, it is characterized by the rapid onset of facial flushing. For this reason, developing a methodology for product recommendations in the rosacea patient becomes important. This article is part of a two part series discussing methods of optimizing redness reduction through the use of skin care products, cosmetics, and cosmeceuticals. While it is clear that prescription therapy is necessary for the reduction of inflammatory papules and pustules, as well as to reduce inflammation, the onset of facial redness can be minimized by carefully counseling patients on product selection.
Proper skin care can enhance rosacea treatment or, in some cases, totally negate a positive effect. No skin care act is more important than cleansing. Since demodex and p. acnes may be contributory in some forms of rosacea, skin cleansing is the first step to restoring and maintaining a healthy biofilm. Thorough cleansing is also necessary to control the growth of pityrosporum species in patients with the overlap syndrome of rosacea and seborrheic dermatitis. In short, the goals of cleansing in a rosacea patient are to remove excess sebum, environmental debris, desquamating corneocytes, unwanted organisms, and old skin care and cosmetic products while leaving the skin barrier untouched. This can be a challenge since cleansers cannot distinguish between sebum and intercellular lipids meaning that products that clean too well may be problematic. This discussion focuses on the use of the cleansers in rosacea patients with a variety of skin needs to include oily, normal, and dry skin.
Many rosacea patients with highly sebaceous skin produce abundant sebum. Even though the skin is oily, over cleansing will result in shiny, flaky skin. This is due to the barrier disruption created by removal of the intercellular lipids causing premature corneocyte desquamation followed by the subsequent accumulation of sebum. The face is over dry immediately after cleansing, but oily again 2-4 hours after cleansing. This is a challenging situation, since cleansing does not reduce sebum production; it only removes the sebum present at the time of cleansing. This observation accounts for the ill-founded belief of some rosacea patients that skin cleansing produces redness and increased sebum.
The most basic cleanser for oily skin is soap, created as a reaction between a fat and an alkali resulting in a fatty acid salt with detergent properties. Soap is composed of long chain fatty acid alkali salts with a pH between 9-10. The high pH thoroughly removes sebum, but can also damage the intercellular lipids. For persons with extremely oily skin, this type of cleanser may be appropriate (Ivory, Procter & Gamble). Aggressive scrubbing with a washcloth or other implement should be avoided when trying to remove copious sebum, since the manipulation of the skin may provoke redness. A better solution is to wash the face twice, each time removing more sebum. Gentle massaging of the cleanser into the skin with the hands followed by lukewarm water rinsing is best. It is important to avoid exposing the face to water temperature extremes, which could provoke flushing.
There is no definition of normal skin, however for this discussion the term will refer to patients without oily or dry skin. Soap may remove too much sebum in this population, making syndet cleansers the preferred choice. Syndets, also known as synthetic detergents, contain less than 10% soap with an adjusted pH of 5.5-7. The neutral pH, closer to the natural pH of the skin, produces less irritation. In general, all beauty bars, mild cleansing bars, and sensitive skin bars are of the syndet variety (Oil of Olay, Procter & Gamble; Dove, Unilever; Cetaphil Bar, Galderma). The most commonly used detergent is sodium cocyl isethionate. These cleansers also possess excellent rinsability, meaning that a soap scum film is not left behind on the skin when used with water of varying hardness. This is an important property in the sensitive skin rosacea patient where the soap film might produce irritation.
For rosacea patients who are concerned about body odor and desire a “squeaky-clean” skin feel, another type of cleanser, known as a combar, is available. Combars are produced by combining an alkaline soap with a syndet to produce less aggressive sebum removal than a soap, but more aggressive sebum removal than a syndet. Most of the combars also add an antibacterial, such as triclosan, to provide odor control properties. These cleansers are commonly labeled as deodorant soaps (Dial, Dial Corporation; Irish Spring, Colgate Palmolive). For rosacea patients with abundant sebum production and difficult to control pustules, this type of cleanser may be beneficial. Triclosan is not approved as an acne ingredient in the US, but is used in Europe for this purpose. For patients with normal sebum production, the deodorant cleanser can be used once daily or once every other day to provide antibacterial effects without overly drying the face.
Many rosacea patients possess sensitive skin that must be gently cleaned due to limited sebum production. These patients are usually mature postmenopausal women. Lipid-free cleansers represent a cleansing alternative for this population. Lipid-free cleansers, which are characterized by low foam production, are liquids that clean without fats, which distinguishes them from soaps (Cetaphil Cleanser, Galderma; CeraVe, Coria; Aquanil, Person & Covey). The cleanser is applied to dry or moistened skin, rubbed to produce a slight lather, and rinsed or wiped away. These products may contain water, glycerin, cetyl alcohol, stearyl alcohol, sodium laurel sulfate, and occasionally propylene glycol. They leave behind a thin moisturizing film, but do not possess strong antibacterial properties. For this reason, lipid-free cleansers are excellent for the dry face, but are not recommended for cleansing the groin or armpits. They also are not good at removing excessive environmental dirt or sebum.
Cosmetic removal is important in the rosacea patient, especially in the eye area to prevent worsening ocular rosacea. Many of the new polymer based mascaras can be difficult to remove with water necessitating the use of an additional cleanser. Low foaming lipid-free cleansers, previously discussed, may be used to remove cosmetics in the rosacea patient. They can be applied dry and rubbed over the eyelids, cheeks, and lips to remove both water removable and water resistant cosmetics following by lukewarm water rinsing. If necessary, another cleanser can be used for additional cleaning. Many of the commercially marketed cosmetic removers contain solvents that are volatile and damaging to the intercellular lipids, thus provoking facial redness.
Another product for cosmetic removal is cleansing cream. Cleansing cream is composed of water, mineral oil, petrolatum, and waxes (Abolene, DSE Pharmaceuticals). The most common variant of cleansing cream, known as cold cream, is created by adding borax to mineral oil and beeswax (Pond's Cold Cream). These products are popular among mature women as they provide cosmetic removal and mild cleansing in one step. Even though these products are older formulations, they have withstood the test of time and should be considered in the dry complected rosacea patient in need of thorough cosmetic removal.
Cleansing devices combine a cleanser with an implement for washing the skin. The most common cleansing device is a disposable cleansing cloth impregnated with a cleanser. The cloth is composed of polyester, rayon, cotton, and cellulose fibers, which are heated to produce a thermobond. Additional strength is imparted to the cloth by hydroentangling the fibers with high pressure jets of water, eliminating the need for adhesive binders. This creates a soft durable cloth. The cloth can be packaged dry or wet typically with a syndet cleanser. Dry cloths are wetted before use.
The amount of sebum removal produced by the cloth can be varied by the amount of cleanser, but also by the weave of the cloth. There are two types of fiber weaves used in facial cloths: open weave and closed weave. Open weave cloths possess 2-3 mm windows between adjacent fiber bundles. These cloths are used in persons with dry and/or sensitive skin to increase the softness of the cloth and decrease the cleansing surface area. Closed weave cloths, on the hand, are designed with a much tighter weave and provide a more thorough cleansing, but also induce exfoliation. The exfoliation is intended to remove desquamating corneocytes. While this may be beneficial in some rosacea patients, it may be problematic in others. The degree of exfoliation achieved is dependent on the cloth weave, the pressure with which the cloth is stroked over the skin surface, and the length of time the cloth is applied.
Many patients with rosacea wish to exfoliate their face, as this has become a “standard” part of the modern skin care routine. The hydroxy acid and salicylic exfoliant cleansers and moisturizers may be problematic in this population due to the irritation invoked resulting in facial redness. Individuals with sensitive skin may wish to consider using an open weave cloth gently over the face once weekly for mild exfoliation. This can improve skin texture without provoking unnecessary redness.
Moisturizing cleansing cloths are also available and may be the preferable choice in rosacea patients. The cloth contains two sides, which may be differently designed to deliver different benefits. The moisturizing cloths contain a cleanser on the textured side and a moisturizer on the smooth side. The cloth is activated with water and the textured side is used first to clean and gently exfoliate the skin following by rinsing of the cloth. The rinsed cloth is then turned over and the face is rinsed and moisturized simultaneously. This cloth technology can also be used for cosmetic removal in some patients.
A variant of the cleansing cloth is the cleansing pouch. Fusing two cleansing cloths around skin cleansing and conditioning ingredients creates the cleansing pouch. A plastic membrane is placed between two fibered cloths containing holes of various diameters to control the release of ingredients onto the skin surface. Many times the cleansing pouches contain a variety of botanicals, which may be problematic in the rosacea patient.
Some cleansers and cleansing implements may be problematic in the rosacea patient. Products that induce aggressive exfoliation, such as abrasive scrubs, may provoke flushing. Abrasive scrubs incorporate polyethylene beads, aluminum oxide, ground fruit pits, or sodium tetraborate decahydrate granules to induce various degrees of exfoliation. The most aggressive exfoliation is produced by irregularly shaped aluminum oxide particles and ground fruit pits, which should be avoided by the rosacea patient. Milder exfoliation is produced by polyethylene beads, which possess a smooth rounded surface. The least aggressive exfoliation is produced by sodium tetraborate decahydrate granules, which soften and dissolve during use. I would favor avoiding these products and using a cleansing cloth previously discussed once weekly.
Another form of aggressive exfoliation is produced by sponges composed of nonwoven polyester fibers (Buf Puf). These sponges are too aggressive for most rosacea patients. Rosacea patients have sensitive skin that must be handled gently like a fine silk scarf. Pulling, tugging, rubbing vigorously, and strong cleansers will ruin a silk scarf immediately and are not recommended for the rosacea patient with sensitive skin. Some rosacea sufferers will scrub their face mercilessly hoping to cleanse away the inflammatory lesions and redness, when in actuality they are only worsening the barrier damage. However, barrier damage repair can be facilitated with moisturizers, the next topic for discussion.
Moisturizers are important to provide an environment suitable for barrier repair in the rosacea patient. Facial moisturizers are the most important cosmetic in the prevention of a facial rosacea flare. These moisturizers attempt to mimic the effect of sebum and the intercellular lipids composed of sphingolipids, free sterols, and free fatty acids. They intend to provide an environment allowing healing of the stratum corneum barrier by replacement of the corneocytes and the intercellular lipids. Yet, the moisturizing substances must not occlude the sweat ducts, or miliaria will result, must not produce irritation at the follicular ostia, or an acneiform eruption will result, and must not initiate comedone formation. Furthermore, the facial moisturizer must not produce noxious sensory stimuli, which may also provoke a rosacea flare.
Moisturizers are used to heal barrier-damaged skin by minimizing transepidermal water loss (TEWL) and creating an environment optimal for rosacea control. There are three categories of substances that can be combined to enhance the water content of the skin include occlusives, humectants, and hydrocolloids. Occlusives are oily substances that retard transepidermal water loss by placing an oil slick over the skin surface, while humectants are substances that attract water to the skin, not from the environment, unless the ambient humidity is 70%, but rather from the inner layers of the skin. Humectants draw water from the viable dermis into the viable epidermis and then from the nonviable epidermis into the stratum corneum. Lastly, hydrocolloids are physically large substances, which cover the skin thus retarding transepidermal water loss.
The best moisturizers to prevent facial rosacea flares combine occlusive and humectant ingredients. For example, a well-formulated moisturizer might contain petrolatum, mineral oil, and dimethicone as occlusive agents. Petrolatum is the synthetic substance most like intercellular lipids, but too high a concentration will yield a sticky greasy ointment. The aesthetics of petrolatum can be improved by adding dimethicone, also able to prevent water loss, but allowing a reduction in the petrolatum concentration and a thinner more acceptable formulation. Mineral oil is not quite as greasy as petrolatum, but still an excellent barrier repair agent, that further improves the ability of the moisturizer to spread, yielding enhanced aesthetics. The addition of glycerin to the formulation will attract water from the dermis speeding hydration. It is through the careful combination of these ingredients that facial moisturizers can be constructed to prevent facial redness.
Some basic moisturizer recommendations for rosacea patients are listed in Tables 2 and 3. These products were selected from those routinely sampled to dermatologists and organized by skin type. Table 2 lists moisturizers for day wear that contain sunscreen, an important ingredient for the rosacea patient, since redness is worsened by chronic UV exposure. Table 3 listed products appropriate for night time use also arranged by skin type.
Redness reduction remains the biggest challenge in the treatment of facial rosacea. While topical and/or oral prescription medications can adequately control the inflammatory papules and pustules characteristic of the disease, redness reduction remains an enigma. Some of the redness may be due to telangiectasias, which are minimally affected by topical medical therapies. Flushing, a sign of vasomotor instability, may also account for redness due to temperature change, sun exposure, physical exertion, and emotional stress. These causes of redness are difficult to eradicate thus creating a treatment void that might benefit from the ancillary use of cosmetics and cosmeceuticals.
Part one of this series discussed the selection of cleansers and moisturizers to improve the appearance of facial redness in rosacea. This second and final article evaluates the use of cosmetics and cosmeceuticals for redness reduction. Cosmetics are useful to either partially or completely camouflage the redness while cosmeceuticals can reduce the inflammation that contributes to low-grade chronic redness.
Colored cosmetics are a useful adjuvant therapy for female rosacea patients. The cosmetics can camouflage the underlying redness by either blending colors or concealing the underlying skin to achieve a more desirable appearance. The art of blending colors to minimize facial redness utilizes the complementary color to red, which is green. Moisturizers with a slight green tint are applied after the prescription medication and well blended. Several currently marketed moisturizers for rosacea (Eucerin, Beiersdorf) contain a slight green tint. Since the mixture of red and green produce brown, the sheer green tint will tone down bright red cheeks.
Sometimes the green tint is followed by application of a tan facial foundation that matches the desired skin color. The green tint allows a sheer facial foundation to better camouflage the red tones. The green tinted moisturizer can also minimize redness under the currently popular mineral makeup facial foundations. These powder foundations are dusted across the face from a container attached to a brush (L’Oreal, Jane Iredale). The powder foundations have become popular among persons with rosacea as they eliminate the need for a lotion or cream vehicle. The evaporation of the lotion from the face can cause flushing and the increased number of ingredients required in a lotion or cream facial foundation enhances the chance for irritation.
If the red of the face remains apparent, a more translucent or even opaque facial foundation can be used. These facial foundations are usually creams or cream powders. The creams are thick accounting for the increased concentration of pigments and the lack of water. This makes an oil based product that is resistant to water and rubbing removal (Dermablend). Translucent products have less pigment while opaque products have more pigment. Translucent products yield a more natural appearance while opaque products have the appearance of a heavily adorned face (Estee Lauder). Some rosacea patients who require aggressive camouflage may wish to select one of the newer cream/powder formulations that are wiped from a compact with a sponge, but dry on the face with the appearance of a powder (Neutrogena). These products still produce excellent camouflaging with a less adorned appearance.
There are instances where redness reduction is preferable to cosmetic camouflage. This is certainly the case in males or females who do not wish to use cosmetics. Our next topic of conversation is the use of moisturizers that contain ingredients designed to reduce redness.
Cosmeceuticals are over-the-counter moisturizers with a variety of active ingredients designed to enhance the appearance of the skin. Most of the cosmeceuticals designed for rosacea patients contain anti-inflammatory agents intended to reduce redness. The anti-inflammatories are botanical extracts that may compliment prescription therapy in the maintenance phase of rosacea treatment. Commonly used botanical anti-inflammatories in the current marketplace include ginkgo biloba, green tea, aloe vera, allantoin, feverfew, and glycyrrhiza inflata. Their rationale for use in currently marketed cosmeceuticals for redness reduction is discussed.
Ginkgo biloba is a currently popular botanical ingredient in many oral supplements designed to treat cardiovascular disease. The leaves contain polyphenols, which function as antioxidants, such as terpenoids (ginkgolides, bilobalides), flavinoids, and flavonol glycosides with anti-inflammatory effects. These anti-inflammatory effects have been linked to antiradical and antilipoperoxidant effects in experimental fibroblast models. However, it is unknown whether these fibroblast effects translate directly into observable human physiologic effects. Ginkgo leaves are used in homeopathic medicine to alter skin microcirculation by reducing blood flow at the capillary level and inducing a vasomotor change in the arterioles of the subpapillary skin plexus. Taken together, these changes may lead to decreased skin redness in the rosacea patient.
However, it is important to recognize that botanical supplements, such as Gingko, are applied to the skin in a moisturizing vehicle for redness reduction. The moisturizer usually contains a variety of ingredients designed to enhance the skin water content and provide an environment suitable for barrier repair. It is hard to separate the effect of the botanical ingredient from the effect of the moisturizing vehicle. This makes it difficult to accurately study the skin value of the ingredient.
Green tea, also known as Camellia sinensis, is another anti-inflammatory botanical containing polyphenols. However the polyphenols in green tea are different than those found in Gingko biloba. Green tea contains polyphenols, such as epicatechin, epicatechin-3-gallate, epigallocatechin, and epigallocatechin-3-gallate. The term "green tea" refers to the manufacture of the botanical extract from fresh leaves of the tea plant by steaming and drying at elevated temperatures avoiding oxidation and polymerization of the polyphenolic components.
A study by Katiyar et al, demonstrated the anti-inflammatory effects of topical green tea application on C3H mice.(1) A second study by the same authors found topically applied green tea extract containing epigallocatechin-3-gallate reduced UVB-induced inflammation as measured by double skin-fold swelling.(2) Green tea extracts are the most commonly used cosmeceutical botanical anti-inflammatory at the time of this writing.
The second most commonly used anti-inflammatory botanical is aloe vera. The mucilage is released from the plant leaves as a colorless gel and contains 99.5% water and a complex mixture of mucopolysaccharides, amino acids, hydroxy quinone glycosides, and minerals. Compounds isolated from aloe vera juice include aloin, aloe emodin, aletinic acid, choline, and choline salicylate.(17) The reported cutaneous effects of aloe vera relevant to rosacea include reduced inflammation, decreased skin bacterial colonization, and enhanced wound healing. The anti-inflammatory effects of aloe vera may result from its ability to inhibit cyclooxygenase as part of the arachidonic acid pathway through the choline salicylate component of the juice. However, the aloe vera final concentration in any moisturizer must be at least 10% to achieve a cosmeceutical effect relevant to the rosacea patient.
Most of the aloe vera that is used in cosmeceuticals is purchased in the powder form. It is for this reason that it does not have the mucilage effects previously described. Aloe vera is very expensive when added to products in the amount required to achieve a physiologic benefit. Lower priced aloe vera-containing moisturizers usually do not make claims related to the addition of aloe vera. Remember that if the packaging states that the product “contains aloe vera,” this is a statement of the ingredient listing and does not imply functionality. It only indicates what is in the bottle, not its amount or physiologic benefit.
Allantoin is oldest anti-inflammatory ingredient added to many moisturizers labeled as appropriate for sensitive skin. It naturally found in the comfrey root, but usually synthesized by the alkaline oxidation of uric acid in a cold environment.(18) It is a white crystalline powder readily soluble in hot water, making it easy to formulate in cream and lotion moisturizers designed for sensitive skin. It is listed in the skin protectant monograph, which may facilitate redness reduction by improving the skin barrier.
Most commercially available allantoin is chemically synthesized and does not come from the comfrey root botanical source. This brings up the question of the “natural” claims made for many botanical products sold as appropriate for rosacea and sensitive skin. The consumer assumption is that the naturally derived products will produce more skin improvement and less irritation. There is currently no consistent definition in the skin care industry as what “natural” truly means. Thus, natural claims must be viewed as marketing jargon and do not provide any meaningful information about the product effect on the skin of the rosacea patient.
Feverfew is a small bush with citrus scented leaves used as a traditional medicinal herb. It has been used to treat headaches, arthritis, and digestive problems. The anti-inflammatory benefits of this plant have been attributed to parthenolide and tanetin, which are thought to decrease the release of serotonin and prostaglandins.(19) Feverfew also induces vasoconstriction. This reduction in inflammation and blood flow may allow feverfew to reduce redness in rosacea.
A redness reducing moisturizer for rosacea was introduced that was based on parthenolide-free feverfew (Aveeno, Johnson & Johnson). Parthenolide is a known cause of allergic contact dermatitis, thus the ability to synthesize parthenolide-free feverfew was necessary before this ingredient could be used in sensitive skin products.
Glycyrrhiza inflata is a member of the licorice family, known for containing a variety of anti-inflammatory botanicals. One extract isolated by heating from the root of the Glycyrrhiza inflata licorice plant is licochalcone A. It possesses anti-inflammatory properties as evidenced its in vitro ability to inhibit the keratinocytes release of PGE2 in response to UVB-induced erythema and the lipopolysaccharide-induced release of PGE2 by adult dermal fibroblasts.(20) Licochalcone A is the active agent in one of the largest product lines currently sold internationally for redness reduction (Eucerin, Biersdorf).
Cosmetics and cosmeceuticals may be useful in patients who are looking for ancillary products to compliment their prescription therapy. Redness reducing cosmeceutical botanical moisturizers may be helpful in some patients. Camouflaging cosmetics may be necessary in some patients requiring 4-8 weeks of treatment before perceiving a redness reduction. It is also worthwhile to understand the ingredients and intended functioning of products specifically marketed to persons with facial redness.
The redness reducing market has become a new niche at the cosmetic counter. Some redness reducing products contain hydrocortisone as the active agent (Clinique), which is an ingredient of interest to the dermatologist who may have a rosacea patient with concomitant perioral or periocular dermatitis.
The newest frontier in redness reducing products will be the use of antimicrobial peptides, which can be incorporated into cosmeceuticals. These peptides can modulate facial inflammation and have the potential to offer effective redness reduction. At present, antimicrobial peptides are not in any nationally market products, however, more innovation is certainly to be expected in this newly discovered skin care niche.