Rosacea - Volume 1, Issue 1 January 2022
In our inaugural newsletter, we'll discuss rosacea, the subtypes, potential causes, treatment modalities, recommended products and why I think the use of low pH skincare products (especially glycolic acid) can be extremely beneficial for those with a bacterial or mite component to their rosacea. Learn more so that you will be better able to discuss your case with your dermatologist or help someone you know.
We hope to write one newsletter quarterly. These are intended to be educational and helpful. Please contact us if there is a subject you would like to know more about.
- What is Rosacea
- Theories of Causes
- Demodex Mites
- Recommended Products
- Other Treatment Options
What is Rosacea
Rosacea is a complex and chronic inflammatory skin condition. Typically, rosacea affects the skin on the cheeks, forehead, and nose. Symptoms can include diffuse redness, flushing, skin thickening, pimples, papules and pustules, irritation, and rough skin. What’s the difference between rosacea and acne? Rosacea is usually vascular in nature and acne is not.
Dermatologists often separate rosacea into five different subtypes:
- Erythema or Redness (facial flushing, often accompanied by burning or stinging).
- Telangiectasias or small red blood vessels.
- Pustule or typical acne lesions on the forehead, nose, cheeks, and chin (shown above).
- Hypertrophic, irregular raised and thickened areas on the nose, chin, forehead, one or both ears, and/or the eyelids (especially prevalent on the nose).
- Ocular rosacea is inflammation that causes redness, burning and itching of the eyes (includes blepharitis, conjunctival hyperaemia, and keratitis).
Theories of Causes
While the cause of rosacea is unknown, it is likely multifactorial, triggered by environmental factors, changes in the skin’s pH level with age, foods, and possibly Demodex mites that often reside in hair follicles and sebaceous glands on the face.
Since there are so many theories about potential causes, I strongly encourage you to work with your dermatologist or someone that specializes in treating the “whole person” when it comes to rosacea. I focus on potential ‘skin-related’ causes since that is my expertise and experience.
The skin’s “normal” pH is around 4.7. Rosacea is more common at higher skin pH levels of 5.1–6.5. [Pathogens—bad bugs, essentially—thrive at these higher, (more alkaline) pH levels as well. Skin surface pH increases after the age of 50 [Man MQ, Xin SJ, Song SP, et al.]. Bonus, the lower acidic pH also protects against aging.
Rosacea is more common in dry skin, as opposed to oily skin, and more common among those that only cleanse their face once a day instead of twice a day. Demodex mites are also more prevalent under these conditions. Failure to wash the face, supplies the Demodex mites with extra lipid nourishment, which promotes reproduction of mites in large numbers. The stratum corneum (outermost layer of the epidermis) consists of corneocytes (layers of dead skin cells) and lipids (the skin’s natural fats).
Demodex mites can be found in the skin of healthy persons without creating any pathogenic (infectious) effect. There are two types of mites found on human skin. D. folliculorum is the most prevalent species; the fact that it lives in the hair follicles makes detection easier by your doctor (skin scraping and a microscope) than that of D. brevis, which lives in the sebaceous glands.
The first type, D. folliculorum is different from other types of mites because it can actually increase the number of skin cells in hair follicles. This can give people the appearance of scaly skin. D. folliculorum is currently being investigated as a potential cause of rosacea. There is evidence that these mites can cause flare-ups if you have rosacea. The National Rosacea Society estimates that rosacea patients have up to 18 times more D. folliculorum mites than patients without rosacea.
Over the last 13 years, I have worked with many clients that have struggled with rosacea. I feel compelled to share some significant improvements many have experienced. I have some theories as to why a routine of cleansing your face twice daily (not with bar soap), along with morning use of CE Ferulic and Glycolic acid may be tremendously powerful in fighting bacteria and mites. And these products are just the tip of the iceberg.
First, cleansing removes dead skin cells, allows for better product penetration and ability to moisturize. Second, Demodex mites will find it difficult, if not impossible, to survive in the environment these two very acidic (pH <3.5) products (CE Ferulic and Glycolic acid) create.
In two clinical studies (Kubanov  and Zeytun  – both referenced below), the Demodex mite infestation rate was higher in older as compared to younger individuals, as well as in those that only washed their face once a day as compared to twice. Also, the dryer the skin, the higher the infestation rate. Individuals with higher skin pH levels (5.1–6.5) were more infested than those with lower pH levels. Patients with papulopustular rosacea had increased facial pH levels and reduced skin surface hydration levels. Experiments in the laboratory (not on humans), show higher concentrations of Demodex mites in higher pH culture mediums, versus lower (more acidic) culture mediums.
In summary, Demodex mites are very prevalent in healthy individuals of both sexes and all age groups. These mites were more often found in those aged over 41 years, those with dryer skin, those that only washed their face once a day, and those with more alkaline skin (higher pH levels).
Why Glycolic Acid coupled with an antioxidant CE Ferulic, can play such an important role? Glycolic acid is one of the most effective ingredients in skin rejuvenation because it works on both the epidermis and dermis. Due to its small molecular size, it penetrates readily and deeper than most products. Glycolic has the ability to really get down into the hair follicles and sebaceous glands, loosening up any built-up sebum and proteins that could lead to blackheads and breakouts. Vitamin C (l-ascorbic acid) also penetrates very well at the low pH values, is compatible with the Glycolic, and offers it's own set of benefits (antioxidant, anti-aging).
As we age, we don’t shed our dead skin cells as fast as we did in our teens and 20s. Glycolic Acid dissolves the “glue” (called desmosomes) that holds dead skin cells together, allowing these dead skin cells to be easily exfoliated to reveal new skin underneath.
Glycolic acid is appropriate for all skin types, and all skin types can receive all of the benefits from glycolic. For oily skin, it helps to remove dead cells, which can clog pores. For dry skin, glycolic allows moisturizers to penetrate the skin better and removes the flakes of dry, dulling dead skin. For normal skin, glycolic creates a smooth surface and a youthful, luminous glow. For sensitive skin, glycolic can be paired with moisturizers. Oily skin will be able to tolerate a higher strength versus dry, sensitive, thin skin.
The very low pH of both the CE Ferulic and Glycolic acid (< 3.5) kill P. acnes cells (most prevalent bacteria linked to acne) by disrupting bacterial cell membranes and we've already discussed the detection of less mites at the lower pH levels as compared to higher pH levels.
Based on the success our clients are seeing with the routine outlined below, I think our theories hold some merit. To reduce the chance of the mites proliferating excessively, you need to create an environment undesirable for them to live and thrive.
I recommend this routine to help manage Rosacea:
- Cleanse the face twice daily with a non-soap cleanser, using either Bev Sidders Soothing Antioxidant Cleanser or Bev Sidders Gly/Sal Foaming Acne Cleanser. Avoid oil-based cleansers and greasy makeup. Exfoliate periodically to remove dead skin cells. I recommend the AHA/BHA Exfoliating Cleanser (a dime-size of this scrub) mixed with the Gly/Sal Foam.
- Use medical-grade skincare products, such as Vitamin CE Ferulic and Glycolic acid, with low pH levels (<3.5) in the morning, followed by a 100% mineral-based broadspectrum physical SPF sunscreen, such as EltaMD SPF 40 UV Restore (Tinted) or ISDIN Eryfotona Actinica SPF 50+, untinted.
- Consider using a Retinol 1.0 cream or talk to your doctor about using a prescription tretinoin in the evening, along with Bev Sidders Facial Jojoba Serum, which is formulated specifically for our clients with inflammatory skin conditions.
For a complete list of all our products beneficial for skin prone to rosacea, please visit: https://bevsidders.com/collections/rosacea
Tips for Glycolic Acid use:
- Start with the lower concentration (10%), before moving up to the higher strengths.
- Only use a “pea-size” amount (overuse can cause irritation that is beyond the normal acclimation period).
- Apply glycolic acid after CE Ferulic antioxidant.
- Glycolic acid makes you photosensitive, so you should always wear a sunscreen when using this product!
Other Treatment Options
Unfortunately, there is no known cure for rosacea but it is considered a treatable condition. Treatment strategies vary depending on the subtype and pathophysiology laid out at the beginning of this newsletter.
Dermatologist treatments vary and can include behavioral modification, topical and oral medications, and laser treatments. Topical treatments have shown modest improvement in most cases of Rosacea. You can treat them temporarily (and only at your doctor’s recommendation) with topical insecticides, especially crotamiton cream, and permethrin cream. Among the medical treatment options, the most commonly used topicals include metronidazole, azelaic acid, sulfacetamide/sulfur, benzoyl peroxide (not my favorite due to drying effect), and retinoids – often used with oral antibiotics (commonly tetracyclines) for the pustular subtype.
- Ivermectin 1% cream (Soolantra ®)
- Metronidazole 0.75% (Metrogel ®)
- Azelaic Acid 15% (Finacea ®)
- Oxymetazoline Cream (Rhofade ®)
For blepharitis due to ocular rosacea, talk to your dermatologist or ophthalmologist about hypochlorous acid (HOCl).
Lastly, lasers have been used successfully for many years to treat the telangiectatic component of rosacea. Diffuse redness is more difficult to control. The 532 pulsed dye laser has been very effective in some and is considered the “gold standard.” The Nd:YAG 1064 nm laser light is a very useful alternative when the 532 is ineffective or not recommended due to darker skin pigmentation.
Consult with your physician about all of your treatment options and whether laser treatments may be a good option for you.
For a printable version, click here (PDF).