What works best for reducing the redness of rosacea?

April is Rosacea Awareness Month. Rosacea is a skin condition that causes redness, dilated capillaries, red papules and pustules on the face. When it affects the eyes, the eyes can feel dry, irritated and red. There may be a sensation of sand in the eyes as well. Rosacea usually starts with easy flushing or blushing and may or may not progress to other lesions like pustules and papules.

Eye manifestations are usually diagnosed when the patient is seen for redness of the face. However, ocular rosacea may occur before skin involvement or even by itself. In 20% of patients, ocular rosacea develops before skin symptoms.

If left untreated ocular rosacea may cause serious eye problems. Eye involvement can range from dryness, burning, irritation and blurry vision to chalazia (styes), inflammation of the cornea (keratitis), corneal erosions, ulceration and scarring, Keratitis can lead to perforation of the cornea. Ocular rosacea needs to be treated quickly.

What causes rosacea?

Our skin normally regulates body temperature by opening and closing blood vessels at the skin surface. When the body is hot, more blood vessels open to allow the circulating blood to cool at the skin surface and therefore cool the internal structures as well. When it is cold, the surface blood vessels constrict keeping the heat inside.

One of the problems with rosacea is that the facial capillaries open readily but don’t constrict back to normal very well. Over time, more and more of these capillaries stay open producing chronic redness and even visible blood vessels.

Factors to consider when treating rosacea:

Anything that warms up the face can flare rosacea. Examples include hot showers/sauna/steam rooms, hot drinks, spicy foods, direct sunlight, wind exposure, alcohol, exercise, stress and others. Scrubbing the face with abrasive cleansers, getting facials or using topical preparations containing alcohol, salicylic acid or other irritating substances can also flare rosacea. What I recommend after exercise is applying a paper towel or wash cloth with cool water to the face for 2-3 minutes to help shrink the blood vessels. Scrubbing the face with abrasive cleansers, getting facials or using topical preparations containing alcohol, salicylic acid, retinols or other irritating substances can also flare rosacea.
Patients with rosacea may have burning or stinging of the facial skin especially when they apply lotions or medicines.
There are good over the counter face washes and moisturizer/sunscreen combinations that usually do not inflame rosacea, such as Eucerin Redness Relief and Aveeno Ultra Calming. For sunscreens, there are also chemical-free sunscreens from Aveeno and COTZ.
Rosacea is a chronic condition and some form of treatment/long term maintenance is usually needed.
Topical and oral medications that treat rosacea usually work for the papular/pustular/inflammatory components, but are not very effective for the dilated blood vessels.
Topical prescription medications for rosacea include:

Metrogel
(topical metronidazole). This also contains some niacinamide which
acts and a calming and anti-inflammatory medication.
Sulfur/sulfacetamide combinations like Rosula, Clarifoam, and others
Aczone gel (topical dapsone)
Finacea

6. Oral medications include:

Tetracycline class antibiotics. These work very well for ocular rosacea, where we cannot use any topical medications.
For very resistant cases, isotretinoin (generic of Accutane)

Ocular rosacea usually requires oral medications and, possibly, topical anti-inflammatory ophthalmic drops. Topical and ophthalmic steroids should be avoided as they can lead to worsening of rosacea long-term.

For persistent redness and/or dilated blood vessels, laser or intense pulsed light treatments are the most effective. Laser treatments help shrink the blood vessels and improve the redness and sensitivity of the skin.

There are some medications that can be applied in a pinch to shrink broken capillaries for a few hours, such as for an important event, but those are usually not part of the regular treatment of rosacea.