Extinguishing the Fire of Rosacea (the most-searched tag on my blog)

Rosacea is probably one of the commonest and most annoying conditions-it can render the sufferer beetroot red at a moment’s notice, and usually when least convenient. Unpredictable and terribly self-conscious making.

Treatment works best on the spotty papulo-pustular type; treating the flushing, fixed redness and broken capillaries is harder. But the key to developing better treatments is a more detailed understanding of the processes behind the disease, and how current therapies modify it. I think we can now safely say we we’re closer to understanding this capricious condition.

The key to understanding rosacea is to appreciate how the skin senses the environment, in it’s bid to keep our insides safe. The innate immune system is a primitive-but-useful part of this protective mechanism that serves as a warning system, which responds to dangers in the environment. Like the sun. But in rosacea, this system is hyperactive and over-anxious.

Think of it like a fire-alarm-designed to ‘go off’ when there is a significant hazard. Like the oven has caught fire. Instead, it goes off when the kettle boils. The premature alarm generates pro-inflammatory changes, which are disproportionately strong. This leads to leaking from capillaries, weakening of capillary walls leading to inflammation and visible surface blood vessels. And, through the release of nerve-stimulating peptides, can cause burning, stinging and sensitivity. And all of this is compounded by sun exposure, with the associated damage to elastin and collagen fibres that can further weaken blood vessels and strength of the skin’s scaffolding.

Finally, if this goes on unchecked, the chronic, ongoing inflammation can recruit white cells and overwhelm lymphatic vessels, leading to fibrosis and distortion of facial features, like the nose.

Much of this process is due to genetics with environmental triggers. People are probably bored of hearing about sun protection, but I think the above explanation makes it clear that first-line therapy for rosacea sufferers is to know your environmental triggers and use daily sun protection. I find patients tolerate a well-formulated sunscreen with broad-spectrum filters-I like both Obagi and Skinceuticals sunscreens for this reason, as they really are compatible with daily wear.

The treatments that I think work best have been shown to influence the innate immune system-oral tetracyclines turn down the over-active response pathways generated by the alarm going off, as do effective topical agents like azelaic acid.

In the future we will have better treatments to target the premature alarm bell itself-receptors called Toll-like receptors. We think azelaic acid may well do this too. And we will also be better able to target the family of response molecules called cathelicidins which have a specific action on the blood vessels themselves.

A complex disease with complex mechanisms-but I think we’re getting thereJ

    • Lucs
    • February 25th, 2015

    Any tips on using azelaic acid? I used the 15% gel for a while, but could never use everyday (not even once a day) because it made me so dry (even though I was using a non-foaming cleanser, moisturizer and face oil). Once I stop it, skin got more radiant and moist because it wasn’t as dehydrated.

    • Try applying after moisturiser to slow down penetration. Or consider a lower strength over-the-counter product if sensitivity is an issue. Niacinamide can often improve barrier function so it might be worth pretreating with this first to improve tolerance further.

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