Lets Talk - Rosacea

In this episode of Let’s Talk Skin, Dr Farah dives into one of the most misunderstood skin conditions… rosacea.

From persistent redness and flushing to breakouts, sensitivity and triggers you may not expect -  we’re unpacking what rosacea actually is, common myths, what can make it worse, and the treatment options that can help manage symptoms and support healthier skin long term.

If you’ve ever wondered whether your skin is “just sensitive” or something more, this episode is for you.

🎧 Listen now and let’s talk skin.

Transcript

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Right, so you've been told you have sensitive skin your whole life. You flush easily, you've tried every kind of green tinted primer known to mankind. You've been recommended La Roche Posay toleran about 47 times and nothing is working. Hi, I'm Dr. Farah, and today on Let's Talk Skin, we're going to do a full deep dive on Rosacea. What it actually is, what it isn't, why so many people have it and don't know, and most importantly, what we can actually do about it. So, what is rosacea? Rosacea is a chronic inflammatory skin condition. Chronic inflammatory. So these two words matter because they tell us everything about how and we need to approach it. It's not something you grow out of, it's not caused by having bad skincare routine, and it's absolutely not just sensitive skin type that you manage with gentle products and hope for the best. There are four subtypes, and most people with rosacea don't just have one of them, they have a mix. So, subtype one, okay. Here, bear with me because I can heart barely pronounce it. Erethemato tellingjectasic rosacea. So that is flushing and redness type, and this is the one most people recognize your face goes red, it stays red, you've got visible broken capillaries, and the redness doesn't just come and go anymore, it becomes your baseline. So your subtype 2 is papillopostular rosacea. This is the one that gets misdiagnosed the most because it looks like acne. You've got bombs, you've got postules, you've been handed benzy peroxide and salicyclic acid, and your skin is getting worse because it's not acne. Treatment is completely different. Subtype three is fematous rosacea. This is where the skin thickens, particularly around the nose. If you've ever seen someone that looks like a ball with a bulbous and large nose, that is likely rhinophymia. And it's far more common in men. Men tend to get a milder course of rosacea, but when it progresses, it progresses badly. Subtype 4 is ocular rosacea, eyes, dry, gritty, red, sensitive to light. People walking around with undiagnosed ocular rosacea, being told that they just have dry eye syndrome when it's all connected. So who gets rosacea? Fair-skinned people, Northern Europe heritage, Irish, Scottish, Scandinavian. So yes, as an Irish clinic, I see a lot, a lot of rosacea. It typically presents in your 30s, 40s, 50s. Women can get it, women get it more often. Men get the severe end, and it does not go away on its own. Left untreated, it will progress. So now I want to, before I go into what works, I do want to talk about what makes rosacea significantly worse because I see this in clinic constantly. People doing all the right things with the wrong products. Oils. We need to talk about oils. There's been a huge push in skincare over the last few years, particularly around facial oils. And the idea is that your skin is red and reactive, so it must be dry. And then you need to add an oil back in. And for some skin conditions, that logic holds, but for rosacea, it can be catastrophic. Like certain oils are high in oleic acid. Coconut oil is the classic example. Marula oil, rose hip, argon, they all have a high content of oleic acid. What oleic acid does in rosacea prune skin is trigger and sustain inflammation. So it disrupts the skin's microbiome. And I'll come to why that matters in a moment. But it feeds the organisms that drive rosacea flares. Demodex mites. We need to say it. Demodex mites. They're tiny mites that live in our hair follicles. Everyone has them completely normal in small numbers. But in rosacea, the population is out of control. They thrive in an oily, lipid-rich environment. So fat-rich environment. So when someone with rossacea is slathering a facial oil on every night in the name of hydration, they're essentially feeding the problem. So the oils to avoid if you have rosacea, I think you might have rosacea is coconut oil, marula oil, rose hip oil, and anything with high oleic acid content. Check the ingredients. If it's calming face oil and it's high in oleic acid, it's not calming anything. And this extends to cleansers and makeup too. So all-based cleansing bombs, um, used nightly, same issue. So I'm not saying never use them, I'm saying if your rosacea isn't responding to treatment and you're using heavy oils, that's where I would look first. So this is um the next part I want to talk about the microbiome, the skin's microbiome, and why we love Sosta. So why does the microbiome matter so much here? So rosacea is fundamentally a dysbiosis, an imbalance in the skin's microbiome. The organisms that should be in check are the demo the demodex, cutie bacterium, acne, cephylococcus, epi, epidermidis are dysregulated. So the inflammatory cascade that follows is what produces the redness, the flushing, and the postules. So one of the first things I focus on with rosacea patients is microbiome regulation. And my go-to for this is my duo of Sasta, your Sasta microbiome, and a good hydrator. So Sasta is formulated specifically for skin conditions driven by microbiome imbalance, rosacea, perioral dermatitis, acne. This product is gentle enough not to strip the barrier while actively regulating the microbiome. It soothes, it calms, it's anti-inflammatory, inflammatory, it boosts hydration, and it's not loaded with fragrance or irritants. The principle of this is simple. You can't treat Rosacea with a compromised skin barrier and a dysregulated microbiome. You have to get the foundations right before anything will work. And this is why I see patients who've been on prescription creams for years with no real improvement, because nobody has addressed the baseline. Regulate the microbiome, repair the barrier, then layer it on top of that foundation. Now, I wanted to talk about some of the skincare protocols that we use. Now, remember this is an overview, so it's not, you know, don't take this as gospel without coming in for a consultation. Now, one of the most amazing ingredients I I love using in Rosacea prone skin is aslic acid. So it's my favorite active for rosacea. It's anti-inflammatory, it reduces redness, it works on papillopustular element, it's gentle enough for compromised barrier, and it doesn't cause the purging or irritation you get from a retinoid. Now, a quick note on this for my Irish listeners in particular aslic acid is available over the counter. Like, for example, in Australia, 15%, 20% aslic acid is available over the counter. You can walk into a pharmacy and buy it. In Ireland, 15% is prescription only. So when you're seeing content from Australian American influencers recommending these products, just be aware that they're casually picking up in the local chemist, but you'd need a prescription for here. Over the counter in Ireland, you can access lower concentrations around 10%. And they do have efficacy, but for more significant rosacea, you want to be working with a prescriber. So, with regards to moisturizing your skin, this is key in improving your barrier function of the skin. So it needs to be simple, barrier supportive, look for ceramites, niacinamites, centella, sciatica, beta glucans, avoid anything with essential oils, alcohol, high up in the ingredient list, or natural fragrance, which is just fragrance with better PR, basically. So the goal of moisturizer, moisturizing your skin in Rosacea routine is not to add a load of active ingredients, it's to maintain the barrier so everything else can do its job. I will never ever ever stop saying this. SPF is not optional in Rosacea. UV is a primary trigger. Every time your face is exposed to unprotected UV, you are triggering a vascular inflammatory response that worsens your rosacea over time, every single time. And I hear, but I'm in Ireland, there's no sun at least once a week. Um UVA does not care about clouds. UVA comes through your window. UVA is there in January. Mineral SBF, zinc oxide-based, tends to be better tolerated for rosacea-prone skin. That chemical filters, which can cause chemical filters, basically can cause some stinging and irritation. So SBF every single morning, every day, no exception. So now we're moving on to prescription options. So you've got the foundations, right? Your microbiome is sorted, your barrier is repaired, you're on azalic acid, and you are protecting your skin with SBF. So what if that's not enough? This is where we move into prescription territory. So here, as I mentioned earlier, we can go up with the acid, which is 15%. We generally start off with that, and here I find with acalic acid, you need to use enough. You know, you need to use enough to cover your face and come and see a prescriber. It's not complicated to get, but you do need to be assessed first. The next kind of prescription option that I use a good bit is Sulantra, which is ivermectin 1%. This has changed Rosa treatment significantly when it comes when it came out. So ivermectin, most people know, is an antiparasitic. And it's that it's exactly that's exactly what it's doing here. So it targets the demodex the demodex mites directly, and it has a powerful anti-inflammatory action on top of that. So cilantra is applied once a day in the evening time. Results build over three to four months. Patients often see a dramatic reduction in postules, the postpapula pastula element of um rosacea in particular. So it considered it is one of the most effective topical treatments we have for rosacea, and I do prescribe it quite regularly. However, you do need to bear in mind without your foundation work, which is microbiome regulation, hydration, SPF, you're not going to get a result using cilantra on its own. So there was a product um a few years ago called Mervaso, it's bromonadin gel. So this is exciting when it was launched because it is a vasoconstrictor, so it reduces redness quickly within 30 minutes, and it works for a few hours. So it looked brilliant in before and after photos. The problem is the rebound effect. When the effects wear off, and it does wear off, the blood vessels dilate again, often worse than baseline. So patients were reporting the rosacea was significantly worse after stopping. So there was also a subset of patients who had paradoxical worsening even while using it. So we've largely moved away from your vascular and clinical practice because a short-term visual improvement doesn't justify the long-term rebound worsening. So if you've been prescribed it, um, have a conversation with your doctor. It's not that it never has a role, but it wouldn't be my first, second, or third choice. Another product we use quite regularly is a low dose doxycycline. So this one surprises people. Doxycycline is an antibiotic, but at a dose we use for rosacea, which is 40 milligrams modified release, it's working, it's not working as an antibiotic, it's working as an anti-inflammatory. So sub-antimicrobial dosage of doxycycline has been shown to reduce inflammatory cascade in rosacea without having a meaningful impact on antibiotic resistance, which is a concern for a lot of people. Um so people rightly raise this when antibiotics are mentioned for skin conditions, especially when using it for a few months. It's typically used for three to six months, often alongside topical treatment. It's not a cure. When you stop it, rosacea can return, but it can be really effective for getting significant flares under control while work on the longer-term management. So, what is the long-term management? So, in clinic, we offer our broadband light, so BBL and clear silk. Topicals, orals are managing the inflammatory and microbiome side of rosacea, but what about the vascular component? That is the blood vessels, the persistent redness, the telangectasia, those broken capillaries, the flushing that doesn't respond to anything topical. This is where the light-based treatments or light-based treatments such as BBL is genuinely um effective for people with rosacea. So BBL or broadband light is an intense intense pulse light treatment, but it's not your standard IPL. The technology is more advanced, more precise, and better controlled. We use specific wavelengths that target oxyhemoglobin. So that's a red pigment in blood vessels to selectively destroy the abnormal vasculator that causes persistent redness and tellangjactasia. So what happens in the light energy is absorbed in the blood vessels, it causes it to coagulate and the body then clears it away. So the surrounding skin is not damaged. For rosacea, we typically do a course of treatments, usually three to five spaced over four weeks apart with a maintenance treatment once or twice a year after that. The improvement in overall flushing, visible vessels, is huge. BBL also has an anti-inflammatory effect that goes beyond just a vascular component. There's actually research showing it modulates gene expression in the skin, and patients often report their skin becoming less reactive overall after a course. Then here is the magic, the magic uh potion. Well, it's not a potion really, it's a laser. Clear silk laser. So this is an ND YAG 1064 nanometer laser, is a brilliant complement to BBL for rosacea, where BBL targets the more superficial vascular components. So you see the blood vessels on the skin, on the surface of the skin, the clear silk works at a different depth and particularly effective for diffuse redness and flushing response. So it's also very safe for all skin tones, which matters, and it's well tolerated. Patient describes it as feeling like a warm rubber band snaps being snapped in your skin. Recovery is minimal, it's actually the clear cell component has no downtime and is brilliant for before events, uh gives you a lovely glow. And you can come come in and get it on your lunch break. Together, the BBL and the clear cell gives us a comprehensive approach to the vascular and inflammatory sides of Rossacea. Inflammatory sides of Rossacea, sorry, I don't know my voice is squeaked. There, combined with the prescriptive topicals and the right skincare foundation. This is what genuinely, this is what genuine long-term management looks like. So to bring it all together, Rossacea is a chronic inflammatory condition. It is not a skin type, it does not go away on its own, and it absolutely does not to be something you have to live with. The approach I use is layered, so there is a system. Get your microbiome and barrier function right first. Use the right actives. Perhaps it could be aslic acid or targeted topicals. Protect your skin with SBF every single day. Bring in, you know, we might bring have to bring in prescription options where needed and treat the vascular component with BBL and clear silk. If you've been listening to this and recognize yourself, come and get assessed. You do not need to spend another decade managing this with a green primer. You can find me at medicalskinclinic.ie and I'm Dr. Farah. Thanks for listening to Let's Talk Skin, and I will see you next time.