[Updated] Understanding rosacea: causes, symptoms, skincare and treatments
Rosacea is a long-term inflammatory skin condition usually occurs on the face and affects one in 10 people in the UK, according to research from Bupa, with most in the 30-to-50-year-old age group, or who have fair skin.
The flare-ups that come with the condition are tough to conceal and can be as mentally hard for clients to manage as they are physically, which is why more needs to be done to normalise rosacea in the media, as well as helping clients to manage the symptoms correctly.
We quizzed the experts about why rosacea occurs in the skin, covering the common symptoms and “triggers” that can exacerbate the issue, and the ways you can effectively treat the condition in your beauty salon or spa.
What is rosacea?
“Rosacea is an inflammatory skin condition that generally affects the middle section of the face (known as the butterfly shape) – the forehead, nose, cheeks, above the lips and on the chin. It can also thicken the skin tissue and often when people think of rosacea they think about the bulbous nose,” says top facialist Kate Kerr, owner of Kate Kerr London.
“It is generally categorised into stages with redness, persistent redness, flushing, tingling and burning – especially on the cheek area; broken capillaries and enlarged pores. You can also get papules and pustules but these are a bit different to acne spots, protruding above the surface in a more dome-like shape. They also tend to last longer than acne breakouts.”
How does stress impact rosacea?
"Our skin reflects what’s going on inside the body and stress is a bit of a double whammy for rosacea triggers and its management," explains advanced facialist Mariam Abbas. "Stress can cause flare-ups but it also disrupts the body’s ability to respond to the flare ups. The physical manifestation of the stress symptoms is inflammation, heat, and a rash."
She adds, "Adrenal stress hormones increase sensitivity in the skin while corticosteroids cause high blood pressure, vasodilation, and inflammation.
"At the same time, stress causes sluggish lymphatic drainage, it affects the digestive system, circulatory system, and pretty much efficient functioning of all body systems because the brain is distracted and focusing on responding to danger signals from the nervous system. Enzymatic activity in the skin is raised and dysregulated, this leads to persistently stressed skin in the form of rosacea."
What causes rosacea?
Kerr says that the causes of rosacea are not 100% certain, with some experts thinking it is a 50/50 split between genetics and environmental factors. “What we know is that it is a much more common condition in fair skin and in skin that naturally blushes, even from a very young age,” she explains.
“I treat a huge number of rosacea clients in clinic and when I ask somebody if anybody in the family has had it, generally they tell me that either mum or dad suffers with it. Some clients don’t even realise it might be a genetic thing, so I ask them: does your mum or dad’s skin flush? Have you noticed skin thickening on their nose? You need to ask your clients these key questions.”
Abbas adds, "Despite rosacea being a common skin concern, the butterfly shaped inflammatory rash, which is more visible in paler skins, doesn’t have a known cause. It is associated with a disrupted skin barrier function and responds to many internal and external triggers."
Is rosacea really caused by alcohol?
The short answer is no; however, there is a correlation, as Dr Catherine Carney from Private Rehab Clinic Delamere explains. "Although not a direct cause of the long-term chronic condition, reducing alcohol intake will have an impact on reducing the amount of or severity of flare ups," she says.
“Alcohol is a known trigger of rosacea flare ups as alcohol causes blood vessels to dilate, meaning that more blood flows through, leading to the red appearance of the skin around the face. Certain alcoholic beverages are thought to cause more severe flare ups of the condition, with red and white wine being the most common triggers."
What are the common symptoms of rosacea?
Persistent redness is one of the best known symptoms of rosacea and it commonly appears across the cheek area, but that’s not all, as Kerr explains. “Rosacea is an oily skin condition which is what people don’t tend to realise. They just think of it as being sensitive skin but often you’ll find that people who have it will have suffered with acne in their teenage years,” she says.
“Rosacea is activated by oil and this causes a lot of inflammation – you see a lot of vascularity in the skin, and it often starts with flushing, redness, and/or persistent redness and tingling in the cheeks. Broken capillaries are also a common symptom, which you might see in the corner of the client’s nose or across the cheeks. Those are the first couple of stages, then you start to get the papules and pustules.”
However, the symptoms will vary from client to client and you need to be aware of that when treating customers in salon. “Experts tend to talk about the stages with rosacea – stages one to four (pre-rosacea, mild rosacea, moderate rosacea and severe rosacea) – but I don’t think stages is the correct term because clients don’t necessarily start at stage one and progress to stage four,” explains Kerr.
“You may have a customer suffering with symptoms in stage one and two, who then progress further in those two stages more severely, or another client who might just have stage one and three and have it super mild.”
How can I treat rosacea in my beauty salon?
“We recommend that therapists conduct an in-depth consultation to include key questions regarding the clients concerns and expectations from their treatment.” shares Lauren Evans, CACI training officer.
“Truly listen to your client’s needs, ask them about their lifestyle habits and current skin care routine to help decide the best treatment and product recommendations for them.”
Kerr adds, “Rosacea is a condition that generally does progress – it can go into remission or disappear at times, but it will come back. Unless you’re treating it, it tends to get worse. As a therapist, you want to prevent the progression because it’s much harder to claw it back when rosacea has progressed to the later stages.
“With rosacea, the key thing is to make sure your client has a really strong barrier function, so work to strengthen it to prevent transdermal water loss (the evaporation of moisture from the skin), which will help with hydration and make the client’s skin glow more.”
Kerr also advises working to inhibit oil production, which will help to minimise inflammation. “I want rosacea clients to have a really healthy skin cycle, so I get them on a regime which is going to do all these things. I often get them on a retinol to regulate all of the above, helping to thicken and strengthen the skin.
“Then I look at things in 12 weeks’ time, which is two skin cycles, assessing: do we need to go any further with treatment? Do we need to step it up a gear? Or do we need to do a referral to a dermatologist or a GP? For example, say I’ve corrected the papules and pustules but the client has still got some underlying redness and broken capillaries, then I would look (after two skin cycles) at using more advanced treatments like lasers, lights or IPL.”
Consultant dermatologist Professor Firas Al-Niaimi agrees that laser treatments are a great option when it comes to treating rosacea, adding, “Advances in laser technology in terms of how the energy and pulse of the light is delivered means we can now treat rosacea very effectively and with little to no downtime.”
He suggests layering treatments for maximum result, adding that “laser treatment can be combined with other treatment modalities such as creams, tablets or even microbotox injections.”
Abbas uses Byonik PTL laser treatments and adds, "These are focused on maintaining skin health and restoring a disrupted barrier function without causing any thermal damage to the skin."
“They use the trinity of cold laser light, bioengineered hyaluronic acid-based gels and transmembrane convection to help restore cells to healthy function and calm down inflammation."
LED therapy is also a great option for treating rosacea, with Evans adding “Rather than focus on the lifting and tightening effects of microcurrent, we [at CACI] focus on rejuvenating the skin by delivering LED light therapy using red and blue light.
“Red LED light promotes tissue healing, while blue LED light has an antibacterial and calming effect on inflamed or sensitised skin, particularly beneficial. A slow alternating LED mode is effective at treating rosacea. A course of treatments is recommended for optimum results.”
What ingredients are best to use on rosacea clients?
“Salicylic acid will help control oil production, but you also want clients to exfoliate, which a lot of people with an inflammatory skin condition are quite frightened of doing. When you speed up cell turnover, you speed up cell function too, so when people aren’t exfoliating, they’re accumulating dead cells on the surface which leads to dull skin,” explains Kerr.
“However, anything can get in when you exfoliate, which makes the skin more on edge – the inflammatory systems within the skin are on high alert, so the client’s complexion will become more easily inflamed. Strengthen that barrier and follow it with application of lots of antioxidants and sun protection, as the sun is a big trigger for rosacea. Clients also need to look at their diet and alcohol intake as all of these things are triggers for the condition.”
What treatments should I avoid using on rosacea clients?
“I would be very careful with exfoliation, especially microdermabrasion,” says Kerr. “A lot of advanced treatments are actually very beneficial for rosacea as long as the skin is strong, resilient and prepped. You need to make sure the skin is calm and functioning beautifully first and foremost, then you can boost it further with peels or microneedling, which can help with healthy cell turnover and to refine the skin’s texture.”
When should you refer rosacea clients to a GP or medical practitioner?
“It depends on the severity of the rosacea. I also take into account their emotions as well as the physical symptoms. For example, If you have a client who just has some redness, flushing, and a few broken capillaries and spots, then I can treat that in clinic, but if the client has got thickening of the skin tissue, lots of breakouts which happen repetitively and really enlarged pores, then this is more long-term damage that we’d like to prevent, so I would recommend a referral to a GP,” says Kerr.
“I also give clients the opportunity to choose the best course of action for them: I say, ‘we can refer you now; or we can try and treat you in clinic and then refer you if we don’t see the results we want; or we can do both – I can refer you to a GP and treat you in clinic as I know how rosacea medications work, so I will be able to treat you safely alongside any prescribed medication.”
Working in partnership with a medical professional could be the perfect combination for some clients, providing the best of both worlds. “Often, when clients see medical professionals for these sorts of things, they are just treating the disease and the symptoms of the disease, they’re not looking at the overall skin health, which is where our expertise as facialists come in,” explains Kerr.
“The skin is our body’s biggest organ, so we need to check it is functioning well, and that every cell type within it is functioning right, so the client has skin that looks beautiful and is less likely to have disease. I believe in the three-prong treatment approach – clinical, medical and skincare. Find out about the medical treatment of rosacea so you can work alongside a GP to help complement what they’re doing.”