The Role of Skin Care in Optimizing Treatment of Acne and Rosacea

Catherine Zip, MD, FRCPC

Disclosures

Skin Therapy Letter. 2017;22(3) 

In This Article

Rosacea

As is the case with acne, proper skin care is an important component of the management of rosacea. A triad approach to rosacea care has been suggested, which includes treatment, patient education regarding triggers, and advice as to appropriate skin care and cosmetics.[15] In a questionnaire sent to over 7000 individuals registered in the Canadian Rosacea Awareness Program, respondents expressed a strong interest in receiving more information on skin care, makeup and psychological aspects of rosacea.[16]

The involved skin of rosacea has been shown to exhibit increased transepidermal water loss due to impaired epidermal barrier function.[17] Rosacea prone skin is also hyper-reactive; cutaneous insult results in prolonged vasodilation, exhibited clinically as facial erythema. Furthermore, the presence of an impaired stratum corneum barrier increases the irritancy of skin care products by enhancing penetration into the skin. Hence, skin care practices that optimize barrier function should be recommended.

Cleansing

Although skin cleansing is an important component of general skin care, surfactants contained in skin cleansers can weaken epidermal barrier function by disrupting proteins and lipids in the stratum corneum.[18] Given the fact that patients with rosacea have impaired barrier function and a higher susceptibility to irritants, including sodium lauryl sulphate, mild cleansing is important.

The type of surfactant in the cleanser as well as its hydrogen ion concentration (pH) are major factors contributing to the irritant potential of a cleanser.[18] Mild cleansers include synthetic detergents (syndets) and lipid-free cleansers. Syndet liquid cleansers or bars contain synthetic detergents and less than 10% soap. They have a favorable pH (5.5–7) and provide effective cleansing with less irritation potential than true soaps. Lipid-free cleansers have a neutral or slightly acidic pH. They are effective cleansers that leave a moisturizing film on the skin but do not lather.

Studies have shown benefits of mild cleansing in patients with rosacea. In a 4-week randomized, double-blind study of 70 patients with moderate rosacea who were using metronidazole 1% gel, subjects were instructed to use either a soap bar or a mild syndet bar. Use of the syndet cleanser reduced dryness, burning, stinging and itching compared to use of the soap bar.[19]

In addition to recommending an appropriate cleanser, physicians should advise rosacea patients to wash with lukewarm water, as hot water causes vasodilation and increased facial erythema. Mechanical trauma to the skin should also be minimized, including avoidance of granular exfoliants.

Astringents and toners, which are typically applied after cleansing, should likewise be avoided, as they tend to increase erythema and remove desirable oil from the skin.

Moisturizing

Use of appropriate moisturizers has several potential benefits in the management of rosacea. As rosacea skin has been shown to have increased transepidermal water loss, use of an emollient may improve barrier function and reduce dryness. Improved barrier function may also lead to reduced skin sensitivity and improved tolerance of topical medications.[20]

Regarding choice of emollient, those containing potential irritants such as urea, glycolic acid, lactic acid, menthol and camphor should be avoided. Although the barrier dysfunction associated with rosacea may potentially increase allergenicity of skin care products, minimal data is available on the prevalence of contact allergy in rosacea patients.[21] However, as fragrances can cause both irritant and allergic reactions, fragrance-free products should be recommended. Cream type moisturizers are generally preferred over thin lotions and gels.

Sun Protection

Daily sun protection is an important component of rosacea management. Sun exposure is a common trigger of acute flares of rosacea, and chronic photodamage may also contribute to the pathogenesis of rosacea.[22] Acute ultraviolet light may aggravate rosacea by stimulating proinflammatory peptide production, reducing cutaneous antioxidant reserves, and increasing production of reactive oxygen species.[23] However, finding a welltolerated sunscreen can be difficult for rosacea patients. Selecting a cream based product containing an inorganic ultraviolet light filter and a silicone derivative, such as dimethicone orcyclomethicone, may reduce the likelihood of irritation.

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