Perhaps the most important thing to know about this disorder is that a good dermatologist can change your life. And here’s how you know you have a doc who’s truly looking out for your best interests: She doesn’t jump to write you a prescription for antibiotics.
She prefers to try other solutions first, like prescription topical medications or supplements. So many rosacea patients are overprescribed antibiotics, which can help in the short term but come with risks, including intestinal infection; death of good bacteria; stomach upset; skin sensitivity to light; headaches; ringing in the ears; and, of course, antibiotic resistance.
According to the Centers for Disease Control and Prevention, antibiotic resistance is becoming “one of the world’s most pressing public health threats.” Dermatologists in the United States write up to 4 million topical antibiotics and up to 9 million oral antibiotic prescriptions per year for inflammatory and infectious diseases (most are tetracycline antibiotics). But rosacea can be effectively treated without antibiotics.
What is Rosacea?
Rosacea is a common, chronic inflammatory skin problem that affects the face primarily. It’s characterized by facial flushing, redness and bumps in a symmetrical distribution, and acnelike breakouts in some of the flushed areas. People also complain of extreme sensitivity to environmental triggers, such as sun, wind, hot liquids, spicy foods, and facial cleansers and soaps. Women get it more than men, but men will often progress to more advanced stages, perhaps because they are less likely to seek treatment.
There are four subtypes of rosacea: acne rosacea (papulopustular), which is acne along with rosacea; vascular rosacea (erythematotelangiectatic), which is characterized by enlarged small blood vessels in the facial skin that may appear to be broken (also called telangiectasias); ocular rosacea, which impacts the eyes leading to dryness, redness, and swelling; and phymatous rosacea, a severe form that causes visible thickening of the skin, especially around the nose, enlarged pores, and oily skin.
Experts aren’t sure what causes rosacea, but it may be genetic, some kind of sensitivity to environmental triggers, a bacteria—or some combination of all three. (Some researchers believe that Helicobacter pylori, the bacterium that’s been linked to ulcers and cancer in the gastrointestinal tract, may also increase the risk of rosacea, but this is very controversial and hasn’t been proven.) Unfortunately, there are no specific laboratory tests for rosacea; your doctor will diagnose it based on an exam and your complaints.
Natural Remedies For Rosacea
1. Niacinamide (vitamin B3 or nicotinamide) combination see dosage information below
Vitamin B3 can take two forms: niacinamide or niacin (also known as nicotinic acid). However, only niacinamide has anti-inflammatory properties that may help several dermatologic conditions, including rosacea and acne (see the Acne section).
Make sure you don’t get them confused when you’re perusing store shelves. In a trial known as NICOS (the Nicomide Improvement in Clinical Outcomes Study), a dietary supplement formula containing niacinamide (750 milligrams), zinc (25 milligrams), copper (1.5 milligrams), and folic acid (500 micrograms) reduced the severity of rosacea (and also acne) and improved facial appearance after 4 and 8 weeks of daily use. In fact, it appeared to work as well as antibiotics! (Some people may experience nausea and stomachache, so take it during or right after a meal.)
The NICOS trial was groundbreaking for rosacea because for many years there was skepticism about how well it could be treated without antibiotics. I’ve seen this supplement combination work with patients, and it can even be used with conventional topical treatments (like azelaic acid), so by all means, start with this before going the antibiotic route. I’ve had patients see reduced redness and faster skin healing with a 2 percent niacinamide facial moisturizer as well.
The exact product used in the NICOS trial, called Nicomide, is available, but you have to ask your doctor about it, or you can make your own version, which is pretty inexpensive to do. There is also a prescription dietary supplement known as NicAzel that contains nicotinamide, azelaic acid, zinc, B6, copper, and folic acid. It reduces acne and scarring and accelerates healing, based on the NICOS results (look for a product called NicAzel Forte).
2. Azelaic acid topical cream 3 to 10 percent concentration
Prescription-strength (15 to 20 percent) azelaic acid, an anti-inflammatory, has a long, successful track record for rosacea, but the jury is still out on over-the- counter formulas (3 to 10 percent concentrations).
I’ve seen this lower-dose plant-based supplement—which is found naturally in wheat, rye, and barley— work, and it’s a good option for people who find the higher concentration to be a little too harsh. There just needs to be more extensive testing. Plants use azelaic acid as a warning signal when they’re invaded or infected. It triggers the release of salicylic acid and other defense compounds to attack the pathogen, and scientists think it may work similarly in humans; it’s essentially an antimicrobial. Apply it every 6 to 8 hours (no more than three times a day) until the redness begins to fade.
3. Omega-3 fatty acids and omega-6 fatty acids dosage varies by type
Researchers now know that omega-3 and omega-6 supplements may be effective for treating dry eye (see the Dry Eye section). The ocular form of rosacea causes dry eye problems along with inflammation, and although these supplements haven’t been studied for ocular rosacea, they work well for related conditions, so in this case the benefit exceeds the risk. (It’s also worth asking your dermatologist if you can try omega-3s or omega-6s for facial redness and dryness.)
Omega-3s: Flaxseed oil can be taken as a dietary supplement softgel, but you would need to take six or seven a day to get the 3,300-milligram-per-day dose that has shown anti-inflammatory benefits for the eyes in studies. It’s much easier to just take 1 or 2 tablespoons daily of flaxseed oil (my favorite is Omega Swirl from Barlean’s). Alternatively, you could take 800 to 1,500 milligrams (one or two pills daily) of the active ingredients in marine or fish oil (EPA and DHA omega-3 fatty acids); Omega Swirl also has an incredible-tasting fish oil option.
Omega-6s: If you are allergic to marine products, prefer not to take them, or aren’t seeing enough benefit from omega-3s, you can take 200 to 300 milligrams of gamma-linolenic acid (GLA), which is an anti-inf lammatory omega-6, and 100 to 200 milligrams of linoleic acid (LA), another omega-6, in the form of evening primrose oil, black currant oil, or even borage oil. That’s the equivalent of one or two softgels a day from most companies. We’re often told that omega- 6 fatty acids are bad for us because they create inflammation, but this is a gross generalization. Some omega-6 compounds have anti-inflammatory effects when used in the moderate dosages recommended in this section, which is why they are potentially effective for the treatment of ocular rosacea.
I recommend combining omega-3 and omega-6 supplements only if your rosacea does not improve in 3 months of taking either type on its own.
The benefit in combining them is that they fight inflammation in different ways, so it’s possible for someone who’s not responding to omega-3 supplements to get a better response from omega-6s and vice versa; and some people do better with both. It’s like taking aspirin or ibuprofen: Both reduce inflammation and pain, but in some individuals one works better than the other or the combination works better than either one alone.
Regardless, many sources of omega-3s (like f laxseed) also contain some omega-6s and vice versa, but larger doses are often needed to really see a benefit. If you want to combine them, try taking either 750 to 1,000 milligrams of fish oil or 1,000 milligrams of flaxseed oil plus up to 100 milligrams of GLA or 150 milligrams of LA.
What Are Useless For Treating Rosacea?
If I had a dime for every call I’ve gotten from someone who thought they had rosacea, only to discover this person was taking niacin, I would be so rich I could buy an island. This is a popular supplement for managing cholesterol, although recent evidence has begun to question whether it’s truly beneficial. Regardless, niacin causes facial flushing in doses as low as 50 milligrams, and this can give the appearance of rosacea or temporarily make it look worse.
In a recent clinical trial, individuals with rosacea took 220 milligrams of zinc sulfate twice daily for 90 days, and researchers found that it worked no better than a placebo. Although an earlier study of zinc sulfate (100 milligrams three times daily) appeared to help rosacea, this recent research, along with the potential for side effects (such as nausea) at these larger dosages, makes this difficult to recommend.
Curcumin and capsaicin
Because these supplements have anti-inflammatory properties, some people are taking them for rosacea, but more research is needed, plus they can cause gastrointestinal problems, like stomachache. Remember, when there is no research, my rule is first do no harm. (I got that little tidbit from some dude named Hippocrates, who also said “Let food be thy medicine.”) Also, keep in mind that capsaicin is the active ingredient in hot chile peppers, and heat-generating compounds can only make the redness of rosacea worse.
Other Natural Treatments For Rosacea
Try limiting carbs
Recent studies linking low-carbohydrate diets with a reduction in duration, frequency, and severity of acne have come as a surprise, and I suspect researchers would potentially find similar benefits with rosacea.
Here’s a soapbox moment: With everything that’s known about rosacea being an inflammatory disorder with numerous environmental triggers, you would think there’d be a plethora (my SAT teacher would be proud of me for using that word) of studies exploring the connection to diet and lifestyle, but there aren’t. So if any of you readers are planning on going into dermatology, initiate a diet- and-rosacea study and you will be famous.
Go retro with sunscreen
You definitely want to protect your skin from the sun if you have rosacea, but the newer sunscreen formulas with chemical blocking agents (avobenzone, oxybenzone, etc.) can be irritating to skin, so stick with “older” products that have physical blockers that aren’t absorbed as easily, such as zinc oxide and titanium dioxide. This is one area that has seen extensive research, and it’s striking how many sunscreens cause sensitivity and irritation in those with rosacea.
Identify your triggers—and avoid them
There are all sorts of things that can cause rosacea, including emotional stress, sun, hot or cold weather, wind, hot liquids, spicy foods, facial cleansers and soaps, heavy exercise, and alcohol (the National Rosacea Society has found that red wine may be a greater trigger than other alcohols).
Up your fiber intake
There is a small amount of evidence suggesting that the faster food moves through the gut, the less chance there is for it to cause facial flushing or irritation. Fiber (25 to 30 grams per day) can help speed up transit time through the intestinal tract. Look at it this way: Even if it doesn’t improve symptoms, it can help reduce inflammation in general. Fiber also functions as a prebiotic, so it helps improve healthy bacteria colonization in the gut. I have seen many rosacea patients get better after increasing fiber intake.
Slather on oats
Colloidal oatmeal has historically been used to treat itching and skin irritation because it soothes inflammation. It’s available over the counter and there’s minimal risk to trying it.