Rosacea treatment

Rosacea is a consequence of problems in the gastrointestinal tract and refers to diseases dealt with by gastroenterology.

For 2018, if topical drugs are ineffective, oral antibiotics, especially tetracyclines, become the basis for treatment.

For 2018, according to international recommendations, the gold standard of therapy for this dermatosis is metronidazole derivatives, antibiotics and retinoids. Domestic recommendations regarding systemic therapy of rosacea are generally similar to international ones, somewhat differing in dosage and/or frequency of drug administration:

• tetracyclines - doxycycline 100-200 mg, 1 times a day;
• erythromycin - 250 mg, 4 times a day;
• clarithromycin - 500 mg per day;
• metronidazole - 1.0-1.5 gr per day^[1]).

However, long-term antibiotic therapy cannot be considered as an ideal treatment option due to possible side effects and the potential development of antibiotic resistance. Therefore, the focus was again on the role of modifiable lifestyle factors, including nutrition.

It is well known that certain foods can act as triggers for the development of rosacea. Research has even suggested certain mechanisms by which other foods may be useful in this disease. Dietary change can become an important component of rosacea therapy through the study of the pathogenesis of the disease.

Causes of rosacea

Main article on the disease: Rosacea

As of the beginning of 2022, the main cause of rosacea in 80% of cases is gastritis, accompanied by the presence of Helicobacter pylori and reduced stomach acidity. Successful treatment of rosacea consists in a systemic approach, namely working with the bile-liver-pancreas-acidity axis.

Analyses

At the beginning of 2022, the following analyses were recommended:

• analysis for Helicobacter pylori - this can be done by a breath test;
• checking the acidity of gastric juice (can be with betaine capsules or a soda test);
• checking for gastritis in a gastroenterologist;
• scraping for the presence of demodex;
• collagen level check (total protein and albumin test passed).

In 2022, it was also recommended to diagnose:

• liver and gallbladder enzymes;
• the presence of duodenitis, cholecystitis, pancreatitis, etc.;
• intestinal flora for harmful bacteria and fungi, thrush, cystitis,
• allergic and autoimmune diseases.

Relationship between digestive system and skin

Rosacea patients have an increased risk of gastrointestinal (GI) disease. Studies indicate a possible role for the relationship between GI and skin in the development of rosacea. According to a population-based cohort study of approximately 50,000 Danish patients with rosacea, celiac disease, Crohn's disease, nonspecific ulcerative colitis, Helicobacter pylori infection (HPI), small intestine bacterial overgrowth (SIBO), and irritable bowel syndrome were more common among rosacea patients compared to controls^[2].

Other researchers also considered this association, however, conflicting results were noted in different groups and different conditions.

Several studies have observed an increased prevalence of HPI in patients with rosacea^[3]-^[4]]. H. pylori is a Gram-negative bacterium responsible for the development of chronic gastritis, gastric and duodenal ulcers, and gastric adenocarcinoma. A number of studies have reported improvement in rosacea symptoms following eradication of H. pylori ^[5][6][7]. However, it is rather difficult to establish a pathogenetic link, since antibiotics are used in the treatment of both diseases.

Two separate studies reported an increased incidence of SIBO in rosacea patients, although a prospective study by Gravina et al. did not confirm these results.

The relationship between inflammatory bowel disease (IBD) and rosacea is also of interest to researchers. In a Taiwanese cohort study among 89,000 patients with rosacea, there was an independent increase in the frequency of IBD compared to the control sample. This relationship was confirmed by the Danish study by Egeberg et al, as well as a prospective study by Li et al. among residents of the United States. Moreover, IBD and rosacea may share the HLA class II histocompatibility gene DRB1 * 03:01.

Clinically, patients with rosacea and symptoms of GI involvement should be referred to a specialist for further evaluation. Infection with H. pylori and SIBO can be established by non-invasive laboratory testing of urine and feces or by a respiratory test. In particular, SIBO can be detected by a breath test with lactulose and H2/CH4 glucose, although reports indicate a wide range of sensitivity and specificity of these tests. Similarly, H. pylori can be identified by a non-invasive urease respiratory test, fecal antigen testing, and serum or urine antibody assay. In particular, the urease respiratory test is highly sensitive.

Although studies on GI effects in rosacea therapy are insufficient, such treatments may be promising for further study given the evidence of a GI-skin relationship. These data also suggest that nutritional adjustments to reduce the risk of gastrointestinal comorbidities may be included in standard guidelines in the future.

Gastrointestinal Tract - Treatment Goal for Rosacea

The link between gastrointestinal pathology and rosacea is quite interesting as it suggests new opportunities for therapeutic intervention. In one study, rosacea patients were found to be 13 times more likely to develop SIBO. The researchers suggested that circulating cytokines, especially TNO- α, play a role in the increased occurrence of this disease in rosacea. Antibiotic therapy with SIBO led to rosacea remission in 40 patients in all cases. What is even more remarkable - in most cases, remission persisted throughout the three-year follow-up period.

In addition, SIBO was often accompanied by intestinal hypokinesia. According to a report of one of the clinical cases, a reduction in intestinal transit time for a fiber-rich diet resulted in reduced symptoms of rosacea, indicating another promising area of research.

Prebiotics, probiotics and the role of intestinal flora

Considering the increased risk of gastrointestinal diseases in rosacea, it is necessary to conduct a study of the role of intestinal microflora in the pathogenesis of this disease. The role of intestinal microflora is an area of study for a variety of inflammatory skin diseases. Synbiotics are a combination of prebiotics and probiotics, substances that support healthy intestinal microflora. A meta-analysis of published randomized controlled trials (RCTs) of atopic dermatitis (BP) found that the use of synbiotics for at least eight weeks significantly reduced the severity of BP symptoms. In 2017, research is underway on the use of synbiotics in other inflammatory skin diseases.

Microbiome

Main article: Microbiome

Many studies focus on the gut microflora, known as the microbiota, along with its individual genes (the microbiome).

The composition of intestinal microflora has been found to play a role in the pathogenesis of rosacea. According to one theory, intestinal dysbiosis leads to the activation of the kallikrein-kinin system of blood plasma, causing further neurogenic inflammation. Some authors suggest that this may partly explain the efficacy of antibiotics in rosacea therapy. Although the microbiome represents a significant target for therapy, it is important to consider how large the inter-individual variability of the gut microbiome is. These differences can be attributed to a variety of factors, including heredity, nutrition, environmental exposure, hygiene, and other indicators. The composition of the gut microbiome is significantly different in different regions, which requires further study of human intestinal mycoflora across the global community.

Nutrition correction to maintain healthy intestinal microflora

Prebiotics and dietary fiber

Recommendations for maintaining healthy intestinal microflora include eating fiber-rich foods. Many dietary plant fibers act as prebiotics. Prebiotics are indigestible food ingredients that selectively stimulate the growth and/or activity of beneficial GI microorganisms. Studies show that eating enough different dietary fiber will contribute to the growth of a diverse and healthy gut microbiota.

Studies show that the effect of nutrition on the microbiome can manifest itself extremely quickly and unexpectedly. The lack of dietary fiber has been linked to detrimental effects on the intestinal flora and the gut itself. In one study, in the intestines of mice that received food without fiber, pathogenic bacteria began to proliferate actively. These bacteria subsequently began to digest the intestinal mucosa. In contrast, a plant fiber-rich diet promotes the growth of beneficial microflora. This beneficial microflora has been shown to support gut and skin health in various ways.

Probiotics

The growth of beneficial microbes in the gastrointestinal tract can be stimulated by special nutrition. In addition, they can enter the body as probiotics. The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) define probiotics as "living microorganisms that, when administered in sufficient quantities, benefit host health."

Probiotic products and supplements deserve more detailed consideration, but for 2017, their impact on rosacea in clinical studies has not been studied enough. These include fermented foods, the key component of which are live active microorganisms. These are products such as:

• yogurt,
• kefir,
• miso,
• kimchi and
• sauerkraut.

A number of retail probiotic foods have been developed to which live microflora is added additionally, however studies show that many contain fewer microorganisms and their composition is less diverse. A number of probiotic additives are also sold, significantly different in dosage, composition and variety of microorganisms.

Further studies are needed to determine the optimal doses and strains of microflora, as well as to assess the viability of microorganisms admitted to the gastrointestinal tract. Despite encouraging results in other inflammatory skin diseases, no clinical studies of rosacea had been conducted by 2017. However, the researchers suggest what potential mechanisms of action for probiotics might be useful in treating rosacea. First, probiotics change the composition of the intestinal microflora and help resist pathogenic bacteria. Gut microbiota imbalance has been associated with both IBD and other chronic diseases. Studies have shown an anti-inflammatory effect of probiotics, such as reducing T cell-mediated skin inflammation in mice after oral probiotics. In addition, in vitro incubation of metabolites of a particular probiotic strain prevented both uncontrolled and stress-induced ROS formation. Finally, probiotic bacteria can affect the barrier function of the skin. In one RCT, the use of an oral probiotic led to stabilization of the barrier function of the skin and a decrease in its sensitivity in humans.

Given the similar effect of probiotics on the skin, as well as their estimated effectiveness in other inflammatory skin diseases, it is recommended to conduct further studies of their clinical use.

Individual nutrients

For 2017, there is no conclusive evidence to suggest that certain nutrients can ease the symptoms of rosacea. However, promising results from several studies support the need for further study of omega-3 fatty acids and zinc.

These products have an anti-inflammatory effect and generally have a positive effect on the condition of the skin, improving its elasticity and leaving it hydrated. Zinc, on the other hand, is an indispensable element for cell regeneration and repair.

Omega-3 fatty acids are polyunsaturated fatty acids and include eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), and alpha-linolenic acid (ALA). Because EPA and DHA are substrates for producing anti-inflammatory prostaglandins that competitively inhibit pro-inflammatory pathways, they have been studied in a variety of diseases. Their use in rosacea has not been studied sufficiently, although one RCT using 325 mg EPA and 175 mg DHA twice daily for three months found statistically significant improvement in patients with dry eye symptoms, some of whom suffered from rosacea.

The use of zinc preparations in rosacea has not been studied sufficiently. Zinc is a fundamental element for the development of cellular innate immunity and acts as an antioxidant and anti-inflammatory. Studies on the use of zinc in rosacea have yielded conflicting results. While one study showed significant improvement with 100 mg zinc sulfate three times a day, the other showed no statistically significant difference after 90 days of administration of 220 mg zinc sulfate twice a day.

Elimination of low stomach acidity

If vessels need to be treated with cuperosis, rosacea - the stomach and intestines. You should work with a gastroenterologist: eliminate hypoacidity (low acidity of gastric juice), restore microflora and intestinal mucosa^[8]. More often, this is solved not so much by drugs as by nutrition.

Strengthen the vessels: the use of vitamin C and K2, rutin, curcumin/berberin, methylsulfonylmethane/astaxanthin, resveratrol should be coordinated with the doctor.

Some doctors may prescribe roaccutane. Don't do it unless it's the last degrees of rosacea.

Diet

Recommended products

• poultry meat,
• sauerkraut (preferably self-made) - three times a week 150-200 gr as a salad (vitamin C)
• fish, it is better to bake in the oven with dill, celery, thyme and salt a little.

It is recommended to include probiotic and prebiotic foods in the diet as well. These are:

• immature cheeses,
• yoghurts,
• kefir,
• soy milk,
• pickled vegetables and fruits,
• bananas,
• chicory,
• cabbage,
• lentils and
• green grains^[9].

The diet should include the so-called anti-inflammatory products, rich in minerals and as non-allergenic as possible. These are:

• asparagus,
• cauliflower,
• celery,
• green beans,
• pumpkin,
• cucumber,
• grapes,
• sweet potatoes,
• zucchini,
• greens^[9].

The list of products containing the right substances mentions^[9]:

• linseed, sunflower, sesame, pumpkin and ghee oil. Olive oil, known for its antioxidant properties, can also help alleviate the symptoms of rosacea.
• nuts (especially almonds and walnuts),
• fatty varieties of fish like mackerel, salmon and herring.

Is coffee healthy in the fight against rosacea?

In October 2018, the results of a study by scientists from Brown University in Providence, America, were published. Results involving 82,000 women showed that regular consumption of coffee, tea as well as chocolate, which contain caffeine, helps reduce the manifestations of rosacea. The lowest risk group was women who consumed at least 4 servings of coffee per day. At the same time, the use of decaffeinated coffee did not have any effect.

Experts have found that people who actively lean on coffee reduce the likelihood of inflammatory skin disease by 20%, compared to those who drink coffee no more than once a month. The authors of the study themselves are convinced that coffee has anti-inflammatory properties and narrows blood vessels, which reduces the redness of^[10]. Previous studies have long linked coffee to treatments for heart disease, cancer, dementia, diabetes and depression. The authors of the current study hope that they will provide another argument for drinking this beloved drink.

In May 2020, a team of scientists from Qingdao University in China led by Dr. Li Suyun (Suyun Li) conducted a study among 82,737 women to study the relationship between the risk of rosacea and caffeine consumption.

The group of subjects was formed in 1989 and was examined every two years from 1991 to 2005. All analyzes were carried out from June 2017 to June 2018. The results are published in the journal JAMA Dermatology, reports Change.

As a result of the study, scientists recorded 4,945 cases of the disease and, after analyzing the date of diagnosis, the amount of caffeine in the foods consumed, and also found a significant inverse association between the risk of rosacea and an increase in caffeine intake - in particular, from coffee. Such a connection with other sources of caffeine (tea, chocolate) has not been identified.

The study found that the ratio of probability of occurrence of rosacea in those who consumed four or more portions of caffeinated coffee per day to probability of disease in those who drank the same amount of caffeine less than once a month was 0.77^[11].

The researchers emphasize that their findings cannot be a preventive strategy to prevent the development of the disease, but will help to study and explain the association of caffeine with rosacea subtypes.

Contraindicated products

Reduce consumption:

• cakes, cakes, cupcakes
• alcohol.

In 2021, the adverse effects of rosacea were mentioned:

• soy sauce,
• vanilla^[12].

In 2023, it was recommended to reduce consumption:

• cheese,
• Meat^[13].

Getting rid of the Demodex folliculoruma tick

It is recommended to start the treatment of rosacea with antidemodecotic therapy (see Demodex folliculorum tick), for which the following is used:

• liquid nitrogen,
• treatment according to the method of Mikhail Demyanovich and
• Seronodegtar alcohol^[14].

In 2023, if a demodex tick was detected as prescribed by a dermatologist [4] , sulfuric-salicyl ointments, metronidazole preparations, 20% benzyl benzoate solution, benzyl benzoate cream, Sprégal aerosol were recommended (treat a cotton swab and wipe the facial skin). Prescribes a doctor.

Medicinal ingredients

Dacarcide

In 2024, Dacarcid ointment[5] with a simple composition, including tar and sulfur, was mentioned as an effective agent for the treatment of rosacea^[15]. According to preclinical studies conducted at JSC Retinoids, the experimental drug D-18 has a low degree of toxicity, which indicates its increased safety^[16].

1% oxymetazoline hydrochloride cream

New at the beginning of 2021, a topical agent that has been approved for the treatment of facial erythema is 1% oxymetazoline hydrochloride cream. It is an alpha-1a adrenergic receptor agonist that is used to treat moderate to severe persistent facial erythema in patients with rosacea. At higher concentrations, it also binds to alpha-2-adrenergic receptors.

Bauman et al followed patients with facial erythema on oximetazoline cream for 29 days and concluded that topical oximetazoline was a safe and effective treatment for moderate to severe facial erythema once daily.

Tangetti et al have demonstrated that oxymetazoline is effective in reducing facial erythema from the first hour after its initial use. Thus, oxymetazoline cream is an effective and easy-to-use alternative for topical use in the treatment of resistant facial erythema with its single daily regimen of use^[17]

2017: Allergan receives FDA approval for Rhofade cream

Oxymetazoline (oxymetazoline) is a synthetic, direct-acting, imidazoline sympathomimetic agonist highly selective for _α1A adrenoreceptor (ADRA1A) and partially selective for _α2 (ADRA2). Oxymetazoline is a strong vasoconstrictor of the skin microvasculature.

Back in January 2017, Allergan was granted approval by the US Food and Drug Administration (FDA) for Rhofade (oxymetazoline) cream for topical use against chronic facial erythema (facial redness) associated with rosacea (pink acne) in adult^[18]

By this time, for decades, many topical over-the-counter drugs of the class of _α1 adrenoreceptor agonists have been available that can relieve erythema by relieving redness: phenylephrine (phenylephrine), naphazoline (naphazoline), tetrahydrozoline (tetrahydrozoline), xylomethazoline (xylometazoline). They are used with might and main as anticongestants in the therapy of allergic rhinitis and allergic conjunctivitis.

The efficacy and safety of Rofade were tested in two identical phase III clinical trials of NCT02131636 and NCT02132117 (randomized, double-blind, placebo-controlled), covering adult patients (n = 885) who were prescribed an experimental cream or placebo once daily for 29 days. The primary endpoint was defined by the proportion of subjects with a reduction in erythema of at least 2 points according to the Erythema Clinical Assessment Scale (CEA) and the Self-Reported Scale (SSA) at Hour 3, 6, 9 and 12 on Day 29 of treatment. In the drug group, a significantly larger number of patients recorded improvements in two scales at once.

Every year in the United States at this time 450 thousand laser therapies are carried out to eliminate pink acne. The novelty "Allergan" is quite capable of acting as a "more or less decent alternative."

For September 2020, doctors recommended five medicinal ingredients for the treatment of rosacea^[19]

Metronidazole 0.75% and 1%

The medicinal product for the external treatment of pink acne in rosacea is the antibiotic metronidazole (Metrogyl gel 1%, Rosamet). Depending on the severity, the patient may need it in combination with another drug.

Metronidazole can reduce oxidative stress, discoloration and inflammation. It comes in the form of a lotion, cream or gel. Side effects of metronidazole, such as dryness, irritation and itching, are usually minor.

Azelaic acid 15%

15% azelaic acid is used to treat papulopustular rosacea. Azelaic acid acts by inhibiting the production of reactive oxygen species in immune cells.

It can be applied once or twice a day. Typical side effects include mild, short-term burning, and irritation^[20]

Although theoretically topical metronidazole and topical azeleic acid should treat erythema on a molecular basis, studies available at the beginning of 2021 show that they do not usually help in the treatment of erythema, especially if it has become resistant^[21]

In 2023, among the drugs with azelaic acid [6] , the cream and Skinoren gel were mentioned.

Albucid 10% and sulfur 5%

Solutions containing the two ingredients have been effective in the past, but are now the second line of treatment.

It is important to note that anyone with a sulfur allergy should not use it. In addition, many find the smell unpleasant, and some experience localized irritation.

Brimonidine 0.33%

Metronidazole and azelaic acid can reduce skin discoloration, but have little effect on color changes caused by permanently dilated blood vessels.

Brimonidine tartrate 0.5% gel is a topical agent approved for the treatment of transient and persistent facial erythema in patients with rosacea over 18 years of age. It is a potent vasoconstrictor that selectively binds to the alpha-2 adrenoceptors of the smooth vessels of muscle cells of the peripheral skin vasculature. Brimonidine constricts blood vessels on the surface of the skin, which can help with a persistent form of rosacea^[22]

Patients treated with topical brimonidine clinically show a 60-70% reduction in erythema with minimal side effects.

Some possible side effects include:

• irritation
• burning
• dry skin
• itch
• redness

As experts pointed out in 2021, brimonidine tartrate was used to treat some forms of glaucoma. It starts working after 30 minutes and ends its action after 9-12 hours^[23]

Therefore, a single appointment per day may not be enough, and may need to be applied twice a day. However, it is important to pay attention to the fact that due to the use of brimonidine, erythema may deteriorate. This side effect can be overcome by properly using protective creams and avoiding excessive use of brimonidine.

Ivermectin 1%

Ivermectin is used for treatment of papulopustular rosacea. Doctors believe that ivermectin in the treatment of rosacea attenuates inflammation by fighting pathogens and especially targeting demodex mites that occur in the skin of people with rosacea. 1% ivermectin can reduce the appearance of bumps and spots associated with rosacea. However, the cream can cause burning and irritation.

This drug works perfectly in the presence of inflammatory elements (papules, pustules), but redness can still remain.

Tetracycline antibiotics: isotretinoin and doxycycline

Some types of rosacea require treatment that goes beyond face creams and ointments.

Patients with papulopustular rosacea need tetracycline antibiotics such as doxycycline. Another oral drug that may be effective is isotretinoin (Accutan). Studies have shown^[24]isotretinoin works better than doxycycline.

In 2023, among the agents with antibiotics, in addition to tetracycline ointment [7] , erythromycin ointment, levomycetin alcohol, Zinerite, Dalacin, Erifluid were also mentioned.

Nadolol, propranolol and carvedilol

In addition to topical antihypertensive drugs, systemic antihypertensive drugs are used in the treatment of off-label facial erythema at the beginning of 2021. Beta-blockers can be used in the treatment of refractory facial erythema. Nadolol and propranolol, which are non-selective beta-adrenoreceptor antagonists, are effective in reducing hot flashes.

However, their use was abandoned due to possible side effects: hypotension and bradycardia. Carvedilol, a non-selective beta-adrenergic agent and alpha-1 antagonist, is the best alternative in the treatment of refractory facial erythema. When used at a dose of 3.125-6.25 mg 2-3 times a day, carvedilol leads to clinical improvement for 3 weeks without the side effects of nadolol and propranolol. Carvedilol differs from other non-selective beta-blockers in that its metabolites are potent antioxidants.

This feature further enhances its therapeutic efficacy in facial erythema. On the other hand, the use of calcium channel blockers in the treatment of facial erythema is not recommended as they may exacerbate the course of rosacea^[25]

Recommendations for avoiding bromine and iodine derivative drugs

In 2019, patients with rosacea were advised to abandon drugs containing bromine and iodine derivatives and be careful with topical steroids (taken to stop the exacerbation of the disease itself), non-steroidal anti-inflammatory drugs and proretinoids. The latter option is the most extreme, because proretinoids are quite toxic and, when taken, cause a lot of inconvenience to a person (dryness of all mucous membranes, a powerful effect on the liver up to a change in liver parameters in the blood).^[26].

For lesions of the rosacea eyelid, dermatologists recommend eyelid hygiene, topical cyclosporine, and topical or systemic antibiotics.

Clindamycin, permethrin

In 2022, therapy with topical erythromycin (2%), isotretinoin, clindamycin, permethrin, doxycycline, minocycline and oral erythromycin was also reported to have performed well. Combination therapy often helps to prolong periods without symptoms. In severe or refractory cases, systemic treatment with metronidazole, clarithromycin and azithromycin may be performed. When demodex is detected, permethrin or ivermectin cream and oral ivermectin may improve the therapeutic outcome^[27].

Steroids

A therapeutic problem for dermatologists is that there is a limited number of effective topical agents that can be used in the treatment of diffuse facial erythema in rosacea patients. Among them, topical steroids are very often used.

However, as of the beginning of 2021, skin atrophy is inevitable with topical steroids, and exacerbations are observed after discontinuation of therapy. For these reasons, topical corticosteroids should be avoided in patients with rosacea. Topical calcineurin inhibitors may in some cases help reduce facial erythema, but in most cases they do exacerbate rosacea^[28]

Enzymes, vitamins, folk remedies

Enzymes:

• festal,
• pancreatitis or something from this group,
• omesis.

De-nol (as a remedy against helicobacter).

A complex of vitamins of group "B" in a complex in one ampoule, preferably puncture them.

Experienced dermatologists recommend topically:

• erythromycin and tetracycline ointment, several times daily.
• find clean grass in an environmentally clean place, keep narwhum and keep it in the refrigerator in a cellophane bag: grind the 5-6 leaves together with the stalk into small particles and 100 gr. warm water for 2-3 hours and wipe the redness with this infusion. Do not buy pharmacy cleanliness, it is very strong and concentrated.

At the initial stages, lotions with a solution of boric acid and dumplings, which are prepared in pharmacies according to a doctor's prescription, help well. Hormonal preparations for external use give a quick positive effect, but not for long; they should be used in short courses under the supervision of a doctor.

It is possible to use folk remedies together with traditional medical procedures. It is better to start with lotions. Chilled decoctions, juices and extracts of calendula, chamomile, series can be used. Oat and kefir masks help with rosacea and cuperosis (vascular stars)^[10] to^[10].

A good prevention will be the toning of the walls of the vessels. It's very easy to do at home with ice cube massages. Freeze a decoction of chamomile, sage, string or green tea and perform ice cubes of movement from the center of the face to the sides for three minutes in the morning and evening. These are simple, but objectively effective recommendations^[29].

In May 2019, it is recommended to keep a food diary, use special care products containing vitamins PP, groups B, rutin, escin, gammamelis extract, centella, panthenol, copper. It is advisable to take vitamins and venotonics, avoid temperature changes. Essential oils of chamomile, immortal, myrrh, issop, cypress, rosewood, mastic pistachio, iris work perfectly.

It is also recommended not to do physical exercises with a lowering of the head, girls do not apply foundation during gym classes. All activities that strengthen the immunity^[30] are very^[30].

Apple cider vinegar

One of the remedies that can work wonders with the skin. Vinegar also helps with rosacea. It has the anti-inflammatory properties necessary to treat inflammation. Combine one or two tablespoons of apple cider vinegar with a glass of warm water and drink. You can also add some honey to the glass. It is recommended to consume it once a day before eating^[31].

Turmeric

This spice contains an active ingredient called curcumin, which has anti-inflammatory properties and can help relieve inflammation. It is recommended to mix a teaspoon of turmeric powder with a glass of water and drink. Turmeric can also be applied to affected areas of the skin by mixing the spice with yogurt. Do this once a day for the best^[32].

Ginger

It contains gingerol, which has anti-inflammatory properties to help reduce swelling, inflammation and redness. Mix 6-7 cm of ginger in a glass of water. Bring to the boil and simmer for a few minutes. Strain and drink ginger tea as it cools. You need to do this two to three times a day^[33].

In 2022, recommended^[34] use herb concentrates: eleuterococcus, garlic extract, grapefruit stone extract, berberin, oregano oil.

Reducing symptoms

According to the recommendations of dermatologists for 2018, the reduction of rosacea symptoms is achieved using a properly selected diet, cosmetics, peels and laser therapy.

Hardware therapy

Vascular laser therapy and light therapy serve as additional treatment options for telangiectasia in patients who do not respond to conventional therapy. Laser and light therapy have the ability to reorganize and reconstruct the dystrophic connective tissue of the skin and strengthen the epidermal barrier by thermal induction of fibroblast and endothelium proliferation or by endothelial destruction, resulting in activation of cytokines, growth factors, and heat shock protein.

Vascular laser treatments used in 2007 for telangiectasia and erythema include standard pulse dye laser (585 or 595 nm), long pulse dye lasers (595 nm), potassium titanyl phosphate laser (532 nm), and diode pumped laser (532 nm).

Shortwave lasers (541 and 577 nm) cause vascular destruction without causing collateral tissue damage. Therefore, short-wave vascular lasers are preferred for superficial red vessels and persistent erythema. Intense pulse light therapy penetrates deeper into the skin than vascular laser therapy and is best suited for vascular lesions and pigment lesions. Its main advantages are the ability to treat larger and deeper vessels and promote collagen remodeling. For best results, laser and light therapy may require one to three treatments, four to eight weeks apart^[35].

Photocoagulation, cryotherapy, electrocoagulation and dermabrasion

As of June 2018, laser treatment, as well as cryotherapy, electrocoagulation and dermabrasion (mechanical skin resurfacing with special equipment) give a good result. After the inflammatory manifestations of rosacea are eliminated, it is necessary to switch to the very cause of the disease - an expanded vascular network. Photocoagulation and local cryotherapy are the only reliable methods^[36].

In September 2018, it was reported that modern developments in phototherapy protocols allow effective treatment of acne and rosacea^[37].

IPL and PDL therapy for rosacea

IPL systems are sources of broadband polychromatic incoherent light in the visible to infrared (400-1200 nm) wavelength range. IPL was first used to treat vascular dyschromia in 1976. Later, the use of high-intensity pulse lamps to eliminate vascular malformations was described, which resulted in the creation of commercial devices. One of the principles of the biological effects of intense pulsed light on the skin is the absorption of photons by endogenous and exogenous chromophores. At the same time, the therapy of rosacea takes into account the absorption of light energy not only by hemoglobin, but also by other structures^[38]).

Hemoglobin: IPL causes selective hemoglobin heating and coagulation of dilated dermal vessels, which has a positive effect on the state of centrofacial erythema and telangiectasias.

Melanin: IPL causes selective heating of epidermal melanin, which contributes to better exfoliation of horn scales from the surface of the skin.

The pigmented exoskeleton Demodex folliculorum: IPL causes selective exoskeleton heating and tick death, which reduces parasitic and, as a result, bacterial stress on the skin.

Bacterial porphyrins: light in the range of 400-600 nm causes the formation of free radicals from the metabolic products of some bacteria (in particular, P. acne), followed by the death of these bacteria.

The second direction of action of IPL is the effect on the cascade of inflammatory reactions accompanying rosacea. It is implemented in several ways:

• increased activity of anti-inflammatory cytokines;
• suppression of pro-inflammatory cytokine activity;
• both effects at once.

The efficacy of IPL in the treatment of various forms of rosacea has been proven by many clinical trials. It can be assumed that it is associated with multifactorial exposure to IPL. When using IPL, the spectral range, pulse characteristics and fluence value, which should be chosen based on the phototype of the patient's skin and the clinical picture of the disease, are important.

Examples of the use of IPL in the treatment of various forms of rosacea.

Erythematous telangiectatic form

This form of rosacea lends itself well to IPL and laser therapy. Nine randomized controlled trials have shown that both PDL (pulsed dye lasers) and IPL are effective. At the same time, IPL is better suited for the treatment of centrofacial erythema, since exposure to pulsed laser on dyes often leads to the development of purpura, which is poorly perceived by patients, and laser exposure to inflamed PDL skin can cause a burning feeling. At the same time, when combining local or systemic therapy with IPL, such complications are almost always avoided. As a result, after intense pulsed light, only temporary redness of the skin remains.

A certain benefit for patients with centrofacial erythema in erythematous-telangiectatic rosacea is the use of a Nd: YAG laser with a wavelength of 1064 nm. However, the Nd: YAG laser in rosacea monotherapy is less effective compared to a pulsed dye laser (PDL - Pulsed Dye Laser, PDL) with a wavelength of 577, 585 or 595 nm. At the same time, the Nd: YAG laser is of greater value in the treatment of facial dilated vessels refractory to therapy. This is due to the greater depth of radiation penetration of 1064 nm and the targeted effect on deep vessels.

Papulopustular form

Few papers have been published on the effectiveness of IPL and lasers for the treatment of the papulopustular form of rosacea by 2018. In one of them, IPL therapy showed an improvement in the condition of papules and pustules on the skin in 64% of patients.

When examining the possibilities of PDL, it was found that the dye laser improved the condition in 50% of patients, while in the other 50%, papulopustular lesions remained unchanged or even worsened.

Treatment with a Nd: YAG laser with a wavelength of 1064 nm showed good results - in one work, the condition of papules and pustules in 22 patients improved, and in the other, 12 out of 27 patients showed a pronounced effect (described as "excellent").

Ophthalmic form

Intense pulsed light can be used in therapeutic regimens for the ophthalmic form of rosacea. By 2018, 52 patients aged 20 to 84 years (44 women and 8 men) with symptoms of dry eyes due to this disease had participated in a recent study conducted at the Mayo Clinic (USA). The average number of IPL therapy sessions was three (1 to 7). As a result, 14 people (27%) showed a pronounced positive response to treatment, in 16 (31%) the result was moderate, in 14 (27%) it was weak, and in 8 (15%) it was not at all. At the same time, in 37 (71%) patients, the function of the meibomian glands improved after treatment.

Thus, light methods are well suited for the treatment of various types of rosacea - best for erythematous-telangiectatic and papulopustular forms. The combination of systemic and topical therapy with IPL therapy and the use of Nd: YAG laser is optimal. It is recommended to use IPL with the ability to change the spectral range and time-energy characteristics of the pulses to achieve maximum efficiency without increasing the risk of complications.

Microcurrent therapy

In 2011-2022, it was mentioned that microcurrent therapy does not mask, namely, it treats skin diseases, including rosacea.

The methodology is based on the laws of physics. Action of positive and negative electrons. The American device Bio Ultimate Platinum generates a weak pulsed electric current. The specialist acts on the patient's tissues.

Treatment of rosacea on Lumenis M22

To get rid of the symptoms of rosacea with phototherapy in 2020, a special nozzle is used - the IPL module (Intensive Pulse Light). Short-term flashes of light absorb hemoglobin and melanin in the affected tissues. In larger containers, the temperature rises, "sticks," and then completely disappears. The skin becomes thicker, more elastic, redness and rashes disappear. Light affects only tissues with rosacea and nodules. Rehabilitation is not required. As a good bonus, phototherapy destroys bacteria, improves metabolism in the skin, tightens and refreshes it^[39]

Immediately after the session, a slight redness of the areas where the device was used may appear. It takes from 1 to 3 hours to 2-3 days. Instead of rashes and nodules, dry crusts can form - they do not need to be exfoliated.

Service providers assure that the result is visible after the first procedure:

• small capillaries disappear, redness disappears;
• the pores are cleaned, the skin becomes matte;
• abscesses, pustules, pimples shrink and pass.

Autolymphocytotherapy

Doctors have special diagnostic devices that focus a section of the skin by means of light emission of different lengths, and the condition of the vessels is displayed on the monitor screen. Thanks to special computer programs, the condition of the skin and blood vessels in general is being deciphered and analyzed.

In May 2019, the main methods of treatment include laser and phototherapy^[40].

Recently (May 2019), autolymphocytotherapy began to be practiced. A method in which special cells-lymphocytes are released from the patient's blood, they are enriched with immunomodulators and injected into the patient locally into damaged skin foci.

The protective functions of the skin, blood vessels and its immunity are restored. It is carried out in courses of 8-10 procedures for two months.

Pulsed dye laser is recognized as a safe and effective treatment for rosacea

In May 2018, in a single-center clinical trial of 20 patients, the use of Syneron Candela's 15 mm beam pulsed dye laser VBeam Prima was considered safe and effective for the treatment of rosacea. Read more here.

Ivermectin cream and 595 nm pulsed dye laser (PDL)

External manifestations of rosacea occur under the influence of antimicrobial peptides and activation of cellular receptors. To succeed in the therapy of this recurrent disease, combined treatment protocols are required.

In November 2019, it became known that a team of Russian specialists conducted a study in mice, after introducing a peptide that caused vasodilation and minor hemorrhages in the skin, similar to the manifestations of rosacea. For therapy, the cream Ivermectin"" was used in combination with exposure to a pulsed dye laser (PDL) with a wavelength of 595 nm.

"Ivermectin" blocks special types of channels in the calcium membranes of cells and opens them up to pass calcium ions. As a result, the nerve and muscle cells of helminths stop their normal work. Parasites have paralysis and death^[41].

After the use of the combined protocol, the clinical picture changed: the accumulation of white blood cells in the dermis and hypoderma decreased, desolation of part of the vessels was observed in the dermis, dilated full blood vessels remained in the hypoderma, and there was no endothelium in them. Such results suggest the promise of this treatment protocol and open up new possibilities in the treatment of facial rosacea in non-invasive ways^[42].

Lasers for the treatment of the phimatous form of rosacea

In case of phimatous form of rosacea, treatment is carried out with the help of the following types of lasers emitting light in infrared range:

• carbon dioxide laser (SO2, 10,600 nm);
• erbium laser (Er: YAG, 2900 nm);
• neodymium laser (Nd: YAG, 1064 nm).

Infrared radiation is well absorbed by water and causes heating. Depending on the temperature achieved in a particular area, various changes appear in the tissues (coagulation, evaporation or removal), which helps to solve the problem of growth of^[43] tissue^[43].

Carbon peeling

Carbon peeling refers to hardware (laser) peels and is carried out using a nanogel (carbon amplifier). The procedure is recommended for diseases such as rosacea, acne, acne rash. Thanks to active interaction with the skin, it carefully exfoliates dead layers and has an antiseptic effect. It also stimulates the production of collagen and elastin. A slight redness after the procedure resolves on its own within one to two days.

Diode light (LED therapy)

Main article: Diode light (LED gadgets)

Phototherapy: BBL broadband light technology

Broadband Light Technology BBL (Broadband Light) for 2020 is a relative novelty of the market, but it has been reported to perform well among both physicians and patients suffering from various vascular skin pathologies. According to the assurances of the clinics, with the help of this technology, in 2-4 procedures it is possible to achieve selective coagulation of dilated superficial vessels, telangioectasias, remove rosacea and angiomas, and at the same time significantly improve the color and texture of the skin.

The procedure consists in exposing the skin to pulses of visible, ultraviolet and infrared radiation. The device emits pulses of light energy on the skin, gently warming it up. Light waves are absorbed by the pigment melanin and dilated blood vessels. From exposure to light, the pigment is destroyed, which leads to the disappearance of pigment spots. In vessels, thanks to the energy of light, the process of coagulation is launched - the walls of the expanded vessel are glued to each other, thanks to which traces of cuperosis and rosacea disappear on the face. Heating the skin also activates the activity of fibroplasts - cells responsible for the synthesis of collagen and elastin. As a result, the texture of the skin gradually aligns, its turgor and elasticity improve, pores narrow.

The nose is the most difficult fragment of the face for conducting photo procedures. There is almost no subcutaneous fat on the nose, and there is nowhere to dissipate electromagnetic energy. You need to work carefully so as not to cause a burn^[44].

Ozone therapy

In January 2021, ozone therapy was recommended for the treatment of rosacea - the introduction of ozone-oxygen mixture into the lumen of the vessel using the microneedle^[45].

Cosmetic procedures

Centers for cosmetology also recommend cleansing procedures.

According to the available data for 2018, alpha-hydroxy acids (AHAs) such as almond and azelaic acid should be used for peeling formulations in rosacea - they provide a minimal risk of developing side effects such as erythema, peeling, burning. Of course, they are not completely excluded, but still quite rare in the case of the use of these active substances in rosacea^[46].

Azelaic Acid Peel (AHA)

Main article: Azelaic (nonandic) acid

One of the most successful therapies for rosacea is based on the use of azelaic acid in various cosmetic forms, which has a keratolytic, antibacterial, vasoconstrictive, anti-inflammatory and antioxidant effect, which completely "covers" the pathogenetic links of this disease^[26]. Read more here.

Beta-hydroxy acid (BHA) peels

Good results in rosacea are also provided by beta-hydroxy acid (BHA) peels - salicylic acid, an organic carboxylic acid with a hydroxyl group, which can be used in this case with a concentration ranging from 20% to 30% (in rare cases this figure is increased to 50%)^[46].

Plasma and mesotherapy with peptides

In 2023, plasma therapy and peptide mesotherapy were mentioned among the treatments for rosacea^[47].

Aloe vera

Aloe vera is an essential ingredient in sunburn. The clear gel inside the leaves of the succulent contains the main benefit - it has anti-inflammatory, antibacterial, antiviral and antioxidant properties that contribute to the overall healing of the skin and reduce^[48] of^[49]

Fresh Aloe Vera leaf gel acts as an emollient and moisturizer for the skin. Its healing properties make Aloe an excellent home remedy for rosacea. In December 2020, it was recommended to apply gel to affected skin areas after washing. Leave for half an hour and flush. Do this twice a day to manage rosacea rosacea symptoms^[50].

Oatmeal porridge

Oats contain phenolic compounds possessing anti-inflammatory properties. It also relieves itching, inflammation, swelling and irritations caused by skin inflammation. Grind half a cup of oats and mix with a quarter cup of water. Apply the mixture to the affected areas and leave for 20-30 minutes. You can apply a mask twice a day^[51].

Honey

Raw honey is an effective remedy that can help get rid of rosacea. Honey helps to keep moisture in the skin and relieves dryness. Take some honey and apply to the affected areas. Leave for 30 minutes and rinse. Do it twice a day for effective results, wrote The Health Site^[52] December 2020:6^[53].

Botulinum toxin injections: mesobotox, mesotox, baby botox, microtox

As reported in May 2019, a number of studies have shown that botulinum toxin effectively reduces facial redness in rosacea as well as during menopause (so-called hot flushes). This effect is due to a decrease in stimulation of the blood vessels of the facial skin by the autonomic nervous system. For the treatment of rosacea, Botox is used in significantly higher dilutions than for the treatment of wrinkles, so this procedure is called mesobotox. It is carried out like other types of mesotherapy - surface injections of the drug with a small step throughout the affected area. Improvement is usually observed for 3-4 months, to maintain remission, the procedure should be repeated approximately 3 times a year^[54]

In early 2020, the same procedure appeared under the names "baby botox," "microtox," "mesotox"^[55]. The main goals of the technique of administering botulinotoxin are called pore narrowing and reducing the production of sebum (sebum) and sweat. Its feature is the introduction of small doses of botulinum toxin into the surface layer of the skin. This technique allows you to act only on the epidermis, where sebum formation occurs, redness, inflammation appear, acne occurs. Botulinotoxin has two targets - muscles and sweat glands.

Unlike the traditional use of botulinotoxins (for muscle relaxation), microinjections do not smooth out wrinkles. The drug only slightly penetrates the muscles, softens, but does not paralyze the expression of the face. He directs his action precisely on the skin and sweat glands. The "baby botox" technique copes perfectly with increased production of sebum, and also reduces the severity of vessels, for example, with rosacea.

Botox prevents the release of acetylcholine and provides relief of symptoms in patients with hyperemia and erythema of the face. In early 2021, it was reported that Park et al reported two patients whose erythema was successfully treated with Botox injections. The first patient received a total dose of 50 units and the second patient received a total dose of 65 units. Each patient received the full dose over two treatment sessions, and notable cosmetic results were achieved one week after the second treatment session in both cases.

Symptomatic relief persisted for 4 months in both cases, and patients went to the clinic for the second course of treatment. Bloom et al. conducted a study of 15 patients with facial erythema, each receiving 15-45 units of intradermal Botox injection.

They concluded that intradermal Botox injection is an effective and safe treatment for facial erythema in rosacea. Intradermal Botox injections have been shown to help relieve facial erythema in several rosacea patients; further conduct of a study with a large sample size is needed to illustrate this treatment method in detail.

Hyaluronic acid injections

In 2019, the use of hyaluronic acid injections in patients with rosacea causes controversy in a number of specialists. This is due to the probability of exacerbation of the disease with the use of local topical anesthetics and frequent skin injuries with the classical protocol for the use of biorevitalizers in papular technology every two weeks in the amount of 4-5 procedures.

Profhilo^[56] is used to neutralize adverse events in patients with rosacea for biorevitalization and dermis remodeling^[57].

Cosmetics

In 2023, Toleriane Rosaliac AR serum (La Roche-Posay)^[58] was named^[59] an example^[60] topical agent targeting the main pathogenetic pathways of rosacea development].

Soft cosmetics with extracts of grapefruit, blueberries, chamomile, cucumber are recommended. All cosmetics for rosacea (lotions, tonic, cream) should not contain alcohol, and it is better to choose from those products that have the mark "hypoallergenic" or "against cuperosis"^[36].

For the treatment of rosacea, back in 2014, Galderma Laboratories promoted Rosex, one of the topical preparations of metronidazole, which has a "special balanced basis that improves the ability of the active substance to penetrate the skin." The manufacturer claimed that this makes it possible to obtain the necessary therapeutic effect at a lower concentration of metronidazole: 0.75% versus 1% in analogues. At the same time, a lower concentration of the active ingredient ensures higher tolerance of the drug and minimizes the occurrence of side effects even with long-term use.

In 2018, the following creams were advertised as a means of combating the manifestations of rosacea:

• Крем Redness Neutralizer, SkinCeuticals
• Ultra Red Action Moisturiser Cream, Ultraceuticals^[61]

In 2019, the Russian drug Klindovit was called as a means of combating acne rosacea.

In 2019, it is recommended that neither cream nor any other care product contains stimuli (the most famous of them and widely used in the cosmetics industry are ethanol and numerous essential oils, as well as extracts of rosemary, thyme, lavender). When choosing a facial skin care cream, you should carefully study its composition and choose the one that contains the smallest number of components. In the same way, it is impossible to apply cosmetics to the face in layers.

For hypersensitivity, cuperosis and rosacea, neutral cleansers are used, as well as special serums and creams - manufacturers usually put them together in a series marked as for sensitive skin.

Vitamins are often added to the formulas of such special cosmetics. Most effective for vascular problems:

• Vitamin C (ascorbic acid) - strengthens capillaries and is actively involved in collagen synthesis.

• Vitamin B3, which is also known as niacinamide, nicotinic acid or nicotinamide, are all different forms of vitamin V3: perfectly relieves irritation and redness on the skin. Niacinomide-based cosmetics as a treatment in the fight against rosacea were also mentioned in popular articles in 2020-2022 [Get to ^[62]
• Vitamin P (rutin, rutoside) - this glycoside of the flavonoid quercetin strengthens capillaries, reduces their permeability, brittleness increases their resistance to adverse environmental effects. Rutin in combination with vitamin C is especially effective.
• Vitamin K (phytonadion) - a synthetic form of this compound, it increases the density of the endothelium (vascular wall), reduces the permeability of the capillaries^[63].

Vitamins tend to be combined with other active ingredients that predominantly refer to anti-inflammatory agents: licorice root extract, green tea extract, beta-glucan, or curcumin.

Daily application of sunscreen with high SPF - and thick layer - is mandatory.

In 2020, it is also recommended to use creams containing allantoin and neurosensin^[64].

In 2020, an incredible result was mentioned from washing with a microfiber napkin and baby moisturiser, followed by SPF^[65], the^[65].

In 2020, the Rozellan complex (Uriage, France), represented by a cleansing emulsion, cream, foundation and containing plant extracts of rose, malva, calendula, mimosa, grapes and green tea, macdamia oil, carite, apricot seeds, rose wax, camouflaging green pigments, was recommended as agents with pronounced capillary protective action.

Dirosial cream (Pierre Fabre Dermo-Cosmetique, France), contains hesperidine methylhalkone, dextrin sulfate, retinaldehyde, green pigments. In the initial stages of the disease, it is necessary to remind the patient of the need for twofold (morning and evening) rotational self-massage of the face with circular stroking movements of the nose, forehead and cheeks for several minutes.

In 2021, for the care of reddened facial skin, it was recommended to choose only natural cosmetics that do not contain "old generation" stimuli, such as benzoates, alcohol, limonene, linalol^[66] innovative^[67]. The Latvian cream Rosacea & Strike back was advertised as "the only natural cream in the world that acts against both rosacea and signs of aging."

Benzoyl peroxide

Benzoyl peroxide is a substance that has some success in the treatment of acne, seborrhea and in the violation of seborulation. Dermatologists from California in 2022 claim that it can now be prescribed for rosacea, but under one condition^[68] be^[69].

Standard indications for the use of benzoyl peroxide are all problems inherent in oily skin: acne, increased sebum production, inflammatory elements, and bacterial control. Dermatologists typically prescribe external drugs containing this component for mild to moderate acne.

At the same time, despite the positive results of therapy, frequent side effects from their use are associated with negative reactions - redness, burning, dryness and peeling.

Since the main manifestation of rosacea is redness of the skin and dilation of local vessels, the use of benzoyl peroxide for the treatment of this condition was not considered due to the pronounced side effects associated with skin irritation.

Benzoyl peroxide, entering the skin, breaks down into oxygen and benzoic acid. Oxygen allows you to destroy bacteria that provoke inflammatory processes, and benzoic acid stimulates the regeneration of skin cells. As a result, during the treatment of acne, provocateurs are simultaneously eliminated and skin is renewed.

According to the latest data, the state of the skin microbiota, namely the presence of staphylococcus and mites of the genus Demodex, is of great importance in the appearance of rosacea. Therefore, benzoyl peroxide may be effective for the therapy of this disease.

Dermatologists returned to this issue and created a drug (cream) with a new formula based on microencapsulation technology. Benzoyl peroxide was encapsulated in silica microcapsules and showed good results in both tolerability, including long-term use, and efficacy.

Therapy included a single daily application of an encapsulated agent to the skin. Among the side effects, minor tingling or redness of the skin was noted in 1.1% of cases.

The study showed that more than 70% of subjects experienced decreased erythema severity (redness of the skin) one month after treatment initiation.

The technology of microencapsulation of active components in cosmetics, including with the help of liposomes, has obvious advantages. It allows the necessary substances to quickly and easily enter the deep layers of the skin without causing undesirable reactions on its surface, and then gradually release from the capsule, prolonging and increasing the effect.

Skin hydration

"In patients with chronic rosacea, transepidermal water loss is very pronounced, which leads to an increase in the inflammatory reaction, degradation of the intercellular matrix and collagen structures - this contributes to early skin aging," said Elena, cosmetologist, Doctor of Medical Sciences, in 2021. - In overwhelming numbers, rosacea sufferers have sensitive skin, so they need adequate daily skin care. Such agents are based on microcirculatory caffeine, glycerretinic acid derivatives that restore the skin barrier. "

It was previously mentioned that moisturising your skin two to three times a day is a necessity if you have rosacea. It is best to give preference to hypoallergenic agents that do not contain fragrances and oils. It is also recommended - thermal water with a neutral pH, which will both moisturize and calm the skin.

Make-up

When choosing cosmetics, carefully read the composition: many ingredients included in the composition can provoke an exacerbation of rosacea. Use with caution those products that include:

• retinol,
• hydrogen peroxide,
• alpha-hydroxy acids,

it is also advisable to abandon oil-based products, with talc and flavors^[70]

What to avoid in makeup formulations

Below is a checklist that will avoid unnecessary purchases at the beginning of 2023.

Preservatives are ​ potential allergens that do not druzhelyubnyye​ components to the microbiome for people with rosacea. We exclude without variantov:​ ​

• Methylisothiazolinone (MIT)
• Methylchloroisothiazolinone (CMIT)
• Bronopol
• Diazolidinyl urea
• DMDM hydantoin
• Imidazolidinyl urea
• Sodium hydroxymethylglycinate
• Quaternium-15

If this is a means of protecting against the sun, we pay attention to the filters of the old generation and exclude funds from the nimi:​ ​

• Octocrylene
• Butyl Methoxydibenzoylmethane
• Homosalate
• Benzophenone-3,4

If the skin is extremely reactive, pay attention to fragrances in cosmetic compositions:

• Linalool​
• Limonene​
• Citronellol​

Simple alcohols in the composition of care products can also be the cause of skin irritation during rozatsea:​

• Methanol
• Alcohol denat​
• Ethanol​
• Isopropyl alcohol​

As part of cleansing products, we are looking for and isklyuchayem:​ ​

• Sodium laureth​ sulfate​
• Potassum​ Hydroxide​
• Stearic acid
• Myristic acid
• Lauric acid
• Palmytic acid​ ​​​​​​​

Essential oils. Here everything is as controversial as it is individual. Almost all essential oils, osobenno​ citrus oils, can have a potential irritating effect. In the composition, they are designated kak​

• Orange peel oil​
• Graipefruit oli and drugiye.​

Not an absolute contraindication, but it makes sense to pay attention if the current condition of the skin can be called hysterical. The same applies to extracts, for example, mint extract in the composition of the agent can make sensitive skin swear. Sometimes, in addition to mint, it is also... chamomile (azulene, a component of chamomile essential oil - CLAIRS). Once again, to the word about individual reactions that can be present even at the most seemingly neutral sostave.​

Sedative Skin Care Remedy [Comfort Zone]

For sensitive, redness-prone skin, we recommend trying SOS therapy Remedy. This procedure is especially effective for rosacea. The procedure is the application of a soothing plasticizing mask, which the beautician mixes in a shaker with concentrates and a water base. The mask contains marula oil, known for its strengthening properties, and macrogialuronic acid, which gives the skin elasticity and softness. There are two options for performing care to choose from - with and without massage.

Don't shave your face with blunt blades

For rosacea in men, it is recommended to use an electric shaver. Blades can only be used if they are very sharp^[36] to^[36].

Treatment of telangiectasias

Telangiectasias cause cosmetic inconvenience in patients and they often seek treatment. Nevertheless, topical or systemic agents are ineffective in the treatment of telangiectasias. For 2021, physical methods are used to treat vascular manifestations of rosacea, that is, devices based on laser and light. To obtain cosmetically acceptable results, an average of one to four sessions are required^[71]

Underlying these treatments is that hemoglobin absorbs the energy emitted by these devices, leading to the disappearance of vascular lesions. Neodymium-doped, yttrium aluminum garnet (Nd-YAG), 532 nm potassium titanyl phosphate (KTP), 595 nm PDL, IPL, and double wave long pulse 775 nm alexandrite/1064 nm neodymium: yttrium aluminum (LPAN) are examples of these methods. 26, 27

The most common examples of these are PDL, Nd: YAG and IPL. In a review article by Anzegruber et al. It was concluded that IPL is recommended at A level and the Nd: YAG laser (including KTP) and PDL is recommended at B. Due to the larger spot size, IPL causes fewer side effects compared to PDL; therefore, its use is more advantageous compared to PDL. In addition, PDL is more effective than Nd: YAG in treating vascular manifestations, however, Nd: YAG causes less pain.

The efficacy of Nd: YAG lasers in the treatment of erythema, telangiectasia, and skin texture in rosacea patients may be increased by combining it with topical retinoic acid drugs. Independent evaluators have found that topical use of retinoic acid increases the efficacy of Nd: YAG laser treatment by 47%.

Radio frequency (RF) devices cause focal damage to the dermis, producing heat and electric current through electromagnetic radiation. This damage stimulates the formation of new collagen through a rapid healing process. Compared to laser treatment, RF is a newer treatment for rosacea. In a study by Kim et al. The efficacy of RF and PDL treatment in rosacea was compared. Both methods were used for 3 sessions at monthly intervals.

RF and PDL produced similar results in the treatment of erythematothelenegiectatic rosacea; there was no statistically significant difference. Thus, both RF and PDL are effective in treating erythema and telangiectasias. On the other hand, RF was more effective than PDL in patients suffering from papulopustular telangiectasia. In a study of 21 patients with moderate to severe rosacea, PDL was combined with RF.

It was concluded that combination therapy is more effective than PDL alone in treating erythema, hot flashes and telangiectasias. Thus, in the treatment of resistant erythematosectatic rosacea, PDL and RF can be considered for treatment alone or in combination.

Recently emerging combination therapies have been found to be more effective in treating patients with resistant rosacea than single-use therapies. The addition of PDL treatment to oral minocycline therapy was found to reduce relapse rates in patients suffering from erythema and telangiectasia. The recurrence rate with minocycline alone was 48%; however, the recurrence rate of minocycline in combination with PDL was 37%.

In addition, laser treatment with Nd: YAG may be added to topical brimonidine therapy. Brimonidine alone is effective in treating erythema, although this effect is transient. However, telangiectasias persist after treatment with brimonidine. Cosmetically better treatment results were obtained when patients with erythematotelengiectatic rosacea were first treated with an Nd: YAG laser and topical brimonidinoma therapy was added after 1 month.31

Treatment of papulopustular lesions

Inflammatory papules and pustules are the main phenotypes observed in rosacea patients. In mild lesions, topical treatment is sufficient. On the other hand, systemic and topical treatments should be combined in moderate to severe cases. A wide variety of topical medications are used to treat papulopustular rosacea (PPR): metronidazole, azelaic acid, ivermectin, pimecrolimus, retinoids, permethrin, benzoyl peroxide, erythromycin, and dapsone.

Nd: YAG laser, PDL and RF are also effective in the treatment of papulopustular lesions. Systemic treatments for papulopustular lesions are oral antibiotics, oral zinc sulfate, and oral ivermectin^[72]

Metronidazole cream 0.75-1% is effective in the treatment of PPM when used twice a day. In a 51-patient randomized controlled trial, the clearance level of topical metronidazole was found to be 90%, similar to that of oral tetracyclines.

In a study by Dahl et al. compared the efficacy of 0.75% and 1% of metronidazole for topical use and no difference was found between the two concentrations.

When administered topically, azelaic acid inhibits the production of reactive oxygen species and induces the production of pro-inflammatory cytokines.

15% azelaic acid gel applied twice daily for 15 weeks gives significantly better treatment results for papules and pustules compared to 0.75% metronidazole cream. 12 weeks. Moreover, the azelaic acid foam produces fewer side effects than the azelaic acid gel when both are used at 15% concentration. Thus, metronidazole (0.75-1%) and azelaic acid (15%) are effective in the treatment of topical PPM.

Ivermectin is an antiparasitic drug that reduces the density of demodex on the skin of patients with rosacea. Demodex mites are commonly found in human flora; however, their density increases in rosacea patients. Ivermectin has an anti-inflammatory effect by acting on these ticks.

Ivermectin 1% cream is a safe and tolerable alternative to the first-line drug for the treatment of PPM. It is more effective at treating PPR than metronidazole cream 0.75%. However, its efficacy has not been compared with 15% topical azelaic acid, which is also more effective than 0.75% topical metronidazole.Dall'Oglio et al., conducted a study that investigated the efficacy of 1% ivermectin cream in the treatment of PPM.

To evaluate the results, they used erythema-directed photography. Thirty-two percent of cases achieved complete resolution with 8 weeks of topical ivermectin. In addition, a significant decrease in erythema was observed. Ivermectin is a safe and effective alternative to the topical treatment of patients with refractive PPM and is approved in Europe and the United States.

Cream with pimecrolimus 1%, which is a calcineurin inhibitor, is also an effective alternative in the treatment of PPR. It is as effective as 1% metronidazole cream. However, it is also a rosacea provoking drug.

Retinoids are also an alternative for the treatment of inflammatory rosacea lesions. However, it should be borne in mind that the side irritant effects of retinoids may be more pronounced in patients with rosacea with delicate skin. Of the retinoids, only 0.025% tretinoin and adapalene gel were tolerated and successfully used for the treatment of PPR.

Permethrin 5% cream when administered topically twice daily for 2 months is as effective as metronidazole in the treatment of PPM. It has an even greater effect in combination with other anti-inflammatory agents. 40 5% permethrin for topical use is effective in the treatment of erythema and papules in patients with rosacea, but it is ineffective in telangiectasias and pustules. However, it is recommended as class A for the treatment of PPR.

2% erythromycin gel for topical use is as effective as metronidazole cream 0.75% in the treatment of PPM. 26 In combination with benzoyl peroxide, topical erythromycin produces better results than topical metronidazole. Thus, this combination is a good alternative for the treatment of rose.41 A combination of 5% benzoyl peroxide gel with clarithromycin gel is also recommended for the treatment of PPR. 26 Dapsone 5% gel when used for 12 weeks is also as effective as metronidazole 0.75% cream, so it can be used to treat PPM.

For systemic antibiotics, oral low doses of tetracyclines (eg, doxycycline 40 mg/day) are effective in the treatment of PPR. Azithromycin and clarithromycin are also used in the treatment of PPR. Although one randomized clinical trial found that azithromycin 500 mg daily is as effective as doxycycline 100 mg daily, overall azithromycin and clarithromycin are considered less effective than doxycycline for the treatment of PPR.

Ampicillin can also be tried in refractory cases. However, it is not as effective as oral tetracyclines. 26 Although antibiotic resistance is a major problem worldwide, daily use of doxycycline at a dose of 40 mg/day does not lead to antibiotic resistance even with long-term use.

Retinoids are topically or systemically used to treat rosacea because of their anti-inflammatory properties at lower doses (e.g. 0.3-0.5 mg/kg/day). Isotretinoin 20 mg/day is effective in reducing erythema and inflammatory lesions. Oral isotretinoin not only provides rapid improvement, but also reduces recurrence rates. Compared to topical retinoids such as tretinoin 0.025% cream, systemic retinoids are more effective.

Zinc sulfate when taken orally at a dose of 100 mg/day is also effective in reducing inflammatory lesions of rosacea. The only reported side effect was indigestion in 12% of patients. Oral ivermectin (200 μg/kg/day) is also an alternative to the treatment of PPR, although it is supported by evidence of D-level.

In patients with treatment-resistant rosacea, a combination of oral ivermectin and 5% permethrin cream may be considered as this combination has been shown to be effective in reducing demodex density in immunocompromised patients.

Treatment of ophthalmorozacea

More than 50% of patients with cutaneous rosacea have ocular symptoms, which may include watery eyes, foreign body sensation, itching, photophobia, and blurred vision. For 2022, an ophthalmic consultation is recommended due to possible complications: corneal ulcers, scleritis, episcleritis, iritis, persistent gordeolum (barley) and chalazion. Mild symptoms can be managed with artificial tears, warm compresses and baby shampoo cleansing of the eyelashes. Long-term intake of omega-3 fatty acids may normalize meibomian gland dysfunction. Topical oculosporin ophthalmic drops show statistically significant improvement in overall signs and symptoms compared to artificial tears. Topical metronidazole and erythromycin may be useful for relieving eyelid symptoms. Patients may be recommended systemic therapy using tetracyclines or azithromycin Current state of^[73].

Treatment of rhinophyma

Phymatous rosacea is generally difficult to treat. The best results are achieved at its early onset. Oral isotretinoin may be effective in reducing nasal volume early in the disease; however, after discontinuation of the drug, relapse is likely, and mucinous and fibrous changes do not respond to retinoids. Surgical methods, including laser or light therapy (pulsed coloring laser, intense pulsed light, carbon dioxide laser), electrosurgery, dermabrasion, tangential excision, electroscalpel, loop cauterization, are effective in correcting or minimizing physiological changes and can improve the quality of life of patients^[74].

Phymatous changes occur due to hypertrophy of the sebaceous glands, growth of vessels and connective tissues. Most often, phimates occur on the nose, especially in the lower third of the nose, which is called rhinophyma. Other forms of phimates are gnatophyma (jaw/chin), metophyma (forehead), blepharophyma (eyelid), and otophyma (ear). Although all of these formations have a benign course, they pose a challenge to patients due to their cosmetic and functional impairments. Systemic treatment options for phimatous changes include low-dose doxycycline (40 mg/day) and low-dose isotretinoin (0.3 mg/kg/day). Both are supported by Level A evidence. Surgical methods can also be used in the treatment of phymatous changes, and in fact they are more effective. These methods include excision, dermabrasion, electrocoagulation and laser ablation^[75]

Simple excision is a widespread method. However, since phimatous changes have a large blood supply, removal of phimates can lead to excessive bleeding, which is an undesirable complication. In addition, there is a risk of removing excess tissue. Dermabrasion can also be used to smooth the surface of the skin. However, like surgical removal, dermabrasion can also lead to excessive bleeding.

Electrocoagulation is more effective in terms of bleeding control compared to surgical removal. It is also a faster method compared to simple excision. However, it conceals the risk of necrosis of the cartilaginous tissue of the nose due to excessive heat. In addition, atrophic scars and prolonged wound healing have also been reported in the treatment of phymatous changes by electrocoagulation.

For 2021, laser devices are used to treat phimatous changes: CO2 laser and Erbium: YAG laser. Both of these lasers have a high affinity for water, resulting in ablative changes because the skin has a high aqueous composition.

Madan et al evaluated the effectiveness of the CO2 laser in the treatment of rhinophyma. They demonstrated that during the three-month recovery period after a single treatment session, out of 124 patients, 115 were very pleased with the results. In addition, the method had an acceptable adverse event profile. The CO2 laser is also good at hemostasis due to its coagulation properties.

Another combination therapy that can be used in the treatment of rosacea is the treatment of Er: YAG and CO2 laser. A CO2 laser is used for its coagulation properties when used in conjunction with an Er: YAG laser. Goon et al suggested that optimal cosmetic results with minimal scarring could be obtained with this combination therapy.

Patents for the treatment of rosacea

2024: Method of Ekaterina Glagoleva and Elena of Arabia

In early 2024, a patent was issued for a method developed by Ekaterina Glagoleva and Doctor of Medical Sciences, Professor Elena of Arabia. This is a global breakthrough in the treatment of rosacea, in which Alexei Bogatenkov, head physician of the medical cosmetology department of the GALACTICA Beauty Institute in St. Petersburg, is listed as a co-author, but insists on the modesty of his mission^[76] is^[77]

Notes