Rosacea is a common, chronic skin condition that affects the face and sometimes the eyes, as well. While not a debilitating condition, it can impact an individual’s confidence and mental health when struggling with persistent red, irritated skin. It's common for rosacea on face, chest, neck, and ears to be associated with anxiety and depression, as we'll discuss.
We’ve known for a long time how important hormones are for maintaining healthy skin and are now learning more about the connection between female hormones and rosacea.
The cause of rosacea isn’t well understood, although female hormonal imbalance has been linked to higher incidences. This article will take you through everything you need to know about rosacea, including:
- What is rosacea?
- Symptoms of rosacea
- What causes rosacea?
- Rosacea and hormone imbalance
- Rosacea triggers
- How to manage rosacea with lifestyle tools and supplements
What Is Rosacea?
Rosacea is a chronic skin condition affecting as many as 22% of adults globally with only about 5% receiving a diagnosis. It appears as persistent redness and abnormal blood vessel function on the face, primarily the cheeks, nose, chin, and forehead. Although primary symptoms show up on the face, some researchers suggest rosacea is a systemic disease with aspects of autoimmunity.
Rosacea can negatively impact your quality of life, self-esteem, and well-being.
Who Gets Rosacea?
Rosacea primarily affects fair-skinned, middle aged women. We see the highest incidences among those in their thirties who have skin that is prone to sunburns.
What Are the Symptoms of Rosacea?
Since many skin conditions primarily affect the face and may cause similar symptoms, it’s essential to get a thorough evaluation from a dermatologist or other healthcare provider.
Rosacea symptoms may include:
- Flushing or red patches on skin
- Visible blood vessels
- Skin irritation
- Thickened skin
- Bumps on skin
- Pimples or papules
- Eye irritation
There are several ways that rosacea can show up, which is classified as phenotypes per the ROSacea COnsensus (ROSCO). These include diagnostic, major, and secondary phenotypes, which help encompass the multiple ways that rosacea can appear.
- Centrofacial erythema – includes redness (erythema) over the central part of the face (nose and cheeks).
- Phymatous change – thickening of the skin, most commonly seen on the nose.
- Papules and pustules – small, raised bumps or pimples.
- Flushing – increased blood flow with heat.
- Telangiectasia – enlarged blood vessels.
- Ocular features – eye involvement, which can look like redness, tearing, and light sensitivity.
- Burning and stinging
- Dry skin
At first, rosacea may look like a sunburn, with redness across the cheeks and nose. A sunburn, however, gets better with time, whereas rosacea may progress to redness on the forehead, neck, ears, scalp, chest, and chin. The redness and irritated skin persist. T.
Rosacea is most frequently observed in those with fair skin because the redness is more visible. However, it may be underdiagnosed in people with darker skin because the redness is harder to see.
Involuntary increased blood flow with a warm sensation can accompany rosacea. Sweating and mild swelling can also accompany the flushing. Certain triggers can make flushing worse or cause it to persist (see below).
If redness and flushing persists for several days then significant swelling can also occur. Avoiding triggers may help reduce swelling.
Visible Blood Vessels (Telangiectasia)
Another telltale symptom of rosacea is telangiectasias, which are enlarged blood vessels near the skin’s surface that appear as thin red lines. Telangiectasias is often most visible on the cheeks and bridge of the nose. Like the redness, these small blood vessels may be more difficult to see on more pigmented skin.
Bumps, Pimples, or Papules
On top of the redness and irritation, you may find bumps on the skin. While they might initially appear as acne, they aren’t blackheads. Instead, you might find pus-filled pimples called papules. These lesions on the face can be mistaken for adult acne, however, the other signs and symptoms of rosacea help in determining that they are a feature of this condition.
Thickening of Skin
It’s also possible to get swelling and skin thickening on the nose that may appear as larger bumps, called rhinophyma. This symptom tends to happen more in men.
It is also possible to see thickening of the skin on the cheeks, chin and forehead. The oil glands of the skin can become more pronounced when this happens leading to oily skin.
Burning or Stinging
Unfortunately, some skin care products can irritate in burning or stinging sensations with rosacea. But even in the absence of skin care products, burning or stinging can accompany the areas affected by rosacea.
Roughness, scaling, and overall dry appearance often accompanies rosacea.
Eye Irritation (Ocular Rosacea)
While much more rare, as many as 1% of people with rosacea can have eye involvement. Rosacea can affect the eyes and eye area, called ocular rosacea. You may notice redness and swelling of the eyelids and areas around the eyes. The eyes themselves can feel dry or watery and appear red or bloodshot. Ocular rosacea can also feel like something is constantly in your eye, and can have sensitivity to light (photophobia) and blurry vision.
Recurrent eyelid swelling, red bumps on the eyelid (chalazion) or styes, and crusting on the eyelash line can be a sign of ocular rosacea.If ocular rosacea is left undiagnosed and untreated, it can cause blindness in extreme cases.
Some research has shown that Demodex mites may play a role in ocular manifestations of rosacea. The degree of infestation seems to be associated with the development of rosacea in general. Demodex mites have been found along the eyelashes and glands of the eyelid in those with ocular rosacea.
The Causes of Rosacea on Face
Rosacea causes likely include multiple factors, some of which are not yet well understood. While the exact cause of rosacea isn’t known, many experts point to it being a systemic disease (full body), rather than simply just a skin issue.
Risk factors for rosacea and associated conditions include:
- Microbiome imbalance (dysbiosis)
- H. pylori infection
- SIBO (small intestinal bacterial overgrowth)
- Inflammatory bowel disease
- Hormone imbalance
- Obesity and body composition
- Certain psychological and nervous system disorders, like anxiety, migraines, dementia, and Parkinson’s
- Metabolic syndrome, diabetes, high cholesterol
- Certain autoimmune conditions, like multiple sclerosis, type 1 diabetes, and rheumatoid arthritis
- Demodex mite infestation
Many of the proposed risk factors for rosacea involve gut health. There is a powerful connection between the digestive tract and skin, known as the gut-skin axis. Inflammation, imbalances, and leaky gut may contribute to increased skin vulnerability.
Like autoimmune conditions, rosacea may result from a complex interplay between genetic factors and environmental triggers that impact the immune and vascular systems. While we can’t change our genes, we can influence gene expression by adjusting our environment regarding nutrition and lifestyle habits. We’ll explore treating rosacea naturally and review the pharmaceutical options below.
Rosacea and Hormonal Imbalance
Some research suggests that rosacea is more prevalent in women than men because female hormones play a role.
Estrogen is a critical hormone for skin health; it helps the skin maintain its structure and hydration. Declining estrogen in perimenopause and menopause correlates with increased signs of skin aging, such as dryness and wrinkles. The skin barrier becomes more sensitive and easily irritated.
Interestingly, the skin can synthesize steroid hormones (like estrogen), and impairment of this function may play a role in the development of rosacea.
Perimenopause, Menopause, and Rosacea
Rosacea symptoms are most prevalent in women aged thirty to sixty years old, which are the years that coincide with perimenopause and the menopausal transition. In addition, a decline in the prevalence of rosacea coincides with the natural decline of estrogen in postmenopausal years.
Increased prostaglandin production, hormone-like chemicals that cause contractions, during perimenopause is understood to play a role in exacerbating rosacea symptoms. As I explain in this article on prostaglandins and painful periods, omega-3 fatty acids and magnesium can help in balancing these chemicals. More on this soon.
The natural hormonal changes of perimenopause and menopause result in fluctuations in estrogen, among other hormones. Hormonal issues, such as hot flashes, can trigger symptoms. Vasomotor symptoms, including hot flashes and night sweats, affect around 80% of women during the perimenopausal transition and can trigger rosacea.
Menstrual Cycle Hormones and Rosacea
Hormonal changes during the menstrual cycle may trigger rosacea symptoms, especially if symptoms appear cyclically along with your cycle.
Estrogen is dominant in the first half of the menstrual cycle (follicular phase). After ovulation, in the second half of the cycle (luteal phase), progesterone is dominant. (Read this for a menstrual cycle refresher.)
An imbalance of estrogen and progesterone may increase the risk for rosacea or trigger rosacea symptoms. In addition, a hormone imbalance affects health and immunity, and immune dysregulation can be another underlying driver of rosacea.
Oral Contraceptive Pills, Birth Control, and Fertility Treatments
Just as natural fluctuations in hormones can lead to rosacea flares, so can changing hormonal birth control, stopping the birth control pill, and some fertility treatments. While some practitioners report improvement in rosacea in patients taking the pill, others have reported worsening symptoms. This is where it is best to discuss with your provider what your options are and let them know if you’re experiencing worsening rosacea with hormone treatments.
Learn more about the birth control pill, including risks and alternatives, in my first book, Beyond the Pill.
Common Rosacea Triggers
Now that we understand more about the root causes of rosacea let’s look at what triggers symptoms. Understanding personal triggers provides clues to personalized rosacea treatment strategies.
Common Rosacea Triggers:
- Heat, humidity, sun exposure
- Personal care products
- Psychological factors
- Spicy, hot, high histamine foods
- Skin barrier disruption
- Certain medications
Menstrual Cycle Changes
Rosacea symptoms may also become worse with menstrual cycle changes. For example, rosacea may coincide with PMS symptoms when inflammation increases before your period.
In addition, changes in estrogen through the menstrual cycle or perimenopause can make you more sensitive to high-histamine foods and may aggravate histamine related rosacea symptoms overall. Learn more about histamine and rosacea below.
Hormonal Hot Flashes
Perimenopause is the transition into menopause, where you no longer ovulate or cycle. In perimenopause, you’ll experience fluctuations in estrogen, and these hormonal swings may trigger various symptoms, including hot flashes.
You can experience redness and flushing on the face during a hot flash, like the flushing experienced with rosacea. In addition, for women with rosacea, hot flashes are a trigger for rosacea symptoms.
Interestingly, the onset of rosacea is more common during the reproductive years and perimenopause than post-menopause.
Heat, Humidity, and Sunlight
Sun exposure, heat, excess humidity, and rapid changes in weather or temperature may trigger rosacea symptoms.
It’s important to use sunscreen or wear a sun hat outside to prevent sunburn, which can make rosacea worse. When using sunscreen, try to opt for a non-toxic, non-irritating product. This likely means using a mineral sunscreen (with zinc oxide) instead of chemical sunscreens. However, since certain skin care products, like sunscreen, can aggravate rosacea, it is best to choose the product that works best for your skin.
If you struggle with rosacea, opt for the shade and consider using a portable fan or mister to help you keep cool. Topical rose water spray is an ayurvedic remedy that can help keep you cool.
Wind and Cold Weather
While the heat can make your rosacea skin flare, the opposite of cold or windy weather can do the same. Taking precautions to protect your face from the elements and be sure to moisturize it appropriately.
Skincare and Haircare Products
Figuring out the personal care products that are your trigger can be a frustrating trial and error situation. Before applying to your full face, try doing a test sample on a smaller area.
Harsher chemicals, such as hair spray, alcohol, and witch hazel and make rosacea symptoms worse. Fragrance, which can also wreak havoc on your hormones, is not only known to aggravate symptoms of rosacea on face, but also is a common culprit in contact dermatitis.
Less is more when it comes to skincare for rosacea on face and surrounding areas. Keep your routine to the minimal necessary products. For example, face wash, moisturizer, and sunscreen may be all you need for your skin to feel and look its best.
Avoiding toxins and irritants is a good rule of thumb for all skincare and personal care products. Chemicals in products can irritate the skin, increasing redness and other rosacea symptoms. The Environmental Working Group Skin Deep Database is an excellent resource for learning about safe skincare ingredients and products. Always spot-test new products and find what works for your unique skin.
Anxiety, Stress, and Lack of Sleep
Stress and anxiety can result in more hormonal swings, increased inflammation, and immune system issues—all of which can trigger rosacea. Managing stress is key, since you can’t eliminate all stressors.
Making self care a priority is a must in healing your skin. Try out different practices such as journaling, meditation, coloring, walking in nature, and dancing to your favorite songs to shift yourself into a more relaxed state.
Sleep is another area that may require your attention, as poor sleep can lead to inflammation, immune, and hormonal issues. Keep your bedroom dark and cool. And try to add in some TLC to the end of your day to help you unwind and get your best sleep.
Spicy, Hot, and High Histamine Foods
What you eat can also trigger rosacea. And while mid-flare you may be feeling the answer is to cut out all these foods, keep in mind that not all will affect everyone the same way and many of these foods are also full of beneficial nutrients.
My advice is to work with a nutrition expert before cutting everything from your diet.
Common dietary triggers include:
- Hot peppers
- Spicy foods
Histamine is a chemical that plays a role in allergic reactions to foods and environmental exposures like pollen and dander. Histamine causes blood vessels to expand (vasodilate), which can increase the redness and symptoms of rosacea.
High histamine foods include:
Some foods are naturally higher in histamine than others.
- Fermented foods
- Aged foods (cheeses, cured meats)
- Packaged or processed meats
- Dried fruit
- Some fruits
- Fish and shellfish
Foods that cause a histamine release:
Some foods can cause histamine to be released by the body.
- Food dyes
- Citrus fruits
Exercise is crucial to managing rosacea and has many health benefits. But as body temperature rises, so can the redness and swelling of rosacea. Research has shown that muscle can be protective against rosacea and the more severe forms, so skipping the fitness routine is not the answer.
Instead, exercise in a well ventilated area and consider using a fan. Strength training in the cooler part of the day may offer the most benefit with the least risk of a rosacea skin flare. Keep hydrated with a water bottle nearby and consider a cool towel or misting the skin. While prolonged activity may make rosacea on face and other areas worse, short bursts like a 10-15 minute HIIT routine may be all you need to get the benefits of exercise without the risk of a rosacea flare.
Treating Rosacea Naturally
Treating rosacea naturally requires working with a licensed practitioner who can help guide you on the best approach for you. When choosing a holistic approach for rosacea management, it’s essential to consider your individual root causes and take a whole-person approach. Since rosacea may have roots in gut health, immunity, and hormone balance, it’s essential to look at those pieces.
We’ll discuss some of the natural therapies for rosacea to consider and I’ll share some of the pharmaceutical treatments your doctor may want to employ. The good news about natural therapies is that they can often be combined with conventional approaches to help you get the individualized care you need.
Foods That May Reduce Rosacea Flares
There are many nutrient dense foods to include in your diet that can help with rosacea on the face and the other symptoms that accompany it. The following foods are low histamine and can support skin, immune, and gut health.
Low Histamine Foods for Rosacea:
- Fresh fish and meats
- Non-citrus fruits
- Gluten free grains like rice and quinoa
- Olive and coconut oil
- Fresh vegetables, excluded the ones previously mentioned in the histamine section
Vitamin Deficiencies and Rosacea
Many nutrients are important for skin health, including vitamin A, vitamin C, and zinc. While it is unknown if rosacea is caused by vitamin deficiencies, there are nutrients that can contribute to vascular issues.
Eating foods rich in magnesium, selenium, and vitamin B6 can help with blood vessel integrity. Additionally, vitamin C and vitamin B6 can help with the histamine issues that can contribute to rosacea. You can read about key nutrients to support skin health and potentially rosacea, along with the foods they are found in, by clicking the linked nutrients.
Nutrients for Skin Health:
Adding a quality multivitamin as part of your routine, like the Women’s Twice Daily, can help give your skin additional nutritional support.
Many studies have pointed to gut-skin-microbiome connection when it comes to managing rosacea. In addition to taking a high quality probiotic, like Women’s Probiotic, eating a higher fiber diet can also be beneficial.
For help on upping your daily dietary fiber, grab our free recipe guide.
Hormone Replacement Therapy
Hormone replacement therapy, also known as menopausal replacement therapy, is helpful for many women in perimenopause and menopause to reduce hot flashes, inflammation, and other symptoms associated with the hormonal transition. More stable hormone levels may reduce the hormonal triggers for rosacea.
With hormone replacement therapy, some noticed a decrease in the redness and flushing that accompanies rosacea.
Hormone therapy requires an individualized conversation with your healthcare provider who knows your medical history, a prescription, and monitoring.
Supporting estrogen metabolism is important at all stages of life, including when you’re using hormone replacement therapy. And for women who are still cycling in the reproductive and perimenopausal years, many natural therapies, including DIM and vitex, can help balance hormones, including estrogen.
In addition to the nutrition and lifestyle therapies discussed in this article, adding hormone supporting supplements can provide added benefit..
- Balance Women’s Hormone Support – A comprehensive formula designed to support female hormone balance with potent nutrients and plant extracts. This formula includes DIM, broccoli extract (sulforaphane), resveratrol, calcium D-glucarate for optimal estrogen. You’ll also find vitamin B6, selenium, magnesium, and vitamin C, which can help with supporting optimal histamine, blood vessel function, and skin health.
- Adrenal Support – This adrenal formula contains adaptogenic herbs and nutrients to support resilience to life’s stressors. As discussed, stress and anxiety make managing rosacea much more difficult. An improved stress response is good for skin health. This formula gives your adrenals extra love so they can do their job when it comes to inflammation and helping you keep your cool.
- Women’s Probiotic by Dr. Brighten – A women-specific probiotic blend to support gut and vaginal health and the gut-skin axis. The formula contains probiotics, prebiotics, and antioxidants. As discussed previously, the gut microbiome plays a crucial role in skin health.
If you’re interested in trying them all, you can find them as part of our hormone bundle by Dr. Brighten.
Laser and Pulse Light Therapy
Rosacea treatment with laser therapy can be beneficial in addressing symptoms. Both redness and telangiectasia have shown to improve with laser and pulse light therapy treatment. While not a cure for rosacea, this therapy can help with the common symptoms.
Laser therapy may be effective for rosacea on face, however, it can have risks like depigmentation, blistering, and scarring. Meeting with a licensed provider can help you evaluate if this is the best therapy for you.
Omega-3 Fatty Acids
Omega-3 fatty acids are another supplement to consider for skin health and overall health. Omega-3s are anti-inflammatory, especially the EPA fatty acid, and some research suggests that they support rosacea subtypes, including ocular rosacea.
As previously mentioned, omega-3’s support a healthy prostaglandin balance, which may also benefit those with rosacea prone skin.
Omega Plus by Dr. Brighten is a concentrated omega-3 formula containing EPA and DHA fatty acids along with lipase to ensure maximum absorption.
Once you identify your rosacea triggers, such as spicy food, stress, sun exposure, or skincare products, work to remove the triggers as much as possible. Avoiding triggers will help manage rosacea and prevent flushing and flares. See the section above on triggers for additional tips.
There are several topical and oral therapies that can help with the management of rosacea symptoms. The best medication for rosacea depends on the symptoms and how well you tolerate the therapy.
Topical Rosacea Treatments
Your doctor may prescribe topical creams, lotions, or gels to help you manage rosacea. Depending on your symptoms, your doctor may recommend one or more topical medications to help resolve your rosacea symptoms.
- Azelaic acid
- Benzoyl peroxide with Clindamycin
Oral Rosacea Treatments
There are several oral treatments for rosacea available to manage the various symptoms that accompany this condition.
If you’re experiencing the pimples, papules, and pustules of rosacea, your provider may recommend:
Oral rosacea treatments include medications that cause vasoconstriction:
All of these medications can have side effects, which is why it is important to communicate with your prescribing physician if issues arise. When it comes to retinoids, these can cause birth defects, which is why your doctor may recommend birth control pills or an IUD to prevent pregnancy.
As with all medications, always ask your provider what the risks are, how long they expect you’ll need to stay on them, what it looks like to transition off, and what the alternatives are. Asking these questions can help you make an informed decision and get the best treatment for your needs.
Dry eyes can be a sign of ocular rosacea and compromise eye health. Your doctor may recommend artificial tears to alleviate dry eye symptoms. In some cases, your doctor may recommend an immunosuppressive drug known as Cyclosporine. As with all medications mentioned here, it is best to talk with your provider.
Rosacea is a chronic skin condition with inflammation, redness, bumps, and irritation affecting more women more than men. It is most common to see rosacea on face, especially on the cheeks and nose, but it can present on the scalp, ears, neck, chest, and eyes. When addressing the root causes of rosacea, don’t overlook the role hormones, including estrogen, play in the onset and symptoms. Addressing hormone balance with a holistic approach and avoiding personal triggers can help you look and, most importantly, feel your best.
The best treatment for rosacea is the one that gives your symptom relief with the least amount of side effects.
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