Rosacea is a common chronic inflammatory facial dermatosis, characterized by persistent flushing, erythema, papules, pustules, and telangiectasias. It is often a relapsing and remitting condition, holding an estimated worldwide prevalence of just below 5.5%.[1] An essential aspect of rosacea care is the integration of an effective daily skincare regimen. This serves to maintain skin hydration and skin-barrier integrity, thus potentially limiting symptom severity.[2] Skin-cleanser and moisturizer selection are key in this regard and will comprise the focus for this first part of the article. Part 2 will examine the emergence of cosmeceuticals’ active ingredients directed toward rosacea management, which have become a notable area of clinical study. It will also highlight the critical role of UV protection, now recognized as a cornerstone of rosacea skincare due to its link with the disease’s pathophysiology.
A detailed review is beyond the scope of our discussion; however, more recent diagnostic data is worth highlighting. First, previous subtype classifications of rosacea, such as erythematotelangiectatic rosacea (ETR, subtype 1) and papulopustular rosacea (PPR, subtype 2) have been replaced with classifications according to primary phenotype features a patient presents with, such as flushing or erythema, papules and pustules, telangiectasias, and phymatous changes (See Table 1). This shift is believed to allow for more personalized therapy since, under the previous system, many patients could present with various subtypes concurrently.[3], [4]
Table 1: Phenotype-based diagnosis of rosacea [5], [6]
| Diagnostic features | • Persistent erythema over central face with associated periodic intensification • Phymatous changes (ex. rhinophyma) |
| Major features | • Presence of two or more are diagnostic: • Flushing of skin • Papules and pustules • Telangiectasia • Ocular manifestation (e.g., lid inflammation or conjunctival erythema; may be a feature symptom or separate form of rosacea itself) |
| Secondary features | • Skin itching, burning, stinging • Edema • Skin dryness |
Basic Clinical and Pathophysiological Review of Rosacea
Although various pathophysiological mechanisms have been associated with rosacea (Table 2), this discussion will focus on those most relevant to topical interventions. Specifically, we will examine evidence supporting a role for epidermal-barrier integrity, mitigating the effects of reactive oxygen species, as well as elements within neurovascular dysregulation and aberrant innate immunity, factors that contribute to inflammation, angiogenesis, and vasodilation.
Table 2: Possible Pathophysiological Mechanisms of Rosacea [7], [8]
| Mechanism | Comment |
| Genetic predisposition | Associated with an augmented responsiveness of proinflammatory mediators regulating inflammatory activity, angiogenesis and leukocyte chemotaxis. |
| Neurovascular dysregulation | Elevated transient receptor potential vanilloid (TRPV) activity and proinflammatory neuromediators. Includes abnormal responses to various triggers, leading to heightened cutaneous blood-vessel density and blood flow. |
| Innate immune response dysfunction | Characterized by upregulation of the antimicrobial peptide LL‑37, leading to proinflammatory and angiogenic activity. |
| Ultraviolet radiation | Can induce angiogenesis and damage vascular and dermal matrix via reactive oxygen species generation. |
| Microbial exposure | Association between Demodex folliculorum mite infestation of the skin and rosacea. |
| Epidermal barrier dysfunction | Studies have shown rosacea patients to have increased transepidermal water loss (TEWL), with barrier disruption facilitating entry of sensory irritants. Facial dryness is common in rosacea. |
The Role and Evidence of Skin Barrier Disruption in Rosacea
Table 3 summarizes select lines of evidence implicating a role for skin-barrier disruption in the context of rosacea pathophysiology. The clinical relevance here is such that, with an impaired barrier, irritant and allergenic agents’ entry into the skin is augmented. This may trigger features such as hypersensitivity, vasodilation, and inflammation seen in rosacea.[9] The question of whether it itself causes, or is a result of, rosacea pathophysiological mechanisms is still debated.[10], [11] Despite this, however, what this underscores is the importance of maintaining barrier integrity, achieved via the proper selection of skin cleansers and moisturizers as part of our discussion below.
Table 3: Evidence of Skin-Barrier Disruption in Rosacea
| Evidence of increased transepidermal water loss and reduced stratum corneum hydration [12], [13] |
| Evidence of increased skin-surface pH (which can interfere with barrier maintenance) [14] |
| Increased reaction to the lactic-acid stinging test [15] |
| Increased incidence of allergic and irritant contact dermatitis [16] |
| Reduced expression of claudins, which represent a major component of barrier-supportive tight junctions [17] |
| Abnormal expression and functioning of transient receptor potential ion channels (e.g., in sensory nerves) may impair the epidermal barrier via disruption in both intra- and extracellular calcium ion concentrations [18] |
| Barrier disruption leading to increased expression and secretion of antimicrobial peptides (e.g., LL‑37) which can induce inflammation and angiogenesis: Increased expression of Toll-like receptor‑2 (TLR‑2) on keratinocytes can lead to elevated serine protease (e.g., Kallikrein‑5) which converts cathelicidin to LL‑37 [19] |
General Goals of a Skincare Regimen
When establishing a skincare regimen for rosacea patients, it is important to appreciate the four goals of such a regimen.
First is the importance of maintaining skin hydration, with a particular focus on supporting epidermal-barrier functioning.[20], [21]
The second goal is to limit the insults, so to speak: to avoid as much as possible the agents which can trigger flare-ups. Relating to the first goal, you can say that products that hinder the skin barrier will indirectly contribute toward irritation via their negative impact on the skin-barrier functioning. In this context, improper selection of skin-cleanser type would be an example. This aspect may also take time to fully elucidate in each patient as they gradually explore if, and which, topical products and/or specific ingredients trigger a flare-up.[22], [23] Table 4 provides a list of common cosmetic ingredients which carry a potential for irritation in some individuals. It is essential to keep in mind, however, that the way ingredients are formulated together in a product may help mitigate the degree of irritancy they may otherwise impart.[24]
The third goal encompasses the importance of protection from ultraviolet light. This is of particular importance given the notable effects UV light has on rosacea pathophysiology.[25] This will be further explored in the second part of this article.
The fourth goal is about taking a personalized approach based on patient presentation and involves the selective use of cosmeceutical agents to help manage given aspects of a patient’s rosacea features. Such agents are typically included within topicals like cleansers, moisturizers, and serums and often target one or more aspects of rosacea’s pathophysiology, such as providing an antierythema effect.[26], [27] Again, a deep dive in a few cosmeceutical actives ingredients will be done in part 2.
Table 4: Ingredients in OTC Skincare with Potential for Skin Irritancy [28], [29], [30]
| Acetone Alcohol Propylene glycol Propylene carbonate alpha‑Hydroxy acids, such as glycolic acid and lactic acid Sodium lauryl sulfate Benzalkonium chloride Formaldehyde Formaldehyde releasers, such as quaternium‑15, imidazolidinyl urea, diazolidinyl urea, and DMDM hydantoin Menthol Benzyl alcohol Benzene Camphor Urea Lanolin Fragrance ingredients Sorbic acid Salicylic acid Vitamin A derivatives, such as retinol and retinaldehyde Phosphoric acid Resorcinol Benzoyl peroxide Sodium carbonate Trisodium phosphate Propylene glycol diacetate Dimethylacetamide Dimethylformamide Dimethylsulfoxide Diethyltoluamine Dimethyl phthalate 2‑Ethyl‑1,3‑hexanediol |
Role and Considerations for Skin Cleansers and Skin Moisturizers
Table 5 provides a synopsis of some of the more common formulations of cleansers on the market. In seeking to achieve our skincare goals as described above, the bulk of the literature to date encourages directing rosacea patients toward the use of synthetic-detergent (aka syndet) or lipid-free cleanser-type formulas.[31], [32], [33], [34] General tips and considerations regarding skin cleansing behaviour are listed in Box 1.
As a means of managing skin dryness and sensitivity, a common experience in rosacea-affected skin, the application of a moisturizer after facial washing is essential. In general, selecting moisturizers containing emollient and humectant moisturizing agents is recommended.[35] Products containing skin barrier–supporting lipids, such as ceramides, are especially recommended. Given how the epidermal barrier is composed of free fatty acids, cholesterol, and ceramides, a growing amount of literature suggests how it is especially key to ensure that such physiologic lipids are embedded within skin moisturizers.[36], [37], [38], [39]
Table 5: Common Types of Skin Cleansers [40], [41], [42]
| Skin Cleanser Type | Comment |
| True Soap | • Very efficient at removing oil-rich debris from the skin, but this can also act to disrupt the lipids within the skin barrier • Less gentle on skin and more alkaline in pH • May worsen skin sensitivity and irritation in rosacea patients |
| Combar | • Antibacterial soap bars which combine an antibacterial agent with both true soap and syndet surfactants • Although beneficial to reduce harmful bacteria, they may worsen rosacea by also eradicating the healthy bacterial flora residing on the skin • May worsen skin dryness or irritation |
| Synthetic Detergent (Syndet) | • Typically combine mild surfactant cleansers with moisturizing ingredients • Contain under 10% soap • Maintain a more neutral/acidic pH (5.5–7.0), like that of normal skin • Support skin-barrier integrity |
| Oil/Lipid-free | • Among the gentlest cleansers • Like syndets, leave behind a thin layer of moisturizationOften formulated with little-to-no fragrances, dyes, or irritating preservatives |
Box 1: General Consideration for Skin Cleansing in Rosacea [43], [44]
| • Wash the face, using a gentle nonirritating, noncomedogenic synthetic detergent (syndet) or lipid-free cleanser • Avoid using any type of abrasive washing accessories (e.g., loofahs or washcloth) • Wash the face using a gentle motion with the fingertips • Avoid use of alcohol or astringent-based toners as these can be irritating; instead, consider micellar-water topicals as these may be better tolerated for secondary cleansing or makeup removal • Always use lukewarm or tepid water when cleansing—avoid use of hot water • Avoid the use of cleansers containing strong exfoliating ingredients (e.g., scrubs), such as: • Mechanical: e.g., aluminum-oxide particles, salt, sugar, polyethylene beads, ground fruit pits • Chemical: e.g., salicylic acid, alpha‑hydroxy acids like glycolic acid • If exfoliation is desired, cleansers containing polyhydroxy acids (e.g., gluconolactone) may be considered, as these are less irritating and offer a moisturization effect. Incorporate use once or twice a week initially, then adjust according to tolerance. At-home patch-testing prior to full application is recommended when introducing a new product for the first time. |
A Study Showcasing the Speed at Which Treatment Can Take Effect
We will conclude with notable findings from a clinical study examining the use of skin cleanser and moisturizer in managing rosacea symptoms.
The trial explored the effects of adding skin moisturization to standard topical treatment in managing rosacea.[45] It was designed as a seven‑day, multicentre, open-label, split-faced (intraindividual) study of individuals with mild-to-moderate papulopustular rosacea treated with 15% azelaic acid gel. A total of 102 subjects participated (85 females, 17 males), the majority aged 59 or younger and presenting with 20 or fewer inflammatory lesions. Interestingly, the author indicated that the subject group had roughly equal representation of skin reported to be either dry, oily, normal, or a combination thereof.
Given the split-faced study design, the subjects were instructed to follow a set regimen twice daily in the morning and evening for seven days. They first washed their face with a provided non‑soap–based gentle cleanser, then applied 15% azelaic acid gel over the entire face. A moisturizer was then applied only to the right side. Each subject received one of two multi‑ingredient moisturizers—some containing ceramides—though allocation details were not reported. Finally, sensations of stinging, burning, tingling, and itching on the left and right sides of the face were rated for severity on a four-point scale as well as for duration in minutes with entries recorded in a morning and evening diary. From the average of the individual symptom scores, a cumulative symptom score (CSS) was established, and this was used to measure for overall facial discomfort.
Notable outcomes include:[46]
- Reduced CSS v. baseline for regimen with moisturizer (p = 0.008)
- CSS v. baseline for regimen without moisturizer did not reach significance (p value not listed)
- End-of-study CSS scores were lower for the regimen with moisturizer v. the non–moisturizer regimen (p = 0.015)
Although this was a short trial, it also showed how quickly the effects can be obtained. A notable takeaway is that the use of a gentle cleanser and moisturizer in conjunction with azelaic acid treatment for papulopustular rosacea can further reduce the degree of facial discomfort experienced in terms of stinging, itching, burning and tingling.
Disclaimer: The information presented in this article is for general information purposes only and does not constitute medical advice. Please first review with your personal health-care practitioner(s) what therapeutic approaches and products would be best for your case.
Références
[1] Baldwin, H.E., S.M. Habib, Z. Fedorowicz, and D. Randall. “Rosacea.” DynaMed®. https://www.dynamed.com/condition/rosacea. Updated 2025‑01‑24. Accessed 2025‑04‑02.
[2] Baldwin, H., A. Alexis, A. Andriessen, D. Berson, J. Harper, E. Lain, S. Marchbein, and L. Stein Gold. “Skin barrier deficiency in rosacea: An algorithm integrating OTC skincare products into treatment regimens.” Journal of Drugs in Dermatology, Vol. 21, No. 9 (2022): SF3595563–SF35955610.
[3] Baldwin et al, “Rosacea.”
[4] Baldwin et al, “Skin barrier deficiency in rosacea.”
[5] Baldwin et al, “Skin barrier deficiency in rosacea.”
[6] Semenescu, I., D. Similie, Z. Diaconeasa, and C. Danciu. “Recent advances in the management of rosacea through natural compounds.” Pharmaceuticals, Vol. 17, No. 2 (2024): 212.
[7] Baldwin et al, “Rosacea.”
[8] Powell, F., and S. Raghallaigh. “Rosacea and related disorders.” Chapter 37 (p. 604–614) in: Bolognia, J.L., J.V. Schaffer, and L. Cerroni, eds. Dermatology, 4th Edition, Elsevier, 2017, 2880 p., ISBN 978‑0‑7020‑6275‑9.
[9] Baldwin, H., A.F. Alexis, A. Andriessen, D.S. Berson, P. Farris, J. Harper, E. Lain, S. Marchbein, L. Stein Gold, and J. Tan. “Evidence of barrier deficiency in rosacea and the importance of integrating OTC skincare products into treatment regimens.” Journal of Drugs in Dermatology, Vol. 20, No. 4 (2021): 384–392.
[10] Baldwin et al, “Skin barrier deficiency in rosacea.”
[11] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[12] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[13] Chen, C., P. Wang, L. Zhang, X. Liu, H. Zhang, Y. Cao, X. Wang, and Q. Zeng. “Exploring the pathogenesis and mechanism-targeted treatments of rosacea: previous understanding and updates.” Biomedicines, Vol. 11, No. 8 (2023): 2153.
[14] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[15] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[16] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[17] Chen et al, “Exploring the pathogenesis and mechanism-targeted treatments of rosacea.”
[18] Chen et al, “Exploring the pathogenesis and mechanism-targeted treatments of rosacea.”
[19] Del Rosso, J.Q. “Advances in understanding and managing rosacea: Part 1: Connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema.” Journal of Clinical and Aesthetic Dermatology, Vol. 5, No. 3 (2012): 16–25.
[20] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[21] Levin, J., and R. Miller. “A guide to the ingredients and potential benefits of over-the-counter cleansers and moisturizers for rosacea patients.” Journal of Clinical and Aesthetic Dermatology, Vol. 4, No. 8 (2011): 31–49.
[22] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[23] Levin and Miller, “A guide to the ingredients.”
[24] Levin and Miller, “A guide to the ingredients.”
[25] Morgado‑Carrasco, D., C. Granger, C. Trullas, and J. Piquero‑Casals. “Impact of ultraviolet radiation and exposome on rosacea: Key role of photoprotection in optimizing treatment.” Journal of Cosmetic Dermatology, Vol. 20, No. 11 (2021): 3415–3421.
[26] Semenescu et al, “Recent advances in the management of rosacea.”
[27] Sobkowska D. et al. “The role of cosmetology in an effective treatment of rosacea: A narrative review.” Clinical, Cosmetic and Investigational Dermatology, Vol. 16 (2023): 1419–1430.
[28] Levin and Miller, “A guide to the ingredients.”
[29] de Melo Magalhães Gonçalves, M.M.B., and M.E. Soares Rodrigues Tavares de Pina. “Dermocosmetic care for rosacea.” Brazilian Journal of Pharmaceutical Sciences, Vol. 53, No. 4 (2017): e00182.
[30] Del Rosso, J.Q. “The role of skin care and maintaining proper barrier function in the management of rosacea.” Cosmetic Dermatology, Vol. 20, No. 8 (2007): 485–490.
[31] Baldwin et al, “Skin barrier deficiency in rosacea.”
[32] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[33] Levin and Miller, “A guide to the ingredients.”
[34] Schachner, L., A. Alexis, A. Andriessen, H. Baldwin, M. Cork, R. Kirsner, and H. Woolery‑Lloyd. “The importance of a healthy skin barrier from the cradle to the grave using ceramide-containing cleansers and moisturizers: A review and consensus.” Journal of Drugs in Dermatology, Vol. 22, No. 2 (2023): SF344607s3–SF344607s14.
[35] Bikowski, J. “Rosacea regimens.” Chapter 58 (p. 509–516) in: Draelos, Z.D.D. Cosmetic Dermatology: Products and Procedures, 2nd Edition. West Sussex: Wiley Blackwell, 2016, 546 p. + xiv, ISBN 978‑1‑118‑65558‑0.
[36] Baldwin et al, “Skin barrier deficiency in rosacea.”
[37] Baldwin et al, “Evidence of barrier deficiency in rosacea.”
[38] Levin and Miller, “A guide to the ingredients.”
[39] Schachner et al, “The importance of a healthy skin barrier.”
[40] Levin and Miller, “A guide to the ingredients.”
[41] Levin, J. “The relationship of proper skin cleansing to pathophysiology, clinical benefits, and the concomitant use of prescription topical therapies in patients with acne vulgaris.” Dermatologic Clinics, Vol. 34, No. 2 (2016): 133–145.
[42] Talakoub, L., I.M. Neuhans, and S.S. Yu. “Cosmeceuticals.” Chapter 2 (p. 7–34) in: Murad, A., H.B. Gladstone, and R.C. Tung, eds. Cosmetic Dermatology. Edinburgh, London, New York, Oxford, Philadelphia, St. Louis, Sydney, and Toronto: Elsevier Saunders, 2009, 276 p. +xiii, ISBN 978‑0‑7020‑3143‑4.
[43] Bikowski, “Rosacea regimens.”
[44] Draelos, Z.D.D., B.A. Green, and B.L. Edison. “An evaluation of a polyhydroxy acid skin care regimen in combination with azelaic acid 15% gel in rosacea patients.” Journal of Cosmetic Dermatology, Vol. 5, No. 1 (2006): 23–29.
[45] Del Rosso, J.Q. “The use of moisturizers as an integral component of topical therapy for rosacea: Clinical results based on the Assessment of Skin Characteristics Study.” Cutis, Vol. 84, No. 2 (2009): 72–76.
[46] Del Rosso, “The use of moisturizers.”