Rosacea

Rosacea can be complicated to treat, which is why it’s best to arm yourself with the knowledge to confidently help clients with this challenging condition, write Amanda Pauley and Eleanor Vousden

Rosacea is a long-term inflammatory skin condition that usually occurs on the face and affects one in 10 people in the UK, according to research from Bupa. Most are in the 30 to 50-year-old age group, or have fair skin. It can also affect those with darker skin, although this is less common.

The flare-ups that come with the condition are tough to conceal and can be as hard for clients to manage mentally as they are physically. Therefore, it’s important to treat the symptoms correctly and help clients to keep on top of the condition.

What is rosacea?

“Rosacea is a progressive, inflammatory vascular disorder,” explains Kerry Belba, clinic director of Laser Skin Solutions in Bournemouth, and a laser and IPL consultant and trainer. “It is characterised by some distinct stages and subtypes.” The main subtypes she lists are:

• Erythematotelangiectatic - which involves permanent redness and often some itching

• papulopustular - permanent redness with some bumps and pustules

• Phymatous - where skin thickens and can develop nodules

• Ocular - with dryness and irritation of the eyes and eyelids

• Neurogenic - a strong discomfort in the skin that may stem from neurological or psychological reasons.

Celebrity facialist Kate Kerr, owner of salon Kate Kerr London, explains that the condition generally affects the middle section of the face (known as the butterfly shape) - the forehead, nose, cheeks, above the lips and on the chin, adding, “It can also thicken the skin tissue and often when people think of rosacea they think about the bulbous nose. It is generally categorised into stages with redness, persistent redness, flushing, tingling and burning, especially on the cheek area, broken capillaries and enlarged pores,” she says. “You can also get papules and pustules, but these are a bit different to acne spots, protruding above the surface in a more dome-like shape.”

What causes rosacea?

“Vessels are made up of muscular tissue that enables them to dilate and contract back but rosacea makes these vessles a bit defunct, so the elasticity doesn’t work and the vessels dilate very easily,” says Belba.

Some experts believe the cause is a 50/50 split between genetics and environmental factors. “I treat a huge number of rosacea clients in clinic and when I ask if anybody in the family has had it, generally they tell me that either mum or dad suffers with it,” explains Kerr. “Some clients don’t even realise it might be a genetic thing, so I ask them: does your mum or dad’s skin flush? Have you noticed skin thickening on their nose (Rhinophyma)?”.

Belba notes that there is also a link between rosacea and a proliferation of the demodex skin mite. “In rosacea, there can be up to 18 times more of these mites than there should be so we’re not sure whether the mite is causing more of the inflammation or whether rosacea is providing a breeding ground for these mites.

“There are solutions for getting this mite under control so this is one thing I would always look out for in clinic before I start treatment,” she adds.

What are the symptoms ?

Persistent redness is one of the best-known symptoms of rosacea and commonly appears across the cheek area, but that’s not all, as Kerr explains. “Rosacea is an oily skin condition, which is what people don’t tend to realise. They just think of it as being sensitive skin but often you’ll find that people who have it will have suffered with acne in their teenage years.

“Rosacea is activated by oil and this causes a lot of inflammation - you see a lot of vascularity in the skin, and it often starts with flushing, redness, and/or persistent redness and tingling in the cheeks,” she says. “Broken capillaries are also a common symptom, which you might see in the corner of the client’s nose or across the cheeks. Those are the first couple of stages, then you start to get the papules and pustules.”

However, the symptoms will vary from client to client and you need to be aware of that when treating customers in salon. “Experts tend to talk about the stages with rosacea - stages one to four (pre-rosacea, mild rosacea, moderate rosacea and severe rosacea),” she explains.

How can I treat rosacea?

However, clients don’t necessarily start at stage one. “You may have a customer suffering with symptoms in stage one and two, who then progress further in those two stages more severely, or another client who might just have stage one and three and have it super mild,” adds Kerr.

“There is no single approach to treating rosacea and not everyone is going to present in the same way so there isn’t a one-type-fits all treatment,” says Belba. “There are different subtypes and treatment should generally be geared towards that.”

Meanwhile, Kerr advises that rosacea is also a condition that generally progresses. “It can go into remission or disappear at times, but it will come back,” she says. Left untreated, it tends to get worse. “As a therapist, you want to prevent the progression because it’s much harder to claw it back when rosacea has progressed to the later stages. With rosacea, the key thing is to make sure your client has a really strong barrier function, so work to strengthen it to prevent transdermal water loss (the evaporation of moisture from the skin), which will help with hydration.”

Kerr also advises working to inhibit oil production to minimise inflammation. “I want rosacea clients to have a really healthy skin cycle, so I get them on a regime that is going to do all these things. I often get them on a retinol to regulate all of the above, helping to thicken and strengthen the skin.

Kerr then reviews the skin in 12 weeks’ time (two skin cycles) and assesses if she needs to gear up the treatment or refer to a medical practitioner. “For example, say I’ve corrected the papules and pustules but the client has still got some underlying redness and broken capillaries, then I would look at using more advanced treatments like lasers, lights or IPL,” she says.

Which ingredients and technologies are best for rosacea?

“Salicylic acid will help control oil production but you also want clients to exfoliate, which a lot of people are quite frightened of doing. When you speed up cell turnover, you speed up cell function too. When people aren’t exfoliating, they’re accumulating dead cells on the surface which leads to dull skin,” explains Kerr.

However, exfoliation can cause the inflammatory systems within the skin to be on high alert, so the client’s complexion can become more easily inflamed. “Strengthen that barrier and follow it with application of antioxidants and sun protection, as the sun is a big trigger for rosacea. Clients also need to look at their diet and alcohol intake as all of these things are triggers for the condition,” explains Kerr.

For vascular rosacea with no pustules, Belba often uses laser, IPL or LED. “Sometimes it requires a combination of technologies and a topical skin cream,” she adds.

What treatments should be avoided?

“I would be very careful with exfoliation, especially microdermabrasion,” says Kerr. “A lot of advanced treatments are actually very beneficial for rosacea as long as the skin is strong, resilient and prepped.”

Therefore, you should ensure the skin barrier is calm and functioning. “Then you can boost it further with peels or microneedling, which can help with healthy cell turnover and to refine the skin’s texture,” says Kerr.

When should you refer a client to a medical practitioner?

It depends on the severity of the rosacea. “If I see someone who is very enflamed with pustular rosacea, I tend to refer them to their GP to rule out the demodex mite,” says Belba. “They can be prescribed treatment that will determine if that is the cause.”

Kerr says it is important to take into account their emotions as well as the physical symptoms, too. Redness, flushing or a few broken capillaries and spots can be treated in clinic, she adds, but if the client has got thickening skin tissue, repetitive breakouts and enlarged pores, you should refer them to prevent any further damage.

Kerr gives her clients the option to choose the best course of action for them. “I say, ‘we can refer you now; or we can try and treat you in clinic and then refer you if we don’t see the results we want; or we can do both - I can refer you to a GP and treat you in clinic as I know how rosacea medications work, so I will be able to treat you safely alongside any prescribed medication’.”

Working in partnership with a medical professional provides the best of both worlds. “When clients see medical professionals for these sorts of things, they are just treating the disease and its symptoms; they’re not looking at the overall skin health, which is where our expertise as facialists come in,” explains Kerr. PB