Rosacea Alert: Non-Prescription Topicals that may be Harmful to Rosacea Sufferers

Topics Discussed Below

Introduction
Beta hydroxy acids (salicylic acid)
Alpha hydroxy acids (glycolic and lactic acid)
Anti-aging products (cleansers, creams, gels & exfoliants)
Topical steroids
References

I. Introduction

Over the counter skincare products can wreak havoc with rosacea skin. One of the problems is that these offending skincare products never come with warnings that they can traumatize rosacea skin. Below are some common skincare products that are known to cause rosacea flushing and irritation.

II. Beta-Hydroxy Acids (Salicylic Acid)

Salicylic acid is a popular beta-hydroxy acid (BHA) that is used in facial cleansers, moisturizers, anti-acne products, and makeup. Products containing salicylic acid are effective in treating acne and seborrheic dermatitis, and in smoothing out the skin and reducing facial pore size. However, salicylic acid is also one of the most common irritants to facial skin.

In a recent Rosacea Review article, "Tips for Choosing the Right Skincare Products", rosacea experts state, "Rosacea can be a skincare nightmare. When buying any skincare products, avoid ingredients such as salicylic acid." (118) Consistent with the above report, Dr. Diane Thiboutot stated at a recent American Academy of Dermatology meeting that rosacea sufferers, "Should avoid potentially irritating ingredients such as salicylic acid." (119) Numerous Other medical articles point out specific reasons why patients with sensitive skin should avoid salicylic acid. (120 - 124)

Confusion Surrounding Salicylic Acid: Salicylic acid is classified by some physicians as a topical anti-inflammatory, so how can this ingredient be bad for rosacea? To explain, salicylic acid's anti-inflammatory actions are solely due to its effect on the papule or pustule; it is not effective in decreasing the real rosacea inflammation (generalized facial redness, vascular hyper-reactivity, vascular damage, and swelling). In most cases, salicylic acid is a two-edged sword - at the same time that it is decreasing inflammation around facial papules and pustules, it is usually irritating facial skin and blood vessels. In most rosacea sufferers this is not a good trade off!

III. Alpha-Hydroxy Acids (Glycolic and Lactic Acids)

Currently, alpha-hydroxy acids are the biggest buzz in the skincare industry due to their ability to clear acne lesions, erase wrinkles, and reduce pore size. There is no doubt that alpha-hydroxy acids are effective at clearing acne and papules. However, most alpha-hydroxy acids are strong irritants, no matter what the product label claims. In a recent article in the Journal of the American Academy of Dermatology, Dr. Rapaport indicates that in his clinical experience, skincare products with alpha-hydroxy acids are one of the most common sources of facial irritation. (125) Medical experts indicate that alpha-hydroxy acids can cause direct irritation to blood vessels and can damage the epidermis. (85, 126, 127) More importantly, rosacea experts stress that alpha-hydroxy acids are a frequent cause of rosacea irritation and flushing. (119) Medical experts stress that alpha-hydroxy acids, "Can cause intense and long-lasting facial redness in many rosacea sufferers." (108) Glycolic acid and lactic acid of any strength are powerful irritants. Skincare products with glycolic or lactic acids should never be used on rosacea skin.

IV. Anti-Aging Products (Cleansers, Creams, Gels and Exfoliants)

Topical anti-aging products such as alpha-hydroxy acids, beta-hydroxy acids, and retinoids are able to diminish fine lines, smooth out skin texture, and reduce pore size. Based on hundreds of personal reports from rosacea sufferers, and on medical literature from rosacea experts, I personally feel that these anti-aging products have had a negative impact on our disorder. These products have single-handedly pushed a large percentage of mild rosacea sufferers into the moderate or severe forms. Anti-aging products are, for the most part, powerful irritants that are designed to remove part of the epidermis, or to irritate collagen in order to re-build the superficial dermis. Rosacea experts emphasize that these general qualities of anti-aging products are powerful triggers for rosacea flushing. (85, 108, 119, 126, 127) While I do not argue with the effectiveness of anti-aging products in making skin look younger, I do not feel that removal of a few superficial lines, and temporary shrinkage of facial pores is a fair trade off for a burning-red, inflamed face!

V. Topical Steroids

In the 1950's, topical steroids were first used in dermatology to treat patients with severe skin inflammation. These topical medications greatly improved the treatment of a variety of skin diseases; in fact, most dermatologists indicate that topical steroids have revolutionized dermatological therapy. Today, topical steroids are the most widely used class of drugs in dermatology.

Topical steroid preparations are available in many different forms and strengths. Below is a short list of topical steroids that are commonly used on the skin (the steroids are listed from strongest to weakest):

Super potency:

Never used on facial skin

High potency:

Never used on facial skin

Medium potency:

Cutivate™ by Glaxo Wellcome (0.05% fluticasone cream).
Westcort™ by Westwood-Sqibb (0.2% Hydrocortisone valearate cream or ointment).
Elocon™ by Schering (0.1% mometasone furoate ointment, cream, or lotion).

Mild potency:

Aclovate™ by Glaxo Wellcome (Aclometasone diproprionate cream or ointment).
Desowen™ by Galderma (0.05% Desonide ointment, cream, or lotion).

Low potency:

Hytone™ by Dermik (2.5% hydrocortisone cream or ointment).
Nonprescription (1% hydrocortisone cream or ointment).
Nonprescription (0.5% hydrocortisone cream or ointment -- the weakest topical steroid).

Stay Away from Over-The-Counter Hydrocortisone (1%)

It is widely known that strong topical steroids can cause or aggravate rosacea. There is now medical evidence indicating that mild, over-the-counter hydrocortisone (1%) can also cause or aggravate rosacea symptoms.

In the medical article "Complications of Topical Hydrocortisone" in the Journal of the American Academy of Dermatology, Dr. Guin reported on six cases of rosacea that were caused by daily use of 1% hydrocortisone. (236) In the first two patients, facial redness and pustules occurred after only 1 month of topical hydrocortisone (1%). In the third and fourth patients, similar adverse reactions to 1% hydrocortisone were documented after only two and three months, respectively. In the last two patients, significant atrophy and telangiectasia of the eyelids were caused after only one month of topical application of 1% hydrocortisone cream. These findings are not in isolation, as other experts warn that prolonged use of topical hydrocortisone can be deleterious to rosacea sufferers, or patients with pre-rosacea symptoms. (237)
Experts emphasize that over-the-counter hydrocortisone (1%) can induce rosacea, and worsen pre-existing rosacea. (238) In fact, over an 8-year period, Drs. Weston and Morelli have treated 106 patients who developed steroid rosacea. (238) Out of these 106 patients, 54% developed steroid rosacea after using the mildest topical steroid -- 1% hydrocortisone.
Medical experts indicate that some general physicians do not take topical hydrocortisone (1%) seriously enough. (236) These experts also indicate that, "For most situations, it would seem better to avoid uninterrupted and unsupervised topical application of 1% hydrocortisone to vulnerable areas such as the face and eyelids." (236)
Dr. Skellchock states, "Hydrocortisone, a mainstay of therapy for seborrheic dermatitis, must be avoided in patients with rosacea. Any topical steroid will worsen rosacea." (129)
At a recent International meeting, Dr. Suzana Ljubojevic, a noted dermatologist, cautioned all physicians about the use of topical steroids. She stressed that mild over-the-counter hydrocortisone should not be used on patients who have rosacea or are predisposed to rosacea (frequent flushers and blushers). (235) She emphasized to physicians that topical hydrocortisone can cause true rosacea in many patients or worsen pre-existing rosacea. Dr. Ljubojevic recently performed a survey of 502 rosacea patients (339 women and 163 men) and found that a whopping 61% of the patients were using topical steroids.
In a major medical review article, "Diagnosis and Management of the Red Face Syndrome", Dr. Uehara and colleagues reported on 135 patients with the "Red face syndrome". (239) All 135 patients acquired the red face by using mild, "safe" topical steroids.
In a major medical rosacea article by Drs. Garver and Wilkin, "Flushing and Rosacea: Overview and Nursing Interventions", they stress that all topical steroids should be avoided. (107) Let me emphasize this last point, they stated that all topical steroids should be avoided on rosacea skin -- not just some forms of topical steroids - all forms.

VI. References

115. De Kort, W.J. and A.C. De Groot. Clindamycin allergy presenting as rosacea. Contact Dermatitis 20: 72-73, 1989.

116. National Rosacea Society. "Rosacea Review". Spring. 1997. Drake,L.

117. Plewig, G. and A.M. Kligman. Rosacea. In: Acne and Rosacea, edited by G. Plewig and A.M. Kligman. Berlin: Springer-Verlag, 1993, p. 433-475.

118. National Rosacea Society. "Rosacea Review". In: edited by J.K. Wilkin. 1994.

119. National Rosacea Society. "Rosacea Review". Fall. 1996. Drake,L.

120. Prins, M., O.Q. Swinkels, E.G. Kolkman, E.W. Wuis, Y.A. Hekster, and d. van, V. Skin irritation by dithranol cream. A blind study to assess the role of the cream formulation. Acta Derm Venereol 78: 262-265, 1998.

121. De Groot, A.C., J.W. Weyland, and J.P. Nater. "Toxic and irritant contact dermatitis". In: Unwanted effects of cosmetics and drugs used in dermatology, edited by A.C. De Groot, J.W. Weyland, and J.P. Nater. New York: Elseveir Science, 1994, p. 2-5.

122. Ortonne, J.P. Clinical potential of topical corticosteroids. Drugs 36 Suppl 5: 38-42, 1988.

123. Griffiths, W.A. and J.D. Wilkinson. "Topical Therapy". In: Textbook of Dermatology, edited by R.H. Champion, J.L. Burton, and et al. Malden: Blackwell Science, 1998, p. 3519-3563.

124. Olsen, T.G. "Therapy of acne". Med Clin North Am 66: 851-871, 1982.

125. Rapaport, M.J. and V. Rapaport. "Eyelid dermatitis to red face syndrome to cure: Clinical experience in 100 cases". J Am Acad Dermatol 41: 435-442, 1999.

126. Effendy, I., C. Kwangsukstith, J.Y. Lee, and H.I. Maibach. Functional changes in human stratum corneum induced by topical glycolic acid: comparison with all-trans retinoic acid. Acta Derm Venereol 75: 455-458, 1995.

127. Plewig, G. and A.M. Kligman. "Appraisal of efficacy". In: Acne and Rosacea, edited by G. Plewig and A.M. Kligman. Berlin: Springer-Verlag, 1993, p. 566-569.

128. Singer, M.I. Drug therapy of rosacea: a problem-directed approach. J Cutan Med Surg 2 Suppl 4: S4-3, 1998.

129. Skellchock, L.E. "Rosacea: Whats the best treatment?". In: edited by Health Publishing Inc. 1995.

130. Baran, R., M. Chivot, and A.R. Shalita. "Acne". In: Cosmetic Dermatology, edited by R. Baran and H.I. Maibach. Baltimore: Williams & Wilkins, 1994, p. 299-310.

235. Ljubojevic. "Topical corticosteroid overuse and rosacea" First World Congress of the International Academy of Cosmetic Dermatology, St. Julians, Malta. 1990.

236. Guin, J.D. Complications of topical hydrocortisone. J Am Acad Dermatol 4: 417-422, 1981.

237. Sneddon, I.B. "The treatment of steroid-induced rosacea and perioral dermatitis". Dermatologica 152 (suppl 1): 231-237, 1976.

238. Weston, W.L. and J.G. Morelli. "Steroid rosacea in prepubertal children". Arch Pediatr Adolesc Med 154(1): 62-64, 2000.

239. Uehara, M., O. Mitsuyoshi, and H. Sugiura. "Diagnosis and management of the red face syndrome". Dermatol The 1: 19-23, 1996.

240. Weirich, E.G. and J. Longauer. "Tierexperimetelle Prufung des epidermal-hypoplastischen Effektes von Externcoricoiden (Hypoplastic effect of topical corticosteroids on the animal epidermis)". Arztl-Forsch 25: 292-298, 1971.

241. Ryan, T.J. "Inflammation, fibrin and fibrinolysis". In: The physiology and pathophysiology of the skin, edited by A. Jarrett. New York: Academic Press, 1973, p. 745-777.

242. Marks, R. "Rosacea: hopeless hypotheses, marvellous myths and dermal disorganization". In: Proceedings of an International Symposium, Cardiff, edited by R. Marks and G. Plewig. Cardiff: Martin Dunitz Ltd, 1988, p. 293-299.

243. Manna, V., R. Marks, and P. Holt. Involvement of immune mechanisms in the pathogenesis of rosacea. Br J Dermatol 107: 203-208, 1982.

244. Bleicher, P. A. "Rosacea". 1992. Recommendations by Paul A. Bleicher, M.D.

245. Varani, J. and P.A. Ward. Mechanisms of endothelial cell injury in acute inflammation. Shock 2: 311-319, 1994.

246. Varani, J. and P.A. Ward. Mechanisms of neutrophil-dependent and neutrophil-independent endothelial cell injury. Biol Signals 3: 1-14, 1994.

247. Gerritsen, M.E. and C.M. Bloor. Endothelial cell gene expression in response to injury. FASEB J 7: 523-532, 1993.

248. Lowe, N.J., K.L. Behr, R. Fitzpatrick, M. Goldman, and J. Ruiz-Esparza. Flash lamp pumped dye laser for rosacea-associated telangiectasia and erythema. J Dermatol Surg Oncol 17: 522-525, 1991.

249. Ramelet, A.A. and G. Perroulaz. Rosacea: histopathologic study of 75 cases. Ann Dermatol Venereol 115: 801-806, 1988.

250. Katz, A.M. Rosacea: epidemiology and pathogenesis. J Cutan Med Surg 2 Suppl 4: S4-10, 1998.

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