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Non-Prescription Topicals that may be Harmful to Rosacea Sufferers
Topics Discussed Below
- Beta hydroxy acids (salicylic acid)
- Alpha hydroxy acids (glycolic and lactic acid)
- Anti-aging products (cleansers, creams, gels & exfoliants)
- Topical steroids
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.
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!
Acids (Glycolic and Lactic Acids)
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.
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):
- Never used on facial skin
- Never used on facial skin
- 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).
- Aclovate by Glaxo Wellcome (Aclometasone diproprionate
cream or ointment).
- Desowen by Galderma (0.05% Desonide ointment,
cream, or lotion).
- Hytone by Dermik (2.5% hydrocortisone cream or
- 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."
- 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"
- 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.
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.
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.
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.
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In: Textbook of Dermatology, edited by R.H. Champion, J.L. Burton,
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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?".
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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.
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First World Congress of the International Academy of Cosmetic
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236. Guin, J.D. Complications of topical hydrocortisone. J
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240. Weirich, E.G. and J. Longauer. "Tierexperimetelle Prufung
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