Eczema and rosacea are both inflammatory skin disorders with complex, poorly understood origins. They frequently occur as comorbidities. Given the common inflammatory nature and their frequent co-occurrence, it makes sense to ask if treatments might overlap. Can you use eczema cream to treat rosacea, for example?
Many eczema products can make Rosacea worse. Only with understanding this and with careful supervision can coexistent Rosacea and Facial Atopic Dermatitis be treated together.
Caused by microbial overgrowth and an overactive innate immune system, inflammation underlies both rosacea and eczema. Many people with Rosacea (red flushing central face and adult acne) also have stinging skin and sensitive skin. These are the hardest patients for a dermatology clinic to help. When Facial Atopic Dermatitis overlaps with Rosacea, these patients suffer the most with failed treatments they can’t tolerate.
Our immune system exists to protect us from invasion by microorganisms and foreign particles, or antigens. Injury or introduction of antigens to your skin sets off an elaborate chain of signals and responses between cells.
Inflammation–evident in redness, swelling, itching, and oozing–is the outward result of this well-coordinated response. Injured tissues are repaired through this process, while the offending antigen is isolated and ejected.
When their tasks are accomplished, immune system cells receive a signal to stand down. The inflammation resolves once this is accomplished, usually over the course of days.
Some of us, though, have overly vigilant innate immune systems with inadequate signals to stand down. Encounters with normally harmless environmental triggers set off disproportionately strong inflammatory responses that do not shut themselves down appropriately.
There are dozens of genes involved in regulating this and if a few of them are not fully participating, the immune system cells don’t seem to get the order to stand down once the “threat” is repelled. Inflammation goes on, becoming a chronic problem.
This is an elementary outline of the process involved in eczema and rosacea flares. Rosacea also has a vascular or flushing component which is related to face-specific immune dysregulation, and topical steroids can make this worse.
Eczema is a general term for a group of several related dermatoses, or inflammatory skin disorders. This umbrella term can refer to atopic dermatitis, nummular dermatitis, dyshidrosis, and contact dermatitis, to name but a few.
These disorders are common, affecting an estimated 20–25% of the American population. They can be challenging to treat, with frequent relapses of symptoms that resist treatment.
The symptoms of eczema vary, depending upon the type, the trigger, and the severity. They all include redness, swelling, and itching, in addition to dryness. Oozing can also be a symptom; in fact, the Greek root word from which eczema is derived means “boiling over.”
The disorders under the eczema umbrella are all chronic.
Eczema has no one, discrete cause. Each type of eczema has several different factors that play into its development.
Damage to the skin barrier, either structural or functional, is the primary risk factor for eczema. Most of its influencing factors are related to this damage. This includes the following:
Unhealthy skin microbiome: A microbiome is any niche ecosystem of microbes; your body has many different, highly-specific microbiomes. When your skin’s microbiome is out of balance (dysbiosis), populations of beneficial microbes decline while populations of more problematic microbes increase. Staphylococcus aureus, or staph, is the microbe most commonly associated with eczema flares.
Immune system dysfunction: For those prone to inflammation, exposure to environmental irritants or pathogens can trigger inflammation, causing eczema flares.
Most often, it is not one of these factors, but the intersection of several, that give rise to eczema.
The most common treatments for eczema are topical corticosteroids to address inflammation; antihistamines are frequently used to relieve itching. Biologic treatments such as dupilumab and immunosuppressants such as cyclosporine or methotrexate may be used initially for severe cases that resist treatment.
Supportive self-care practices include avoiding triggers and moisturizing twice daily.
Rosacea has several different subtypes with different symptoms, but in all cases it is characterized by flushing, redness, and dilated or broken blood vessels (a symptom called telangiectasis) visible in the epidermis.
Rosacea affects approximately 14 million Americans–around 5% of the population. In Northern Europe, it affects around 10%. Rosacea is most visible in fair-skinned people but affects people of all skin types, and it may be underreported in people of color.
Rosacea primarily affects the cheeks and nose, but it is not unusual for it to present on the neck and the scalp. Occasionally, it affects skin on the shoulders or other parts of the body..
Rosacea has four subtypes, classified by symptomatology:
Erythematotelangiectatic Rosacea (ETR) is the “textbook” subtype. Facial redness and flushing affecting the cheeks, nose, and forehead are the most recognizable symptoms of this subtype, although it can involve the scalp, chin, neck and upper chest. Upper chest and neck rosacea is very commonly misdiagnosed as folliculitis or acne.
Patients may experience warmth, tingling, stinging, or swelling in the affected skin. The skin sometimes feels dry or scaly. Patients often report “combination skin.”
Without proper treatment, ETR can progress, with more frequent, longer-lasting flares that affect more skin. Without treatment Rosacea can progress to a thick, permanently red and permanently purple disfiguring skin condition. These untreated and unfortunate individuals are often mislabeled as “big boozers, drunks” by their co-workers.
Papulopustular (Acne) Rosacea (PPR) is characterized by acne-like breakouts, along with the typical rosacea symptoms of flushing and patchy redness. The papules (small red bumps) both with and without pustules are usually larger than typical acne pustules, and inflammation can extend deeper into the skin. There is often deeper swelling (edema) than with an acne pimple.
Like other subtypes, the papules primarily affect the center of the face, although they can spread to the scalp, neck, and upper chest.
Patients with papulopustular rosacea often report that the affected skin is sensitive, prone to burning or stinging. Patches of extremely oily and/or excessively dry skin often develop during flares. Dry patches may become thick and scaly, forming rough, lichenified plaques. Immune dysregulation contributes to the problem.
Phymatous Rosacea (PR) most usually begins as small areas of red, unevenly-thickened skin from persistent edema and congested lymphatics. Rhinophyma, a condition in which thickened skin continues to build up over the nose, is a complication of untreated or badly-managed PR. As it progresses, the nose takes on an increasingly bulbous appearance. Rhinophyma more commonly affects men than women.
Ocular Rosacea (OR) causes redness and inflammation in the eyes, the eyelids, and skin around the eyes. Bloodshot eyes, swelling around the eye, and bumps on the eyelids are all symptoms of OR. The eyes burn and water excessively during flares.
The eyes may become dry and more sensitive. Patients sometimes experience blurred vision and sensitivity to bright light. These patients require a skilled dermatologist for proper eyelid cleansing, skin care, and oral antibiotics that treat Rosacea.
Rosacea is not as well-studied as eczema, and there’s little concrete understanding of the condition. Most symptoms and triggers are self-reported, but these are difficult to corroborate in a clinical setting or a scientific study.
Factors that contribute to rosacea:
Skin barrier dysfunction.is a well-documented contributor to rosacea flares, just as it is with eczema. Yeast overgrowth in the microbiome can affect both. Demodex folliculitis or simply excess demodex organisms in the skin pores is strongly associated with flares of rosacea. The pure element sulfur is known to reduce Demodex, and it is present as part of the pre-biotic complex in SmartLotion®. This complex, combined with the very low strength hydrocortisone and barrier repairing components makes SmartLotion® an important therapy for Rosacea patients with stinging skin or eczema.
Disordered gut and skin microbiomes correlate strongly with rosacea, according to recent studies.
Genetics: Like eczema, rosacea itself is not inherited. However, researchers have identified two areas of the genome associated with rosacea. These areas are also strongly associated with inflammation and autoimmune disorders such as MS and lupus; rosacea is often comorbid with these disorders.
Spicy food, red wine, heat, sunlight, caffeine or chocolate consumption, excess alcohol, and extreme cold are all triggers self-reported by rosacea sufferers.
Treatments for rosacea work on several different fronts. They include:
Metronidazole, a topical antibiotic. It should be a first line treatment for Rosacea and SmartLotion added only for poor responders, or for sensitive skin and stinging rosacea patients.
Topical vasoconstrictors such as oxymetazoline and brimonidine, prescribed to reduce flushing and to shrink damaged blood vessels.
Oral antibiotics are often prescribed for rosacea symptoms and redness. These are especially important for Eczema patients with rosacea, and for Ocular rosacea.
Lubricating eye drops are commonly prescribed for ocular rosacea, like Refresh®.
Topical steroids are sometimes used with caution, and only in combination with other Rosacea therapies, to treat inflamed skin during rosacea flares. Prolonged use of strong topical steroids can worsen rosacea after only two or three weeks, and lead to a rebound condition called rosacea-like dermatitis (TCIRD) or TSW once steroids are withdrawn.
- Antibiotics are often used to treat flares of rosacea and secondarily infected eczema. On their own, antibiotics are not as effective at treating inflammation; they work best when combined with safe low potency topical steroids.
As with eczema, supportive treatment is an important part of healing from rosacea flares. This means avoiding your known triggers, protecting your skin from sunlight, gentle cleansing to remove bacteria and demodex, and moisturizing and repairing dry, stinging skin.
Getting inflammation under control is key in treating either eczema or rosacea. Unfortunately, this is not as direct or simple as it might sound.
Topical steroids, a mainstay in treating skin inflammation, can cause thinning of the skin (atrophy) after prolonged use. They can also cause rebound effects such as the previously mentioned TCIRD and topical steroid withdrawal (TSW).
This is where SmartLotionⓇ comes in. The brainchild of Board certified dermatologist Steve Harlan, MD, SmartLotionⓇ combines the prebiotic properties of sulfur, glycerin, and grapefruit seed extract, the anti-inflammatory power of 0.75% hydrocortisone, together with true barrier repairing and “skin breathing” base lotion, to safely bring healing and relief from chronic skin disorders.
Combining a prebiotic strategy and a low dose (0.75%) of hydrocortisone, SmartLotionⓇ effectively treats inflammation without the risk of TCIRD, TSW, or skin atrophy–even when used over long periods, under the supervision of your dermatology provider.
Under your doctor’s supervision, SmartLotionⓇ can be used alongside antibiotics, as well as most other prescription treatments, without risk of adverse effects. Dr. Harlan’s peer-reviewed study demonstrated that a combination of antibiotic therapy and SmartLotionⓇ accelerates the resolution of inflammation for rosacea patients. SmartLotion® has been used for over 15 years by a network of board certified dermatologists in their clinics as a physician-dispensed product to help their patients.
SmartLotionⓇ relieves the redness, itching, and stinging that plague both eczema and rosacea sufferers while promoting the health of the skin barrier..
SmartLotionⓇ protocols for rosacea and eczema
Dr. Harlan has his adult rosacea patients cleanse their skin daily with a gentle cleanser and use Baby shampoo to cleanse eyelashes and eyebrows. (Eyelashes can be full of Demodex). Patients apply SmartLotion® two times daily for up to two weeks when they have stinging skin, or when they are not responding to topical Metronidazole alone.
If the patient sees improvement within the first two weeks, he typically advises them to taper down to one application daily for two weeks. The rate of tapering depends upon how quickly symptoms are improving. Continue daily Rosacea therapies and strategies, and use SmartLotion 3 times weekly, or as needed for preventing inflammation or stinging. Patients are seen every 3 to 6 months for supervision by a Dermatology provider.
Because eczema comprises several different disorders, the treatment protocols vary. Visit Dr. Harlan’s indispensable SmartLotion® Knowledgebase for details in treating your specific type of eczema.
Damage to the skin barrier contributes to both eczema and rosacea. This damage causes moisture to evaporate too quickly from the epidermis, leading to dry, dull, stinging or itchy skin. Far from being a mere aesthetic concern, this dryness aggravates both eczema and rosacea. Regular moisturization is a critical part of preventing flares of either disorder.
Dr. Harlan’s considerable experience and expertise once again brings us a revolutionary new way to care for sensitive, damaged skin. He has worked with manufacturing chemists to create the Most Advanced Dermatologist Designed Moisturizer for body, hands, lips, and face.
Perfect Repair™ moisturizing cream combines abundant natural ceramides with the healing properties of coconut oil to reduce inflammation, repair skin barrier functions, rehydrate skin cells and protect them from moisture loss. Jojoba oil, grapefruit seed extract, and glycerin, a powerful humectant, produce an amazing prebiotic strategy and give your skin’s microbiome a needed boost.
Perfect Repair™ is gentle and fragrance-free, and it does not clog pores. It contains no propylene glycol and no methylisothiazolinone. Used twice a day, it is an excellent part of maintaining your skin’s health. During flares of eczema or rosacea, consider using it more often to address dryness.
Apply it to skin affected by rosacea or eczema before applying SmartLotionⓇ to maximize absorption and reduce stinging. Perfect Repair™ is also quickly becoming used by dentists, surgeons, and nurses to repair hands. And there’s nothing better for damaged or chapped lips!