Understanding Rosacea: An Inside-Out Approach to Skin Health

The Science Behind Rosacea: Key Pathophysiological Mechanisms

Immune Dysregulation:

• Rosacea is associated with innate immune system dysfunction, particularly the over activation of cathelicidin (a peptide involved in immune defence).
• Excessive cathelicidin leads to inflammatory and angiogenic responses, contributing to the  redness and visible vessels commonly seen in rosacea (Yamasaki et al., 2007).

Neurovascular Dysregulation:

• Triggers such as heat, stress, alcohol, or spicy foods activate sensory nerves within the body, that release vasoactive neuropeptides, resulting in flushing and vasodilation (Steinhoff et al., 2011).

Microbial Involvement:

• Overgrowth of Demodex folliculorum, a skin mite, is more common in rosacea-prone skin. Its presence can stimulate inflammation, potentially through triggering Toll-like receptor 2 (TLR2) pathways.

Types of Rosacea 

Rosacea is a chronic skin condition with four main types: erythematotelangiectatic, papulopustular, phymatous, and ocular. Erythematotelangiectatic rosacea is characterized by persistent redness and visible blood vessels. Papulopustular rosacea presents with pimple-like bumps and pus-filled spots. Phymatous rosacea involves skin thickening and bumpy areas, often on the nose. Ocular rosacea affects the eyes, causing redness, irritation, and potentially other eye problems. 

Here's a more detailed look at each type:

Erythematotelangiectatic (Vascular) Rosacea

Erythematotelangiectatic rosacea, also known as vascular rosacea, is characterized by persistent redness across the central face that often resembles a prolonged flush. This subtype is marked by increased visibility of small, dilated blood vessels—commonly referred to as telangiectasias—especially around the cheeks, nose, and chin. Individuals may experience frequent and intense episodes of flushing, often triggered by heat, stress, sun exposure, or certain foods and beverages. Alongside the visible redness, there can be sensations of burning, stinging, or warmth in the affected areas. In some cases, the skin may also feel dry or rough, and mild facial swelling can occur.

Papulopustular (Inflammatory) Rosacea:

Papulopustular rosacea, also known as inflammatory rosacea, is characterized by persistent facial redness accompanied by small, inflamed red bumps (papules) and pus-filled lesions (pustules) that closely resemble acne. These symptoms typically appear in the central areas of the face, including the cheeks, nose, and chin. In addition to these breakouts, individuals may experience burning, stinging, or itching sensations, as well as visible blood vessels (telangiectasias) and, in more severe cases, facial swelling due to ongoing inflammation.

Although the pustules and papules can look similar to acne, there are key differences. Papulopustular rosacea tends to develop in adults between the ages of 30 and 60, whereas acne is more common in adolescents and young adults. Rosacea is usually confined to the central face, while acne can appear on the back, chest, and shoulders. Another distinguishing feature is the absence of comedones (blackheads and whiteheads), which are typical in acne but not in rosacea. Proper identification of these features is essential for accurate diagnosis and treatment.

Phymatous Rosacea:

Phymatous rosacea is a less common but more severe subtype of rosacea, marked by thickened, bumpy skin, enlarged pores, and an uneven surface texture caused by nodular growths. While it can affect various areas of the face—including the ears, chin, forehead, and eyelids—it most commonly appears on the nose, a condition known as rhinophyma. This leads to a visibly enlarged, red, and bulbous appearance of the nose. Phymatous rosacea occurs more frequently in men and tends to progress gradually over time if left untreated.

The physical changes associated with this form of rosacea can cause significant emotional distress, contributing to social anxiety and reduced quality of life. Studies, including those from the Revival Research Institute, have highlighted the potential psychological impact of phymatous rosacea. Early identification and medical intervention are essential in managing this condition and preventing further skin thickening and disfigurement.

Ocular Rosacea:

Ocular rosacea is a form of rosacea that affects the eyes and the surrounding skin, often leading to discomfort and inflammation. Common symptoms include red, itchy, and burning eyes, along with a gritty or sandy sensation, as if something is stuck in the eye. Individuals may also experience dry eyes, excessive tearing, swollen eyelids, and increased sensitivity to light. In some cases, the eyes may appear bloodshot or develop blurred vision. Ocular rosacea can also lead to recurring styes or chalazia—small, painful bumps on the eyelid. Because these symptoms can easily be mistaken for other eye conditions, it’s important to seek professional care to manage the inflammation and prevent complications.

Who is Commonly Affected?

Rosacea most commonly affects adults between the ages of 25 and 50, with women being more frequently diagnosed. However, when men do develop rosacea, they are more likely to experience more severe symptoms, particularly phymatous changes such as thickened skin. Individuals with fair skin, blue eyes, and of Northern European descent are at higher risk of developing rosacea. A family history of the condition also increases susceptibility, suggesting that genetics may play a significant role in its development. Hormonal changes in women, particularly during pregnancy and the postpartum period, can influence the course of rosacea. Fluctuations in estrogen and progesterone levels may exacerbate underlying inflammation, trigger increased facial redness or sensitivity, and contribute to flare-ups. These hormonal shifts can make rosacea more unpredictable, requiring adjustments in both topical and internal treatment approaches during these life stages.

Common Rosacea Triggers

The exact cause of rosacea is not fully understood, but it's believed to be a complex interplay of genetic and environmental factors. Understanding and avoiding personal triggers is foundational in rosacea management. 

• Environmental Sun exposure, wind, temperature extremes
• Emotional Stress, anxiety, embarrassment (*hello to that facial flush feeling during a public talk)
• Dietary Spicy foods, hot beverages, alcohol (especially red wine), chocolate
• Physical Strenuous exercise, hot showers or saunas
• Topical Harsh products, chemical sunscreens, exfoliants

A Naturopathic Approach: Approaching Rosacea from the Inside-Out

Rosacea is not just a skin condition—it often reflects internal imbalances, particularly in the gut and endocrine systems.

The Gut-Skin Axis:

Studies show a strong association between rosacea and gastrointestinal disorders, particularly: small intestinal bacterial overgrowth (SIBO), Helicobacter pylori infection and irritable bowel syndrome (IBS). A 2016 Danish population study found that patients with rosacea were significantly more likely to have celiac disease, Crohn’s disease, and ulcerative colitis (Egeberg et al., 2016). The hypothesis behind this interaction is that the dysbiosis can increase intestinal permeability ("leaky gut"), allowing inflammatory mediators and microbial byproducts to circulate systemically. This can contribute to neurovascular activation and immune dysregulation in the skin.

Hormonal Influences:

Hormonal fluctuations play a significant role in rosacea, particularly in women. Many women struggling with rosacea report flare-ups around ovulation or during menstruation, indicating a strong hormonal influence. Estrogen, in particular, plays a key role in modulating both vascular reactivity and sebaceous gland activity. When estrogen levels shift—such as during the luteal phase of the menstrual cycle, pregnancy, or perimenopause — there can be an increase in vasodilation and inflammation, which may trigger facial flushing, sensitivity, and flare-ups. During pregnancy, elevated estrogen and progesterone can both calm or worsen rosacea, depending on the individual's inflammatory and vascular response. In contrast, perimenopause and menopause often exacerbate symptoms due to the steady decline in estrogen and progesterone, resulting in increased skin dryness, barrier disruption, and heightened vascular sensitivity. These hormonal changes influence the neurovascular and immune pathways associated with rosacea, including increased activation of transient receptor potential (TRP) channels and the release of inflammatory mediators such as cathelicidins, which contribute to redness, flushing, and inflammation. Understanding these internal hormonal dynamics can help guide more personalized and effective treatment approaches, especially in women navigating different reproductive life stages.

Nutraceuticals: 

Certain evidence-based nutraceuticals can be supportive in managing rosacea by addressing inflammation, hormonal imbalances, oxidative stress, and gut-skin axis dysfunction. Below are some of the most well-researched supplements for rosacea support:

• Omega-3 Fatty Acids (EPA & DHA)
• Zinc (especially Zinc Picolinate or Zinc Methionine) 
• DIM (Diindolylmethane) 
• Probiotics (Lactobacillus and Bifidobacterium strains) 
• Ashwagandha (Withania somnifera) 
• Curcumin (from Turmeric) 
• Vitamin D 
• Quercetin 
• N-Acetylcysteine (NAC)

Disclaimer: Always consult with a qualified healthcare provider before starting any new supplement, especially if you are pregnant, breastfeeding, managing chronic conditions, or taking medications. Nutraceuticals may interact with medications or be contraindicated based on your personal health history.

Mind-Body Practices:

Chronic stress is a well-known trigger for rosacea flares due to its impact on the nervous system, hormonal balance, and inflammatory pathways. When stress levels rise, the body increases production of cortisol and activates the sympathetic nervous system, leading to vasodilation, immune dysregulation, and heightened neurovascular reactivity—mechanisms strongly implicated in the pathophysiology of rosacea. Therefore, mind-body practices that regulate the stress response and promote parasympathetic (rest-and-digest) activity can be valuable adjuncts in managing rosacea.

1. Meditation and Mindfulness-Based Stress Reduction (MBSR)
2. Breath-work
3. Yoga and Gentle Movement
4. Acupuncture 
5. Guided Visualization and Biofeedback

Topical Skincare for Rosacea-Prone Skin 

A consistent, gentle skincare routine is a cornerstone of managing rosacea. Because rosacea-prone skin tends to be sensitive, inflamed, and reactive, it’s important to use products that support the skin barrier, minimize irritation, and reduce inflammatory responses.

Cleanse Gently: Rosacea patients should opt for non-foaming (gel, oil, cream), fragrance-free cleansers that do not strip the skin of its natural oils. The harsh surfactants of foam cleansers, scrubs, and exfoliating agents can aggravate already sensitive skin. A study by Draelos (2012) emphasized the importance of mild, soap-free cleansers in reducing irritation in rosacea patients and improving overall treatment outcomes.

Moisturize to Support Barrier Function: Barrier repair is essential, as disrupted skin barrier function is a common feature in rosacea. Moisturizers containing niacinamide, ceramides, and azelaic acid (10%) have been shown to reduce inflammation and enhance the skin’s natural defence system. Niacinamide has anti-inflammatory properties and helps improve the stratum corneum’s lipid barrier, while ceramides restore moisture and integrity (Gehring, 2004). Azelaic acid is also commonly recommended for rosacea due to its anti-inflammatory and antimicrobial effects, and it may reduce papules and pustules with minimal irritation (Kawashima et al., 2007).

Daily Sun Protection: Sun protection is a non-negotiable. Sun exposure is one of the most frequently reported rosacea triggers. Mineral-based sunscreens containing zinc oxide or titanium dioxide provide broad-spectrum protection and are less likely to cause irritation compared to chemical sunscreens. A randomized study by Del Rosso (2008) highlighted that daily application of physical sunscreen significantly reduced rosacea flares and erythema over time.

Avoid Common Irritants: Many over-the-counter skincare products contain ingredients that are known rosacea triggers. These include alcohol, menthol, eucalyptus oil, witch hazel, and synthetic fragrance—all of which can increase vasodilation and skin reactivity. The National Rosacea Society and several dermatological studies support the use of hypoallergenic and non-comedogenic products specifically formulated for sensitive or reactive skin types.

Medical Aesthetic Treatment Options - from Heidi Graham, RN, BScN, Founder of G-Lab Skincare

As a nurse with a passion for skin health, I’ve seen firsthand how powerful it can be when we combine internal and external approaches to treating conditions like rosacea. Medical aesthetics is the perfect complement to the inside-out philosophy of Naturopathic Medicine. While naturopathic doctors focus on uncovering and treating the root causes—from gut health to hormonal imbalances—medical aesthetic treatments work externally to reduce visible inflammation, calm redness, and restore skin confidence.

When we blend these two approaches, that’s where the magic really happens. Patients often see longer-lasting, more holistic results. Below is a quick overview of some of the professional medical aesthetic treatment options available in Canada that can help manage rosacea alongside naturopathic care.

Topical Treatments

For clients experiencing more persistent or inflammatory rosacea, topical medications prescribed by a physician or nurse practitioner may help calm the skin and reduce flare-ups. Some of the most common options in Canada include:

Metronidazole and ivermectin: Both are anti-inflammatory creams approved by Health Canada that can help reduce redness and treat the small pustules that often appear with rosacea. Ivermectin also targets Demodex folliculorum, a mite associated with some rosacea subtypes (Taïeb et al., 2015; Stein Gold et al., 2014).

Azelaic acid: A naturally derived dicarboxylic acid that helps exfoliate gently, calm inflammation, and even out tone. It’s commonly used for its anti-inflammatory and antimicrobial properties, and often well tolerated (Thiboutot et al., 2009).

Brimonidine and oxymetazoline: These prescription vasoconstrictive gels reduce persistent facial redness by constricting dilated blood vessels at the skin's surface. Brimonidine, an α2-adrenergic agonist, can show visible effects within 30 minutes and last up to 12 hours (Fowler et al., 2013; Liu et al., 2017).

Laser and Light-Based Therapies

When redness or visible blood vessels become more persistent, light-based treatments can offer relief. At GMA, I use Intense Pulsed Light (IPL) — a non-invasive therapy that targets vascular changes and redness over time. IPL uses broad-spectrum light to minimize background erythema and reduce inflammation through selective photothermolysis (Papageorgiou et al., 2008).

For more targeted vascular concerns like telangiectasia, vascular lasers such as Pulsed Dye Laser (PDL) are highly effective and often available through dermatology clinics. PDL specifically targets oxyhemoglobin and has demonstrated strong clinical outcomes for rosacea-related vascular changes (Gold et al., 2011).

These technologies aren’t about replacing natural or internal care—they’re tools that can work beautifully alongside lifestyle changes, skincare, and naturopathic support. I love seeing clients feel empowered by a care plan that blends science with a whole-person approach.

Curious to learn more?