Seeing Red (Part 2) — Rosacea Management |

Seeing Red (Part 2) — Rosacea Management

Acne rosacea affects over fourteen million Americans, the majority of them women. Fair skinned descendents from northwest Europe – Scandinavian, British, and Celtic ethnicities – are particularly prone, with onset usually occurring between the ages of 30 and 60. While not disabling, rosacea can result in significant social stigmatization and isolation. Anyone with this condition knows all too well the angst and trepidation that occurs every time there is a major increase in symptoms – the dreaded “flare-up”. Stepping out the door to take on the day is not easy when bright red patches on your face announce to the world you have rosacea. The stinging, burning, and tenderness remind you even when cosmetics make the visible signs less obvious.

In surveys by the National Rosacea Society, more than 76 percent of rosacea patients said their condition had lowered their self-confidence and self-esteem, and 41 percent reported that it had caused them to avoid public contact or cancel social engagements. Among rosacea patients with severe symptoms, 88 percent said the disorder had adversely affected their professional interactions, and 51 percent said they had even missed work because of their condition. Rosacea has no cure but can be managed to reduce its potentially life-disruptive impact.

The hallmark of rosacea is persistent redness resulting from networks of superficial blood vessels (telangiectasias) in the skin of the nose, cheeks, chin, forehead, or eyes.  There are four major subtypes.

Subtype 1 (erythematotelangiectatic) rosacea is characterized by flushing and persistent facial redness. Visible blood vessels may be present, and stinging and burning discomfort is common. Because this subtype is difficult to treat with medical therapy, it may be especially important to identify and avoid lifestyle and environmental factors that trigger flushing or irritate the skin. (see the list of rosacea triggers below). A personal diary helps to identify and avoid those factors that affect an individual case. The appearance of flushing, redness and visible blood vessels may also be concealed with cosmetics, and facial discomfort may benefit from appropriate skin care. (See Skin Care and Cosmetics below) Visible blood vessels and severe background redness may be reduced with lasers or intense pulsed light therapy. Several sessions are typically required for satisfactory results, and touch-up sessions may later be needed as the underlying disease process is still present. In specific cases, extensive flushing may be moderated somewhat through the use of certain drugs.

Subtype 2 (papulopustular) rosacea is characterized by persistent facial redness and acne-like bumps and pimples, and is often seen after or at the same time as subtype 1. Fortunately, a number of medications have been studied and approved for this common form of rosacea, and may be used on a long-term basis to prevent recurrence. In mild to moderate cases, doctors often prescribe oral and topical rosacea therapy to bring the condition under immediate control, followed by long-term use of the topical therapy to maintain remission. A version of an oral therapy with less risk of microbial resistance has also been developed specifically for rosacea and has been shown to be safe for long-term use. Higher doses of oral antibiotics may be prescribed, and other drugs may be used for patients who are unresponsive to conventional treatments.

Subtype 3 (phymatous) rosacea is characterized by skin thickening and enlargement, most frequently around the nose. This condition develops primarily in men. Although mild cases may be treated with medications, moderate to severe manifestations typically require surgery. A wide range of surgical options is available, including cryosurgery, radiofrequency ablation, electrosurgery tangential excision combined with scissor sculpturing and skin grafting. A surgical laser may be used as a bloodless scalpel to remove excess tissue and re-contour the nose, often followed by dermabrasion


Subtype 4 (ocular) rosacea is characterized by any one of many eye symptoms, including a watery or bloodshot appearance, foreign body sensation, burning or stinging, dryness, itching, light sensitivity and blurred vision. A history of having styes is a strong indication, as well as having “dry eye” or blepharitis. Treatment for mild to moderate ocular rosacea may include artificial tears, oral antibiotics and the daily cleansing of the eyelashes with baby shampoo on a wet washcloth. More severe cases should be examined by an eye specialist, who may prescribe ophthalmic treatments, as potential corneal complications may involve the loss of visual acuity.


1. Odom R, Dahl M, Dover J, Draelos Z, Drake L, Macsai M, Powell F, Thiboutot D, Webster GF, Wilkin J. Standard management options for rosacea, part 2: Options according to subtype. Cutis 2009;84:97-104.


Most people have only mild redness and are never formally diagnosed or treated and there is no single, specific test for rosacea. What is common, however, among nearly all patients is a relationship between worsening of symptoms and certain, food, beverages, emotional states, and environmental factors, so called triggers. There are numerous triggers that can tend to lead to exacerbations. The following triggers were cited by 1066 rosacea patients surveyed by the National Rosacea Society.

  • Sun exposure 81%
  • Emotional stress 79%
  • Hot weather 75%
  • Wind 57%
  • Heavy exercise 56%
  • Alcoholic drinks 52%
  • Hot baths 51%
  • Cold weather 46%
  • Spicy foods 45%
  • Humidity 44%
  • Indoor heat 41%
  • Skin products 41%
  • Hot beverages 36%
  • Some cosmetics 27%
  • Medications 15%

Certain medications and topical irritants can quickly trigger rosacea. Some acne and wrinkle treatments reported to cause rosacea include microdermabrasion and chemical peels, high doses of isotretinoin, benzoyl peroxide, and tretinoin.

Management and Treatment

Patients should determine which triggers cause flare-ups. A diary of foods, beverages, or activities is helpful. Avoidance of such triggers does not prevent all recurrences except in very mild cases. Use of daily sunscreen protection or hats with wide brims is widely recommended to prevent sun exposure. Sunscreen should have aSPFof 15 or higher and block both UVA and UVB ultraviolet light as well as infrared.

Medical treatment for rosacea depends on severity and subtype. Mild cases may not be treated at all or simply covered up with cosmetics (something easier and more familiar to female patients.) No therapy is curative and is best measured in terms of reduction in the amount of erythema (redness) and inflammatory lesions, decrease in the number and severity of flare-ups, and associated itching, burning and tenderness.

Mainstays of treatment are topical (metronidazole) and oral antibiotics (tetracyclines) to reduce pimples (pustules), bumps (papules), inflammation and some redness. Topical azelaic acid may be helpful. Improvement can take one to two months or longer. For advanced cases, dermabrasion, cryosurgery, or laser (intense pulsed laser or laser surgery) treatment may be recommended. Rosacea patients should seek professional consultation from specialists in the field to determine their own specific recommended treatments. Nonetheless, there are many things that are helpful and easy to do.

Skin Care and Cosmetics

Consistent gentle skin care and effective use of cosmetics can make a visible difference in managing rosacea and improving the look of one’s skin. The key is to use only skin care products that minimize irritation. Select products marked for use on sensitive skin, avoiding any that sting or burn. Examine the list of ingredients of any product that touches your face to avoid irritants known to worsen rosacea symptoms. Common problem ingredients include alcohol, witch hazel, menthol, peppermint, and eucalyptus oil. Astringents and exfoliating agents are often too harsh for sensitive skin. Fragrances are especially troublesome and are responsible for more allergic contact dermatitis than any other ingredient according to the American Academy of Dermatology.

It is a good idea to test any new product on unaffected skin prior to using them on the areas of rosacea. An unaffected peripheral area of the face or neck is a good choice. Using a product with multiple functions instead of multiple products is also recommended to reduce the number of ingredients. This applies equally to cosmetics – the fewer the better.

Cleansers should be selected according to skin type and some are formulated specifically for sensitive or redness-prone skin. Unless your skin is oily, non-soap cleanser is a good option. They contain less than 10% soap, rinse off easily, and have a neutral pH that is close to that of the skin. If skin is very oily, a mild soap should be used, taking care to avoid scrubbing as aggressive rubbing or over-cleansing is often irritating.


Many dermatologists consider the proper moisturizer as key for preventing burning, stinging, itching, and irritation. A strong moisture barrier is important in helping to keep our impurities and irritants that may aggravate sensitive skin. There are moisturizers specifically developed with ingredients intended to calm and sooth the skin. They may contain green color neutralizers to offset the red appearance.


Before applying makeup, cleanse and moisturize gently, avoiding scrubbing or rubbing. Use gentle tools to apply cosmetics, keeping the number of products to a minimum to reduce chances of applying an irritating ingredient. Green tinted bases are available that contain UVA/UVB sunscreen protection. Foundation should be oil free and match your natural skin tone as closes as possible.

Cleansing Tips

Dermatologists recommend a gentle cleansing routine for people with rosacea. A suggested method is:

1. Using your fingertips, wash skin with a cleanser suitable for your skin type. Avoid using an abrasive washcloth or sponge, which may irritate.

2. Rinse away cleanser with lukewarm water. Hot or cold water may cause flushing or irritation. If your face is irritated by water at any temperature, try using a soothing cream cleanser you can simply tissue off.

3. Gently blot your face dry with a thick-pile cotton towel. Don’t rub skin, as this may cause irritation.

4. Since stinging most often occurs on damp skin, wait 30 minutes for the face to dry completely before applying any topical medication. Slowly reduce the drying time until you find the least amount of time your skin needs to avoid a stinging sensation.

5. After applying topical medication, wait five to 10 minutes more before applying moisturizer, sunscreen or makeup.

6. If you have ocular rosacea, be sure to follow your doctor’s directions for eyelid scrubbing and medication.

Shaving Tips for Men

Shaving poses a unique challenge for men with rosacea, but there are ways to cope. It may be preferable to use an electric razor, thus avoiding the irritation of a less than perfectly sharp blade. Shaving creams or lotions that sting or burn should be avoided. Use of a post-shave balm and/or moisturizer will help sooth the skin.




  1. Jina says:

    Drgeorge hi,
    My skin can get quite red if I am out and come into a warm environment during winter months. The worst it has been is redness like your subtype 1 picture with a couple of raised spots but go away. Also last week I switched cleansing/moisturizer to one by whole foods for sensitive skin by Weleda. What a mistake it almost burnt my skin. Figured it was the alcohol used as the preservative. Pharmasist took pity on me as I enquired about cortisol cream and told me to come bqck next day and he will give me something. Turns out he is from Egypt and his wife has same issues as me. Made me small batch of sesame oil and few drops of chamomile oil. Wow what a potion. Dissapated redness on cheeks and burning stopped. Even mixed it with some avocado oil and applied on itchy legs las night. I stopped scratching immediately. Please explain the science behind that. This lovely gentlemen is a compound pharmacist No drugstore rep to tow big pharma line. I hope there are good people in this world that do care about others in need. And I was in need those few days.

  2. Taylor says:

    What do you think of the new product Instant Ageless ? “Botox in a bottle” doesn’t sound very healthy for the skin.


    • drjohn says:

      INGREDIENTS: Water (Aqua), Sodium Silicate, Magnesium Silicate, Acetyl Hexapeptide-8 (Argireline), Phenoxyethanol, Ethylexylglycerin, Yellow 5 (Cl 19140), Red 40 (Cl16035). Yikes! Silicates, alcohols, and the phony Botox wannabe argirline (from that company in Spain that specializes in whacky made up science that makes no sense to real scientists). If a topical actually worked like Botox your eyelids would start drooping, your mouth drooling, you couldn’t smile, and you would be quite a mess. of course, it doesn’t actually do much of anything whatsoever, so you are safe on that front. It’s all a farce. The silicates are like a paste to fill in lines. Washes right off. Sounds and looks like drywall patch. Instant? maybe. Ageless? More like instant senseless. I guess we don’t like it.

  3. G says:

    Is topical caffeine a vasoconstrictor or vasodilator? Also, would daily/bi-daily use of caffeine worsen tangelistae or rosy cheeks because of such vascular effects?

    • drgeorge says:

      Caffeine actually serves multiple purposes when applied to the skin. It does have a vasoconstrictive effect which tends to lessen redness and localized edema. It also has antioxidant properties, and has even shown benefit in inhibiting cancer-prone changes in the skin. It has effects of fat metabolism making it useful in cellulite creams. When ingested in our morning coffee (tea, mate’, etc.), it has a CNS stimulatory effect, hence the mental “arousal” we all seek (like I am as I write this.) As a CNS stimulant it also has a tendency to elevate blood pressure (vasoconstrictive) and find long-term use in OTC pain formulas and even in treatments for headaches, especially vascular types like migraine.

      So, bottom line: yes, of benefit in managing facial redness including rosacea. Some references below.

      WARNING – COMMERCIAL PLUG: I (Drgeorge) have not had a flare up of my rosacea in almost five years and I was on oral doxycycline, Metrogel, and topical steroids as necessary for decades. The product Drjohn and I developed is all I use. I test its efficacy almost daily as I love my spicy foods, jacuzzi, exercise, and more than the occasional glass of red wine. No flare ups also means I don’t steal my wife’s makeup when we go out. She loves that!

  4. G says:

    Thanks for your reply. Regarding your comment on fat metabolism, since topically applied caffeine can induce lipolysis, should we be worried about the fat layer under our skin thinning? This happens to mice:

    Loss of volume in the face (esp around the eyes) is very aging to one’s appearance.

    • drjohn says:

      Somebody tell those mice to switch their Starbuck’s lattes to decaf! Yes, caffeine does inhibit fat deposition, so there is that potential drawback if you apply it to your face. You sometimes see caffeine in eye creams because you can squeeze out “bags”. The skin is already thin in the area around eyes, so volume loss there would not be a good thing.

  5. Jenna says:

    I’ve been using my own face as a personal rosacea test laboratory for the past 20 years (I’m 41). I’ve recently resorted to rubbing raw garlic cloves on my face at night before bedtime every night for the past three weeks. Surprisingly, even though it stings, the redness goes away within a very short period of time. Overall, the mini whiteheads and flaky pimples are about 80% improved over what they had been before treatment. Even the scaly skin problem is almost completely resolved. Do you have any comment on the theory that rosacea is either an allergic response to demodex mite feces, or that it’s the result of an unchecked problem with intestinal parasites?

  6. Sara says:

    Is there a place where you can give us the name or link to the product that the doctors have created to help rosacea?

    • drgeorge says:

      While we make no overt claims about rosacea (FDA labeling issues), we can state that we have numerous and growing numbers of reports of significant improvements in flare ups. Drgeorge has not required any prescription meds since starting AnteAGE Serum over five years ago. His previous regimen included oral low dose doxycycline every day, along with topical Metrogel and topical steroids as necessary for severe flare ups. You can visit and order online. AnteAGE MD is available only through physician offices. Both work well.

  7. Diane Sturley says:

    HI Dr. George. I am interestep in the AnteAge MD line. I live just east of Toronto, Ontario. I would appreciate finding out where I can purchase in Canada and if I can get a discount as a BFT reader.

    I have suffered withme lama since 18. I am 52 and continue to cover up with sunscreen and hats anywhere outside. I have also been experiencing worsening of broken capillaries.

    Any assistance would be appreciated.

  8. Caroline Dase says:

    Hi, just finished my first bottle of anteage serum. Love it. My red face has never looked better! Ready to order another, can’t find that nice discount code. Please send?

  9. Dorothy says:


    I recently started AnteAge MD, too early to tell, but I do like the simplicity of it. I was also recently dx’d with rosacea as I hit menopause – it’s a somewhat mild case, combo of types 1 and 2. I’m too chicken to just stop my doxy and soolantra. Is there any problem using them with the AnteAge for now?

    • drgeorge says:

      No problem at all, but let me tell you my own personal story. I used doxycycline, Metrogel, and topical steroids (as needed) for many, many years to control my own rosacea problem. I had had too many flare ups to count and my wife was very annoyed when I used her makeup to cover the bright red area whenever they occurred. It was quite socially stressful when flare ups occurred and I was sensitive to all the usual triggers – spicy food, alcohol, sun, stress, anxiety, etc.

      Because our new skincare system prototype was ready, I decided to be guinea pig number one and stopped all prescription meds on July 1, 2011 and began to use our AnteAGE system twice daily. Within a week, I noticed my facial redness disappearing. I have not had a flare up since. I still have the almost full large tube of Metrogel in my medicine cabinet as a reminder “souvenir” of what happened.

      So, to your point: no problem using WITH the preventive products you are using and also, no problem using WITHOUT them. If you don’t see the improvement that I experienced, you can reintroduce the regimen along with AnteAGE. Let us know how you do. We have had many, many users over the years tell stories just like mine. Maybe you’ll be the latest one. Good luck!

  10. Dorothy says:

    One more question about my rosacea management: I’ve been using the Soolantra at night, waiting 30 min, then applying the AnteAGE, then waiting another 30, then applying Finacea. Since the AnteAGE is supposed to be applied while skin is damp, but I don’t want to wash after the Soolantra, I’ve been using a probiotic toner (just a light spray) then applying AnteAGE. I don’t want to lessen the AnteAGE effect. My plan is once the rosacea is under control, I will stop the doxy and Soolantra and see how the AnteAGE alone does – and will let you know.

    • drgeorge says:

      It’s clear you are doing everything you can to get this rosacea issue under control, and I don’t blame you. It is a pain to live with. I see nothing wrong with what you are doing although one would never know what was improving the rosacea in the manner you are using. Is it the Soolantra (ivermectine, an antiparasitic also used to treat head lice, scabies, onchocerciasis, strongloidiasis, trichuriasis and lymphatic filariasis), the Finacea (azuleic acid) or the AnteAGE that makes your rosacea improve? You won’t know. That may or may not be important to you but in my case, I wanted to see if the AnteAGE system was helpful with my long history of flare ups. I stopped the meds, the condition started to return and then disappeared with the twice daily use of AnteAGE (my version was our original and not the enhance MD version.)

      Being a MD, you are likely aware of “N-of-1” trials. They are the simplest clinical trial design there is. A patient with condition “X” uses a treatment that improves the condition, stops the treatment and the condition returns. That proves that the treatment was effective in managing condition “X”. In your case that condition is rosacea. For that reason, and the fact that rosacea is never “cured” but rather managed, trying the AnteAGE MD system alone burns no bridges and will tell you if it is sufficient treatment for your condition. If it is, great. If more oomph is needed, there is no harm in returning to your current management regimen. Let us know how it goes. As far as the specifics of how you are using the various products, I see no major issue.

  11. Kathy says:

    Hi. I have rosacea and have just recently ordered the full size Anteage system after trying the trial size. At the same time I ordered some products from Paula’s Choice. Is it ok to use other serums with Anteage, and if so, in what order? Thanks!

  12. Kathy says:

    I use Metrogel first and wait ten minutes. Then I use BHA, Anteage System, Niacinamide 20%, Azelaic Acid Booster, Calm Repairing Serum, and Cerave Moisturizer. I recently switched to the MD version of Anteage. Will any of the other products decrease the effects of Anteage? Thanks!

  13. Kathy says:

    I just noticed on the site that the two of you have different opinions about using BHA with AnteAge. Dr. George says, “The lower pH is not helpful in maintaining bio-signals potency”, while Dr. John says, “In fact AnteAge will accelerate the positive effects of exfoliation (quicker turnover of old surface skin). Could you both please clarify. Thanks!

    • drjohn says:

      Kathy, both are true! Acids kill cells, and AnteAGE rejuvenates. It’s all about the timing. BHA lowers pH and disrupts biosignaling in a limited time frame. So you can still benefit from the regenerative molecules in AnteAGE if you seperate them in time. By at least a few hours. Also I’m not fond of daily exfoliation. Causes chronic stress (very low pH is not healthy for skin over time – inflammatory signals predominate). The other useful thing to know is that AnteAGE can actually prevent or shorten the pH drop of acids on skin. We have had several reports of strong acid peels that didn’t peel in AnteAGE users. This is not just rejuvenation – its resuscitation of damaged cells! Again – it’s all about timing, and dosing. I propose a ratio of exfoliation/regeneration. The older we get, the more the equation needs to tilt toward regeneration, because our innate regenerative powers are diminished with age.

    • drgeorge says:

      Both of our comments are correct and appropriate.

      The skin has an acid mantle that is mildly acidic, about 5.5. For comparison, orange juice has a pH of 3 to 4, similar to the exfoliating products that contain alpha and beta hydroxy acids. Recommendations are to limit the use of these products to two or three times a week. If skin becomes reddened and stings following treatments, there is excessive use. The objective is to remove dead skin cells without incurring damage that leads to inflammation.

      AnteAGE contains biosignals that are pro-healing and anti-inflammatory, useful in day-to-day antiaging skincare and for the same reason, following exfoliating regimens. BUT, because low pH is not a “friend” to proteins (the biosignals are proteins potentially damaged by excessively low pH), we recommend AnteAGE not be applied while exfoliating agents are in use. Give your skin a few hours between exfoliation treatment and application of AnteAGE.

  14. Kathy says:

    Thank you both so much! I’m sorry to ask so many questions, but do you happen to know the pH of Metrogel, and are the other products I mentioned above (other than the BHA) ok?

    • drjohn says:

      Metrogel pH is 4.0.

      • drgeorge says:

        It can be confusing and challenging getting the details. Metrogel Vaginal has a pH of 4.0, reasonably close to the normal acidic pH of the vagina. That number is easy to find. The topical facial product, not so much. An aqueous saturated solution of metronidazole has a pH of 5.8 making me think the facial version of Metrogel has a pH that is likely even higher due to the low 1% active ingredient loading in the gel. Even the MSDS (material safety data sheet) for Metrogel lacks a pH value. I certainly wouldn’t lose sleep about its effect on our product efficacy. My personal story, I also have a long history of flares of rosacea up until July 1, 2011, the day I became guinea pig number one to try our serum. I have not had a flare-up since that day even after stopping Metrogel, doxycycline, and prn topical steroids.

  15. Kathy says:

    Since the Metrogel has a pH of 4.0 does that mean that the Metrogel and AnteAge shouldn’t be used together? Thanks!

  16. Kathy says:

    Thank you, Dr. George! I’m so happy for you! You know what a challenge Rosacea can be. I seem to have a particularly stubborn case of it. I’ve had 6 Laser Genesis treatments and 2 IPL, and it’s still not where I would like it to be. The last IPL actually left indentations on my nose that I pray aren’t permanent.

    You both have been very helpful, and I really appreciate it!

  17. Kristina says:

    Would you kindly describe the difference between AnteAGE and AnteAGE MD. Ingredients/ action/ patient selection
    Thank you kindl

    • drgeorge says:

      The first products to be marketed were AnteAGE. A year or so later, after becoming aware of the need within the medical practice community for truly high-science skincare with state-of-the-art cytokine and growth factor ingredients, AnteAGE MD was launched. The two systems are very similar although the MD versions have higher percentages of bone marrow stem cell conditioned media, along with some additional synthetic cytokines. The MD line has found great acceptance, not only for day to day skincare but as anti-inflammatory/pro-healing adjuvant used with controlled trauma aesthetic procedures, including microneedling, laser, RF microneedling, etc. Both systems are based on the same science and represent what we consider best available products in their market niche.

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