Kinerase Pro+ Daily Defense Lotion SPF 30 with Kinetin and Zeatin is an example of a modern dermatological antioxidant sunscreen, priced at US $140.00.

Although less expensive sunscreens tout antioxidant capacity, it is unlikely that they contain relevant concentrations of antioxidants.

If fresh, chemically stable up to the point of use and able to penetrate skin, certain antioxidants formulated in combination (or applied underneath) sunscreens are able to provide increased photoprotection and therefore protection against worsening rosacea symptoms.

Rosacea Oil-Free Antioxidant Daily Wear Sunscreen provides an anti-inflammatory and antioxidant sunscreen formula including:

Vitis Vinifera (Grape Seed) Polyphenols, Green Tea (Camellia Sinensis) Polyphenols, Glycine Soja (Soy) Isoflavones, Silymarin (Milk Thistle) Silybin and Sodium Ascorbyl Phosphate (Vitamin C).

Unlike mass-produced sunscreens, the product is made freshly for each patient in the pharmacy and supplied in hermetically sealed packaging which includes an airless pump system.

The mode of production and supply of the sunscreen also allows for the elimination of paraben preservatives, which increase the burden of oxidative stress on skin and have been shown to heighten sun damage.

These two factors are extremely important in actually obtaining antioxidant protection from sunscreens because antioxidants are inherently unstable and prone to degradation when exposed to air.

Oxidized antioxidants may even be harmful.

For further information on oxidized antioxidant products, see Effects of Oxidized and Denatured Ascorbic Acid on Skin and the discussion surrounding Skinceuticals C E Ferulic Samples.

While native to the Mediterranean, milk thistle is now found throughout the world in dry, sunny areas. The plant derives its name from the white fluid which comes from all parts of the plant when cut. Milk thistle has been used medicinally for over 2,000 years, most commonly for the treatment of liver and gallbladder disorders. Other names for the plant include Marian Thistle, Mary Thistle, St Mary's Thistle, Mediterranean Milk Thistle and Variegated Thistle. Historically, the plant has also been consumed.

Within silymarin, there exists another constituent known as silybin (also known as silibinin) which is considered to be the most potent antioxidant found within the milk thistle plant.

Tests performed on human skin have shown that constituents of silymarin possess marked anti-inflammatory, photoprotective and anti-carcinogenic properties, if applied before and even after daylight exposure.

Photoprotective and anti-inflammatory antioxidants are of great interest in rosacea research because they have the potential to help prevent and treat rosacea symptoms while reducing reliance on sunscreens which are imperfectly protective. Studies routinely show that sunscreens only prevent approximately half the damage in rosacea patients skins' attributable to ultraviolet.

One highly attractive aspect of silymarin is that unlike sunscreens, once absorbed it can retain ability to protect skin from all forms of light for several days — it is more resistant to being worn away or washed off than sunscreens.

A high concentration of silymarin is found in Rosacea Oil-Free Antioxidant Daily Wear Sunscreen, Rosacea Treatment Fluid, Cream and Tri-Emollient Cream to help bolster the skin's defenses against photoaging and rosacea symptoms.

Greater effectiveness can be expected where silymarin is used both topically and systemically. A therapeutic quantity is found in the skin care supplements VitaMedica Broad Spectrum Antioxidant and Vitamedica Anti-Aging Formula Daily Packs together with other synergistic compounds. Blackmores Milk Thistle is an option containing silymarin alone.

Topical and systemic silymarin are welcome additions to the dermatologic armamentarium against rosacea.

• Anti-Inflammatory Creams for Rosacea
• Anti-Aging
• Act on Early Rosacea Symptoms to Prevent/Stem Worsening
• Rosacea Oil-Free Antioxidant Daily Wear Sunscreen SPF 30 — All Skin Types
• Antioxidant Sunscreens
• Rosacea Treatment Fluid — All Skin Types
• Rosacea Treatment Cream — Normal/Dry Skin
• Silybin

Selected Silymarin References

Dermatology Online Journal, Volume 6, Number 1.

Combined effects of silymarin and methylsulfonylmethane in the management of rosacea: clinical and instrumental evaluation. Berardesca E, Cameli N, Cavallotti C, Levy JL, Piérard GE, de Paoli Ambrosi G. San Gallicano Dermatological Institute, Rome, Italy. berardesca@berardesca.it

Silymarin and skin cancer prevention: anti-inflammatory, antioxidant and immunomodulatory effects (Review). Katiyar SK. Department of Dermatology, The University of Alabama at Birmingham, Birmingham, AL 35294, USA.

Chemopreventive Efficacy of Silymarin in Skin and Prostate Cancer, Gagan Deep, PhD, Department of Pharmaceutical Sciences, School of Pharmacy, School of Pharmacy, University of Colorado Cancer Center, University of Colorado Health Sciences Center, Denver, Colorado, Integrative Cancer Therapies, Vol. 6, No. 2, 130-145 (2007).

Svobodová A, Psotová J, Walterová D. Natural phenolics in the prevention of UV-induced skin damage [PDF]. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 147(2):137-45 (2003 Dec).

Dhanalakshmi S, Mallikarjuna GU, Singh RP, et al. Silibinin prevents ultraviolet radiation-caused skin damages in SKH-1 hairless mice via a decrease in thymine dimmer positive cells and an up-regulation of p53-p21/Cip 1 in epidermis. Carcinogenesis 25(8):1459-65 (2004 Aug).

Melbourne Dermatology Silymarin Monograph and Silymarin Improves Rosacea (accessed 15/5/10).

Additional Silymarin References

Hogan F, Krishnegowda N, Mikhailova M, Kahlenberg M. (2007). Flavonoid, silibinin inhibits proliferation and promotes cell-cycle arrest of human colon cancer. J Surg Res 143:58-65.

Tamayo C, Diamond S. (2007). Review of clinical trials evaluating safety and efficacy of milk thistle (Silybum marianum [L.] Gaertn.). Integrative Cancer Therapies.6:146-157.

Hogan F, Krishnegowda N, Mikhailova M, Kahlenberg M. (2007). Flavonoid, silibinin inhibits proliferation and promotes cell-cycle arrest of human colon cancer. J Surg Res 143:58-65.

Gazák R, Walterová D, Kren V (2007). "Silybin and silymarin--new and emerging applications in medicine". Curr. Med. Chem. 14 (3): 315—38. doi:10.2174/092986707779941159. PMID 17305535.

Rainone F. (2005). Milk thistle. American Family Physician72:1285-1288.

Greenlee H, Abascal K, Yarnel E, Ladas E. (2007). Clinical applications of Silybum marianum in oncology. Integrative Cancer Therapies 6:158-165.

Kroll DJ, Shaw HS, Oberlies NH.(2007). Milk thistle nomenclature: why it matters in cancer research and pharmacokinetic studies. Integrative Cancer Therapies.6:110-119.

Hogan F, Krishnegowda N, Mikhailova M, Kahlenberg M. (2007). Flavonoid, silibinin inhibits proliferation and promotes cell-cycle arrest of human colon cancer. J Surg Res 143:58-65.

Rainone F. (2007). Milk thistle. American Family Physician. 72:1285-1288.

Huseini HF, Larijani B, Heshmat R et al. (2006). The efficacy of Silybum marianum (L.)Gaertn. (silymarin) in the treatment of type II diabetes: a randomized, double-blind, placebo-controlled, clinical trial. Phytother Res.20:1036-1039.

Gordon A, Hobbs DA, Bowden DS et al. (2006). Effects of Silybum marianum on serum hepatitis C virus RNA alanine aminotransferase levels and well-being in patients with chronic hepatitis C. J Gastroenterol Hepatol 21:275-280.

Greenlee H, Abascal K, Yarnel E, Ladas E. (2007). Clinical applications of Silybum marianum in oncology. Integrative Cancer Therapies 6:158-165.

Tamayo C, Diamond S. (2007). Review of clinical trials evaluating safety and efficacy of milk thistle (Silybum marianum [L.] Gaertn.). Integrative Cancer Therapies.6:146-157.

Rambaldi A, Jacobs BP, Iaquinto G, Gluud C (2005). "Milk thistle for alcoholic and/or hepatitis B or C liver diseases--a systematic cochrane hepato-biliary group review with meta-analyses of randomized clinical trials". Am. J. Gastroenterol. 100 (11): 2583—91. doi:10.1111/j.1572-0241.2005.00262.x. PMID 16279916.

Lawrence, Valerie MD, MSc et al. (2000). "Milk Thistle: Effects on Liver Disease and Cirrhosis and Clinical Adverse Effects". AHRQ Publication No. 01-E025.

Angulo P, Patel T, Jorgensen RA, Therneau TM, Lindor KD (2001). "Silymarin in the treatment of patients with primary biliary cirrhosis with a suboptimal response to ursodeoxycholic acid". Hepatology. 2001 Feb;33(2):483-4. 32: 897. doi:10.1053/jhep.2000.18663. PMID 11050036.

Lieber CS, Leo MA, Cao Q, Ren C, DeCarli LM. (2003). "Silymarin retards the progression of alcohol-induced hepatic fibrosis in baboons". Journal of Clinical Gastroenterology. 2003 Oct;37(4):336-9.. PMID 14506392.

Szilard S, Szentgyorgyi G, Dhanalakshmi S et al. (1988). Protective effect of Legalon in workers exposed to organic solvents. Acta Med Hung. 45:249-256.

Palasciano G, Portincasa P, Palmieri V et al. (1994). The effect of silymarin on plasma levels of malon-dialdehyde in patients receiving long-term treatment with psychotropic drugs. Curr Ther Res Clin Exp. 55:537-545.

Floersheim GL, Weber O, Tschumi P et al. [Clinical death-cap (Amanita phalloides) poisoning: prognostic factors and therapeutic measures. Analysis of 205 cases]. Schweiz Med Wochenschr.112:1164-1177.

Hruby K, Fuhrmann M, Csomos G et al. [Pharmcotherapy of Amanita phalloides poisoning using silybin].Wein Klin Wochenschr.95:225-231.

American Botanical Council (2007). "Intravenous Milk Thistle Compound Used to Save Victims of Poisonous Mushrooms". HerbalGram (74): 16.

Agarwal R, Agarwal C, Ichikawa H, Singh RP, Aggarwal BB. Anticancer potential of silymarin: from bench to bed side. Anticancer Res. 2006 Nov-Dec;26(6B):4457-98. Review.

Agency for Healthcare Research and Quality. Milk thistle: effects on liver disease and cirrhosis and clinical adverse effects. Summary, evidence report/technology assessment: number 21, September 2000.

Asghar Z, Masood Z. Evaluation of antioxidant properties of silymarin and its potential to inhibit peroxyl radicals in vitro. Pak J Pharm Sci. 2008 Jul;21(3):249-54.

Barve A, Khan R, Marsano L, Ravindra KV, McClain C. Treatment of alcoholic liver disease. Ann Hepatol. 2008 Jan-Mar;7(1):5-15. Review.

Blumenthal M, Goldberg A, Brinckmann J. Herbal Medicine: Expanded Commission E Monographs. Newton, MA: Integrative Medicine Communications; 2000:257-263.

Ferenci P, Scherzer TM, Kerschner H, Rutter K, Beinhardt S, Hofer H, et al. Silibinin is a potent antiviral agent in patients with chronic hepatitis C not responding to pegylated interferon/ribavirin therapy. Gastroenterology. 2008 Nov;135(5):1561-7.

Gazak R, Walterova D, Kren V. Silybin and silymarin -- new and emerging applications in medicine. Curr Med Chem. 2007;14(3):315-38. Review.

Giese LA. A study of alternative health care use for gastrointestinal disorders. Gastroenterol Nurs. 2000;23(1):19-27.

Gordon A, Hobbs DA, Bowden DS, Bailey MJ, Mitchell J, Francis AJ, Roberts SK. Effects of Silybum marianum on serum hepatitis C virus RNA, alanine aminotransferase levels and well-being in patients with chronic hepatitis C. J Gastroenterol Hepatol. 2006 Jan;21(1 Pt 2):275-80.

Hoh C, Boocock D, Marczylo T, Singh R, Berry DP, Dennison AR, et al. Pilot study of oral silibinin, a putative chemopreventive agent, in colorectal cancer patients: silibinin levels in plasma, colorectum, and liver and their pharmacodynamic consequences. Clin Cancer Res. 2006 May 1;12(9):2944-50.

Jiang C, Agarwal R, Lu J. Anti-angiogenic potential of a cancer chemopreventive flavonoid antioxidant, Silymairn: inhibition of key attributes of vascular endothelial cells and angiogenic cytokine secretion by cancer epithelial cells. Biochem Biophys Res Commun. 2000;276:371-378.

Köksal E, Gülçin I, Beyza S, Sarikaya O, Bursal E. In vitro antioxidant activity of silymarin. J Enzyme Inhib Med Chem. 2009 Apr;24(2):395-405.

Low Dog T. Traditional and alternative therapies for breast cancer. Altern Ther Health Med. 2001;7(3):36-47.

Mayer KE, Myers RP, Lee SS. Silymarin treatment of viral hepatitis: a systematic review. J Viral Hepat. 2005 Nov;12(6):559-67. Review.

Najm W, Lie D. Dietary supplements commonly used for prevention. Prim Care. 2008 Dec;35(4):749-67.

Rainone F. Milk thistle. Am Fam Physician. 2005 Oct 1;72(7):1285-8. Review.

Ramasamy K, Agarwal R. Multitargeted therapy of cancer by silymarin. Cancer Lett. 2008 Oct 8;269(2):352-62. Review.

Rambaldi A, Jacobs BP, Iaquinto G, Gluud C. Milk thistle for alcoholic and/or hepatitis B or C liver diseases — a systematic cochrane hepato-biliary group review with meta-analyses of randomized clinical trials. Am J Gastroenterol. 2005 Nov;100(11):2583-91. Review.

Rotblatt M, Ziment I. Evidence-Based Herbal Medicine. Philadelphia, PA: Hanley & Belfus, Inc; 2002:266-271.

Saller R, Brignoli R, Melzer J, Meier R. An updated systematic review with meta-analysis for the clinical evidence of silymarin. Forsch Komplementmed. 2008 Feb;15(1):9-20. Review.

Zielinska-Przyjemska M, Wiktorowicz K. An in vitro study of the protective effect of the flavonoid silydianin against reactive oxygen species. Phytother Res. 2006 Feb;20(2):115-9

http://www.webmd.com/heart-disease/milk-thistle-benefits-and-side-effects

http://www.chiro.org/nutrition/ABSTRACTS/Silymarin_is_Effective_on_Hyperinsulinemia.shtml

National Center for Complementary and Alternative Medicine. "Milk Thistle". National Institutes of Health. - General information on milk thistle

http://www.femalefirst.co.uk/health/Avoid+hangover+hell+with+milk+thistle-1336.html

http://www.edible-plants.com

Benzoyl peroxide is an anti-bacterial agent effective against acne bacteria (propionibacterium) which works by releasing peroxide, a free radical, which oxidizes the acne bacteria.

Because rosacea isn't caused by acne bacteria the use of benzoyl peroxide seems unwarranted. Moreover, benzoyl peroxide increases the skin's burden of oxidative stress, promoting inflammation and premature aging.

Although some patients report some benefit from benzoyl peroxide, as with Proactiv users, the benefit quickly gives way to counterproductive side effects, the most common of which are stinging, inflammation, burning, tingling, dehydration and a sallow grey-red skin tone.

Ostensibly, benzoyl peroxide has come to be regarded as effective because published trials of its use have not stretched beyond 8 weeks, an inadequate timeframe for a life-long skin condition.

While it is true that very short-term use of benzoyl peroxide may assist with resolving some papules and pustules, there are superior alternatives.

In addition, no studies have shown that papules and pustules always clear more rapidly with benzoyl peroxide than without.

Rosacea patients frequently have impaired skin barrier function which likely furthers the penetration of benzoyl peroxide leading to the vasodilation which appears to encourage worsening rosacea symptoms.

• Cutis Benzoyl Peroxide Rosacea Study Summary
• Is Benzoyl Peroxide Effective for Rosacea?
• Poor Medicine: Rosacea Treatment with Benzoyl Peroxide

Image: Jan Marini Benzoyl Peroxide 10%.

The redness tends to concentrate on the nose and cheeks, however there are occasional early cases where the flushing appears only on the chin and forehead, and where the redness has spread to the chest.

Around the time of the first signs, men tend to experience more severe nasal inflammation whereas women are more prone to more generalized redness, however there are always exceptions.

The redness is caused by a swelling of the capillaries under the skin and can last anywhere from a few minutes to several hours depending on a variety of factors including individual sensitivity to environmental factors and skin care.

With repeated flushing, eventually the capillaries remain permanently swollen and dilated, leaving a permanent redness characteristic of sunburn or alcoholism.

This early stage of rosacea should be a "red flag" for treatment.

Left unchecked, rosacea almost always worsens, with each episode of flushing bringing patients closer to a more "ruddy" redness, bumps, pimples, papules, pustules, gritty or even bloodshot eyes.

The most severe rosacea presents as severe permanent facial inflammation, rhinophyma and impairment or even loss of vision.

Early stages of rosacea can be helped and deterioration slowed or prevented by adopting suitable topical rosacea medications and rosacea skin care.

Together with medication (topical and/or systemic), all rosacea patients should utilize, at minimum, a suitable rosacea cleanser and sunscreen.

The new formula is milder than the original formula and now contains niacinamide, which further helps maintain a healthy skin barrier, despite this being a finely exfoliating product.

Other functional additions include antioxidants and anti-inflammatories to reduce redness, erythema, visibly open pores and the main recalcitrant symptoms of moderate to severe rosacea: papules and pustules.

Rosacea Micro-Exfoliating Cream is applied to damp skin after cleansing with either Rosacea Oil-Free Purifying Gel Cleanser or Rosacea De-Sensitizing Cleansing Emulsion.

Instead of the prior jar packaging, the product is now supplied free of preservatives in a hermetically sealed container featuring an airless pump.

The product is now larger at 50 ml instead of 30 ml in size.

Note: The original Rosacea Micro-Exfoliating Cream remains available as a special-order item for patients where it has been specifically prescribed along with individual instructions.

13/5/10

Thank you for contacting us with your question, it's great to hear from someone who is concerned about what is meant by optimal sunscreen use.

For rosacea patients to benefit fully from sunscreen use, they must apply their sunscreen 365 days a year, irrespective of season or cloud coverage.

This is because the most detrimental of the sun's rays are "ultraviolet," meaning beyond violet, the last colour in the rainbow of visible light.

Ultraviolet light cannot be seen or felt as warmth.

For all intensive purposes, in the medium to long term, ultraviolet light is as much a risk factor for worsening rosacea symptoms in the bright of summer as the relative dark of winter. Remember that ultraviolet penetrates glass.

If you don't wear sunscreen year-long, those seemingly brief episodes of exposure sitting by windows, traveling in a car and running daily errands actually add up to several sunburns each year.

Although the damage is incremental and not accompanied by visible burning or tanning, your skin registers (and doesn't forget or substantially repair) the damage.

An added benefit of year-long sunscreen use is that it is one of the very few proven (and relatively inexpensive) means by which to protect against visible signs of aging, also known as sun damage, or in dermatological parlance, as photoaging.

Unfortunately, paraben preservatives, found in the majority of sunscreens, have been shown to heighten the photodamage which helps cause and exacerbate rosacea and premature signs of aging. Therefore if possible, avoid parabens in your sunscreen (and skin care). If you can't, the benefits of sunscreen use still outweigh the side effects.

The Clinic's two sunscreens, Rosacea Oil-Free Antioxidant Daily Wear Sunscreen SPF 30 and Rosacea Hypoallergenic Daily Wear Sunscreen SPF 20, are unique insofar as they contain no preservatives (hermetic packaging removes the need for preservatives and other problematic chemicals common to sunscreens). The two sunscreens were made available to the general public and internationally in late 2010.

Sunscreen also protects against skin-degrading enzymes and free radicals which reduce facial volume and encourage fine and deep wrinkles.

There are a lot of sunscreens available on the market and everyone has different preferences.

As a general rule, sunscreens available in drug stores, chemists and supermarkets (if not 100% zinc or titanium dioxide) tend to irritate the skin of rosacea patients sooner or later. If purchasing sunscreen from these outlets, I recommend paediatric sunscreens.

When shopping on the mass market (through chemists/drug stores, general stores and beauty therapists/day spas), aim for sunscreens containing zinc oxide as the only sunscreening agent, or at most zinc plus one chemical block, or if you prefer a non-whitening sunscreen, sunscreens without zinc containing 4-5 chemical blocks (anything less and the sunscreen is most likely not going to provide extended protection against UVA, the most aging and deleterious form of ultraviolet light for rosacea patients).

I would generally avoid sunscreens which contain more than approximately 15% zinc because they tend to be very difficult to remove, with the zinc usually suspended in beeswax or mineral oil.

When sunscreen is difficult to remove, you're likely to do some damage to your skin's barrier and provoke redness and irritation, or alternatively, you won't get the sunscreen off completely at the end of the day, hampering the absorption, and efficacy, of any topical rosacea medications or skin care you apply.

The clinic has developed two sunscreens to meet the specific needs of rosacea patients: Rosacea Oil-Free Antioxidant Daily Wear Sunscreen, a non-whitening sunscreen which is fortified with a broad-spectrum of antioxidants which help reduce inflammation, free radical damage and photoaging; and Hypoallergenic Daily Wear Sunscreen, containing an elegant zinc sunscreen and green tea for added antioxidant protection. While the latter is slightly whitening, spending the time to massage the sunscreen in thoroughly largely avoids this problem. If you wear make-up, you may even find that the sunscreen is an effective skin tone-perfecting base for foundation or other make-up.

Because no one sunscreen is absolutely perfect, some patients apply both in more moderate quantities.

These two sunscreens do not contain the parabens which increase photodamage and provoke rosacea symptoms.

Products for oily skin can be drying, leading to dehydration and a loss of your skin's natural radiance, while products for dry skin can exacerbate rosacea, visibly open pores and lead to unflattering shine.

A reliable solution is to adopt the following protocol:

Cleanse skin twice-daily with Rosacea Oil-Free Purifying Gel Cleanser. It provides deep-cleansing and oil-free hydration together with anti-inflammatory, antioxidant and healing factors which help avoid disrupting your skin, preventing redness and burning, tingling and itching sensations.

Follow with Rosacea Purifying De-Sensitizing Mist, a 95% decoction in 5% deionized water, which purifies, hydrates and gently stimulates skin to promote a fresh appearance. The purifying properties of the mist are 100% non-drying yet help to purge follicles of sebum, wax, papules and pustules.

Finally, hydrate and protect against environmental triggers and the photoaging responsible for rosacea symptoms by applying Rosacea Hydrating Serum, then Rosacea Treatment Fluid and finally one of the Rosacea Sunscreens.

In the evening, follow the same protocol, leaving out sunscreen, and optionally using Rosacea Anti-Inflammatory Clearing Serum in place of Rosacea Hydrating Serum.

If your skin is experiencing a flare-up, you can also use Rosacea Cooling Lotion in place of Rosacea Treatment Fluid, which is lighter than Rosacea Treatment Cream and provides a stronger anti-inflammatory and soothing effect.

The above protocol will bring rapid relief from inappropriate skin care and balance skin toward a more uniform state, less easily provoked by triggers, and more responsive to conventional topical rosacea medications.

This randomized, investigator-blind, controlled observational study (N = 50) was designed to assess whether a niacinamide-containing facial moisturizer would improve the stratum corneum barrier and thus provide a clinical benefit to subjects with rosacea.

Subjects with rosacea applied the test moisturizer to their face and to one forearm twice daily for 4 weeks.

The other forearm remained untreated as a control. Barrier function on the forearms was assessed instrumentally and using a dimethyl sulfoxide (DMSO) chemical probe.

Stratum corneum hydration also was measured instrumentally.

The dermatologist investigator evaluated each subject's rosacea condition over the course of the study, and subjects self-assessed their facial skin condition at study end.

Instruments provided objective measures of stratum corneum barrier function and hydration on the face.

It is notable that Metrogel contains niacinamide as an "inactive ingredient" and that the manufacturer's prescribing information notes that "the contribution to efficacy of individual components of the vehicle has not been established."

It is likely that a Metrogel formulation not containing niacinamide would not be as effective.

For further information, see the Niacinamide Overview.

These factors include :

• systemic heliobacter pylori infection;
  
  
• invisible infestation of skin by demodex mites;
  
  
• sun damage / photoaging;
  
  
• free radicals;
  
  
• fragile or dysfunctional capillaries;
  
  
• allergies (to topical and ingested substances);
  
  
• psychosomatic factors.

Cause #1 — Heliobacter Pylori

Evidence for heliobacter pylori playing a role is controversial. It has been suggested that intestinal bacteria and inflammation sensitize facial neurons, causing capillaries to become dilated, producing redness and leaking pro-inflammatory substances into the facial tissues.

Cause #2 — Demodex Mite Follicular Infestation

Damage to collagen in the dermis (the skin's deepest layer) and to follicles is strongly associated with rosacea. This finding has led some academic dermatologists to suggest that the inflammation seen in rosacea patients is a result of demodex mites and/or bacteria occupying follicles and causing an immune response not found in patients without rosacea.

Stronger evidence exists for rosacea patient's skins' bearing an excess of MMP-9, an enzyme which breaks down the collagen necessary for healthy skin structure and functioning.

Where levels of MMP-9 are greater than the skin's ability to inhibit their action, inflammation and degradation of skin occurs. A similar situation appears to underlie the pathophysiology of ocular rosacea.

Moreover, other studies have shown that poorly regulated levels of MMP-9 are found in rosacea patients both with and without follicular demodex infestation, and that the levels of deleterious MMP-9 are greater in those with demodex than without.

Cause #3 — Irregular Vascular Function

Flushing/blushing and dilated or broken capillaries are associated with all rosacea patients.

The phenomenon of flushing and blushing can be due to a combination of two or more of the following aspects:

• greater superficiality of facial capillaries, increasing the likelihood and frequency of environmental provocation;
  
  
• an increase in blood flow;
  
  
• irregular capillary function, due to immune (humoral) and/or neural factors.

Irregularities in neurotransmitters such as serotonin and histamine may also play a role in the development of visible facial redness (erythema) in rosacea.

Individuals with rosacea have also been found to have excess amounts of certain proteins involved in the skin's immune response against bacteria, viruses and fungi.

High levels of these proteins have been shown to produce all the signs of rosacea: erythema (redness), inflammation (free radical damage), capillary dilation, growth (angiogenesis) and permeability.

In subsequent updates I will detail some of the prime and superior ways in which to manage to manage pre-existing rosacea and prevent frequent exacerbation or permanent worsening or pre-existing rosacea.

If your rosacea is only mild (characterized by only transient flushing/blushing or mild erythema), there is much to be hopeful about, as relatively minor changes to the overall management of your rosacea can produce remission.

While there is no way to directly influence hereditary factors, ideal skin care use can help prevent symptoms such as flushing and appropriate sunscreens can help prevent and reduce the occurrence or severity of symptoms.

Please note that unlike the original metronidazole formulation (Metrolotion) available from Galderma, Metrogel is — with few exceptions — only used once daily.

Broadly speaking, patients experience superior results when Metrogel is used PM rather than AM.

However it is also true that patients' rosacea will worsen more during the day than overnight, whether they are using Metrogel or not, therefore it is not possible to say to what extent evening use is more beneficial, just that the finding is related.

Using Metrogel once daily in the evening has the added benefit of speeding up skin care in the morning.

The development and worsening of rosacea symptoms is also thought to represent a form of photoaging. Tests invariably show severe damage to the dermal matrix of rosacea patients' skins (characteristic of photoaging).

We recommend Melbourne Dermatology's overview of photoaging and photoprotection for further information, in particular the following conclusion:

"Daylight represents any form of outdoor natural light, be it sunny or not, winter or summer, behind glass or not."

In other words, you will need to wear sunscreen while indoors in a naturally-lit environment and when making short trips in the car because the incremental exposure adds up over time.

According to the free radical theory of aging, skin cancer is also thought to represent severe photoaging.

Used as directed, rosacea sunscreens may be used to prevent photoaging and the further development and worsening of pre-existing rosacea symptoms, however please note that paraben preservatives in sunscreens have been shown to exacerbate photoaging and some rosacea symptoms.

For related information, see Invisible Daylight Exposure Produces Dry Skin in Rosacea.

• Prevent — Rosacea Antioxidants
• A Protocol for "Confused" Skin
• Antioxidants
• Anti-Aging
• Rosacea Sunscreens
• Rosacea Oil-Free Antioxidant Daily Wear Sunscreen SPF 30 — All Skin Types
• Flawed Sunscreen Use and Lost "Anti-Aging" Effects
• Rosacea Sunscreen SPF Updated (April 2008)
• What is the best sunscreen for rosacea?
• Antioxidant Sunscreens
• Rosacea Anti-Inflammatory Clearing Serum — Evening Use
• Photoaging
• Invisible Daylight Exposure Produces Dry Skin in Rosacea
• FAQ: What Causes Rosacea?
• Silymarin (Milk Thistle)
• Photoprotection
• Oxidative Stress

Accordingly, daily sunscreen use has become an important part of rosacea treatment.

A recent study (Methylparaben potentiates UV-induced damage of skin keratinocytes — Toxicology , Volume 227 , Issue 1 - 2 , Pages 62 - 72) demonstrated that the paraben preservative methylparaben worsens skin's response to daylight:

UVB exposure significantly increased cell death [skin aging], oxidative stress [skin inflammation], NO production [skin aging], lipid peroxidation [free radical production] and activation of transcription factors in MP-treated HaCaT keratinocytes. These results indicate that methylparaben, which has been considered a safe preservative in cosmetics, may have harmful effects on human skin when exposed to sunlight.

In light of the mounting evidence against parabens, it seems prudent to avoid them where possible.

Always use a suitable rosacea sunscreen when using skin care products containing parabens and ideally use a sunscreen free of parabens.

For additional important information, refer Avoid Parabens in Rosacea Skin Care.

Rosacea is a chronic disorder characterized by hypersensitivity of the facial vasculature, presenting with intense flushing eventually leading to chronic erythema and telangiectasia.

Although the precise aetiology of rosacea is not known, numerous associations with inflammatory gastrointestinal tract disorders have been reported.

Furthermore, substance P-immunoreactive neurons occur in considerably greater numbers in tissue surrounding affected blood vessels suggesting involvement of neurogenic inflammation and moreover plasma kallikrein—kinin activation is consistently found in patients.

In this report, a patient without digestive tract disease is described, who experienced complete remission of rosacea symptoms following ingestion of a material intended to sweep through the digestive tract and reduce transit time below 30 h.

It is possible that intestinal bacteria are capable of plasma kallikrein—kinin activation and that flushing symptoms and the development of other characteristic features of rosacea result from frequent episodes of neurogenic inflammation caused by bradykinin-induced hypersensitization of facial afferent neurons.

The possible relevance of this hypothesis to other conditions featuring afferent hypersensitivity, such as fibromyalgia, is considered.

Clinical and Experimental Dermatology

Volume 29 Issue 3, Pages 297 - 299.