The chronicity of rosacea often leads patients to try alternative therapies, even when there is nothing but a friend’s recommendation or “Dr Google” to speak for the “evidence.”1 With no cure, and symptoms that can contribute to social isolation, people with rosacea are often more than willing to seek out and try unproven treatment modalities, all the while risking making their symptoms worse.
As a treating clinician, it is important to understand the “why” behind this behavior, and even more important to know how to extract such information out of patients to help them make educated and safe choices.
Why Patients Turn to Alternative Therapies
Alinia and colleagues analyzed online discussions of 346 rosacea-specific posts in online forums and found that patients are clamoring for information on natural products (19.4% of posts), complementary and alternative medicine (16.5%), and homeopathic treatments (3.8%).1
Distrust of clinicians and treatment failures with prescription medications drive an overwhelming 80% of patients with chronic disorders to participate in online disease-specific forums.1
A 6-study systematic review found that topical polyphenols (plant-derived compounds with antioxidant and anti-inflammatory effects) reduced the erythema and pustules of rosacea.2 Saric and colleagues examined the efficacy of licochalcone (n=2), silymarin (n=2), Crysanthellum indicum extract (n=1), and quassia extract (n=1).
Overall, the polyphenols improved facial appearance by reducing erythema. Licochalcone improved quality of life and appearance, silymarin and quassia extract reduced the papule counts, and C indicum reduced the papule but not the pustule count. Only quassia extract decreased patients’ telangiectasia score.2 Adverse reactions included tearing, burning, and stinging.2
“We reviewed the literature and found that some natural sources of polyphenols may affect signs and symptoms of rosacea,” explained coauthor Hadar A. Lev-Tov, MD, MAS, assistant professor of dermatology and cutaneous surgery at the University of Miami Miller School of Medicine in Florida. “This is no different from aspirin derived from the bark of the willow tree, and there are numerous examples for natural sources making their way into mainstream medicine. Overall, doctors should use their judgement. I instruct my patients to test any product on their forearm for a few days to exclude contact dermatitis.”
Polyphenols in green tea, specifically epigallocatechin-3-gallate (EGCG), exert the most influence on rosacea, with antioxidant, anti-inflammatory, anticarcinogenic, and antimicrobial properties.3 Of the 4 common catechins found in green tea, EGCG is the most pharmacologically potent.3 Despite its strong bioactivity, less than 10% of EGCG is present in an average cup of green tea.3
Domingo and colleagues compared the efficacy of 2.5% green tea cream with vehicle to determine whether twice-daily applications would reduce erythema and telangiectasia after 6 weeks of treatment in a 4-person split-face study.4 The presence of vascular endothelial growth factor and hypoxia-inducible factor 1-alpha decreased significantly compared with vehicle (6.7% in EGCG-treated vs 11.0% in vehicle-treated skin [P <.005]; and 13.8% in EGCG-treated vs 28.4% in vehicle-treated areas [P <.001], respectively).4 Despite reductions in the biomarkers, which confirmed EGCG’s role as an antiangiogenic compound, there was no visible improvement in erythema.4
Diet for Prevention and Treatment
When clinicians previously mentioned diet in treating rosacea, they usually spoke of culinary triggers that would worsen symptoms, such as alcohol, caffeine, sugar, citrus, and chocolate.5 Now, however, there is evidence to suggest that certain foods can ameliorate symptoms5:
- chamomile for its anti-inflammatory and antipruritic effects,
- green tea for its antitelangiectasia property and ultraviolet protection,
- vitamin C to promote collagen growth, and
- omega-3 fatty acids to reduce dry eyes in ocular rosacea.
Caffeine may soon be added to that list, as Li and colleagues recently found that an increase in caffeine intake from coffee was associated with a decreased incidence of rosacea in women recruited from the Nurses’ Health Study II (N=82,737).6 The amount of coffee consumed daily was equivalent to 4 cups.6 The vasoconstrictive and immunosuppressant properties of caffeine might have reduced the risk for rosacea. The researchers stopped short of recommending coffee to reduce rosacea flares, however, noting that other sources of caffeine, including chocolate, tea, and soda, did not have a similar effect.6
The Gut-Rosacea Connection
McCusker and colleagues have reported growing evidence linking gastrointestinal health to rosacea.7 A low concentration of pancreatic lipase was found in adults with erythematotelangectatic rosacea. In both adults and children, those with rosacea frequently had pancreatic insufficiency and Helicobacter pylori infections.7
Although robust clinical evidence is scant, patients claim that probiotics have eradicated their H pylori infections as well as their rosacea.7 Likewise, naturopathic clinicians reported success with hydrochloric acid therapy to clear rosacea. Histamine-rich foods that have been implicated in rosacea, as well as gastrointestinal symptoms, include fermented foods, vinegar, processed meats, and certain fruits and vegetables.7
Counterproductive Remedies Abound
Medical student Laura H. Riddoch, BSc, found some eye-opening conversations when she anonymously joined online patient forums, viewed YouTube, read Facebook, and searched the major search engines.8 Without referencing evidence, patients routinely touted such harmful remedies as apple cider vinegar, hydrogen peroxide (used full strength), and melanotan.8
“Dermatologists should investigate the psychological effects rosacea is having on the patient to determine how at-risk each patient is to attempt online peer-suggested remedies,” said Ms Riddoch, who is a student at the School of Medicine, University of Dundee, Scotland. “Ultimately, this will allow the clinician to educate patients, demonstrating up-to-date knowledge of trending therapies, and advise the patient appropriately.”
1. Alinia H, Lan L, Kuo S, Huang KE, Taylor SL, Feldman SR. Rosacea patient perspectives on homeopathic and over-the-counter therapies. J Clin Aesthet Dermatol. 2015;8(10):30-34.
2. Saric S, Clark AK, Sivamani RK, Lio PA, Lev-Tov HA. The role of polyphenols in rosacea treatment: a systematic review. J Altern Complement Med. 2017;23(12):920-929.
3. Zink A, Traidl-Hoffmann C. Green tea in dermatology–myths and facts. J Dtsch Dermatol Ges. 2015;13(8):768-775.
4. Domingo DS, Camouse MM, Hsia AH, et al. Anti-angiogenic effects of epigallocatechin-3-gallate in human skin. Int J Clin Exp Pathol. 2010;3(7):705-709.
5. Kallis PJ, Price A, Dosal JR, Nichols AJ, Keri J. A biologically based approach to acne and rosacea. J Drugs Dermatol. 2018;17(6):611-617.
6. Li S, Chen ML, Drucker AM, et al. Association of caffeine intake and caffeinated coffee consumption with risk of incident rosacea in women [published online October 17, 2018]. JAMA Dermatol. doi: 10.1001/jamadermatol.2018.3301
7. McCusker M, Sidbury R. Nutrition and skin: kids are not just little people. Clin Dermatol. 2016;34(6):698-709.
8. Riddoch LH. It takes one to know one: exploring patient dialogue on rosacea web-based platforms and their potential for significant harm [published online May 10, 2018]. J Dermatolog Treat. doi: 10.1080/09546634.2018.1468067