Rosacea: Ayurvedic Treatment, Modern Concepts

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Rosacea is a chronic skin disease whose causes and treatment are not known clearly. The disease has a typical manifestation and affects only the skin on the nose, forehead and cheeks. Small, red, pus filled bumps are its trademark symptoms which are manifested in the above mentioned areas of the body, mainly during the flare-ups. The disease is marked by blushing / flushing in face, visible blood vessels in the face and pus filled bumps on face.

Flare-ups of rosacea are common and occur in cycles. The symptoms may remain for weeks or months together, may also flare up for varying time periods and may disappear for a while. Commonly occur in white-middle-aged women. When treated promptly and with proper measures the signs and symptoms of the disease may be controlled and reduced.
Read – Ayurvedic Summer Skin Care, Acne Solutions, Anti Aging Remedies

Rosacea Ayurveda Understanding

Rosacea as Kushta – a type of skin disorder

Since Rosacea is a skin disease it can be classified under kushta. Kushta is a condition which encompasses wide array of skin disorders. But amongst Kushta we cannot find any disease specified to be occurring in the face as is in the case of Rosacea which predominantly manifests in the face. The typical presentation of rosacea is on the nose, forehead and cheeks wherein small, red, pus-filled bumps are formed. Apart from this blushing / flushing and visible blood vessels are seen in the face.

In the context of kushta, it has not being specified where and in which part of the body would the disease manifest with the exception of couple of conditions. This means to tell that Kushta can occur anywhere in the body, including face and the above-mentioned areas of the body. Any subtype of kushta presenting with bumps which are red and also filled with pus shall be considered as rosacea. Since redness, flushing and pus-filled bumps are present in rosacea, we can consider it as a pitta predominant skin condition.

Flare-ups in Kushta?
Rosacea presents with flare-ups. This means that the disease doesn’t go away entirely. It presents with a pattern of appearance and disappearance occurring in typical cycles. Ayurveda has also indirectly mentioned about the ‘flare-ups’ in the context of Kushta. Master Sushruta has explained repetitive and periodic treatments to be done in Kushta. This indirectly means to tell that Kushta has a nature of recurrence and in order to prevent recurrence repeated-periodic treatments and expulsion of morbid doshas shall be done.
Read – Kushta Purvarupa: Premonitory Symptoms Of Skin Disorders

Types of Kushta which resemble with Rosacea

Below mentioned types of Kushta closely resemble the clinical picture of rosacea though they can occur on any part of the body –

Mandala Kushta – presents with lesions / bumps that are –

• shwetha – white (may be due to accumulation of pus)
• rakta – reddish
• sthira – stiff / raised and hard
• styanam – unctuous / wet
• utsanna mandalam – raised circular bumps
• krchhram – difficult to cure
• anyonya samyuktam – bumps fuse with each other

It is caused by predominant vitiation of kapha.

Pundarika Kushta – presents with lesions / bumps that are –

• sa shwetam – white
• rakta paryantam – red colored edges
• pundarika dala upamam – resembling the bud of red colored lotus
• sa utsedham – raised
• sa ragam – reddish color

It is caused by predominant vitiation of kapha and pitta.

Alasaka – presents with lesions / bumps that are –

• kandumadbhih – itching
• saragai cha – redness

It is caused by predominant vitiation of vata and kapha.
Read – Ayurvedic Treatment For Pimple: Causes, Herbs, Home Remedies

Dosha predominance in rosacea

The dosha association in some of the causes of rosacea flare-ups is as below mentioned –

• Hot drinks / hot coffee or hot tea – Pitta
• Spicy foods – Pitta
• Red wine – Pitta, Tridosha
• Alcoholic beverages – Pitta, Tridosha
• Extremes of temperature – Tridosha
• Exposure to excessive heat, cold, wind or sun – Tridosha
• Varying and high-end emotions – Tridosha
• Long term / excessive stress and anxiety / extremely stressful life event – Vata, Tridosha
• Certain cosmetics, hair care or skin care products and makeup products especially those having topical alcohol as ingredient – Vata, Pitta
• Drugs which cause dilatation of blood vessels (vasodilators) – Vata
• Excessive exercising – Vata
• Overheating of skin – as in outdoor workouts in sun, cold showers immediately after workouts in sun, drinking hot drinks and beverages etc – Pitta

Amongst the risk factors – the fact that rosacea occurs in those having sensitive skin points towards vata or pitta predominant individuals being more prone to the disease. Rosacea usually manifests in those between 30-50 years of age – the age of pitta predominance.
Read – Maha Kushta: Major Skin Diseases, Symptoms, Prognosis

Ayurveda Treatment

Ayurveda Treatment for Rosacea – A hypothetical understanding

From the dosha perspective – From the above explanation, the disease is either caused or triggered by severely aggravated pitta or vata or both though kapha involvement and association is also seen in few conditions. We can tell that Rosacea is a tridosha condition with predominant aggravation of pitta and vata in the pathogenesis and clinical presentation. In this direction, the treatment would include the therapies, medicines, lifestyle changes and dietetic inclusions which would expel or balance the aggravated doshas.

Virechana – therapeutic purgation is the ideal treatment for pitta predominant conditions, especially when rosacea is severe and has become chronic and shows frequent flare-ups. Virechana is the predominant therapy for rosacea since most symptoms are due to aggravated pitta. Keeping away the causative factors of pitta aggravation and triggers of pitta (nidana parivarjana) is an essential part of rosacea treatment.

Vamana – therapeutic emesis shall also be included in the treatment if kapha is associated with pitta and kapha predominant symptoms are also present in the disease. In such cases ubhayatah shodhana i.e. emesis followed by purgation will be an ideal choice.

Kushta Chikitsa – As already explained above, rosacea is a special type of kushta manifested in the face. The treatment principles, therapies, medicines and dietetic inclusions indicated in the treatment of kushta shall be skillfully implemented in the treatment of rosacea, as and when needed.
Read – General Causes For Skin Diseases As Per Ayurveda

Other treatment principles

Vatarakta Chikitsa
Many causes and symptoms of rosacea also resemble those mentioned in the context of Vatarakta. Though we do not have specification of vatarakta manifesting in the face as in rosacea and vatarakta is also a disease wherein the symptoms predominantly pertain to the joints and soft tissues, the pathogenesis of vatarakta, in its initial phases is limited to the superficial tissues (skin), especially that of the face – rosacea can be considered as vatarakta occurring on the face and treated accordingly. In Ayurveda practice we can see the overlap of pathogenesis and treatment of kushta and vatarakta. Many times when the skin diseases do not respond to the traditional treatment, medicines and therapies of kushta, they do respond to those mentioned and indicated in vatarakta and the other way is also true i.e. treatment of vatarakta is also applicable for kushta treatment. Rheumatoid arthritis / inflammatory arthritis is one of the conditions associated with rosacea and RA is compared to Vatarakta explained in Ayurveda.

Shotha Chikitsa
Shotha means swelling or inflammation. In rosacea there is swelling of the face and nose. The treatments and medicines mentioned in shotha can also be useful in treatment of rosacea.
Read – Shotha: Causes, Types, Treatment, Medicines

Visphota – Masurika Chikitsa
Visphota means eruptions or bumps. Most often they are inflammatory. They may also be non-inflammatory. Masurika means pox, chicken pox to be precise. Both these conditions can afflict the face. Visphota or Masurika is not explained to be limited to face, but since they are generalized explanations they might afflict the face too or may appear only on face. The treatments and medicines mentioned in these conditions can also be applicable in treating rosacea.
Read – Blisters: Ayuvedic Understanding, Treatment Principles

Kshudra Roga Chikitsa
Kshudra Roga means minor diseases. There are some diseases mentioned in kshudra rogas which mimic the clinical picture of rosacea. Again these are not specified to be manifested on the face. But they may.

Antralaji (Andhalaji, Alaji) – is a condition wherein there is manifestation of big (thick), elevated, round bumps which has less pus inside and devoid of opening. It is caused by kapha and vata.
Vivruta – is another condition where in round bumps which have large opening and severe burning sensation and presents with color of ripe udumbara fruit. This condition is caused by aggravated pitta.
Indraviddha – is a condition wherein there are multiple small bumps in a particular region having the appearance of cluster of lotus seeds. This condition is caused by vata and pitta.
Gardabhika – is a condition which presents with a raised red area of skin comprising of many small bumps and is also associated with pain. This condition too is caused by vata and pitta.

The treatment principles of these conditions can be adopted in treating rosacea.

Panchakarma and Rasayana for Rosacea
Since rosacea has flare-ups and runs a chronic course and also can occur repeatedly, systemic cleansing by administration of Panchakarma therapies as and when needed and also frequently may not only help in curing the disease but will also prevent recurrences and flare-ups of the disease.

Vamana and Virechana – Since pitta and vata are mostly involved in the causation of rosacea, its symptoms and flare-ups – virechana – therapeutic purgation will be an ideal choice. When kapha is associated in the disease and causes the symptoms, vamana – therapeutic emesis shall be administered as first hand therapy. When kapha is associated with pitta, the patient should be initially treated by administering therapeutic emesis followed by therapeutic purgation. Many inflammatory gut conditions are also associated with rosacea. Vamana and Virechana will also help in such conditions.
Read – Vamana And Virechana In The Treatment Of Kushta

Nasya – Nasal instillation of medicines is the best treatment for all the diseases manifesting above the level of collar bone, which includes diseases manifesting on the face like acne, pigmentation disorders, and other skin diseases limited to the face and may also include rosacea. Nasya can be used as an independent therapy and also following emesis, purgation or both.

Rasayana – Following the cleansing therapies immune modulators in the form of Rasayanas, mainly those mentioned in the context of kushta or vatarakta shall be administered. This would provide long standing immunity against the disease and also would help in prevention of recurrences and flare-ups.
Read – Rasayana Therapy (Anti Ageing, Rejuvenation) Benefits, Meaning, Medicines

Important and Effective Herbal formulations for rosacea

• Tiktakam Kashayam
• Mahatiktakam Kashayam
• Aragvadadi Kashayam
• Guggulutiktakam Kashayam
• Nimbadi Kashayam
• Patoladi Kashayam
• Patolakaturohinyadi Kashayam
• Manjishtadi Kashayam
• Khadirarishtam
• Aragvadharishtam
• Arogyavardhini
• Gandhaka Rasayanam
• Madhusnuhi Rasayanam
• Tiktaka Ghrta
• Mahatiktaka Ghrta
• Kalyanaka Ghrta
• Indukantam Ghrta
• Aragvadhadi Ghrtam
• Avipattikara Churna
• Trivrt Leham

Diet

The dietetic inclusions and exclusions and lifestyle practices as mentioned and advised in the context of kushta and vatarakta shall be considered in the treatment of rosacea. Mainly pitta and vata aggravating foods and activities shall be avoided. On the other hand foods and activities which pacify pitta and vata (and kapha if associated) shall be administered.
Read – Importance Of Diet (Pathya) For Specific Diseases

Rosacea – Modern view

Rosacea is a chronic skin condition. Many research works related to rosacea has paved ways to treat this condition by minimizing the symptoms and signs of the disease.  

The disease is marked by –

Generalized Signs and symptoms of Rosacea

Blushing or flushing of face – In patients of rosacea, persistent blushing or flushing is evident in the center of the face. This might be difficult to identify in people having brown and black skin.
Visible veins (spider veins) – The small blood vessels over the cheeks and nose break and become visible.
Swollen bumps – Pimples resembling acne appear on the face of many people suffering from rosacea. They may contain pus sometimes.
Burning sensation – Increased heat and tenderness may be felt over the skin of the affected area.
Eye problems (Ocular Rosacea) – Dryness, irritation, swollen eyes and eyelids can be seen in some people. In some cases, the eye symptoms are seen before skin symptoms.
Nose problems (Rhinophyma) – Over period of time, enlargement of nose can be seen in rosacea. Here, the skin of the nose is thickened. This in turn causes the nose to appear bulbous. This can be seen more in men in comparison to women.
Read – Atopic Dermatitis – Charmadala Kushta: Case Study

Types of Rosacea

There are 4 subtypes of rosacea and each subtype has its own set of signs and symptoms. More than one subtype of rosacea can be found in a patient at the same time.
1. ETR (Erythematotelangiectatic Rosacea) / Subtype One
2. Papulopustular (Acne) Rosacea / Subtype Two
3. Rhinophyma / Subtype Three
4. Ocular Rosacea / Subtype Four

Causes of Rosacea

Causes of rosacea are not clearly known. It is possible that this condition might be caused due to individual or a combination of different factors including

• overactive immune system
• heredity factors
• environmental factors

One need to know that this condition is neither contagious nor is caused by poor hygiene.

Triggers which might cause flare-ups in rosacea are as below mentioned –

• Hot drinks / hot coffee or hot tea
• Spicy foods
• Red wine
• Alcoholic beverages
• Extremes of temperature
• Exposure to excessive heat, cold, wind or sun
• Varying and high end emotions
• Long term / excessive stress and anxiety / extremely stressful life event
• Certain cosmetics, hair care or skin care products and makeup products especially those having topical alcohol as ingredient
• Drugs which cause dilatation of blood vessels (vasodilators)
• Excessive use of topical steroids on face
• Foods having compound cinnamaldehyde (cinnamon, chocolate, citrus, tomatoes etc)
• Having intestinal bacteria – H pylori
• Skin mite (demodax) and Bacillus oleronius (which carries this mite)
• Products having preservatives and fragrances
• Excessive exercising
• Overheating of skin – as in outdoor workouts in sun, cold showers immediately after workouts in sun, drinking hot drinks and beverages etc
• Vitamin B12 deficiency, excessive use of vitamin B3 and higher than normal vitamin D levels

Rosacea flare-ups may also be associated with the below mentioned conditions –

Risk Factors

• Being a female (men who develop rosacea will often have more severe symptoms)
• Having a family history of the disease
• Having sensitive skin i.e. skin that burns easily in the sun
• Those having fair skin, blond hairs and blue eyes
• Being over 30 years of age (people between 30-50 years of age)
• Those who smoke
• Having Scandinavian / Celtic ancestors

Diagnosis

There are in fact no specific or confirmatory diagnostic tests for Rosacea. History of the illness and related symptoms and thorough examination of the skin will help the physician to reach the diagnosis of rosacea. Tests to rule out other conditions like lupus or psoriasis are done. Most often rosacea can be misdiagnosed or its diagnosis missed in people with dark color. In these cases it may be diagnosed wrongly as an allergic reaction or seborrheic dermatitis. You may be referred to an ophthalmologist for an evaluation if symptoms involve your eyes.

Control and Prevention

A. Control and prevention of rosacea symptoms

Since there is no known cure for Rosacea, one can take steps to keep the signs and symptoms in control.

• One should take care of the skin using gentle cleansers, oil free, water based skin products. The products containing menthol, alcohol and exfoliating agents which might irritate the skin shall be avoided.
• A comprehensive treatment plan shall be developed with the help of a doctor which would usually be a combo of oral antibiotics and antibiotic creams.
• Maintain a diary with entries of the foods you eat, cosmetics you use and things which are good and bad for your skin. This will help you shortlist the things which make your symptoms worse. This will also help your doctor to understand the causes and triggers for your problem. You may avoid anything which worsens your skin.
• Avoid exposure to direct sunlight. Wear sunscreen.
• Avoid alcohol.
• Use prescribed medicines, creams and antibiotics regularly.
• Avoid triggers of flare-ups.
  Read – Intertrigo: Skin Fold Rashes: Causes, Ayurvedic Treatment, Remedies

B. Can the flare-ups of rosacea be prevented?

Yes, you may follow the below mentioned measures to prevent rosacea flare-ups. When outdoors don’t forget to

• Wear brimmed hats
• Use broad spectrum sunscreen

• Relax and work out ways to decrease stress levels on day-to-day basis
• Avoid hot and spicy foods, choose warm foods and drinks over them
• During extreme conditions of heat, humidity or cold, try staying indoors as much as possible
• Avoid taking hot saunas or using hot tubs, take cool baths instead
• Avoid excessive consumption of caffeine and alcohol
• For makeup select products which carry labels like ‘hypoallergenic’, ‘non-acnegenic’ or ‘fragrance free’
• Mention every OTC and prescription medications you are taking to your doctor
• Maintain a ‘rosacea flare up diary’
  Read – Ayurvedic Treatment For Ringworm, Dermatophytosis, Tinea

C. Prevention of triggers of flare-ups

• Limiting exposure to sun, mainly during midday hours
• Keep away stress and anxiety; adopt self-care habits including having good sleep and eating good food
• Avoid alcohol
• Avoid skin and hair care products and make up products having topical alcohol as ingredient
• Avoid products having acetone, fragrances and preservatives
• Avoid topical steroids on face (except in acute inflammatory conditions) and also vasodilators
• Avoid excessive exercising
• Keep away your skin from overheating – drinking hot water and drinks, limit outdoor workouts in sun, taking cold showers immediately after workouts in sun
• Keep away from hot and spicy foods
• Keep away and protect from extreme cold weather and winds – use scarf on face and moisturizer application
• Some studies showed that vitamin B-12 deficiency might cause rosacea, its values need to be checked. Excessive use of Niacin (vitamin B-3) may cause flushing. Another study shows that people with rosacea have higher than normal levels of vitamin D.

D. Diet inclusions which might reduce rosacea flare-ups

According to research – certain foods might trigger flare-ups in rosacea. About 78% adults with rosacea reported making dietetic changes (according to 2005 survey by National Rosacea Society). Gut health and rosacea might also be closely linked.
According to a clinical study in Denmark, high numbers of adults with rosacea were also found to have gastrointestinal disorders like IBS, celiac disease, inflammatory bowel disease and overgrowth of bacteria in small intestine.

Foods which may reduce flare-ups
Nutritional supplements containing healthy fats and other nutrients might help in improving rosacea symptoms. They include omega-3 fatty acids and zinc sulfate.
It was also seen that the foods which promote good bacteria may also reduce symptoms of rosacea. They include fiber-rich foods, prebiotics and probiotics.

Foods which may trigger flare-ups
Similarly some foods which worsen rosacea are also found. Avoiding or limited consumption of these foods might help in improving symptoms of rosacea in few people. They are –

• Alcohol – wine, hard liquor and other alcoholic beverages (vodka, champagne, gin, beer etc)
• Beverages – hot drinks (tea, coffee, hot cocoa etc)
• Spicy foods – certain spices and peppers having the chemical capsaicin are found to trigger the symptoms of rosacea. They include – chili pepper, hot sauce, jalapenos, etc
• Cinnamaldehyde foods – foods containing cinnamaldehyde might trigger rosacea symptoms. They include cinnamon, citrus fruits, tomatoes, chocolate etc
  Read – Prickly Heat – Ayurvedic Treatment, Medicines, Remedies

Medicines which might trigger flare-ups in rosacea

Niacin (Vitamin B3), blood pressure medications and topical steroids may trigger rosacea symptoms.

Treatment

Proper and timely skin care plus effective drugs for healing is an ideal combination strategy towards controlling the signs and symptoms in the treatment of rosacea. The type and severity of the signs and symptoms of rosacea determines the duration of the treatment. In spite of all treatment, recurrence is common in this case.

Medications

Different options or combinations of drugs might be tried to find out so as to which suits the patient better. Different medicines might work with different patients and not with others. Below mentioned drugs may be included in the treatment –

• Topical drugs – These are generally used for reducing flushing associated with the disease. A cream or gel may work for mild to moderate cases. Brimonidine and oxymetazoline are used for this purpose. Azelaic acid, metronidazole and ivermectin are used in milder cases. These need to be applied regularly and for longer times to find improvement.
• Oral antibiotics – are prescribed in moderate to severe disease with pimples and bumps. Example – doxycycline.
• Oral drugs used in acne like isotretinoin are useful in severe rosacea.

Laser therapy

This is a useful therapy which makes enlarged blood vessels less visible. This therapy will carry its risks as well as benefits. Long lasting swelling and bruising are some of the side effects of laser therapy in rosacea. Permanent / long term discoloration of the treated skin is also a side effect especially in those having brown or black skin. To maintain the improvement seen on the skin multiple and repeated treatments may be needed periodically.

Alternative medicine

• Swelling and inflammation shall be reduced by using gentle facial massage daily.
• According to a recent study – caffeine may reduce the risk of developing rosacea. On the other side hot beverages are a common trigger in some people having rosacea.
• Oregano oil, laurelwood oil and emu oil are also used for treating rosacea. There are no sufficient evidences which might support the effectiveness of these things.

Outlook for Rosacea
Rosacea doesn’t have a proved line of treatment or cure. The symptoms of the disease can be controlled with a proper planning of treatment. It is also wise to identify your triggers and avoid them with the help of your doctor.

Support and coping with rosacea
Rosacea can be distressing as a disease and also from a cosmetic perspective. One might become anxious, self-conscious or withdrawn, become upset or frustrated. These may become triggers in long run. Therefore it is wise to take counseling in this regard. One may also take help from rosacea support groups.
Click here to know New treatments and research in Rosacea

Home Remedies

Home remedies are not a solution for rosacea. They may be tried for symptomatic relief of certain symptoms or to keep the disease in check and balance once it has been treated with comprehensive measures. But nothing in this perspective has been proved. Changes observed in the skin might be a clue to take immediate medical attention when you have rosacea. Flare-ups also are good clues. Skin changes might also point towards more serious underlying condition which needs almost immediate medical treatment. Rosacea without serious underlying conditions might have a good prognosis. The treatment options are also good. Click here to check home remedies in Rosacea

The home remedies and natural treatments come in handy in the interim period i.e. the time gap between the diagnosis and start of actual treatment for the condition. Many might want to attempt something at home before starting the prescription medicines. These remedies may also be tried to prevent recurrence though their role has not been proved. 

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