Chemical Peels with Rosacea? Yes.

Do you have adult acne? I thought I did too.

I discovered a few years ago, when I started getting acne in my 40s, that it wasn’t acne at all. It was rosacea, type 2, referred to in the medical world as P&P or papulopustular rosacea. Sounds pretty, eh? "Most people classify rosacea into four types," says Sandra Marchese Johnson, MD. “Papulopustular rosacea or inflammatory rosacea’s key symptom is chronic red [patches] on the face, as well as an outbreak of red bumps and pimples. These bumps, known as pustules and papules, are different from actual acne and require a different treatment." [1]

This is a picture with a rosacea flare on my face: red, inflamed bumps that look like pimples somewhat, rough, tight skin. This is not an easy picture to post, but I think it's important for people to understand that rosacea skin SHOULD be treated with peeling agents. It's really the only thing I've found that keeps my skin clear, and I've used metro gel, azeliac acid, steroids, antibiotics, and more. 

Here's my skin now: click both to enlarge.

My keys to successful chemical peels with rosacea are …

1.      Dr. Steven Wallace in Manhattan says, “get the rosacea under control before doing anything else,” [2] and I totally agree. Find triggers and avoid them! This is a time-consuming process, but well worth it. I won’t bore you with how to do that, but post a comment if you’re interested and I’ll reply on the method that worked for me.

2. Use a gentle chemical peel agent on a regular basis, such as 5% glycolic acid in combination with 2% salicylic acid; alternate these on an interval that works with skin type and problems. BHA is also a great anti-inflammatory agent, so this will help! I use one of these every night, although I substitute the glycolic acid with retin-a about 3 times a week.

3. Do not proceed with a scheduled chemical peel if flaring; wait until flare is completely gone. My medium chemical peel of choice is TCA at about 25%, and I try to do this at least three times a year.

4. Stop the daily exfoliants 3-10 days before the scheduled chemical peel, depending upon skin condition

5. Clean up diet, which will help flares and contribute to better skin overall

6. Get a copper-based healing moisturizer to use post-peel only; don’t use this regularly because too much copper is bad for the skin but great for healing

7. Find a good zinc-based sunscreen to use every day, not just after the peels

I've linked the products I've found to work best with my skin.


Should I use an AHA or BHA?


Glycolic acid, an AHA, is a good choice for combination skin. Glycolic acid has the smallest molecule of all the AHAs, so it is able to penetrate without encouraging more sebum production. This acid is derived from fruit sugars. AHAs are water soluable, so they also work well for areas that are not as oily. 

For a mild nightly cream that is inexpensive and highly rated, I really like Reviva's 10% cream. Lots of people rave about this. I've also found this at Ulta on sale occasionally.

For a bi-weekly or monthly peel, I like Skin Obsession's 40% Glycolic Acid Peel. This peel really works well, but it stings and itches A LOT. I use this about once a month.

Be cautious when performing superficial chemical peels; acne can, ironically, be a side effect. [1] Avoid occlusive moisturizers if possible, which will help.

Acne Prone

Salicylic acid is the only BHA available; it encourages skin exfoliation and penetrates deeper than AHAs, so it's a good option for acne-prone skin. This acid is oil soluble, so it's a great option for oily skin that is plagued by acne. 

Beware with BHA: this can increase sun sensitivity by 50%, which can easily result in hyper-pigmentation. Salicylic acid also seems to cause more irritation. 

When to Use

Do NOT choose a daily moisturizer with BHA since it increases sensitivity to sun. Also, avoid cleansers with BHA because the acid must have time to penetrate the skin, and the cleanser will be rinsed too quickly. This is best used in a night-time moisturizer or serum--or monthly chemical peel. Remember to use sunscreen regularly with BHA. 

Dr. Heather Brannon recommends solutions with BHA at 1-2% and pH of 3-4. [2] This 2% Salicyclic Acid by Refresh Skin Therapy is well rated and is naturally derived.

Glycolic acid, an AHA, is another good choice for mild acne-prone skin. See Combination above for more.

Dry and/or Aging

Lactic acid chemical peel  is better suited to aging and/or dry skin because it encourages sebum production, among many other benefits, such as reducing age spots, freckles, sun spots, hyperpigmentation, and wrinkles. This acid is derived from milk sugars. For peels, I like the Lactic Acid by Perfect Image. It has high ratings at a descent price.

For a daily lactic acid lotion, I like AmLactin 12% Lotion. This is also a great body exfoliation lotion that will help retain moisture while increasing cell turnover.

Gloss Chemical Peel

The Gloss peel is the first generation of “non-wounding” chemical peels designed to retexturize the skin without harming it. This chemical peel is reported to contain restorative acids at levels that work symbiotically to restore a healthy, reflective glow to the complexion with little down time.

Before and After:
This is a "before and after" gloss peel picture from Dr. Steven Hopping's website:

It's difficult to see if she achieved HER desired results with this size and resolution.

This peel seems to be most effective in reducing large pores and retexturizing skin that may not seem smooth. The combination of acids indicates (to me) that it would also help reduce acne, fine lines, and hyperpigmentation or dark spots.

This peels contains TCA, Salicylic acid, Azelaic acid, and a retinoid (vitamin A). It’s touted as gently exfoliating the skin as it delivers anti-inflammatory, anti-bacterial, and anti-aging benefits to the skin.

It’s a combination of 17% Trichloroacetic acid (TCA),  17% Salicylic acid, Azelaic Acid, and varying amounts of vitamin A, in a phenol-free,  anhydrous gel vehicle that limits ionization of the free acids. This results in limiting the pain and cellular injury associated with conventional TCA aqueous solutions. It also allows a longer contact time of the peel solution with the skin, thus enhancing efficacy.

To prepare for this peel, one week before the treatment, avoid electrolysis, waxing, sunless tanning, spray tanning, or UV free tanning, depilatory creams, laser hair removal treatments, cosmetic facials, Botox, Retin-A, Renova, Differin, Tazorac, Avage, retinols, alpha hydroxyl acids, beta hydroxyl acids, benzoyl peroxide, or any other exfoliating products that may be drying or irritating.

After a 10-minute contact period, the peel solution is wiped from the skin using a solvent containing 1% retinol. The remaining residue is left on the skin an additional period of time before washing it off, adding retinoid benefits to the keratolytic effects of the peel solution.

After the Peel:
Most of these peels include a take-home kit consisting of a gentle, fragrance-free cleanser, emollient physical sunscreen, additional retinoid treatment pads and niacinamide-containing moisturizer.

I’ve read that the normal reaction is redness for 2-5 days but minimal peeling if at all. Results will vary, but generally users will see smoother skin texture, and revived appearance. Remember to use sunscreen every day after a peel since this new skin is especially vulnerable to hyperpigmentation.
It’s recommended to use this peel only two times per year, or at 6-month intervals.

I haven’t been able to find this peel combination for purchase to use at home, but for treatment by a professional, I’ve seen it listed from about $200 to $600, depending on location.

If you've seen this available online for purchase, please let me know. I want to try it to post pictures and give a review.

FDA Approves First Dermal Filler for Acne Scars

The U.S. Food and Drug Administration approved the first dermal filler to treat scarring caused by acne, the most common skin disorder in the United States afflicting 40-50 million people.
Many plastic surgeons and dermatologists have used other fillers, off label, to help fill acne scars, including ice-pick, pitted, atrophic scars (flat, thin, or depressed), and hypertropic or keloid scars, those that are thick or lumpy. 
While many of us experience the slow actualization of our mortality through those wrinkles we often see as scars from living life, imagine how a young, vibrant person feels going through the onslaught of pain from not only from the appearance of nodular acne but also the resulting scars. My brother experienced this, and I can share that it affected his entire being. My parents had him put on Accutane, but it was too late to avoid the scarring. 
Bellafill, developed by privately held Suneva Medical Inc, has been developed to treat moderate to severe acne scars on the cheeks of patients over the age of 21.
A cure for acne has long eluded drug developers. And from topical gels to lasers, nothing so far has satisfactorily treated scarring that affects up to 95% of acne sufferers.
The U.S. Food and Drug Administration cleared a laser treatment for acne scarring in July, but adoption for this kind of therapy is limited by its high cost, associated pain, and the need for repeat treatments.

FDA Approves Ivermectin Cream for Rosacea

Published 12/24/14:

FDA Clears Ivermectin Cream (Soolantra) for Rosacea

Megan Brooks
DisclosuresDecember 24, 2014
The US Food and Drug Administration has approved 1% ivermectin cream (Soolantra, Galderma Labs), a once-daily treatment for the inflammatory lesions, bumps, and pimples of rosacea.
Rosacea is a common chronic skin condition affecting an estimated 16 million Americans, predominantly women, aged 30 years and older. The exact cause of the characteristic facial redness, pimples, and bumps of rosacea is unknown, but research suggests multiple triggers, including exposure to sun, alcohol, spicy food, and exercise. Recent evidence also suggests that rosacea may be caused by the overproliferation of Demodex mites in the skin.
Ivermectin, the active ingredient in the cream, has both anti-inflammatory and antiparasitic activity. The basis for the cream is Cetaphil moisturizing cream, a dermatologist-recommended formula that is fragrance-free, mild, and nonirritating, the company says.
The approval of ivermectin cream was based on two pivotal phase 3 randomized, double-blind, 12-week, vehicle-controlled studies involving 910 patients with rosacea.
In both studies, ivermectin cream applied once daily met each of its primary efficacy endpoints of treatment success, as defined by an Investigator Global Assessment rating of clear skin and change in inflammatory lesion count.
Beneficial effects were observed as early as week 2, with continuous improvement, the company says.
Rosacea is a "challenging condition to manage as it tends to vary from patient to patient, often requiring a tailored approach," Linda Stein Gold, MD, Galderma consultant and clinical investigator for the phase 3 studies, said in a company statement. "While some rosacea treatments for the common bumps and pimples of the condition may take more than 4 weeks to show effect, Soolantra Cream may provide initial results as early as week 2," she noted.
In long-term extensions to the 12-week studies, ivermectin cream was safe and well-tolerated for an additional 40 weeks (up to 52 weeks in total), although some patients reported skin burning and skin irritation.