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How to Manage Rosacea in Winter: A Doctor’s Guide to Calming Redness and Strengthening Skin

BY David Jack

GUIDES

Winter has an uncanny way of stirring trouble for patients with rosacea. The chill in the air, the fierce burst of indoor heating, wind against an exposed face, low humidity. All of these elements conspire to provoke the very processes that underlie rosacea: vascular reactivity, inflammation and barrier dysfunction. As someone who designs clinics with the same attention to detail as I do patients’ treatment plans, I’ve become ever more aware that winter rosacea isn’t simply about ‘moisturise more’ or ‘avoid wine’ (though those help). Developing a layering strategy so your skin doesn’t simply endure the months ahead but emerges unscathed is essential.

In this article I’ll guide you through a structured, progressive approach (what I like to call a stepladder of interventions - you’ll find many stepladders in my treatment guides), integrating skincare, prescription-topicals (for example azelaic acid and ivermectin), device treatments (such as IPL) and specialised clinic interventions (our microbiome facial) as well as home adjuncts like the blue peel we deploy to really give our patients well rounded care. My aim: the winter months become manageable, your rosacea stays quiet and you don’t feel as though your skin is locked into survival mode.

Why Winter Flares Happen

To begin, let’s examine why rosacea tends to misbehave in winter. Cold air and wind repeatedly cause reflexive vasoconstriction followed by vasodilation. This fluctuation can provoke what you might describe as burning, flushing or increased redness. Indoors, central heating reduces humidity and the skin barrier becomes dry, cracked, more prone to irritants and less able to respond to microbial or environmental stress. On top of that, many patients change their routines: richer creams, heavier make-up, longer hot showers, changing diets laden with heavier food and more alcohol, which we know these are known rosacea triggers.

Underlying all this is rosacea’s pathophysiology. We now understand there is immune dysregulation (including elevated cathelicidins, activation of Toll-like receptor-2 and mast-cell pathways (the cells that produce histamine in your skin)), a disturbed skin and gut microbiome alongside compromised barrier and vascular health. For example, recent work shows a disturbance in the cutaneous microbiome, and growing interest in the gut-skin axis in rosacea patients (Sánchez-Pellicer et al., 2024). Thus, winter amplifies all these vulnerabilities: barrier breakdown, vascular instability, microbial stress. A multi-layered approach is usually best.

The Three Pillars of Winter Rosacea Care

Before we climb our stepladder of treatments, it’s helpful to ground ourselves in three non-negotiable pillars.

Firstly: trigger reduction and barrier protection. Identifying what aggravates a given patient (wind, hot beverages, indoor heating, spicy food, alcohol) and minimising those exposures is essential toto reduce the baseline load on the skin. At the same time reinforcing the barrier through gentle cleansing, hydration, ceramide/niacinamide-rich cleansers and moisturisers, as well as avoiding harsh actives when skin is stressed.

Secondly: tackling the vascular-inflammatory cascade of rosacea. This means not just calming papules or pustules, but also addressing flushing, persistent erythema and telangiectasia (thread veins). Without this, winter flares will continue despite the basic care of trigger reduction and barrier protection.

Thirdly: integrating adjunctive/procedural strategies. In clinic we have tools beyond topicals including device treatments like IPL (intense pulsed light) to reduce visible vessel burden, facial treatments designed to support the skin’s microbiome (which in turn supports barrier and inflammation control) and home adjuncts (for example our Blue Peel) to keep patients actively engaged rather than passive.

The Stepladder Approach to Treating Rosacea in The Wintertime

I generally like the concept of stepladders when it comes to tackling clinical conditions (a remnant of my days as a plastic surgery trainee). When it comes to rosacea treatments, the idea is: begin at Step 1, evaluate after a defined interval and if disease remains uncontrolled or winters worsen, move to Step 2, then Step 3, and so on. Because rosacea is chronic and relapsing, especially in winter, you must plan ahead rather than react.

Step 1: Foundation for All Patients

At this stage I focus purely on prevention and minimising winter stress. We review lifestyle: wind-protection (scarves, minimising exposure), avoiding abrupt indoor-outdoor temperature shifts, humidifier use in dry heated rooms, limiting hot beverages and saunas and monitoring your diet (especially alcohol/spicy foods).

Simultaneously we begin barrier-support skincare: a mild non-foaming ceramide rich cleanser, daily broad-spectrum SPF (yes, even in winter) and an evening richer barrier cream (we’ve called it Skin Cushion as it literally cushions and cares for your skin life a comfortable pillow), containing ceramides, fatty acids and barrier-repair ingredients. Exfoliants are to be paused unless the skin is stable, and fragranced/irritant-laden products avoided.

Crucially, at this stage we also begin home adjunct use where appropriate: our Blue Peel (a gentle enzymatic/chemical exfoliant) is excellent for calming inflammation by virtue of it’s blend of active ingredients including azelaic acid and niacinamide. The blue peel helps remove surface debris, supports barrier repair and sets the skin up for winter.

We review after about four weeks: if skin is stable, we continue with Step 1 maintenance. If papules, pustules or persistent erythema remain, we progress.

Step 2: Topical Prescription Actives

When foundation care alone isn’t enough we move to the prescription level. For most rosacea patients with papulopustular features (bumps/pimples) or persistent flushing, I consider azelaic acid 15% gel (or foam) as first‐line. This topical prescription has strong evidence: in two studies it achieved >50% reduction in lesion count and significantly improved erythema (Draelos et al., 2013).

If you are still not responding sufficiently, we escalate to ivermectin 1% cream (for example Soolantra). The NICE evidence summary indicates it is licensed for inflammatory lesions of rosacea and in randomised controlled trials showed superiority to vehicle and even to metronidazole in some trials.

At this stage we must continue barrier support, minimise triggers and monitor for irritation from these actives (burning, dryness still occur). The winter factor means skin may be more fragile, so we may delay escalation slightly or choose a gentler vehicle.

After this, we tend to review after about 8-12 weeks of consistent use. If lesions are largely cleared and flushing is reduced, we maintain this step and monitor. If the vascular component (persistent erythema/telangiectasia) remains troublesome, we climb further.

Step 3: Addressing the Vascular Component & Adjunctive Procedures

When papules are better but the skin still has that ruddy redness or visible tiny vessels, this is where procedural treatments make a difference. The use of IPL (intense pulsed light) is extremely well supported in the literature for treatment of rosacea, especially the erythematotelangiectatic subtype. A systematic review found most studies showed positive effects of IPL on telangiectasia and erythema in rosacea (Martignago et al., 2024).

In practice we generally offer a series of 3-4 IPL treatments spaced 4-6 weeks apart, using appropriately selected wavelengths and parameters for the patient’s skin type. Patients with Fitzpatrick type I-IV skin are suitable for treatment with IPL. After the initial series of treatments, typically patients will return once per year (most often in the wintertime) for a top-up treatment.

Simultaneously at this stage we deploy what we call the ‘Microbiome Facial’ in clinic: a treatment designed to support the cutaneous microbiome, calm inflammation, bolster barrier repair and prepare the skin for winter stress. The rationale here stems from recent microbiome science: rosacea is increasingly understood to be associated with microbial dysbiosis (skin and gut) which acts via barrier breakdown and inflammation (Zhu et al., 2023).

In the facial we include a gentle exfoliation if suitable, a mask or serum rich in pre-biotic/probiotic or microbial-friendly peptides, calming actives (panthenol, ceramides, niacinamide) and Fluorescent Light Energy (FLE) Technology that is designed to restructure the microbiome and calm the skin, followed by a cold plasma treatment. Scheduling one at the onset of winter and a ‘top-up’ mid-winter strengthens resilience.

Of course at this time, we continue maintenance actives (azelaic/ivermectin), barrier care, trigger avoidance and monitor. If despite all this the patient continues to struggle (frequent flares, phymatous changes, ocular involvement) we can escalate further.

Step 4: Escalation/Maintenance for Persistent or Advanced Disease

In patients who do not respond to Steps 1-3 or who are known to flare each winter badly, there is the possibility to move to an escalation plan. This may include low-dose oral therapy (doxycycline 40 mg ‘anti-inflammatory’ dose), more intensive IPL treatments and a formal maintenance plan: once the skin achieves control, we reduce frequency of topicals (alternate day instead of daily) and device sessions become annual check-ups rather than every winter.

At this stage patient education is critical: explain that rosacea is chronic, winter is a high-risk period and we don’t aim for perfect ‘clear skin’ but for stable, comfortable skin with minimised flares. Therefore a relapse‐prevention mindset helps.

Planning for Next Winter

At the end of winter (late March/early April) we like to schedule a review: discuss what went well, which triggers caused trouble this season, how the barrier held up, how many device sessions were undertaken, review skincare compliance. If the patient achieved good control then we consider stepping down (active therapy every other day). If not, we plan to start proactively earlier next autumn (scheduling microbiome facial in October, reviewing topical adherence, perhaps pre-emptive IPL before the wind bites).

Summary

Winter need not be a season of dread for rosacea patients. Adopting a structured, layered approach: foundation barrier care and trigger avoidance, followed by topical prescription actives, then procedural interventions and finishing with escalation and maintenance planning, can minimise flares, maintain comfort and preserve skin quality through the colder months. The key is starting early (before winter hits), being proactive rather than reactive and remembering that you are seeking control, not cure.

If you are suffering from Rosacea and wish to build a bespoke plan for your skin over the winter, book in for a consultation with one of our experts.

References

Daou, H., Paradiso, M., Hennessy, K. & Seminario-Vidal, L. (2021). Rosacea and the microbiome: a systematic review. Dermatology and Therapy (Heidelberg), 11(1), pp.1–12. Available at: https://pubmed.ncbi.nlm.nih.gov/33170492/ [Accessed 11 November 2025]

Draelos, Z.D., Elewski, B., Staedtler, G. & Havlickova, B. (2013). Azelaic acid foam 15% in the treatment of papulopustular rosacea: a randomized, double-blind, vehicle-controlled study. Cutis, 92(6), pp.306–317. Available at: https://pubmed.ncbi.nlm.nih.gov/24416747/ [Accessed 11 November 2025]

Gold, L.S., Kircik, L., Fowler, J., Tan, J., Draelos, Z., Fleischer, A. et al. (2014). Long-term safety of ivermectin 1% cream vs azelaic acid 15% gel in treating inflammatory lesions of rosacea: results of two 40-week controlled, investigator-blinded trials. Journal of Drugs in Dermatology, 13(11), pp.1380–1386. Available at: https://pubmed.ncbi.nlm.nih.gov/25607706/ [Accessed 11 November 2025]

Luo, Y., Luan, X.-L., Zhang, J.-H., Wu, L.-X. & Zhou, N. (2020). Improved telangiectasia and reduced recurrence rate of rosacea after treatment with 540 nm-wavelength intense pulsed light: a prospective randomized controlled trial with a 2-year follow-up. Experimental and Therapeutic Medicine, 19(6), pp.3543–3550. Available at: https://pubmed.ncbi.nlm.nih.gov/32346416/ [Accessed 11 November 2025]

Martignago, C.C.S., Bonifacio, M., Ascimann, L.T., Vassão, P.G., Parisi, J.R., Renno, A.P., Garcia, L.A., Ribeiro, D.A. & Renno, A.C.M. (2024). Efficacy and safety of intense pulsed light in rosacea: a systematic review. Indian Journal of Dermatology, Venereology and Leprology, 90(5), pp.599–605. Available at: https://pubmed.ncbi.nlm.nih.gov/39152889/ [Accessed 11 November 2025]

NICE (2016). Inflammatory lesions of papulopustular rosacea: ivermectin 10 mg/g cream – Evidence summary (ESNM68). Available at: https://www.nice.org.uk/advice/esnm68/chapter/full-evidence-summary [Accessed 11 November 2025]

NICE CKS (2025). Rosacea: management. Available at: https://cks.nice.org.uk/topics/rosacea/management/rosacea/ [Accessed 11 November 2025]

Raedler, L.A. (2015). Soolantra (ivermectin) 1% cream: a novel, antibiotic-free agent approved for the treatment of patients with rosacea. American Health & Drug Benefits, 8(Special Feature), pp.122–125. Available at: https://pubmed.ncbi.nlm.nih.gov/26629276/ [Accessed 11 November 2025]

Thiboutot, D., Thieroff-Ekerdt, R. & Graupe, K. (2003). Efficacy and safety of azelaic acid (15%) gel as a new treatment for papulopustular rosacea: results from two vehicle-controlled, randomized phase III studies. Journal of the American Academy of Dermatology, 48(6), pp.836–845. Available at: https://pubmed.ncbi.nlm.nih.gov/12789172/ [Accessed 11 November 2025]

Zhu, W., Hamblin, M.R. & Wen, X. (2023). Role of the skin microbiota and intestinal microbiome in rosacea. Frontiers in Microbiology, 14, 1108661. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9950749/ [Accessed 11 November 2025]

Sánchez-Pellicer, P., Calvo-Pérez, A., Muñoz, C., Esplugues, J.V., Martínez-Martínez, A. & Pérez-Reche, A. (2024). Rosacea, microbiome and probiotics: the gut-skin axis. Frontiers in Microbiology, 15, 1323644. Available at: https://www.frontiersin.org/journals/microbiology/articles/10.3389/fmicb.2023.1323644/full [Accessed 11 November 2025]

Draelos, Z.D., Del Rosso, J.Q., Thiboutot, D., Rizer, R.L., Wolfe, J. & Graupe, K. (2015). A phase 3 randomized, double-blind, vehicle-controlled study of azelaic acid foam 15% in the treatment of papulopustular rosacea. Journal of Drugs in Dermatology, 14(8), pp.830–836. Available at: https://pubmed.ncbi.nlm.nih.gov/26244354/ [Accessed 11 November 2025]