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Do You Have A Gut Feeling About Your Rosacea?

  • The RRDi is the only non profit organization for rosacea that recognizes Gastrointestinal Rosacea [GR], aka GUT Rosacea as a rosacea variant. 



The Gut-Brain Axis is well established. Is there also a Gut-Brain-Skin Axis?

The Huff Post speculates there is. [17] The evidence is now established that there is a gut-brain-skin axis. 

You may already have thought about this anyway that somehow the gut is connected to the skin problems you are having. If there is no connection, why do doctors prescribe oral antibiotics for rosacea, i.e., Oracea, which has 10 mg of timed released doxycycline that is released in the gut (the other 30 mg are immediately released)?  "Skin and gut microbiota were initially the subjects of the majority of studies, as the role of the gut–skin axis is widely-recognized, but not fully understood." [25] "The gut microbiome is regarded as a major regulator of the gut–skin axis with a bidirectional modulation between the gut microbiome and host immunity." [27] Watch this Nova Wonders trailer about this subject: 

"An enhanced understanding of the local skin and gut microbiome including the underlying mechanisms is necessary to shed light on the microbial involvement in human skin diseases and to develop new therapeutic approaches." [30]

"The link may involve common predisposing genetic, microbiota, and immunological factors, comprising the theory of the gut–skin axis," [32]

"Rosacea is a chronic inflammatory disease that primarily affects young and middle-aged Caucasian women. Its etiology is multifactorial and appears to be determined by genetic predisposition, alteration of the neurovascular and immune response, as well as an altered dialogue with the microbiota. Additionally, the disease has been linked to gastrointestinal disorders such as Helicobacter pylori infection or small intestine bacterial overgrowth and even neurological disorders such as Parkinson's disease, revealing the existence of a brain-gut-skin axis." [33]

One study confirms antibiotics mess with the gut. The study, published in the Proceedings of the National Academy of Sciences, supports the common wisdom that antibiotics can damage the ‘good’ germs living in the body. [1]

Clearing up any unhealthy bugs and getting a healthy flora may improve not only the skin but also a number of other health issues and “relief from allergies, acne, arthritis, headaches, autoimmune disease, depression, attention deficit, and more–often after years or decades of suffering.” [2]

Bacteria has been one of the theories postulated as the cause of rosacea but this has never been proven. If bacteria isn’t involved the question is always asked, then, why do antibiotics improve rosacea? The usual response is the anti-inflammatory effect that antibiotics have on rosacea. There is now a low dose antibiotic (Oracea) used to treat rosacea. However, the long term risks of antibiotic treatment, whether low dose or not, is something to consider which may include an upset stomach, antibiotic resistance and bacterial overgrowth and a significant number of side effects or risks. 

Rosacea and the Human Microbiome
However, the question proposed in this article is, do you have a gut feeling about rosacea? This is related to the human microbiome. 

"The brain has a role to play as well, making many call it the gut-brain-skin axis. In this theory, anxiety and stress lead to intestinal permeability and dysbiosis in the gut. This, in turn, leads to inflammation that contributes to skin inflammation." [17]

A report connects gut microbes with rosacea. [9]

Another report said, "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." [8] 

"Acne, along with eczema, rosacea, psoriasis and dermatitis, is not a skin condition. These issues are all autoimmune disorders, that sit inside the gut. You must heal the gut, in order to clear the skin. This is the reason why no topical application alone has ever worked permanently to resolve your skin issues." [24]

"A complex connection between the digestive tract, brain, and skin, referred to as the gut—brain—skin axis, is widely appreciated by researchers of various fields of science, but the exact interactions have not yet been fully elucidated. This theory is supported by the observation of improvements of skin conditions following the use of oral probiotics or prebiotics. [25]

"The increasingly wide use of next-generation sequencing technologies has revolutionised our knowledge of microbial environments associated with human skin, gastrointestinal tract and blood. The collective set of microorganisms influences metabolic processes, affects immune responses, and so directly or indirectly modulates disease. Rosacea is a skin condition of abnormal inflammation and vascular dysfunction, and its progression is affected by Demodex mites on the skin surface. When looking into the effects influencing development of rosacea, it is not only the skin microbiome change that needs to be considered. Changes in the intestinal microbiome and their circulating metabolites, as well as changes in the blood microbiome also affect the progression of rosacea. Recent research has confirmed the increased presence of bacterial genera like Acidaminococcus and Megasphera in the intestinal microbiome and Rheinheimera and Sphingobium in the blood microbiome of rosacea patients." [28]

Fecal calprotectin (FC) levels using the the Gastrointestinal Symptom Rating Scale (GSRS) "were statistically significantly higher in rosacea group than in the control group (65.96 ± 58.86 ng/mL vs. 31.99 ± 20.12 ng/mL, p = 0.026, respectively). A statistically significant difference was also observed in GSRS values between the patient and the control groups (30.26 ± 12.48 vs. 22.62 ± 7.64, p = 0.001, respectively). A positive correlation was noted between FC levels and the values of GSRS in the study group (r: 0.354; p = 0.001) and in the rosacea group (r = 0.392, p = 0.006)." This same study concluded, "The measurement of FC may be useful in the early detection of gastrointestinal system (GIS) diseases that may accompany rosacea and may provide a pathway to develop treatment strategies targeting both skin and intestinal mucosa." [31]

Antibiotics, without a doubt, plays a role in the treatment of rosacea in the gut. Could it be possible that rosacea is somehow related to something going wrong in your gut?

Long term antibiotic treatment has some serious side effects and risks associated with it. [3]

"Prolonged use of systemic antibiotics in rosacea may be a confounder in the relationship." [27]

An article by Whitney Bowe, M.D., Probiotics in Acne and Rosacea, Dr. Bowe suggests taking probiotics may help rosacea. [10] Dr. Bowe has written a book, The Beauty of Dirty Skin, worth reading.

One way is to balance the good bacteria (should be 80%) with the bad bacteria (should be 20%) accomplished by adding probiotics to your intake. There are a number of probiotics on the market that contain several strains of the good bacteria to choose from. Wouldn't it be good to do a clinical study on rosacea sufferers who take probiotics with a double blind, placebo controlled group to see? The RRDi could sponsor such a clinical study if we had 10K members who each donated one dollar. Why not join the RRDi and help us reach this goal?

Foods rich in probiotics are Yogurt, Buttermilk, Fermented Cheese, Sauerkraut, Tempeh, Kimchi, Miso, Kombucha, Pickles, and Natto. 

Butyric Acid
There is evidence that adding butyric acid supplements along with probiotics possibly mediates FFaR2 to induce the synthesis of collagen through p-ERK activation. [29]

One recommendation is to stop eating sugar mentioned in the book, Rosacea Diet, that will help control your rosacea. There is ample anecdotal evidence that sugar is a rosacea trigger

An article suggests five ways to kill bugs in your gut and one of these suggestions is to stop eating sugar. Dr. Hyman, the writer of the article suggests that what is in your gut may be the problem for a number of health problems including skin diseases. [2]

Most rosaceans use trigger avoidance in their treatment of rosacea and the subject of diet triggers always comes up. Rosaceans have a gut feeling that what they are eating and drinking may have something to do with their rosacea but can’t seem to get a handle on it. While some rosaceans on the internet know that sugar is a potential rosacea trigger, the NRS and other rosacea 'authorities' still avoid listing sugar on any ‘official trigger list’ (the RRDi lists sugar as a rosacea trigger).

Since 2004 the RRDi has listed sugar is a rosacea trigger and more rosaceans have confirmed that reducing sugar in the diet does indeed help control their rosacea. Sugar is feeding your rosacea which makes your face warm, not to mention the burning and redness that sometimes results from consuming sugary drink and food. Sugar feeds the fire of rosacea. What does sugar do in your gut? It feeds whatever is in your gut.

Gut Diseases and Rosacea
There has been some discussion of how treating IBS, IBDSIBO, and H Pylori has helped rosacea using antibiotics. You might want to read this interesting post by Nanobugs, especially the last part of the post. So maybe after this article you may have a gut feeling that your rosacea is related to what you are eating and drinking. Maybe your gut is trying to tell you something?

Cybele Fishman, MD, wrote an article on this subject, published in Yahoo Health, stated, "Although why rosacea and SIBO are connected is still not totally clear, there is a connection in at least a subset of patients." [12]

Leonard Weinstock, MD has published a web site with the assistance of an educational grant from Galderma through the RRDi which was announced September 6, 2015 that discusses this subject. [13]

In a large Danish study it was reported, "The investigators found that there was a higher prevalence in rosacea patients of a variety of GI disorders. Compared with individuals without rosacea during the study period, those with rosacea were 46 percent more likely to have celiac disease, 45 percent more likely to have Crohn's disease, 34 percent more likely to have irritable bowel syndrome and 19 percent more likely to have ulcerative colitis." [14]

In 2015,  John Hopkins study found that rosacea patients were more likely than people without the disorder to suffer from gastroesophageal reflux disease (GERD) and other GI disorders. [15]

"Eighty-nine percent of the patients with acne, papular-pustular rosacea and seborrhoic dermatitis responded to E. coli Nissle therapy with significant amelioration or complete recovery in contrast to 56% in the control arm (P < 0.01). Accordingly, in the E. coli Nissle treated patients life quality improved significantly (P < 0.01), and adverse events were not recorded. " [16]

We need to better understand Microbiome-based therapeutic strategies.

One report says, "We found no significant difference in facial microbiome alpha and beta diversity between related twins discordant for rosacea." [18]

There are a number of anecdotal reports that low stomach acid may be connected to rosacea. [20]

A report states, "one study reported improvement in rosacea following successful treatment of small intestinal bacterial overgrowth." [21]

"Scientists have shown that transplanting gut bacteria, from an animal that is vulnerable to social stress to a non-stressed animal, can cause vulnerable behavior in the recipient. The research reveals details of biological interactions between the brain and gut that may someday lead to probiotic treatments for human psychiatric disorders such as depression." [23]

"Among rosacea-associated gastrointestinal diseases, the evidence for inflammatory bowel disease is the strongest." [32]

Metagenome Microbiome
"While further research is required in this area, patients may be advised on measures to support a healthy gut microbiome, including the consumption of a fiber-rich (prebiotic) diet." [21]

A paper worth reading on the subject of gut flora discusses the 'metagenome' or the 'second genome' in the human gut which holds microbes containing more genes in the flora in the intestinal system than the rest of our bodies. The paper says, "This creates a huge dataset that has to be disentangled." [4] The paper discusses how understanding gut flora may be a key to understanding diseases.

The Huff Post writes, "the skin has its own microbiome that is just as important to health as that of the gut microbiome. Although it has not yet been studied as in depth as the gut microbiome, studies have found it to be one of the most diverse microbiomes in the body. The microbiota provides protection through acting as a barrier against potential issues. It is essential to have a good balance between the commensal and pathogenic bacteria, and dysbiosis has the potential to contribute to skin disorders and diseases, just as in the gut. These similarities also lead to many connections between disorders of the gut and skin." [17] Read more about Microbiome-based therapeutic strategies.

One study by Nature Publishing Group discusses how recent research suggests that humans might be divided into three types of gut bacteria: Bacteroides, Prevotella and Ruminococcus. This may lead to personalizing medical treatment based upon which type gut microbes you predominantly have. [5] "The three gut types can explain why the uptake of medicines and nutrients varies from person to person," reports Jeroen Raes, a bioinformatician at Vrije University. [6] This may develop into a new ‘biological fingerprint’ on the same level as blood types and tissue types. [7] This may lead to a 'gut type diet' (similar to the blood type diet).

"A growing number of studies suggest that part of what determines how the human body functions may be not only our own genes, but also the genes of the trillions of microorganisms that reside on and in our bodies." [11]

"The microbiome is a new frontier in human health. JAX research is revealing the powers of our own microbes to fundamentally change our understanding of diseases of all kinds." [22]

"Dysregulation of the skin and gut microbial community has long been considered to have a pivotal role in rosacea and gastrointestinal disorders. Although related microbial species such as Demodex folliculorum, Staphylococcus epidermidis, H. pylori, Bacillus oleronius, or Chlamydia pneumoniae have not been shown to directly cause the disease, dysbiosis in the composition of the skin and gut microbiota is suspected to play a major role in the pathogenesis of both rosacea and gastrointestinal disorders via impairing the innate and adaptive immunity of the skin and gut epithelium. Intestinal bacteria could also affect the activation of the plasma kallikrein–kinin system (PKKS). The activation of PKKS is observed in patients with intestinal inflammation and rosacea [77,78] and this shared pathogenic link could be a possible explanation for the association." [26]

Microorganisms of the Human Microbiome in Rosacea

In conclusion, if you choose to treat rosacea with antibiotics, whether low dose or not, there may be long term effects and risks that you should consider, including the possibility that such treatment may not be helping your rosacea at all. It may only be treating the symptoms of rosacea and in the long term exacerbates rosacea. Obviously treating a case of severe rosacea with antibiotics and getting relief is a good idea, but should you be taking antibiotics long term for rosacea? What is your gut telling you? Maybe you have Gastrointestinal Rosacea [GR], aka, Gut Rosacea.  Do you have a gut feeling about your rosacea?

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End Notes

[1] Study confirms antibiotics mess with gut
ABC Science, Maggie Fox, Reuters, Tuesday, 14 September 2010
Original Article: les_dethlefsen_david_relman.pdf

[2] 5 Steps to Kill Hidden Bugs in Your Gut That Make You Sick
Mark Hyman, MD
The Huffington Post . September 30, 2010

[3] Antibiotic Resistance, Bacterial Overgrowth Candida Albicans, SIBO, Side Effects of Long Term Antibiotic Therapy,

[4] Human gut microbes hold 'second genome'
By Doreen Walton
Science reporter, BBC News

[5] Gut study divides people into three types
Nicola Jones
Published online 20 April 2011 | Nature | doi:10.1038/news.2011.249

[6] What’s in your gut? Microbiota categories might help simplify personalized medicine
By Katherine Harmon | April 20, 2011
Scientific American

[7] Each human has one of only three gut ecosystems
New Scientist, 18:04 20 April 2011 by Andy Coghlan

[8] Remission of rosacea induced by reduction of gut transit time.
Kendall SN.
Clin Exp Dermatol. 2004 May;29(3):297-9.

[9] Is rosacea another disorder of gut microbes?
Coyle WJ.
Curr Gastroenterol Rep. 2009 Aug;11(4):253-4.

[10] Probiotics in Acne and Rosacea

Probiotic use improved acne, rosacea symptoms

The Beauty of Dirty Skin

[11] The Environment Within: Exploring the Role of the Gut Microbiome in Health and Disease
Lindsey Konkel, Jayne Danska, Sarkis Mazmanian, Lisa Chadwick
Environ Health Perspect. 2013;121(9):a276-a281.

[12] How Your Gut Health Is Linked To Rosacea, Yahoo Health, Cybele Fishman, MD

[13] RRDi Announcement on Rosacea Rescue

[14] Br J Dermatol. 2016 Aug 8. doi: 10.1111/bjd.14930. 
Rosacea and gastrointestinal disorders - a population-based cohort study.
Egeberg A, Weinstock LB, Thyssen EP, Gislason GH, Thyssen JP.

[15] J Am Acad Dermatol. 2015 Oct;73(4):604-8. doi: 10.1016/j.jaad.2015.07.009. Epub 2015 Aug 6.
Rosacea is associated with chronic systemic diseases in a skin severity-dependent manner: results of a case-control study.
Rainer BM, Fischer AH, Luz Felipe da Silva D, Kang S, Chien AL.

[16] World J Gastroenterol. 2016 Jun 21;22(23):5415-21. doi: 10.3748/wjg.v22.i23.5415.
Intestinal-borne dermatoses significantly improved by oral application of Escherichia coli Nissle 1917.
Manzhalii E, Hornuss D, Stremmel W.
For More Info (related to the above article)

[17] The Gut-Skin Axis: The Importance of Gut Health for Radiant Skin, Deanna Minich, Ph.D., Contributor, Huff Post

"Moreover, there is increasing evidence connecting the skin condition with the gastrointestinal microbiome, which has been described as the skin-gut axis."

J Eur Acad Dermatol Venereol. 2019 Sep 14;:
The gut microbiome alterations in allergic and inflammatory skin diseases - an update.

Polkowska-Pruszyńska B, Gerkowicz A, Krasowska D

[18] Characterization of the facial microbiome in twins discordant for rosacea.
Exp Dermatol. 2017 Dec 28;:
Zaidi AK, Spaunhurst K, Sprockett D, Thomason Y, Mann MW, Fu P, Ammons C, Gerstenblith M, Tuttle MS, Popkin DL

The NRS website in discussing the above study quote states that this "study in twins has found a significant correlation between severity of rosacea and facial bacterial dysbiosis – an imbalance in the mix of bacteria, fungi and viruses that are normal inhabitants of the healthy face – potentially providing a basis for future research into what causes rosacea and how to treat it." [19]

[19] Twin Study Shows Change in the Facial Microbiome May Impact Rosacea, NRS WebBlog, Posted: 01/15/2018

[20] Marie Antoinette post no 1 at RF is one such anecdotal report. Here are some more: 

[21] Dermatol Pract Concept. 2017 Oct 31;7(4):31-37. doi: 10.5826/dpc.0704a08. eCollection 2017 Oct.
Diet and rosacea: the role of dietary change in the management of rosacea.

Weiss E1, Katta R1.

[22] Jackson Laboratory and the Microbiome

[23] Transplanting gut bacteria alters depression-related behavior, brain inflammation in animals
Knowledge of stress biology may eventually yield bacterial treatments for psychiatric disorders

Children's Hospital of Philadelphia, ScienceDaily

[24] The real reason that nothing has ever worked to resolve your acne, eczema, psoriasis or rosacea – until now!, Shan Jones, Chucking Goat

[25] Microorganisms. 2020 Nov 08;8(11):
Diversity and Composition of the Skin, Blood and Gut Microbiome in Rosacea-A Systematic Review of the Literature.
Tutka K, Żychowska M, Reich A

[26] Int J Mol Sci. 2020 Nov 10;21(22):
Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis.
Woo YR, Han YJ, Kim HS, Cho SH, Lee JD

[27] Adv Ther. 2021 Jan 28;:
Rosacea, Germs, and Bowels: A Review on Gastrointestinal Comorbidities and Gut-Skin Axis of Rosacea.
Wang FY, Chi CC

[28]Acta Microbiol Immunol Hung. 2021 Jan 29;:
Interactions between immune system and the microbiome of skin, blood and gut in pathogenesis of rosacea.
Joura MI, Brunner A, Nemes-Nikodém É, Sárdy M, Ostorházi E

[29] Butyric Acid in the Gut and Probiotics

[30] Microorganisms. 2021 Feb 11;9(2):353. doi: 10.3390/microorganisms9020353.
Gut-Skin Axis: Current Knowledge of the Interrelationship between Microbial Dysbiosis and Skin Conditions
Britta De Pessemier, Lynda Grine, Melanie Debaere, Aglaya Maes, Bernhard Paetzold, Chris Callewaert  

[31] Evaluation of fecal calprotectin as a marker of gastrointestinal inflammation in rosacea: A case-control study

[32] Adv Ther. 2021; 38(3): 1415–1424.
Rosacea, Germs, and Bowels: A Review on Gastrointestinal Comorbidities and Gut–Skin Axis of Rosacea
Fang-Ying Wang, Ching-Chi Chi

Dysbiotic gut microbiota in inflammatory rosacea patients: another clue towards the existence of a brain-gut-skin axis

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  • Root Admin

"Scientists have shown that transplanting gut bacteria, from an animal that is vulnerable to social stress to a non-stressed animal, can cause vulnerable behavior in the recipient. The research reveals details of biological interactions between the brain and gut that may someday lead to probiotic treatments for human psychiatric disorders such as depression." 

Transplanting gut bacteria alters depression-related behavior, brain inflammation in animals
Knowledge of stress biology may eventually yield bacterial treatments for psychiatric disorders

Children's Hospital of Philadelphia, ScienceDaily

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  • Root Admin

"In a later population-based cohort study of 50,000 Danish patients with rosacea by Egeberg et al., the prevalence of celiac disease (CeD), Crohn’s disease (CD), ulcerative colitis (UC), small intestinal bacterial overgrowth (SIBO), and irritable bowel syndrome (IBS) were all significantly higher among patients with rosacea as compared with controls. These studies, and many others, substantiate the notion of a gut–skin axis. In fact, Nam et al. go a step further, describing the “gut–brain–skin axis” based on clinical evidence demonstrating amelioration of cutaneous inflammation following the administration of prebiotics and probiotics and the exhibition of similar neuronal and inflammatory activity in both the gut and skin." 

Dermatol Ther (Heidelb). 2020 Nov 10;:
Rosacea and the Microbiome: A Systematic Review.
Daou H, Paradiso M, Hennessy K, Seminario-Vidal L

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  • Root Admin



"The findings from this study present the concept of the involvement of the gut–brain–skin axis in rosacea."

Int J Mol Sci. 2020 Nov 10;21(22):
Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis.
Woo YR, Han YJ, Kim HS, Cho SH, Lee JD

Image courtesy of the International Journal of Molecular Sciences, under the terms and conditions of the Creative Commons Attribution (CC BY) license 

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