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Gastrointestinal Rosacea [GR], aka, Gut Rosacea

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Gastrointestinal issues with rosacea have long been noted in literature. Crohn disease, Gastrointestinal disease, GERD, Helicobacter pylori infection, IBD, SIBO, and Ulcerative Colitis are all considered Systemic Cormorbidities in Rosacea.

RosaceaSulphur.jpg

"PATIENT AT the Skin Clinic of the Women's Medical College. Rosacea is a chronic disease of the middle period of life. These "rosy drops" sometimes present a central point of a somewhat darker hue. In severe cases a fiery triangle may be seen on either cheek. In the most remarkable form of the disease the nose may attain the size of the fist. The eruption had troubled her more or less for six years and had been much worse than usual during the last month. She complained greatly of discomfort after eating and often vomited her food. The gastric irritability having subsided under a restricted diet, she was ordered Aug. 6, 1878, a mixture containing sulphate of iron and sulphate of magnesia, and for local application an ointment of sulphur, four parts, cosmoline, ninety-two parts. This was followed by rapid improvement, and when seen again on Sept. 17, all trace of the eruption had disappeared, and she felt much stronger and better." Margaret K., age 45, Ireland: ROSACEA, Art and Medicine

As far back as 1896, Dr. Leviseur mentioned 'gastrointestinal disturbances' with his acne rosacea patients. Here is an excerpt from an article he wrote back then:

"There are a number of skin diseases which occur in connection with disturbance of the stomach and intestine. This fact is well supported by clinical evidence, but, viewed from the more elevated standpoint of theoretical science, it must be admitted that the true nature of this connection is far from being clearly understood….All writers agree that a large percentage of cases of acne rosacea is caused by indigestion…..These patients have factor ex ore, especially in the morning, sour eructations, constipation, and perhaps a distressing feeling of fulness after meals; in short, all the symptoms of a mild fermentative gastritis…..In severe cases lavage is indicated and has sometimes a surprisingly good effect on the skin eruption. It must not, however, be expected that the mechanical removal of the fermenting masses stops the fermentation; the latter will promptly start again with the very next food supply. Careful dieting is almost always necessary; the amount of carbohydrates should be limited; alcohol, tea pastry, the coarser vegetables and milk should be forbidden. Bismuth, carbonate of sodium, creosote, carbolic acid, thymol, and ichthyic may be employed. I have had good results from the use of fluid extract of ergot…..It would carry me too far if I were to consider the various drug eruptions which appear in connection with gastrointestinal disturbances, as for instance erythema after the use of quinine, antipyrin, turpentine, balsam of copaiba, sandalwood oil, arsenic, etc….." [12]

The RRDi is classifying Gastrointestinal Rosacea [GR], aka Gut Rosacea, as a rosacea variant. [1] This is because treatment of rosacea using antimicrobial drugs, as well as other drugs through the gut (i.e., 'a mixture containing sulphate of iron and sulphate of magnesia'), systemically, has been an accepted treatment for many years, and in recent years, probiotics have become an accepted treatment which also is transmitted through the gut. Leonard Weinstock, MD, who volunteers on the RRDi MAC is involved with improving rosacea though the the gut and received a Galderma educational grant through the RRDi to increase the knowledge about this subject. 

Dr. Weinstock states on his web site, "There is a 45% chance that rosacea starts in your intestine, not in your skin or in your eyes. The results of a simple test will determine whether or not treating a bacterial imbalance in your intestine may improve your rosacea symptoms." Dr. Weinstock has written a paper which you can download here: Rosacea_and_SIBO_Weinstock.pdf

There are a number of bacteria associated with rosacea:

Helicobacter Pylori

Chlamydophila pneumoniae

Propionibacterium

Bacillus oleronius  [2]

Staphylococcus epidermidis [3]

Possibly Staphylococcus aureus [4]

Other Microorganisms have been associated with rosacea as well, such as demodex mites. [11] There are a number of other bacteria associated with Demodectic Rosacea (whether these bacteria associated with demodex end up in the gastrointestinal tract remains to be seen). We have no indication that the bacteria from the demodex can somehow survive the gastrointestinal tract but it may be possible? Nevertheless, there are oral systemic treatments such as oral ivermectin that is used to treat rosacea patients through the gut systemically (however, in this case the variant Demodectic Rosacea is preferred in distinguishing this variant of rosacea). 

Associated Gut Diseases with Rosacea
There are a number of associated gut diseases with rosacea, including Inflammatory bowel diseaseSIBO, and Ulcerative Colitis [7] .  

When systemic or topical treatment for rosacea using antimicrobial drugs [whether antibiotic, antifungal, antihelminthic or antiparasitic drugs] or any oral drugs that are released in the gut improves rosacea or the treatment method involves the gut this would indicate using the term Gastrointestinal Rosacea [GR] if the patient exhibits some gastric issues as well. The classic example is the eradication of gastric Helicobacter Pylori improves rosacea in many cases which is done through the gut using antibiotics. [8]

"In conclusion, our study demonstrates a modest association of rosacea with prevalent and incident IBD. Conversely, another study has shown that IBD is associated with an increase in rosacea. Putting together the evidence, rosacea and IBD are related to each other. When rosacea patients suffer from chronic abdominal pain, prolonged diarrhea, and bloody stool, the possibility of comorbid IBD should be considered." [10]

Probiotics
Also Probiotics have been shown to improve rosacea. Dr. Whitney Bowe, who serves on the RRDi MAC, has been an advocate of probiotics for rosacea and you can learn more here

Low Gastric Acid Level and Rosacea
When treatment for low gastric acid level improves rosacea this would be an indicator of using the variant Gastrointestinal Rosacea [GR] in classifying this type of rosacea. For more information on Low Gastric Acid and Rosacea

Conclusion
Therefore, if treatment of the gut for rosacea with antimicrobial drugs improves symptoms or using probiotics improves gastric and rosacea symptoms, along with any signs/symptoms of gastrointestinal complaints in patients, Gastrointestinal Rosacea [GR] seems an appropriate variant name to use and is valid as other variants used in the classification of rosacea into phenotypes and variants. The origin of this variant name was inspired by a discussion with Lady Cappuccino in post no 37 at RF in this thread. If you think of a better name for this variant post in this thread, please post your comment in this thread by finding the green reply button and click. 

One study concluded, "Rosacea is associated with certain gastrointestinal diseases, but the possible pathogenic link is unknown. Gastrointestinal complaints in patients with rosacea should warrant clinical suspicion of disease." [5]

"Rosacea is a disorder with various gastrointestinal symptoms closely related to gastritis, especially involving the antrum mucosa, with Hp expressing cagA in the majority of cases and elevated plasma levels of TNFalpha and IL-8; 2)." [6]

The AARS has a video on this subject. [9]

End Notes

[1] Br J Dermatol. 2016 Dec;175(6):1405. doi: 10.1111/bjd.15052. Epub 2016 Oct 17.
Association between rosacea and gastrointestinal disorders.
Alexoudi A1, Alexoudi I2, Gatzonis S1.

[2] Mite-related bacterial antigens stimulate inflammatory cells in rosacea.
Lacey N, Delaney S, Kavanagh K, Powell FC.
Br J Dermatol. 2007 Sep;157(3):474-81. Epub 2007 Jun 26

Positive correlation between serum immuno-reactivity to Demodex-associated Bacillus proteins and Erythematotelangiectic Rosacea.
O'Reilly N, Menezes N, Kavanagh K.
Br J Dermatol. 2012 Jun 18. doi: 10.1111/j.1365-2133.2012.11114.x.

Demodex-associated Bacillus proteins induce an aberrant wound healing response in a corneal epithelial cell line (hTCEpi).
O'Reilly N, Gallagher C, Katikireddy K, Clynes M, O'Sullivan F, Kavanagh K.
Invest Ophthalmol Vis Sci. 2012 Apr 24.

The potential role of Demodex folliculorum mites and bacteria in the induction of rosacea.
Stanislaw Jarmuda, Niamh O'Reilly, Ryszard Zaba, Oliwia Jakubowicz, Andrzej Szkaradkiewicz and Kevin Kavanagh.
Journal of Medical Microbiology, 2012 DOI: 10.1099/jmm.0.048090-0 Article at PubMed

Media reports have highlighted demodectic rosacea.

More info

[3] Staphylococcus epidermidis: A possible role in the pustules of rosacea.
J Am Acad Dermatol. 2010 Oct 11;
Authors: Whitfeld M, Gunasingam N, Leow LJ, Shirato K, Preda V
J Am Acad Dermatol. 2010 Oct 11.

[4] "No study in rosacea met our inclusion criteria....No studies could be included that assessed S. aureus colonization in patients with rosacea. Also in current review literature S. aureus is not implicated in the pathophysiology of rosacea ...As S. aureus is common at all depths of the skin...For patients with acne a relation between colonization and the disease was less evident and for rosacea no information about colonization could be obtained from the literature."

A systematic review and meta-analysis on Staphylococcus aureus carriage in psoriasis, acne and rosacea
J. E. E. Totté,corresponding author W. T. van der Feltz, L. G. M. Bode, A. van Belkum, E. J. van Zuuren, and S. G. M. A. Pasmans
Eur J Clin Microbiol Infect Dis. 2016; 35: 1069–1077.
Published online 2016 May 5. doi:  10.1007/s10096-016-2647-3

[5] Br J Dermatol. 2017 Jan;176(1):100-106. doi: 10.1111/bjd.14930. Epub 2016 Oct 31.
Rosacea and gastrointestinal disorders: a population-based cohort study.
Egeberg A1, Weinstock LB2, Thyssen EP2, Gislason GH3,4,5, Thyssen JP1.

[6] J Physiol Pharmacol. 1999 Dec;50(5):777-86.
Helicobacter pylori and its eradication in rosacea.
Szlachcic A1, Sliwowski Z, Karczewska E, Bielański W, Pytko-Polonczyk J, Konturek SJ.

[7] J Am Acad Dermatol. 2018 Apr;78(4):786-792.e8. doi: 10.1016/j.jaad.2017.09.016. Epub 2017 Oct 26.
Comorbidities in rosacea: A systematic review and update.
Haber R1, El Gemayel M2.

Systemic Cormorbidities in Rosacea

[8] Helicobacter Pylori And Rosacea

[9]

[10] Medicine: October 2019 - Volume 98 - Issue 41 - p e16448
Association of rosacea with inflammatory bowel disease
A MOOSE-compliant meta-analysis
Wang, Fang-Ying MD, Chi, Ching-Chi MMS, DPhil

[11] Microorganisms of the Human Microbiome

[12] Medical record, A Weekly Journal of Medicine and Surgery
Volume 50, No. 3, Whole No. 1341, New York, July 18, 1896, p 84, 85
Remarks of Some Skin Diseases Occurring in Connection with Gastro-Intestinal Disturbances
edited by George Frederick Shrady, Thomas Lathrop Stedman

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