In 2008 Rosacea News highlighted a paper that suggested that treating patients with rosacea and SIBO with Rifaximin would improve both their SIBO and rosacea symptoms. That posting has attracted a lot of interest, heading towards 100 comments. Two threads in the online support forums are also growing.

In 2010 an article in the St. Louis-Dispatch also highlighted the work or Dr. Weinstock, a Gastroenterologist, in explaining the success in treating some rosacea patients with Xifaxan (brand name for rifaximin 200mg).

Large Clinical Trial

The recent article, extracted below, mentions that a further large randomized clinical trial is underway. That trial (which looks to be NCT01359228) will study 100 patients in two groups – the active group to receive a dosage of Xifaxan 550mg, 3 times a day for 14 days – and the inactive arm to receive placebo (and then cross over).

This is great news! Rifaximin will get a thorough testing as a general treatment for rosacea symptoms.

Latest Publicity

Treating Intestinal Bacteria May Improve Rosacea

11/28/11

By: HEIDI SPLETE, Internal Medicine News Digital Network

FROM THE ANNUAL MEETING OF THE AMERICAN COLLEGE OF GASTROENTEROLOGY

NATIONAL HARBOR, MD. – Treating patients with both rosacea and small intestinal bacterial overgrowth with the drug rifaximin was associated with improved rosacea symptoms in some patients, in a small, preliminary study. The findings were presented at the annual meeting of the American College of Gastroenterology.

..

A total of 32 rosacea patients were positive for SIBO, and 28 of these (including all ocular rosacea patients) received 1200 mg/day of rifaximin (two 200-mg tablets 3 times daily) for 10 days. Of the treated patients, 46% showed clearance of, or marked improvement in, rosacea symptoms, while another 25% showed moderate improvement.

"All four patients with ocular rosacea and SIBO reported marked improvement in conjunctivitis, sclera erythema, and dry eyes following treatment with rifaximin," Dr. Weinstock noted.

VITALS

Major Finding: Of 28 adults with both rosacea and small intestinal bacterial overgrowth (SIBO), 46% of those treated with rifaximin for 10 days showed improvement in rosacea symptoms.

Data Source: A prospective study of 32 adults with rosacea and SIBO.

Disclosures: The study was supported by a grant from Salix Pharmaceuticals, maker of rifaximin.

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1. Internet Searching leads to greater anxiety for melanoma sufferers

Of course everyone is now using the internet to read up on everything health related. You may be headed for some unnecessary anxiety though, so be careful.

Internet Use and Anxiety in People with Melanoma and Nonmelanoma Skin Cancer

Dermatologic Surgery, Volume 37, Issue 9, pages 1252–1259, September 2011

… One-third of participants with melanoma, but many fewer participants with NMSC, reported higher anxiety after Internet use …

Internet use is prevalent and increasing sharply in individuals with skin cancer. The majority of individuals describe their use of the Internet as a positive experience. Greater anxiety from searching the Internet is more common in individuals with melanoma than in those with NMSC.

2. Channel 4 Food Hospital wants Acne Sufferers

The producers of this new show say that the idea is “to explore the possible health benefits of everyday foods in targeting a wide range of medical conditions and symptoms.” For those following the influence of diet on health it will be interesting to see how the mainstream media tackles the idea of treating disorders with food.

The assistant producer wants to “speak to people who might be interested in knowing more about ‘The Food Hospital’. This could be people who are living with a condition which affects their life, or people who have recently started to experience symptoms they wish to address. One condition we are interested in looking at is acne.  We would love to feature someone who suffers from acne in the series and go into the scientific underlying causes of the disorder and potential ways of treating it using food.”  Contact me for more information.

Also see Medicinal diet under microscope in The Food Hospital for more info.

Over at the Acne Blog, Daniel Kern has posted a few high level posts relating to recent readings he has undertaken on the topic of diet and acne. Daniel has read the latest published research to see what new trends are emerging.

It is encouraging to see that research is continuing in this area. Long gone are the days when my dermatologist told me that diet had absolutely nothing to do with skin and suggested I could eat whatever I wanted in whatever quantities I wanted and I would suffer no change in my skin.

Diet and Acne: Wrapping it up

The last few days I have spent going through all clinical studies/trials regarding acne and Omega-3 fats, iodine, antioxidants, chocolate, calorie intake, fatty/oily food, digestion, and zinc.

Adding to this what I have learned regarding dairy and glycemic load, I’m sorry to say that nothing stands out for me as a smoking gun when it comes to diet and acne.

We simply don’t have enough research yet, and nothing feels super compelling to me at this point. However, at least researchers are looking into how diet may affect acne, so hopefully by the next time I review the literature, the evidence available to the scientific community will start taking shape. In the meantime, based on digesting everything the research community has to offer regarding diet and acne, here is what I am personally going to do as far as diet goes:

Dan goes on to offer some advice about what he will personally be doing as far as his diet is concerned; keep taking fish oil, keep eating wild seafood, a zinc supplement of 30mg a day, be eat generally healthily and not worry too much about iodine or chocolate for fatty foods.

Latest Greatest Research: Glycemic Load and Acne

If you eat a high glycemic diet with foods like white bread, sugary soda, white potatoes, and white rice, you will experience insulin spikes. This we know. What we don’t know (sorry Josh) is whether this sort of diet will directly affect acne.

Scientists hypothesize that a high glycemic diet and its resulting insulin reaction will result in higher levels of hormones (IGF-1 and androgens) which may contribute to clogged pores and increased skin oil production.

When it comes to high glycemic diets in particular, scientists also postulate that eating this way may lower the amount of beneficial proteins (IGFBP-3) and natural retinoids, which help keep skin cell growth in check and pores from becoming clogged.

However, as is becoming customary in my research on diet and acne, we do not have enough research to make any strong correlations.

Sadly, as is the case with much research, good thorough studies that will satisfactorily prove or disprove a link are hard to come by. The holy grail here will be to prove that permanently reducing your glycemic load lead to a permanent reduction in acne symptoms. Now that is something I would like to see.

Of course there are many many health benefits from eating a low glycemic diet, so you really can’t lose by trying this out yourself.

Latest Greatest Research: Dairy and Acne

Hormones: Milk contains hormones such as IGF-1 (insulin-like growth factor) and androgen (male hormone) precursors.

Iodine: Milk often contains iodine, largely due to farmers dipping the teats of cows in an iodine solution before milking in order to sterilize. At large doses, iodine can cause what are called acneiform eruptions. Acneiform eruptions look similar to run-of-the-mill acne vulgaris but are different in important ways.

….

What stands out strongly now that I have read all of the evidence is that the design limitations in dairy and acne studies thus far leave us without any concrete answers. After performing a thorough review of existing evidence, authors in the Journal of Clinics in Dermatology agree: “Our conclusion, on the basis of the existing evidence, is that the association between dietary dairy intake and the pathogenesis of acne is slim.”

Although the inflammation associated with acne and that linked to rosacea may not be directly related, I think all this sort of research is important for rosacea sufferers as more is discovered about how what we eat controls so many functions in our body.

Are You Convinced?

Surely there is no argument that a low glycemic diet is good for everyone, good for general health and a good step for your skin. Beyond that, do you believe that there is a causative link between diet and rosacea

How strong would research need to be for you to totally change your diet, if it could be proven that your rosacea is related to what you eat ?

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Diet and acne, Bowe WP, Joshi SS, Shalita AR. J Am Acad Dermatol. 2010 Jul;63(1):124-41.

Historically, the relationship between diet and acne has been highly controversial. Before the 1960s, certain foods were thought to exacerbate acne. However, subsequent studies dispelled these alleged associations as myth for almost half a century. Several studies during the last decade have prompted dermatologists to revisit the potential link between diet and acne. This article critically reviews the literature and discusses how dermatologists might address diet when counseling patients with acne. Dermatologists can no longer dismiss the association between diet and acne. Compelling evidence exists that high glycemic load diets may exacerbate acne. Dairy ingestion appears to be weakly associated with acne, and the roles of omega-3 fatty acids, antioxidants, zinc, vitamin A, and dietary fiber remain to be elucidated. This study was limited by the lack of randomized controlled trials in the literature. We hope that this review will encourage others to explore the effects of diet on acne.

Dr Brian De’Ambrosis, a Brisbane dermatologist and member of All About Acne (a Galderma site) said diets with a high glycaemic load – the typical western diet of processed and refined foods – may exacerbate acne through an effect on sex hormones, metabolic hormones or both.   

“Many health professionals treating acne already recommend a low glycaemic load diet that is rich in fresh fruit and vegetables, lean meats and seafood,” he added.  “This is particularly useful for some groups of people, such as women with polycystic ovarian syndrome (PCOS), but medical treatment remains a core component of effective acne treatment.”

When I was a teenager and suffering from teenage acne there was a body of thought that diet played no part in acne. The popular line of thought was that you could eat as many Mars Bars and drink as much Coke as you wanted and your skin wouldn’t show it.

That thinking has changed and as rosacea sufferers we may do well to take notice of what it means for us.

What is Glycemic Load?

We all know that the Glycemic Index is a measure of the effects of carbohydrates on blood sugar levels. The research that developed this index was developed in the 1980s to find which foods were best for sufferers of diabetes.

High GI foods release glucose into the blood stream quickly, and low GI foods result in the glucose being available more slowly.

The Glycemic Load  combines the GI with the carbohydrate portion size to give a measure of the relative amount of glucose released after you ingest a particular food.

So the takeaway from the GL vs. GI comparison is that it is the total and rate of glucose release that is important in this acne research.

Good News

I read this as good news for those who want to continue to eat carbohydrates but also want to investigate whether diet related hormone changes can improve their acne or rosacea.

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Some research also points to rosacea being related to oxidative stress, so rosacea sufferers everywhere are likely to benefit from good nutrition.

SPF on Your Plate: Researcher Connects the Mediterranean Diet With Skin Cancer Prevention

ScienceDaily (Aug. 16, 2010) — We all want that summer glow that comes from a day at the beach, but taking in the rays can have long-term implications for our health. Now Dr. Niva Shapira of Tel Aviv University’s School of Health Professions suggests a way to make fun in the sun safer — and it’s all in our food.

In a study recently published in Nutrition Reviews, Dr. Shapira has shown that a diet rich in antioxidants and omega-3 fatty acids, like the diet eaten in Mediterranean regions where melanoma rates are extremely low, can help protect us from skin cancer.

The sun’s rays damage both the skin and the immune system by penetrating the skin and causing photo-oxidation, she explains, affecting both the cells themselves and the body’s ability to repair any damage. Her prescription is to “go Greek” with foods such as olive oil, fish, yogurt and colorful fruits and vegetables to fight the oxidizing effect of the sun, as well as regular applications of sunscreen and appropriate body coverings such as hats, beach coverups, and other sportswear.

I’m heartened to see this paragraph as well as I think we can easily get sucked in to the `supplements are as good a real food’ idea all too easily.

It might be tempting to load up on dietary supplements instead of changing the diet, but according to Dr. Shapira, supplements are simply not as effective. Foods provide nutrient “synergy,” she says. “In foods, many vitamins and various antioxidants and bioactive ingredients work to support one another and the body’s natural protective mechanisms. Synergies between the nutrients in your food, which make a significant contribution to health, may contrast with the relative isolation of a vitamin supplement.”

A further extract from the referenced Abstract;

Nutritional approach to sun protection: a suggested complement to external strategies

Penetrating photo-oxidative ultraviolet A radiation reduces skin and blood antioxidants and damages cell components, including DNA. Dietary antioxidant vitamins, minerals, and phytochemicals in addition to n-3 polyunsaturated fatty acids, n-9 monounsaturated fatty acids, and low pro-inflammatory n-6 polyunsaturated fatty acids, have demonstrated protective properties. The presence of these elements in the traditional Greek-style Mediterranean diet may have contributed to the low rates of melanoma in the Mediterranean region despite high levels of solar radiation.

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What are the best known naturopathic treatments for rosacea, and how well have they been shown to work ? Naturopathy is a medical philosophy that tries to improve our health by helping the body’s own ability to recover from illness and injury.

Those who practice naturopathic medicine promote a holistic approach to health and would steer away from synthetic treatments such as antibiotics and metronidazole for example.

If you ever wanted to get to the bottom of the mumbo jumbo that sometimes surrounds naturopathic treatments, then read on.

Herbs

There are now several products on the market to treat rosacea that promote their genesis in natural products. Additionally it may be possible to use some herbs in their natural form. Some of the commercially available products include the Aveeno Ultra Calming range that contains feverfew, and the Eucerin Redness Relief range that contains Licochalcone A, an extract of licorice. One other `naturally based’ topical worth considering is Rosacure which contains MSM and silymarin (Lady Thistle Extract). Although not a herb, colloidal oatmeal containing products from Aveeno are also based on a natural ingredients and my be useful in treating the itch of rosacea.

One herb that stands out (in theory at least) for me is arnica montana. This herb does have a long history of being used to treat swelling and bruising. If this can be extended to include the inflammation of rosacea then arnica might be worth exploring further. One other interesting approach is the Califlora and aloe vera based anti flushing protocol to control angiogenesis between IPL treatments.

It seems to me that products that are sourced from natural ingredients, that also have been tested and developed into commercial products, and are easily available; hold a lot of promise for rosacea sufferers.

Acupuncture

Although acupuncture has been a subject of active research since the late 20th century, accupuncture’s effects are not well understood. It is considered safe when administered by well trained practitioners using sterile needles, but probably like most of these sorts of therapies, needs more research.

See the following acupuncture thread over at the Rosacea Support Community for thoughts from other rosacea sufferers. It seems that acupuncture may be good for overall health, help you relax and might just help you cope with rosacea. Another thread at The Rosacea Forum from a member’s acupuncture trial is also worth reading, although there doesn’t seem to be a conclusion just yet.

Aromatherapy

Aromatherapy uses what are called essential oils and other aromatic compounds to affect one’s mood or health. Note that the `essential’ in essential oils only refers to the oils being concentrated from the plant they were extracted from. Thus the usage of `essential’ here should not be confused with uses of the term such as essential fatty acids for example.

According to wikipedia, the scientific evidence for aromatherapy is weak and could only be considered as mildly encouraging for a limited set of possible uses. Proponents of aromatherapy suggest that there are 2 main ways that the therapy works; firstly by the influence of the aroma on the brain, and secondly by the pharmacological effects of the essential oils.

Unlike acupuncture, aromatherapy is considered a largely Western treatment regime. The delivery of aromatherapy can be via aerial diffusion, inhalation or directly on the body. Many of the potentially interesting essential oils, like lavender oil, eucalyptus oil for eg. may also be useful as a topical treatment in their own right.

As aromatherapy preparations are often concentrated, dilution with a suitable solvent would be advised.

Homeopathy

Does homeopathy rise about the mumbo jumbo sounding statement of `treating like with like’ ?  Can it offer something useful for rosacea sufferers ? While the formal description of homeopathy; “an ill person can be treated using a substance that can produce, in a healthy person, symptoms similar to those of the illness” doesn’t sound too bad, sadly the research has never been able to escape the placebo effect. When you consider that many homeopathic remedies are diluted such that the active ingredient is undetectable in the diluent, it isn’t surprising that any benefits are hard to prove.

What about the Placebo Effect ?

For those not familiar with the placebo effect, it might be worth exploring that further here. When a new medication is trialled, researchers need to prove the efficacy of the medication when compared to placebo. The mind is a powerful influence in any treatment, especially when the patient has an expectation of improving. When trialists expect that they are receiving the active ingredient, but are only receiving the inactive placebo, and do perceive a benefit – this benefit is known as the placebo effect. Thus a blind study is more convincing; where trialists do not know if they are receiving an active ingredient, and the response can be measured objectively.

There are several theories about why the placebo effect exists. A disease may have its own natural cycle, or some people may be predisposed to the power of suggestion.

Despite being hard to prove, homeopathy is one of the most wide spread non conventional treatment approaches alongside Chinese medicine, herbal medicine and osteopathy.

There is a lot of discussion about the merits of homeopathy as treatment regime. One robust criticism of the whole approach that is worth a read Quackwatch: Homeopathy The Ultimate Fake. The author, Stephen Barrett, M.D. asserts that the FDA has not held homeopathic products to the same standards as other drugs and that at best the remedies are just placebos.

Nutrition

We all of course know that what we eat influences our health. Just how much does diet affect our rosacea though ?

Some foods are known to be common rosacea triggers. It can be quite complicated to understand one’s own allergies and food intolerances, especially if there are rosacea flareups related to intake of unknown foods. One good source for further reading is the resource page Dietary Influence.

Beyond some directly traceable intolerance to a particular food, what about a particular style of diet ? Rosacea Diets have been around for several years. Can avoiding processed foods or eating an alkaline diet help your rosacea ? Anecdotal reports suggest that this may be the case.

One paper that looks to be heading an an interesting direction is summarised here; could rosacea be caused by diet ?

Pursuing a whole foods, plant-based diet is also something worth considering when thinking about your general health and longevity. My belief is that we would all benefit from seeking the advice of a dietician for our rosacea and indeed for our general health and wellbeing. With so many chronic diseases having links to diet, it makes good sense to explore good nutrition with a dietician.

Physical Therapies

This sort of therapy includes hydrotherapy, physiotherapy, sports medicine and soft tissue manipulative therapy. While it might be hard to imagine how physical therapies can help rosacea, they may well improve your quality of life. We also know that moderate exercise may help your rosacea.

Psychological Counselling

There has been little direct research between the effects of stress and rosacea. It appears that emotional flushing in rosacea sufferers may be maintained by a combination of both cognitive and physiological factors. What comes first though ? does stress  make rosacea worse, or does rosacea induce its own stress, and feed off itself.

While we wait for more research, those who do suffer from anxiety or depression will likely benefit from meditation, relaxation, and stress management.

Another result from some recent research linking rosacea and flushing found that `The stress and fear of blushing can be mitigated by psychological intervention such as Cognitive Behavioural Therapy and Task Concentration Training.’ These are 2 more options that may be worth exploring to help rosacea sufferers copy with flushing and anxiety.

Over to you.

OK, so I have tried my best to outline the depth of naturopathic treatments and frame them with some relevance to treating rosacea. What successes can you report ? Do these sorts of treatments hold much promise for rosacea sufferers ?

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This sort of abstract just make me shake my head. If you read quickly you will think that this abstract suggests that Small Intestinal Bacterial Overgrowth (SIBO) causes rosacea. What this abstract is saying that is that rosacea sufferers seem to have a higher incidence of SIBO than non rosacea sufferers. The secondary result is that eliminating SIBO clears rosacea. Well that is no surprise ! Antibiotics interrupt the inflammatory pathway that causes the papules and pustules of rosacea. We all know that. This just published abstract doesn’t tell us anything new, although at first glance it might look like it.

What would be interesting to explore further would be what causes the SIBO. Could that cause point back to something triggering papules and pustules ?

If you view the AbstractPlus you will see that SIBO has been linked by the same team to Scleroderma, abnormalities in acromegaly, and IBS.

Small Intestinal Bacterial Overgrowth in Rosacea: Clinical Effectiveness of Its Eradication, Clin Gastroenterol Hepatol. 2008 May 2, Parodi A, Paolino S, Greco A, Drago F, Mansi C, Rebora A, Parodi AU, Savarino V.

Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa, Italy.

….

CONCLUSIONS: This study demonstrated that rosacea patients have a significantly higher SIBO prevalence than controls. Moreover, eradication of SIBO induced an almost complete regression of their cutaneous lesions and maintained this excellent result for at least 9 months.

Extended Conclusion:

(continues) In fact in 78% of our patients, skin lesions fully cleared an in 17.7% improved greatly 1 month after interrupting rifaximin therapy. Moreover, all rosacea patients who remained unchanged with placebo treatment and were switched to the antibiotic arm showed the same dramatic improvement of their lesions. Last, rosacea was kept in remission in 96% patients followed for at least 9 months, and this remarkable finding contrasts with the frequent relapse observed with th traditional therapies.

..

How SIBO might lead to skin lesions is unclear. However, other associations between SIBO and extraintestinal diseases, such as fibromyalgia and NASH, have an unclear pathogenesis.

…

The clearance of cutaneous lesions in almost all rosacea patients after its eradication strongly suggests that SIBO plays a significant pathogenetic role in rosacea, expecially in its papulopustular component. Although the underlying mechanisms linking SIBO to the cutaneous lesions of rosacea need to be elucidated, we believe that our findings represent paramount progress in the clinical management of those frustrated patients.

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[Update]: there is a thread over a the forum SIBO diet/treatment, where Artist mentions that Rifaximin doesn’t leave the gut so doesn’t directly have any effect on the skin. This leads to the question of what inflammation has it blocked and what can we prove that this means ?

On a related note Seth Kendall speculates in his paper Remission of rosacea induced by reduction of gut transit time, that

“It is possible that intestinal bacteria are capable of plasma kallikrein–kinin activation and that flushing symptoms and the development of other characteristic features of rosacea result from frequent episodes of neurogenic inflammation caused by bradykinin-induced hypersensitization of facial afferent neurones.”

[Update 2]: I have a scanned copy of the Clin Gastroenterol Hepatol paper. If you would like to read it, please email me – david@rosacea-support.org

A randomized, double-blind study of a nutritional intervention in the treatment of psoriasis, Mandeep Kaur, MBBS, Steven Feldman, MD, PhD, Ann McCarty, MS, PA, Wake Forest University School of Medicine, Winston-Salem, NC, United States

Background: The cellular immune system plays a dominant role in the exacerbation of psoriasis. The digestive system (by virtue of the profile, number, and species of bacteria present at any given time) influences the status of the immune system. Bacterial pathogens influence specific cytokine activity due to the activity of super antigens. Modulation of bacterial gut flora offers a potential target for psoriasis treatment.

Methods: Approximately 40 adult male and female subjects with mild to moderate plaque-type psoriasis will be enrolled. Subjects will be randomized to take a lactobacillus nutritional supplement versus placebo once daily for 8 weeks.

Results: The primary outcome of this study is the change from baseline to week 8 (or end of treatment) in the composite score of the signs of psoriasis (erythema, scaling, plaque thickness) for target lesions. Other outcomes include Investigator’s and Subject’s Global Assessment of Response and change in pruritus score.

Conclusion: This study will be a first step to understanding the use of nutritional intervention in treatment of mild to moderate psoriasis.

Author disclosure: The Department of Dermatology has received support from Ganeden Biotech. Sponsored by the National Psoriasis Foundation.

Poster Discussion Session P2805, American Academy of Dermatology, 64th Annual Meeting, March 3-7 2006, San Francisco.

Supplement to Journal of The American Academy of Dermatology, March 2006, Volume 54, Number 3.

• JAAD Poster Abstracts Online

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Implications for the Role of Diet in Acne, Seminars in Cutaneous Medicine and Surgery Volume 24, Issue 2, June 2005, Pages 84-91, Advances in Acne Research, Cordain L.

Within the dermatology community, a general consensus has emerged that diet is unrelated to the etiology of acne. Except for 2 poorly designed studies, now more than 30 years old, there are few objective data to support this notion. In contrast, a large body of evidence now exists showing how diet may directly or indirectly influence the following 5 proximate causes of acne:

1. increased proliferation of basal keratinocytes within the pilosebaceous duct
2. incomplete separation of ductal corneocytes from one another via impairment of apoptosis and subsequent obstruction of the pilosebaceous duct
3. androgen-mediated increases in sebum production
4. colonization of the comedo by Propionibacterium acnes
5. inflammation both within and adjacent to the comedo

This article will provide a review of the currently available literature on the association between diet and acne vulgaris as well as a discussion of the physiologic principles that may underlie this association.

Conclusion and Recommendations

The last diet-acne trial was published in 1971. In the ensuing 34 years, great strides have been made in understanding how diet influences long-term health and well being. Unfortunately, appreciation of this information has generally gone unnoticed in the dermatology community, as witnessed by the 34-year vacuum since the last dietary intervention in acne patients. A substantial body of literature now exists that directly implicates diet as the most likely environmental factor underlying the development of acne. Confirmation of the diet-acne hypothesis will require numerous well controlled dietary interventions examining multiple nutritional factors. As a starting point, future experiments testing the diet– acne hypothesis should employ diets that mimic the nutritional characteristics of diets found in nonwesternized populations known to be free of acne. Although there is no single nonwesternized diet, there are certain universal characteristics that have a theoretical basis for testing. These diets are free of processed foods, cereal grains, dairy products, refined sugars, and refined oils and almost entirely comprise unprocessed fresh, fruits, vegetables, and lean meats, fish, and seafood.

• PubMed Extract
• DOI Link
• Full Article Online

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