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.
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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.”
21 comments ↓
Thanks for sharing this study. SIBO causes fermentation in the small intestine, which can be a trigger for some rosaceans. I am very sensitive to fermented foods, and fermented food is listed as a trigger by the NRS. Cipro is also used for SIBO, and I noticed that while on a course of it for a bladder infection, my rosacea improved for about a month. I later tried a course of Rifaximin (after reading this study) with the same results. Specifically, the treatments greatly diminished the redness I tend to experience in the mornings when I first wake up for an hour or so. The fact that Rifaximin does not cross the intestines into the body means it never even gets to the skin, so the benefit may likely be due to eliminating the trigger of SIBO. Cheers! -Artist
So are we only treating the symptoms not the cause?
Could this condition be like the canaries in the mines?
It would be cool to not suffer from it. Thanks for the comments on the journal article always important to ask.
All the best
Interested
Interesting because my doc has been investigating the cause of my GI problems for years.
I find that adding a little flax to my cereal in the morning helps!
I saw this abstract after researching treatments for my rosacea. Coincidently, a week later I came down with diverticulitis and was treated with 2 strong antibiotics, one was cipro the other was metro something, to clear the infection in my colon. So, I waited to see what effect the antibiotics would have on my skin and I can tell you it’s a miracle. I don’t even need cover up. FYI – I would describe my rosacea before the antibiotics as as moderate.
Would be great to hear from more people that have used antibiotics that don’t cross the lining of the stomach i.e. don’t get into tissue that can directly affect the skin.
this may be of interest. Another study supporting the involvement of bacterial overgrowth.
http://uegw08.uegf.org/scienpro/abstract_detail.php?navId=139&ss=1814
David Pascoe asked me to add a few extra words to explain why this article is interesting, I thought I’d give a quick summary and explanation of the two SIBO/intestinal bacteria studies so far produced:
– Study 1 –
The most common way to test for bacterial overgrowth in the small-intestines is for a patient to fast and then ingest a specific carbohydrate. When the carbohydrate reaches bacteria in the intestines they will ferment it and one of the by-products will likely be hydrogen gas which can be detected in the breath. If there is overgrowth in the small-intestine there will be a premature peak of hydrogen released before the material reaches the colon (where it will be fermented regardless). However, hydrogen is not the only gas that bacteria may produce during fermentation and thus this test may give an incomplete picture. This will be returned to in their latest study.
The first Italian study found that about half of rosacea patients were positive by using the hydrogen breath test, where as in healthy people they found the rate was about 5%. The probability of this result being a coincidence is less than 1 in 1000.
Half of the SIBO-positive rosacea patients were treated with rifaximin, which is an antibiotic that is essentially not absorbed from the digestive tract and therefore does not enter the body or bloodstream and cannot directly reach the skin. In fact, the only likely direct effect of rifaximin is on bacteria in the intestines.
In those treated patients, 20 of 28 became symptom-free and 6 more greatly improved. The other half of SIBO-positive rosacea patients were treated with placebo and showed no improvement. Again the probability of these treatment results being coincidence is less than 1 in 1000.
When the placebo treated patients were switched to rifaximin, 17 of 20 cleared completely. Overall, 78% of all rifaximin treated patients became symptom-free and 18% improved greatly. Again the probability of this improvement being coincidence is less than 1 in 1000.
Finally, successfully treated patients were observed for 9 months and 96% maintained symptom clearance/improvement without further intervention. Of the 2 patients who suffered relapse, SIBO proved positive again and another course of rifaximin cleared their rosacea symptoms once more.
However, as mentioned at the beginning, only half of rosacea patients were found to be hydrogen producers (i.e. SIBO-positive) and the results discussed so far only relate to investigating these patients. Rifaximin was also given to patients that had tested negatively in the hydrogen breath test and disappointingly there was little evidence of any symptom improvement.
– Study 2 –
In the new study, a second type of breath test was introduced that measures methane production. They took 15 rosacea patients who were hydrogen positive (as in the first study) and 15 who were methane positive. They gave rifaximin to each group and the hydrogen producers were on average cleared of rosacea symptoms (or at least greatly improved) whereas the methane producing patients showed little or no improvement in symptoms (and no change in methane production).
They then treated the methane producing patients with metronidazole (an antibiotic with a long history of usefulness in rosacea therapy and also very effective at targeting methane-producing bacteria in the intestines). Following treatment, the methane producing patients on average experienced complete symptom-clearance, or at least significant improvement and near-clearance of methane production.
What is interesting about this second study is that it sheds light on why rifaximin was not able to clear rosacea in all patients in the first study. It would seem that the species/class of intestinal bacteria responsible for triggering rosacea symptoms is not specific and different bacteria appear to be responsible in different patients and therefore, different antibiotics are capable of improving symptoms. It is also interesting, since this provides an explanation for why metronidazole has in the past, demonstrated itself as an unusual, but effective treatment for rosacea.
It is also interesting, as they point out, that at the very least, they have found a new way to very accurately predict the patient response to a given antibiotic therapy by their profile of hydrogen and methane breath test results. This is a new and intriguing discovery about rosacea, with important implications.
This study is also inspiring, since it keeps open the possibility that intestinal bacteria may play a fundamental role in causing rosacea symptoms in all patients.
Finally, it is interesting, given the apparent diversity of bacterial species involved, that it would seem less likely that rosacea symptoms can be mediated by a specific metabolic by-product from bacteria fermentation and some other mechanism may be at work (the mechanism I favour – activation of the plasma kallikrein-kinin system >> bradykinin >> neurogenic inflammation – is outlined in my earlier study from 2004).
Anyway, this summarizes what’s been demonstrated and I watch this area with hopeful interest. If anyone has any questioned let me know. I include the abstract to the second study below in case the web link is removed in the future.
—————
Tuesday Oct 21st, 2008
HYDROGEN INSTEAD OF METHANE EXCRETION DURING GLUCOSE BREATH TEST ALLOW US TO PREDICT THE CLINICAL RESPONSE TO ANTIBIOTIC THERAPY WITH RIFAXIMIN IN PATIENTS WITH ROSACEA.
A. Parodi*1, S. Paolino2, A. Parodi2, G. Pieri1, C. De Cassan1, V. Savarino1
1Gastroenterology Unit, Di.M.I., 2Dermatology Unit, Di.S.E.M., Genoa, Italy
Topics: 3.1 Enterocyte biology/pathology and nutrient/water transport/electrolyte transport
INTRODUCTION: Recently, a role of small intestinal bacterial overgrowth in rosacea has been demonstrated (1). The clinical effectiveness of antibiotics in clearing cutaneous lesions of rosacea may be related to their activity on intestinal bacteria.
AIMS & METHODS: We aimed to assess the clinical effectiveness of rifaximin in rosacea patients with different gas excretion patterns. We enrolled 15 rosacea patients with high H2 and 15 with high CH4 excretion during a 50 g glucose breath test. Both groups received rifaximin therapy (1200mg/die for 10 days). Patients performed a further GBT one month after the end of therapy. Two dermatologists evaluated rosacea patients before and after treatment on the basis of an objective scale (IGA score). Patients who did not respond to rifaximin received an antibiotic therapy with metronidazole (500mg bid for 10 days) and underwent a further GBT and a dermatological assessment one month after the and of therapy.
RESULTS: Median IGA score was 4 (range, 3-6) both in H2 and in CH4 group. After therapy with rifaximin, GBT normalized in 14/15 H2 producers and in 2/15 CH4 producers (p <.001). IGA score was 0 (range, 0-2) and 3 (range, 2-4) in H2 and in CH4 group, respectively (p<.001). After metronidazole therapy GBT resulted to be normal in all but one CH4 patients and IGA score became 0 (range 0-4).
CONCLUSION: Rosacea patients with a prevalent CH4 excretion did not respond to rifaximin therapy. Methanogenic bacteria can be controlled by metronidazole, which represents an additional drug to improve rosacea lesions and can explain the partial success of this antibiotic in improving them in the past.
REFERENCE(S): 1) Parodi A, Paolino S, Greco A, Drago F, Mansi C, Rebora A, Parodi AU, Savarino V. Small Intestinal Bacterial Overgrowth in Rosacea: Clinical Effectiveness of ItsEradication.Clin Gastroenterol Hepatol. 2008 May 2.
guys, what about the risks associated with xiafaxan and flagyl taken orally? From what I’ve read both of these antibiotics can cause collitis, something I definitely don’t want. However, the results in these studies makes it extremely tempting. Should I hold on, wait for some more research to be published corroborating these findings? Is the risk of collitis associated with these drugs substantial?
For those interesting in reading some more on a possibly related area, Seth in 2003 posted the text of a paper that he wrote .
A NOVEL METHOD FOR INDUCING REMISSION IN ROSACEA AND A NEW HYPOTHESIS TO ACCOUNT FOR ITS AETIOLOGY
davidp.
After having tried a course of Rifaximin and then an immediate course of Metronidazole following the failed Rifaximin treatment, I can safely say that this study is not as conclusive as it might sound. I experienced little to no clearance in the majority of my symptoms and I did follow the same dosages listed above (1200mg Rifaximin a day for 7 days and 500mg of Metro for 10 days).
May others willing to try this have better luck than I.
Thanks heaps for the feedback Nate, always great to hear from people who have had direct experience. It helps us all learn what the reality might be – especially useful when we start with just the theory and limited experiences.
davidp.
Hello, friends:
I am frustrated about this rosacea condition. I had it diagnosed this year on January and I have been through different medical treatments with no significant improvement. I am a 40 years old female. I have the papulopustular subtype of rosacea. I have had even deep scars because before I used the oral doxycicline, some abscesses came out producing very visible scars. I have been two times using doxycicline 200 mg twice a day for 1 month with significant improvement (no papules or pustules) but still redness. Two weeks after I finish the 1 month course of oral doxycicline, the papules and pustules come back. A physician told me that I should not use doxycycline for more than 1 month because it could cause liver problems on the long run.
Now I am using oral prednisone 2.5 mg twice a day, topical clindamycin 1 % gel twice a day, and evening primrose oil capsules 1300 mg taken orally twice a day, with some control but still not good enough. I still keep getting the so bothersome papules and pustules (not the abscesses) which leave small scars. And they appear in different places in the cheeks and chin. I have been like 7 months trying all kinds of antibiotics (Metronidazole gel , clindamycin gel) and prednisone with no satisfactory improvement. I do not hate the redness, but I hate the pustules and papules.
I want to know if somebody has had a naturopathic or medical treatment that has kept the papulopustular rosacea under control with no or minimal symptoms for short or long time. Or if somebody has discovered a miraculous home remedy to avoid the pustules or papules coming out again for a considerable time or to make them disappear quick. Please let me know by posting at this website and/or by emailing to my email address sheila092001@yahoo.com. I will be eternally grateful if you could help me with my rosacea problem, please.
Not sure you are reading the article correctly, Davo. There seem to be some non sequiturs in your reasoning.
The article does indeed state that in 96% of those rosaceans who were shown to have SIBO (using fermentation tests), eradication of the overgrowth resulted in clearance of their rosacea symptoms. Of those that subsequently relapsed at nine months (4%), all had recurrence of their SIBO. Eradication of that recurrence again led to remission of their rosacea.
As rifaximin has very low systemic absorption (almost all of it stays inside the GI tract and is not carried to the rest of the body), this clearance cannot be accounted for by the antiinflammatory properties of the antibiotic.
While not absolutely conclusion, this is actually fairly strong evidence that, in those rosaceans who had SIBO, the SIBO was causative.
As referenced above, further studies have additionally shown that not all rosaceans with SIBO have overgrowth of the same organisms. Distinction is made between hydrogen producing bacteria (treated with rifaximin) and methane producers (resistant to rifaximin but susceptible to metronidazole).
This is actually an exciting line of inquiring that has compelling initial empirical support and should be encouraged rather than disparaged by the rosacea community.
I have had rosacea about 6 months now. I am currently on Roaccutane (1month). My face is bright red , but the papules are slowly going. My face feels like it is on fire now and has been the last six months on and off. I hate this and cannot function anymore.
Can someone please tell me, if this study is having such great results, why is it not being used. My dermatologist, who cost me an absolute fortune, hasnt even mentioned it. Is this widely known and i have just happened to missed it all this time I have googled rosacea? Please help
Sitika,
This is cutting edge research not standard of care. Few dermatologists have incorporated therapies like this into their practices.
Also keep in mind that in the study remission was achieved only in those rosaceans who had positive breath tests indicating overgrowth. If you don’t have SIBO, this treatment will not be curative. But if you do, it is certainly worthwhile!
Another potentially curable cause of rosacea (in some patients) is overgrowth of the demodex mite. This can be established with a skin scraping or biopsy. If you are one of the lucky few whose rosacea is caused by this mite, treatment with Elimite, Eurax, or ivermectin can be curative.
Unfortunately, rosacea is a complex, multifactorial disease, and it seems that most cases of rosacea do not neatly fall into either of the above two categories. However, this not mean it cannot be controlled.
I think it is the experience of most of us with this disease that we need to be our own advocates. Take the time to educate yourself about rosacea, plug into a support group or online forum, and don’t be afraid to experiment a little to find out what works for you.
One more thing, Sitika: accutane has been known to worsen (sometimes permanently) flushing in rosaceans. For this reason, it is not typically a first line therapy (unless you have phymatous rosacea and rhinophyma). A more traditional approach would usually involve low dose oral antibiotics (doxycycline, tetracycline, or
minocycline) and a topical agent like azaleic acid, metronidazole, or sulfacetamide. This combination significantly improves both the papules and pustules and erythema in most rosaceans.
Good luck!
For those who’d like to follow some related discussions, see this thread at cpnhelp.org
A little experimentation – Lactobacillus Reuteri
and a thread at The Rosacea Forum
Who has had Vitamin D Levels Checked?
davidp.
This is very interesting and exiting!
It was about three years ago that I was diagnosed with rosacea as my symptoms were getting quite bad, at about the same time I started getting bad acid reflux issues and ended up with painful esophageal ulcers.
I have since been treated with doxycycline and rozex for the rosacea and nexium for the acid reflux. Both conditions are better but still definitely there. I have always suspected the two were linked but my doctor never said anything about it.
I wonder if this is related. Anyone else had issues with acid reflux?
Hi Stuart,
years ago, before my rosacea was diagnosed, I saw the doctor regarding what I was concerned was a heart complaint (it was an occassional mild, pain which came on quickly, but not quite quick enough to be considered ’stabbing’. It was located on my left side, a bit above the mid-point of my torso). As I was in my mid-20s at the time, she assured me that people my age don’t have heart problems (reassuring, and I admit hypochondria may be in my repertoire), and suggested that it was an over-production of acid in the stomach burning the stomach wall lining (from memory). “A stomach ulcer?”, I asked her which she replied that it wasn’t, but stomach ulcers are what occur when this isn’t treated. The medication she prescribed worked.
Then, when I was diagnosed with doxycycline, I noted overtime a correlation between it and a return of this pain. I’d presumed that the doxycycline had some effect on the acid in the stomach. I’m not sure if this is related to your reflux though. What do you think?
Dave
Very interesting, but where to get tested for methane ??
Hi David,
A pharmacist told me he thinks doxycycline causes acid reflux burning. When I asked my doctor he said the problem is only when you take it without much water. He said you would expect to see a large ulcer on the esophagus where the pill was stuck. I’m not sure.
Stuart
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