SIBO Eradication Clears Rosacea (Rifaximin/Xifaxan): are you serious ?

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.

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, especially 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 systemic effect on the skin. This leads to the question of what inflammation has it stopped or pathway has it blocked and what can we prove that this means ? How might that be related to digestion in general and rosacea specifically ?

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 –

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About the Author: David Pascoe started the Rosacea Support Group in October 1998. .

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113 Reader Comments

  1. Mike says:

    I live in the uk but got Rifaximin known as Spiraxin in Spain, sent to me by a friend as I was unable to obtain it in the UK. It was like a miracle!! After about 5 days my skin began to clear and after 10 days I had a perfect nose again!!! A week afterwards I have one bad patch, although not sore as it was before. I shall repeat the treatment as mine was particularly severe before the treatment. I have also noted a marked improvement in my stomach and have not experienced on bout of IBS! It has to be worth a try!!

  2. Hammer says:

    Rifaximin is not available in Canada.

    I contacted the manufacturer (Alfawaffermann) in Italy.
    They only sell it to distributors.

    The antibiotic is sold under different brands:

    USA, Germany, Poland –> Xifaxan
    Spain –> Spiraxin
    Tunisia, Venuzuela, Italy –> Normix
    Mexico, Colombia –> Flonorm

    I want to give it a try and see what it does for me, however living in Canada makes it more complicated. I could drive to the US, however it is not sold over the counter and therefore requires a prescription.

    I am tempted to order online, however I want to be absolutely certain that I am getting the real thing. No generic, nothing else.

    Many online pharmacies exist (many appear shady).

    Are any of you aware of a legitimate one I could order from?

    Alternatively, I would be willing to buy directly from you (and pay extra) in order to make certain I am receiving the legitimate product.


  3. Hammer says:

    I forgot another option…

    I would also be willing to travel to purchase the antibiotic personally should it be available over the counter…Mexico, Spain, Italy…

    If anyone knows if thats the case in either of those countries, I’m there!


  4. Darby says:

    I have suffered with acne/rosacea my entire life. I took accutane in my 30’s which cleared me for a while but then rosacea reared it’s ugly head. I am 57. Last December I printed an article about xifaxan and rosacea off and took it with me to my annual gynecologist appointment. He wrote me an RX but for the wrong dosage; 200mg 3xday. I had it filled ($300) my insurance would not cover it. I took the 10 day course and have been clear for 9 months. I am just starting to have a few issues again now. I took the same information to my dermatologist who had never heard of this before. After researching it, she wrote me an RX. (insurance still won’t cover it)We are going to do the lower dose since I responded so well to it before. She also advised me that the NIH is going to do a clinical trial of xifaxan and rosacea. Good news for all of us!! I did take probiotics on and off but was not sure if you should take them for a long period of time. I use Florastor. If anyone has more information on how long to take the probiotics, I would appreciate you sharing it.

  5. Hammer says:

    Hi Darby,

    Probiotics make my symptoms much worse.

    Anyone willing to send me Rifaxin (Im in Canada, none here), I am willing to pay for the antibiotic + your troubles.


  6. Pete H says:

    Hi all…

    I am 76. I have had nose area rosacea since age 41. Tetracycline, and then doxycycline in recent years, always beat it into remission with zero side affects. Lately I have used a topical foam product by Onset Therapeutics called Clarifoam EF. It is sodium sulfacetamide and sulfur based. It works very well.

    This site is really really great for rosacea sufferers. I am convinced that rosacea has many different possible causes and severeties that differ depending on each individual. Thus, the possible remedies differ depending on the individual. The great thing about this site is that it covers the whole waterfront somewhere. So trial and error will most likely narrow down the causes and remedies to one, or several, that work for you.

    The one common piece of advice I will volunteer to fellow sufferers is: Become a compulsive hand-washer, keep your fingers away from your nose, and do not touch your face after petting a dog, or, especially, a cat. The bacteria on a cat’s coat would colonize the solar system.

    With thanks and best wishes for this site.

    Pete H

  7. Deborah says:

    Pete H. well that is interesting what you say about animals. I started with symptoms after getting our two shepherds when i was 30 something. my face broke out into a hundred tiny white heads when i went to the beach one day. I no longer have the dogs, but have had a long hair cat for 16 years and bury my face in his coat often. I had a bad over growth of candida yeast when using tetracycline for two months years ago and have used nothing since. My skin is frequently red and breaks out. I touch my face a lot. I would love to try this antibiotic they speak of but do not have the money nor insurance. Thanks for the tip, guess I can try that.

  8. Heather says:

    I’m 34 and had had symptoms of Rosacea for about 5 years. I tried many approaches: antibiotics and mitrogel cream, Pluse dye laser, low glycemic index diet, herbal and vitamin supplements, etc. I should also mention that I had about an 8 year period of chronic UTIs in which I was on numerous antibiotics, prior to the manifestation of my Rosacea. I had never tried Rifaximin, but after reading the article decided to give it a shot.

    We ordered Rifaximin from India–I believe the death penalty is the puinishment for selling fake drugs in India.

    I followed the dosing in the protcol, athough I don’t remember how I spaced out the doses. (BTW-I did not get the SIBO breath test beforehand because I couldn’t find a MD who would order it for me.) I would say that my symptoms have not completely resolved, but they are at least 50% improved–I have not had a papule or pustule since taking the Rifaximin. Also, I have not been on any antibiotics since taking the Rifaximin.

    One more thing, I took “candigone” after I took the Rifaximin because I thought I might have a yeast infection in my pores.

  9. Oopsiedaisy says:

    I did the course of Rifamixin. Cannot recall the dose or length of time, but basically I printed out the study and my PCP prescribed me exactly what the people in the study were given. I followed it perfectly and saw NO improvement. Also, Rifamixin wasn’t covered by insurance, so I spent several hundred dollars out-of-pocket on this little experiment.

    It just goes to show you that not everyone’s Rosacea has the same cause(s)…

  10. Fern Roy says:

    Does most people get tested for SIBO before they start the treatment? MY GP Dr said they do not usually test because it is to expensive and not reliable. If the Dr thinks you have it they just put you on the meds instead. I have had intestinal problems for around 5 yrs since I had colon surgery. I now have Ocular Rosacea, dry eyes, inflamed eyes and eye lids, etc. Will be seen the GI Dr next week and will take the article w/me to see what he says. My system has not been able to tolorate Doxy, erythorcin since my problem leading up to surgery and the surgery. Not sure how hard xfaxan is on the stomach. I do not know how expensive it is here in the US, I do buy some things from Canada but it does not sound like it is any cheaper there. Fern

  11. Darby says:

    Fern, My husband has had a few colon surgeries. His GI doctor put him on a course of xifaxamin when he was having severe diahrea. I don’t recall how long he took it or the exact dosage because he started it when he was hospitalized but I think it was only 3-5 days. (this was over a year ago) At the time, he was also dealing with nausea issues. He had no adverse side effects from the xifaxamin. Our insurance did cover the RX since it was prescribed by a GI doctor for a GI issue. We did pay 3 tier level co pay. The insurance did not cover it for me as it was written by my gynecologist for my face. I called several pharmacies and the cheapest was Costco. The cost is around $600 if your insurance won’t cover it. It may help you with both your rosacea and your GI issues. My husband’s GI doctor had samples he was going to give us but my husband was discharged on the weekend when he was not on duty. Your doctor may have some samples. It wouldn’t hurt to ask!

  12. Fern Roy says:

    Hi Darby;

    You did not say if it helped with the GI problem or the face?? I will be seeing my GI Dr on Thursday with the lit in hand to show him. I have had the GI problems since my colon surgery about 4 or 5 yrs. I have Ocluar Rosacea, inflamed eyes and eye lids for around 5 mo. I am hoping to try xifaxamine to see if it will help both. Thanks, Fern

  13. Ken says:

    Just thought I’d provide the group with my own experience using Xifaxan/Rifaximin, which I turned to after trying virtually everything else available.

    I am a mid-50’s, fair-skinned US male who has had type-II rosacea since at least his 20’s.

    Through most of that time I have also suffered from acne vulgaris, which kept the rosacea from being diagnosed until telangiactases began to appear late in my 30s. I went through a course of accutane in my late 20s for my “regular acne,” which totally ceased being a problem for me only a couple of years ago. (I no longer get blackheads–just the papules and pustules of rosacea. I’d gladly trade one problem for the other, thank you very much.) I also have seborrhea, mainly in the eyebrows, which tends to be worst in the winter. Otherwise, my health is very good–I exercise regularly, eat well, etc.–although fairly minor, non-specific intestinal issues bother me on occasion (low-level nausea, looser than normal stools, etc.) I am probably a bit lactose intolerant, and stay away from milk products most of the time.

    As for other rosacea treatments, not one of the typically-prescribed topicals (like metronidazole, azelaic acid, etc.) or oral tetracyclines (like doxycycline) work, period. The only things that do work–but only while taking them–are macrolides like azithromycin, and, of all things antibiotic, amoxicillin. (For me, amoxy works like a charm.)

    OK. I took a hydrogen breath test, which I got after sending my GP the 2008 Italian study. It came back mildly positive for SIBO.

    My doctor then prescribed Xifaxan 1200 mg/day for 10 days, just as in the study.

    Immediately before starting the Xifaxan, I had finished a course of Amoxicillin, so I was clear to start. (After completing a course of Amoxy, the rosacea papules always reappear within a couple of days.)

    Well, while taking the Xifaxan, I remained totally clear, until the ninth day of treatment, when one solitary papule appeared near my upper lip.

    Unfortunately, that one uninvited guest was soon joined by scores of others for the usual party, all within three days of finishing the scrip. I am now nine days out from completing the treatment, and it is as if I never took it.

    I was hoping for at least a few months of respite, but it was simply not to be.

    My experience suggests the following, at least to me: given that the body plan of all life forms from planaria to humans is the same (a hollow tube), the skin and the gut are one and the same, just differently placed, and what affects one will likely also affect the other. This may help explain why Rifaximin works on rosacea, regardless of its not being adsorbed into the bloodstream. Rifaximin has anti-inflammatory characteristics, just like other antibiotics. No great surprise then, that it works at least to some extent on the symptoms of the condition.

    It’s back to square one for me. Given that the etiology of rosacea is doubtless multifactorial, don’t let my story keep you from trying Rifaximin as a long-term prophylactic, if not a cure. It might work for you. Just don’t be too disappointed if it doesn’t, or doesn’t work beyond the time you take it.

  14. Pete H says:

    Of all the causes and remedies I have read about on this excellent site I am really starting to focus on mites and the toxicity of their fecal deposits under my nose skin as the real engine of my rosacea. Why don’t the mites burrow into other places on my body that are warm and blood engorged? Maybe they live and colonize on my pillow where my nose rests all night long. Maybe there is a natural selection process whereby only mites of a certain physical character are attracted to burrow into my nose skin. I am starting to rub my nose with alcohol before I get into bed thinking that it might discourage them. What is the best topical mite killer? I want to try it.

    Pete H

  15. Ken says:

    You asked about the best topical mite killer. Definitely alcohol, but it’s really best if taken internally. I suggest MaCallan cask strength or Glenmorangie. 😉

    Seriously, I always thought demodex mites were merely a(nother) symptom, not a cause, and I’ve never tried treating for them.

    Causation seems unlikely to me, but stranger things are no doubt true.

  16. Ken says:

    David Pascoe, in his original blog post more than 3 1/2 years ago, asked what inflammation is blocked by Rifaximin.

    Looking at the studies, ingesting it apparently increases the levels of the anti-inflammatory cytokine known as interleukin-10. (Whatever the heck that is.)

    I have to find my lab coat, polish my glasses and paste on a pointy little beard in order to quote the following, so hold on a minute….

    Ahem: “Rifaximin increases the expression of PXR and PXR-regulated genes involved in the metabolism and excretion of xenobiotics and antagonizes the effects of TNFα in intestinal epithelial cells.”

    That’s from a December 2010 paper published in Biological Pharmacology, entitled “Pregnane-X-receptor mediates the anti-inflammatory activities of rifaximin on detoxification pathways in intestinal epithelial cells.”

    Obviously, the quoted bit means f-all to most, including yours truly.

    Nevertheless, the take-away is pretty clear: rifaximin interrupts the inflammatory processes that lead to typical rosacea symptoms. Hence its effectiveness, at least so long as you are taking it, and perhaps for awhile afterwards.

    What causes the inflammation in the first place, to ask the big-money question?

    Who knows. Probably numerous things, which are different for different people.

    Me, I don’t know what I might be doing (if anything) that is causation linked. I think I’ll start by eliminating all the surmised possibles from my diet (including the usual “triggers”) and if the symptoms subside, I’ll start adding things back in, one at a time. (And if it doesn’t subside, at least I’ll know that diet isn’t a likely contributor to the problem.)

    So goodbye, wine and spirits. Goodbye, all simple carbs, grains and gluten. Goodbye, hot peppers. Goodbye, hot soup. Been nice knowin’ ya.

  17. Deborah says:

    Hi Ken I think the inflamation is from candida yeast which is promoted by sugar intake and many other things. i believe the antibiotic works because it kills the yeast; there are other ways to do that as well such as changing your diet and using caprilic acid (derived from coconut) a website called explains it all. and yes all those things you mentioned except perhas the peppers and hot soup will have to go at least for a while. good luck, i am in the process of killing my yeast once again!

  18. Ken says:

    Sorry, Deborah, but antibiotics kill or prevent or slow the growth of bacteria, not yeasts. They are two different sorts of life entirely, as different, perhaps, as house cats and mushrooms.

    Candida (usually, C. albicans) is, as you know, a yeast. Yeasts are fungi, and to kill or control fungi you need an antifungal. Antibiotics do not kill yeast–in fact, they can at least indirectly promote their growth!

    In other words, killing all sorts of bacteria, both good and bad, with the use of a broad spectrum antibiotic often “makes room” for the growth of yeasts like C. albicans.

    That’s why it is always a good idea to take probiotics when you are taking an antibiotic (if not an antifungal), so that, to the extent you can, you do not enable the overgrowth of other organisms, like C. albicans.

    Anyway, yes, it’s a good idea to stay away from sugars and simple carbs that easily break down into sugars. There is way too much of both in the modern diet. I doubt, however, that there is that much of a connection with rosacea, at least in my case, as I limit my intake of sugar and processed foods, and have for years.

  19. juanita... says:

    Hello all,

    I have a sister who was recently diagnosed wit rosacea.. she is 17.. dermatologist prescribed metronidazole cream and some antibiotics… I’m really hoping it helps and I was reading and thought where can she get a hydrogen breath test.. and if she took rifaximin would it help?

  20. Becca says:

    I have to disagree with this post. The part where it says that it is “no surprise” that this antibiotic clears the skin because of its anti inflammatory properties. There’s just one problem with that: IT NEVER GOES SYSTEMIC. I am a registered nurse. This particular antibiotic never leaves the gastrointestinal tract, which means it never goes systemic, which means its anti inflammatory properties are not used body-wide. It is doing something in the gastrointestinal tract that is affecting the skin, as the two are closely linked. Psoriasis, eczema, etc. can all be linked to digestion as well. Before your start “shaking your head”, familiarize yourself with physiology and pharmacology.

  21. DBeales says:

    *Excellent* point, Becca!

  22. Eric Smith says:

    It is not that hard to piece together. The areas on the face usually affected by rosacea are where the small intestine and large intestine meridians are. If there is bacterial overgrowth in the small intestine, cecum, ileocecal valve and ascending colon (where it belongs, but….) you will see a rash in the malar and upper lip area. You just have to integrate western and eastern medicine. And yes, dermatomes and meridians are able to co-exist.

  23. Jeff D says:

    Rifaximin cannot be clearing rosacea by interrupting the inflammatory pathways as some antibiotics might be, because rifaximin is not absorbed from the digestive track.

  24. Donna Beales says:

    The more I read, David, the more I am convinced that “rosacea” is really a dustbin diagnosis that has little to do with the skin and everything to do with imbalanced gut flora, or dysbiosis. I don’t really know why this appears to be such a hard sell with physicians, except that a focus on microbial peptides, cytokines, and other measures of what may be going on in the body seem wrong-headed to me. If you ask most dermatologists what the etiology of rosacea is, most will admit “we don’t know.” They will point to elevated cytokines and cathlecidin if they’re keeping up with the literature, but many make no association between rosacea and H. pylori and SIBO; also, few are aware of evidence that some people carry a genetic defect that predisposes them to rampant fungal infection (chronic mucocutaneous candidiasis). What’s interesting and what may tie these things together (H. pylori, SIBO, candida) is that they are normally commensal microbes that the body has an exaggerated reaction to, which is consistent with Dr. William Parker, PhD’s “biome depletion theory.” I had the privilege of conversing with him at Duke University, and he gestured to my flushing face and opined, “You know, that’s your mastocytes activating…” Article #1 opines that rosacea is an autoimmune disease.

    1: Aubin F. [What’s new in dermatological research?]. Ann Dermatol Venereol. 2011
    Dec;138 Suppl 4:S233-40. doi: 10.1016/S0151-9638(11)70096-5. Review. French.
    PubMed PMID: 22202644.

    2: Murillo N, Raoult D. Skin microbiota: overview and role in the skin diseases
    acne vulgaris and rosacea. Future Microbiol. 2013 Feb;8(2):209-22. doi:
    10.2217/fmb.12.141. PubMed PMID: 23374126.

    3: Ee HL, Tan HH, Ng SK. Autosomal dominant familial chronic mucocutaneous
    candidiasis associated with acne rosacea. Ann Acad Med Singapore. 2005
    Oct;34(9):571-4. PubMed PMID: 16284681.

    4: Parker W, Perkins SE, Harker M, Muehlenbein MP. A prescription for clinical
    immunology: the pills are available and ready for testing. A review. Curr Med Res
    Opin. 2012 Jul;28(7):1193-202. doi: 10.1185/03007995.2012.695731. Epub 2012 Jun
    12. Review. PubMed PMID: 22612580.

    Donna Beales, MLIS

  25. Hammer says:

    I tried 10 days of Riflaximin.
    No change in symptoms 🙁

  26. Donna Beales says:

    Hammer, the duration of your treatment may not have been long enough; also, dosage may have been inadequate… Too, in essence they’re guessing with the choice of anitbiotic therapy. Have you had a breath test for SIBO? It’s treated with a multidrug regimen, if I understand correctly.

  27. Donna Beales says:

    But the more important point is, keep an eye on research around probiotics. Some are already known to attentuate the exaggerated microbial response in humans, like helminths, which Dr Parker opines are entirely necessary for human immune health. I was not a success with helminthic therapy related to rosacea, but some other factors are present, and I may try again as other have reported remission.

    I wrote a synopsis on Dr. Parker’s research, available on the Helminthic Therapy Form (which I Co-Moderate) at:

    The file is in a folder entitled The Science of Helminthic Therapy, however you have to register to read it.

    • Donna Beales says:

      I’m following up on my original comment to add that I was misdiagnosed with “rosacea.” My condition is instead a mast cell disorder.

  28. D Lee says:

    Do you think that ocular rosacea would also be helped by this treatment for SIBO?

  29. Trish in Austin says:

    One thing that long term SIBO tends to do is cause nutritional deficiencies as the bacteria consume your food for you. If you suffer from B12 deficiency and/or anemia this is a red flag. You may also not absorb niacinamide. There is a face lotion (not that expensive) called CeraVe (I get this at the grocery store). It contains niacinamide and it has helped my rosacea on my face and eyelids. They have an AM and PM version but I just use the PM both morning and night.

  30. Question received via email.

    “Hello, I have read you’re article about rifaximina and rosacea. I have rosacea with great papulous component. I noticed that rifaximina (Normix) 2 capsules a day (200+200 mg) cleared completely my rosacea in 5 days. There’s the possibility I suffer Sibo.

    Which is the more correct way to eliminate Sibo? And what if Sibo is caused by ombelical hernia? Thanks a lot.”

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