The Rosacea – SIBO Connection
The Rosacea – SIBO Connection
The Connection Between Rosacea and SIBO
Rosacea is a common chronic inflammatory disease that mainly affects the central face; typically involving the cheeks, nose, middle part of the forehead and the chin.  It presents as flushing, persistent erythema, papules and pustules, telangiectasia with or without burning or stinging sensation, dry and rough appearance, facial plaques or edema, phymatous changes, and ocular involvement.  It is usually symmetric, affecting both sides equally. It is a relapsing condition, which means the symptoms can flare up, with partial or complete improvement in-between.
There are four types of rosacea:
– Erythematotelangiectatic rosacea: described as vascular rosacea. It is predominated by skin redness with blood vessels that are visible directly underneath the skin.
– Papulopustular rosacea: also called inflammatory rosacea, is characterised by clustered papules or pustules.
– Phymatous rosacea: Phymatous rosacea is typified by hardened bumps and thickened skin. Rhinophyma, which is a condition in which there are hardened nodules on the nose, is a common aspect of this type of rosacea.
– Ocular rosacea: it’s symptoms predominately affecting the eyes and eyelids. This type may also affect the skin.
It affects women more than men, and is more common in the Caucasian population. In Australia, most cases of rosacea are first diagnosed in people aged 30 – 50.
SIBO occurs when there is an increase in the number of bacteria, and/or changes in the types of bacteria present in the small intestine.
Generally, in patients, SIBO is not caused by a single type of bacteria, but by an overgrowth of various types of bacteria in the small intestine that normally inhabit the colon. In less common cases, SIBO is caused by an increase in the normal bacteria in the small intestine. 
The excess bacteria feed off of the undigested food in the small intestine, particularly sugar, simple and complex carbohydrates, starches and alcohol. As the bacteria feeds, it causes the carbohydrates to ferment, which produces hydrogen. Hydrogen can feed single-celled organisms in your small intestine called archaea, which then produce methane. 
The Rosacea – SIBO Connection
The microbiome plays a significant role in human health, homeostasis, immune system, and disease pathogenesis. Disrupted communication between the microbiome and host has been extensively studied in gastrointestinal diseases. 
The gut and skin enjoy a constant two-way dialogue via what has become known as the gut-skin axis. There is emerging research on the skin microbiome and its connection with the gut and its effects on dermatologic conditions such as rosacea. Studies have shown a link between rosacea and a higher incidence of gastrointestinal disease. Essentially, this link means you can treat your gut to treat your skin.
“The microbiome has connections with many different kinds of skin conditions—and rosacea is one of them,” says Dr. Marvin Singh  , integrative gastroenterologist and founder of Precisione Clinic  . “We know that certain foods may act as triggers for exacerbations. We also know that data shows a higher prevalence of rosacea in those with small intestinal bacterial overgrowth (SIBO), and that treatment of SIBO could possibly result in an improvement in rosacea. This further supports that optimising gut health (and microbiome health) can contribute to improvements in rosacea.” 
He goes on to say that one of the biggest triggers is a poor diet and that optimising the diet with a focus on fibre-rich prebiotic foods and probiotic foods is a big focus. Avoiding sugars, refined flours, sodas, vegetable oils, packaged and processed foods and meats, hydrogenated fats, and other pro-inflammatory foods, also helps with rosacea symptoms and severity.
Evidence supporting the Rosacea – SIBO connection
Epidemiologic studies suggest that patients with rosacea have a higher prevalence of gastrointestinal disease, and one study reported improvement in rosacea following successful treatment of small intestinal bacterial overgrowth. 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 fibre-rich (prebiotic) diet.
A research study published in 2008, also found that there is a connection between SIBO and rosacea.  Subjects were tested for their intestinal bacterial growth via a breath test, and those diagnosed with SIBO were provided antibiotics. In about 70 percent of the study subjects, individuals having rosacea and SIBO were cleared of both ailments after following a course of antibiotics. This finding supported the hypothesis that an overgrowth of gut flora can, in many cases, lead toward development of rosacea as well. 
Rosacea patients have a higher prevalence of SIBO than the general population, and when the bacterial overgrowth is eradicated with antibiotics, the resolution of skin lesions is almost 100% and persists for 9 months or more in about 8 out of every 10 patients. 
A cross-over study showed the same effect when unresponsive patients on placebo were switched to the antibiotic arm of the study. The only patients in whom the rosacea relapsed were found to have persistent SIBO, and appropriate treatment of this led to healing of rosacea lesions in them as well. 
At our clinic of Advanced Functional Medicine we commonly treat both hydrogen and methane dominant SIBO naturally with targeted herbal formulations with great success, without potential unwanted side effects from antibiotics.
Anecdotally, patients have frequently cited dietary triggers. In one survey conducted by the National Rosacea Society of over 400 patients, 78% had altered their diet due to rosacea. Of this group, 95% reported a subsequent reduction in flare. 
The triggers reported in this group may be broken down into heat-related, alcohol-related, capsaicin-related, and cinnamaldehyde-related.
Hot beverages acted as a trigger, including
- Hot coffee (33% described it as a trigger)
- Hot tea (30%)
Alcohol was another frequent trigger, including
- Wine (52%)
- Hard liquor (42%)
- Spices as a trigger (75%)
- Hot sauce (54%),
- Cayenne pepper (47%), and
- Red pepper (37%).
- Tomatoes (30%),
- Citrus (22%),
- Chocolate (23%) 
However, we advise to take a multi-pronged approach to treatment and address the underlying causes of SIBO and not just restrict the diet long term.
FUNCTIONAL MEDICINE TREATMENT OF ROSACEA
The above considerations may help in the management of Rosacea symptoms. For long term resolution it is important to assess underlying dysfunction, whether it be SIBO or a different condition.
Our functional medicine approach investigate the root causes of rosacea by supporting key areas that contribute to the condition such as SIBO, gut infections, bacterial overgrowth, hormone balancing and oestrogen clearance. Poor methylation function is also a contributing factor in the clearance of oestrogens. If you or a family member are suffering from rosacea or require assistance with another skin condition we would love to hear from you.