Rosacea is a common, non-contagious inflammatory skin condition that usually begins as facial flushing, which may progress to a varying degree of symptoms.
It is more common in women than men, with a higher prevalence in individuals of northern and western European descent. It is estimated that more than 14 million Americans live with rosacea.
Rosacea has impacts that are not only physical but also psychosocial. A survey conducted by the National Rosacea Society revealed that 75% of respondents reported that their rosacea had lowered their self-esteem, made them feel embarrassed (70%) and frustrated (69%).
A Functional Medicine Approach to Rosacea focuses on finding the root cause, an individualized approach. With proper diagnosis and treatment, many patients can have a long-term improvement in symptoms.
Rosacea Signs & Symptoms
Because rosacea has a wide variety of signs and symptoms, it is often divided into four subcategories that may help guide treatment:
- Subtype 1 Vascular Rosacea: sensitivity, flushing, and redness; sometimes broken blood vessels are visible
- Subtype 2 Inflammatory Rosacea: As well as facial redness, there are red bumps (papules) and pus-filled spots (pimples). This subtype can often be mistaken for acne.
- Subtype 3: Phymatous Rosacea: The skin thickens and may become bumpy, particularly on the nose.
- Subtype 4: Ocular Rosacea: his type of rosacea leads to inflammations of the eyes and eyelids (blepharitis), sometimes with no noticeable skin symptoms.
While these categories are intended to guide treatment, it is worth noting that symptoms often fluctuate with the individual. People can often have a combination of symptoms that fall into more than one of the above-listed subtypes.
In addition to the subtype classification, some clinicians use stages to determine treatment. Stages range from frequent flushing in the pre-rosacea stage to large inflammatory nodules in stage 3.
Rosacea Possible Causes
The exact cause of rosacea is unclear and debated. Some possible reasons include:
Inflammatory and Immune responses
Individuals with rosacea have high levels of a peptide, cathelicidin, in their facial skin, which may demonstrate an exacerbated immune response.
The microbiome is the community of microorganisms (bacteria, fungi, and viruses) that live in or on the body. The skin of rosacea patients regularly contains an overgrowth of skin microorganisms called Demodex folliculorum that live near hair follicles of the skin. It is speculated that individuals with rosacea may have a hypersensitivity to these mites.
The common food triggers include alcohol, spicy food, cinnamaldehyde-containing foods (e.g., tomatoes, citrus fruits, chocolate), hot drinks, and histamine-rich foods (e.g., aged cheese, wine, processed meats).
Impaired Digestive Health
Current theories highlight the role of the microbiome, both skin, as mentioned above, and gut. The balance of these bacteria and the inflammatory response in the body is considered a significant regulator in the connection of gut and skin health.
Small Intestinal Bacterial Overgrowth (SIBO)
Numerous studies highlight the potential pathogenic role of SIBO in the development of rosacea. According to a study by Parodi et al., patients with rosacea were 13 times more likely to have SIBO than control patients. Patients with SIBO treated with the medication rifaximin induced almost complete regression of their rosacea symptoms.
H. Pylori is a bacteria that resides in the stomach and infects approximately 50% of the population. It has been speculated that it plays a role in developing rosacea due to the high prevalence rates. A study in 1999 demonstrated that the eradication of H.Pylori led to an improvement of rosacea symptoms and a reduction in related gastrointestinal symptoms. More studies have been requested since.
Additionally, a wide variety of triggers identified can exacerbate rosacea symptoms. In a survey of 1,066 rosacea patients, the National Rosacea Society ranked sun exposure as the number one rosacea trigger, followed closely by emotional stress.
Other triggers for rosacea flares include:
Functional Medicine Labs to Test for Rosacea
Comprehensive Stool Test
GI health stool test can evaluate the gut microbiome and dysbiosis (imbalance of gut bacteria), any markers for inflammation, and zonulin (a marker for detecting intestinal permeability or leaky gut). Many studies show a direct correlation that improving gut barrier function can improve skin barrier function.
Intestinal Permeability: The leaky gut marker zonulin can be evaluated
SIBO Breath Test
A SIBO breath test is the most common test for diagnosing SIBO. This is an at-home non-invasive test that evaluates bacterial overgrowth of the small intestine. it involves drinking a specialized mixture and breathing into a tube to see if the bacteria in the small intestine release gas: hydrogen, methane, or a combo of both
A Micronutrient Test can measure vitamins, minerals, and other nutrients to determine nutritional deficiencies. The Metabolomix+ test is an at-home test that provides a comprehensive assessment of micronutrients, including a fatty acid profile of omega 3 vs. omega 6. There is increasing evidence that sebaceous fatty acids play a role in maintaining skin barrier integrity.
Functional Medicine Treatment for Rosacea
Conventional medicine treatment used for rosacea is primarily focused on symptom control. These include topical creams and gels that contain antibiotics (such as metronidazole), oral antibiotics (such as tetracycline, minocycline, and doxycycline), and the acne drug Accutane (Isotretinoin). Laser therapy may also help reduce redness and treat broken blood vessels in severe cases.
Following a functional medicine approach involves looking at the root causes and treating the skin from the inside out with a personalized approach. What affects one patient may not affect another. An individualized treatment protocol includes addressing the gut imbalances, food sensitivities, and any nutritional deficiencies identified. If SIBO is identified, a functional medicine approach may consist of specific diets and targeted antimicrobials depending on whether the patient is methane or hydrogen dominant.
The role of diet as a trigger for rosacea is widely accepted. A low inflammatory diet can be an effective complementary therapeutic strategy through the modulation of the gut microbiome, and avoiding foods that cause inflammation has the potential to prevent intestinal inflammatory processes. Elimination of known food sensitivities is the first step in reducing overall inflammation in the body and allowing the skin barrier to heal. diet can be a significant complementary therapeutic strategy through the modulation of the gut microbiome
Probiotics may alter the gut microbiome and modulate the intestinal microbiota, thereby counteracting opportunistic bacteria that cause microbiome imbalances. Probiotics might have an anti-inflammatory role and improve skin barrier efficacy, but more research is needed.
Omega 3 Fatty acids appear to play a protective role, particularly against ocular rosacea. Gamma-linolenic acid (GLA) is an essential omega-6 fatty acid known to restore the defective epidermal skin barrier. In a trial using GLA as an add-on to minocycline therapy, a higher proportion of patients achieved treatment success at the two-month mark (68.75% vs. 33.33%)
Studies have observed zinc supplementation with contradictory results. However, one six-month-long study found zinc to be a good option in treating rosacea, as it was safe, effective and lacked side effects.
Rosacea is quite common and associated with a wide range of physical and physiological factors. There remains a need for an individualized approach to identify root causes and provide long-term improvement of symptoms. Patients’ symptoms can improve by uncovering what’s happening at the cellular level with specialty testing and a functional medicine approach to treat the skin from the inside out.