Integrative Dermatology Approach to Rosacea

If you frequently experience redness, blushing, or flushing, visible blood vessels, and a small bumpy rash on your face, you may have rosacea. This chronic inflammatory skin condition commonly causes redness and flushing across the cheeks and nose and may also impact the eyes.

Over 14 million Americans experience rosacea, which often brings both physical and psychological suffering. Rosacea is most common in women of northern and western European descent, although men tend to suffer from more severe rosacea.

While a conventional treatment approach aims to decrease inflammation, redness, and acne-like lesions with topical or oral medications, an integrative dermatology approach also looks at underlying contributing factors to the inflammation and immune response that underlies this chronic skin condition.

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What is Rosacea?

Rosacea is a chronic inflammatory skin condition that results in redness and a bumpy acne-like rash across the cheeks and sometimes nose. It usually causes persistent flushing or blushing of the cheeks and can result in visible blood vessels (telangiectasias) over time. 

The rash and redness of rosacea often flare up from exposure to changes in temperature, certain foods, or hormonal fluctuation for weeks to months and then can resolve for periods of time. The skin may feel hot and painful. 

In some cases, rosacea can also cause dry, irritated, swollen eyes and eyelids (ocular rosacea). When rosacea is severe and persistent over a long time, it can sometimes result in thicker skin on the nose, which causes the nose to appear bulbous (rhinophyma). This complication is most common in men.

Depending on its distribution and defining characteristics, rosacea can be classified into four subtypes. Type 1 or vascular rosacea causes red areas of skin with small blood vessels on the face. Type 2 or inflammatory rosacea also has red bumps and pus-filled lesions on the face. In phymatous rosacea or type 3, the skin becomes thick over the nose, causing a bumpy, enlarged, bulbous appearance. Type 4 or ocular rosacea involves the eyes, causes inflammation of the eyelids and eyes, and may not cause noticeable skin changes. Individuals with rosacea often experience a combination of these subtypes and can experience differing symptoms during flares over time.

What Are The Possible Causes of Rosacea?

The causes of rosacea continue to be studied, but many factors that increase inflammation and influence the immune system seem to be involved. Imbalances in the microbiome of the skin and gut, abnormal neurovascular signaling, and chronic inflammation all contribute to this skin condition.

Flare-ups are commonly triggered by hot drinks and spicy foods, alcoholic beverages like red wine, extremes in temperature or sun and wind, exercise, emotional responses, medications that dilate blood vessels, and irritating cosmetic, skin, and hair products. 

Those with a family history are more likely to develop this skin condition.

The skin microbiome and immune balance in the skin seem to be altered in people with rosacea. The skin is home to a variety of microorganisms, including bacteria, fungi, and viruses, that regulate immune responses and inflammation. With rosacea, there seems to be an overgrowth of skin mites called Demodex folliculorum that live near hair follicles. People with rosacea may have a hypersensitivity to these mites that contribute to the rash. In addition, imbalances in Cutibacterium acnes, Staphylococcus epidermidis, and Bacillus oleronius in the skin seem to play a role. 

Most people with acne-like rosacea have an overactive immune response to a bacterium called bacillus oleronius, which leads to inflammation. Elevated levels of a peptide known as cathelicidin are also seen in the facial skin of people with rosacea, suggesting an exacerbated immune response. These abnormal immune responses seem to lead to the generation of reactive oxygen species (ROS) that cause inflammation in the skin.

In addition to imbalances in the microbiome and immune response in the skin, people with rosacea have imbalances in the gut microbiome. There is also evidence to suggest that rosacea is associated with inflammatory gastrointestinal disorders such as Helicobacter pylori infection, celiac disease, Crohn’s disease, ulcerative colitis, small intestinal bacterial overgrowth (SIBO), and irritable bowel syndrome (IBS) due to cross-talk between the skin and gut in the gut-skin axis.

Functional Medicine Labs to Test for Root Cause of Rosacea

Functional medicine laboratory testing can help to rule out differential diagnoses and assess underlying causes contributing to rosacea.

Comprehensive Stool Test

Comprehensive stool testing with the GI-MAP can provide an assessment of the microbial landscape of the gastrointestinal tract and evaluate other gut factors that influence inflammation levels in people with rosacea. This test uses PCR technology to detect and quantify the growth of microbes contributing to gut dysbiosis and inflammation and provides an assessment of digestion, absorption, inflammation, and immune function. It can also be helpful when H. pylori infection is suspected to be contributing to rosacea, as the GI-MAP includes testing for H. pylori virulence factors and antibiotic susceptibility to guide treatment. 

In addition, zonulin can be assessed to detect intestinal permeability or leaky gut that can contribute to inflammation and immune dysregulation. 

SIBO Breath Test

Patients with rosacea have a higher prevalence of SIBO, and the successful elimination of SIBO results in a significant improvement in the skin rash, so testing for bacterial overgrowth with a 3-hour SIBO assessment provides a non-invasive way to measure hydrogen and methane to evaluate bacterial overgrowth in the small intestine.

Micronutrient Testing

Micronutrient Testing assesses levels of vitamins, minerals, and other nutrients that impact skin health. In addition, measuring levels of fatty acids with the Essential and Metabolic Fatty Acid Analysis provides important information on omega-3 and omega-6 fatty acids that play a crucial role in maintaining skin barrier integrity.

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Conventional Treatment for Rosacea

A conventional treatment approach relies on topical and/or oral medications to reduce the signs and symptoms of rosacea. In some cases, laser therapy may help reduce the appearance of visible blood vessels, but this has potential side effects and is not effective on pigmented skin.

Topical medications like Brimonidine (Mirvaso) and oxymetazoline (Rhofade) help to reduce flushing by constricting blood vessels but need to be applied regularly. Other topical treatments such as azelaic acid (Azelex, Finacea), metronidazole (Metrogel, Noritate, others), and ivermectin (Soolantra) are sometimes used to reduce acne-like lesions. 

In more severe cases of rosacea, an oral antibiotic such as doxycycline or an oral acne drug like isotretinoin is added to reduce acne-like lesions. Emerging treatments like vitamin D receptor antagonists are also being investigated since the active form of vitamin D (1,25-Dihydroxyvitamin D3) is a natural regulator of the antimicrobial peptide cathelicidin in the skin involved in rosacea.

Functional Medicine Treatment for Rosacea

While a conventional approach aims to reduce symptoms, an integrative dermatology approach to rosacea incorporates a functional medicine view to uncover and address underlying contributing factors. Rebalancing inflammation and the microbiomes of the gut and skin using diet, lifestyle, supplements, and integrative therapies can help reduce inflammation and heal the skin.

Nutritional Recommendations

A dietary approach to rosacea aims to remove common trigger foods and focus on plenty of nutrient-dense anti-inflammatory foods to heal and soothe the skin and gut. 

Common food triggers include alcohol, spicy foods, cinnamaldehyde-containing foods such as tomatoes, citrus fruits, and chocolate, hot drinks, and histamine-rich foods like aged cheese, wine, and processed meats.

In addition to avoiding these foods, emphasis should be placed on nutrient-dense foods that help to heal the gut and balance inflammation. An anti-inflammatory Mediterranean diet focuses on whole fresh vegetables and fruit while avoiding inflammatory additions like processed foods, factory-raised meats, and additives as well as foods that one is allergic to or sensitive to. This way of eating can nourish the microbiome and balance inflammation. 

Incorporating foods rich in prebiotics and probiotics, such as fermented foods, can restore a balanced gut microbiome and reduce inflammation throughout the body. Probiotic-rich foods like kimchi and sauerkraut repopulate the gut with a balance of bacteria, while prebiotics, including fiber and other nondigestible carbohydrates, nourishes probiotic bacteria in the gut to establish a healthy gut microbiome that complements the restoration of a healthy skin microbiome.

Supplements & Herbs for Rosacea

In addition to an anti-inflammatory diet to help bring the gut and skin back into balance and reduce inflammation contributing to rosacea, targeted supplements, and herbs may help heal the skin and improve quality of life.

Omega-3 Fatty Acids

Subcutaneous fatty acids play a key role in maintaining the skin barrier. Patients with papulopustular rosacea have dry, sensitive skin due to an abnormal composition of sebaceous fatty acid, including reduced levels of long-chain saturated fatty acids. Supplementing fats, including omega-3 fatty acids, may help reduce redness and inflammation in patients with rosacea, especially in those with eye involvement.

Herbal SIBO Treatment

Herbal protocols to treat SIBO with an individualized combination of herbs like berberine, oregano, neem, and others may also improve skin lesions in patients with rosacea who show signs of bacterial overgrowth on functional testing. 

Botanical Treatment of H. Pylori

Similarly, rates of infection with H. pylori are increased in people with rosacea, so successful treatment of this bacterial infection is associated with an improvement of rosacea symptoms in addition to a reduction in related gastrointestinal symptoms. Botanical treatments utilizing berberine, mastic gum, and polyphenols in curcumin, cranberry, garlic, licorice, and broccoli are effective options for the eradication of H. pylori infection.

Probiotics

A supplementation regimen of oral probiotics can be tailored to each individual based on the results of comprehensive stool testing, as discussed above. This can also help to heal the gut-skin axis to address skin conditions such as rosacea, acne, and eczema. 

Zinc

Zinc plays many important roles in maintaining the health of the skin and gut. Studies suggest that oral zinc sulfate supplementation improves symptoms of rosacea without significant side effects. In this double-blind, placebo-controlled study, 100 mg of oral zinc sulfate was given three times a day for three months.

Complementary and Integrative Medicine for Rosacea

Integrated medicine approaches can complement diet and supplements' roles in balancing the gut, reducing inflammation, and healing the skin.

Topical Probiotics 

In addition to oral probiotics that help to balance the gut microbiome, topical probiotics can be applied to the skin to help restore balance to the skin microbiome and regulate inflammation and skin immune responses. 

Avoid Triggers

In addition to avoiding the commonly triggering foods mentioned above, it is important to treat skin gently and avoid harsh scrubs, irritating cosmetics, or fragrances. Opt for fragrance-free organic and natural personal care products. Since UV light can trigger symptoms of rosacea and sun damage, lengthen the time it takes to heal from a flare, and take precautions when exposing your skin to the sun during the peak midday hours.

Facial Massage

Daily gentle facial massage can help reduce swelling and inflammation in rosacea and improve blood flow and circulation to encourage healing. Gently massage your face with your fingers in a circular motion, starting on the central part of your face and working toward your ears.

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Summary

Rosacea is a chronic inflammatory skin disease that causes recurring episodes of facial flushing, redness, pustules, and dilated blood vessels. It is most common in women over 30 years of age with fair, sun-sensitive skin.

The cause of rosacea continues to be studied, but changes in the gut and skin microbiome, neurovascular system, and immune responses play a role. The gut-skin axis is out of balance in rosacea patients, with an overgrowth of commensal skin microorganisms like Demodex mites contributing to immune dysregulation and inflammation. 

An integrative dermatology approach to rosacea uncovers factors contributing to the inflammation and dysregulated immune response that underlies this chronic skin condition. Dietary, supplement-based, lifestyle and integrative medicine therapies can be used to develop an individualized treatment plan that brings the gut-skin axis back into balance to improve rosacea symptoms and restore balance.