Rosacea and Gut Health: A manifestation of gut-skin axis dysfunction

The age-old saying of “you are what you eat” really does have some truth to it. We intuitively know that if we eat nutritious food, we feel great and have much more energy than if we eat food that is high in sugar, salt, and refined carbohydrates. The food that we consume is used to create and feed our body’s cells that are constantly turning over, especially in our gut. If we eat healthy foods full of nutrients and fiber, our gut is likely to be healthy and happy, but if we eat foods that cause inflammation, our gut may not be as optimally healthy. Research now shows that inflammation in the gut leads to a disproportionate number of healthy microbes. This effect does not just stay in the gut and can act more globally in the body and cause far-reaching problems, especially for the skin. 

Interactions of the Gut-Skin Axis

The connection between gut health and skin health has been termed the gut-skin axis. While researchers still do not understand every detail of how the gut and skin communicate with one another, they suspect it is through the immune system. This idea stems from the fact that our gut is home to the gut-associated lymphoid tissue (GALT), which is an organized and complex part of our immune system. Peyer’s patches and dendritic cells are part of the GALT and are responsible for overseeing our body’s immune response to the food we eat. Chemical messengers called cytokines are sent from the GALT in the gut through the body’s circulation to the skin, where we also have dendritic cells. 

Short-chain fatty acids (SCFAs) are molecules created by the digestion of beneficial fibers by the healthy bacteria in the gut. These short-chain fatty acids called acetate, propionate, and butyrate can also send messages throughout the body via the immune system and are important for decreasing inflammation and promoting healthy processes in the body, especially the skin. The thought is that if the messages from the gut to the skin are those that promote inflammation, then it may contribute to skin problems and inflammation, but if the messages from the gut are anti-inflammatory, then the health of the skin will be maintained. Although simplified, this is the general idea of the gut-skin axis and communication between the two organ systems. Next, we will discuss a connection between two known conditions: small intestinal bacterial overgrowth and rosacea. 

More than Rosy Cheeks: Rosacea as a Symptom of Microbiome Imbalance

Rosacea is a chronic, inflammatory skin condition that primarily affects the face, nose, and sometimes eyes. Facial redness is a common symptom in addition to pimples, easy flushing, enlarged blood vessels, and thickened skin on the nose. In ocular rosacea, the eyes become extremely red and irritated. There are different types of rosacea, all of which are complex in their own way. 

Known triggers that can worsen rosacea include:

  • Spicy foods 

  • Hot beverages such as tea or coffee

  • Sun exposure 

  • Mental or emotional stress 

  • Exercise, especially in a hot room

Treatment of rosacea typically includes oral and or topical antibiotics such as doxycycline to reduce the inflammation, while laser therapy can be used to reduce facial redness and visible blood vessels.

SIBO and Rosacea: The Gut-Skin Connection

Small intestinal bacterial overgrowth (SIBO) is a condition where, as the name suggests, there is an overgrowth of bacteria in the small intestine where there shouldn’t be. In a normal small intestine, the number of bacteria is typically less than 103 colony-forming units (CFUs) per milliliter, whereases in SIBO, it is more than 105 colony CFUs per milliliter. There are many causes of SIBO such as low stomach acid, pancreatic insufficiency, structural problems like small intestinal obstruction, digestive issues seen in scleroderma, or a combination of several different ones. SIBO has also been seen in older adult populations without any other digestive disease. 

Some of the signs and symptoms of small intestinal bacterial overgrowth include:

  • Gas 

  • Abdominal bloating 

  • Watery diarrhea 

  • Constipation (in some cases)

  • Abdominal pain 

  • Vitamin deficiencies: D, B12, A, and E 

  • Mineral deficiencies: calcium and iron

Testing for SIBO is typically done with a lactulose or glucose breath test as these are non-invasive testing options, and the treatment is generally antibiotics such as rifaximin, although some antimicrobial herbal protocols have been utilized to reduce the amount of bacteria in the small intestine. 

Researchers are starting to find a link between SIBO and rosacea. One study found that people with rosacea were 13 times more likely to have SIBO than people who did not have rosacea. Their thought was that a circulating messenger from the gut to the skin called TNF-α was responsible for the connection. This study found SIBO in 46% of the patients with rosacea, and when treated with a 10-day cycle of the antibiotic rifaximin typically used for SIBO, 64.5% of patients with rosacea had no signs or symptoms of the skin condition three years later, and only 5.7% were positive for SIBO.

Another study looking at the link between SIBO and rosacea found that treating the patient’s SIBO with rifaximin led to almost complete clearance of their rosacea, which was maintained for at least nine months.

Relieving Rosacea and Restoring Gut Microbiome Balance

The continued evidence creating a connection between two seemingly unrelated conditions is starting to change the way doctors and researchers approach gut and skin conditions like SIBO and rosacea. We are looking to the gut as potential treatment options for not only skin conditions like rosacea and acne but also depression, anxiety, and even Parkinson’s disease. 

Here are possible treatments for rosacea related to microbial dysbiosis:

Dr. Raja Sivamani, MD


Dr. Raja Sivamani is a board-certified dermatologist and practices as an integrative dermatologist at Pacific Skin Institute. He is an Adjunct Associate Professor of Clinical Dermatology at the University of California, Davis and Director of Clinical Research and the Clinical Trials Unit. He is also an Adjunct Assistant Professor in the Department of Biological Sciences at the California State University, Sacramento and an Associate Professor of Dermatology at California Northstate University, College of Medicine. He engages in clinical practice as well as both clinical and translational research that integrates bioengineering, nutrition, cosmetics, and skin biology. With training in both Allopathic and Ayurvedic medicine, he takes an integrative approach to his patients and in his research. He has published over 100 peer-reviewed research manuscripts, 10 textbook chapters, and a textbook entitled Cosmeceuticals and Active Cosmetics, 3rd Edition with a passion for expanding the evidence and boundaries of integrative medicine for skin care.

Collective members are paid sponsors and receive compensation for their content, but all opinions are their own.

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