A Concise Guide to Rosacea: a Functional Medicine Approach

What is Rosacea?

Rosacea is a chronic, non-contagious inflammatory skin disease that typically affects the face, causing a permanent flush in parts of the face and other symptoms. It is estimated that about 10% of the global population is affected by this condition.

Rosacea is more common in people of a Northern European background with fair, sun-sensitive skin (skin phototypes I and II). Among these people, the prevalence of rosacea can be as high as 22%¹.

How does it present in the skin?

Rosacea usually appears throughout middle age, between 30-50 years of age, and usually starts with frequent flushing of the face (e.g. nose or cheeks turning red). As the disease progresses, capillaries in the face enlarge, and some skin areas in the face become permanently red, a condition known as erythema. In men, rosacea can lead to the nose becoming reddened and enlarged, a condition known as rhinophyma.

Some typical symptoms of rosacea include:

Enlarged capillaries (telangiectasis)
A permanent flush across the nose and cheeks
Yellow-headed pimples on the forehead, cheeks and chin
Non-tender lumps under the skin
Swollen cheeks and nose (hyperplasia)
Frequent blushing
A sensation of burning, itching or stinging
Eye problems, including dry, irritated, swollen eyes and red, swollen eyelids
Enlarged nose, caused by the thickening of the skin on the nose (more common in men)

Rosacea is also associated with a higher risk of developing other diseases, including certain allergies (airborne and food), respiratory diseases, gastrointestinal (GI) diseases, hypertension, metabolic diseases, urogenital diseases, and female hormone imbalance.

Table 1, below, lists typical diagnostic features of rosacea, including major and minor phenotypes / characteristics of this condition.

How does rosacea develop?

Rosacea is thought to be a disease caused by multiple factors. However, the underlying factors leading to the development of rosacea are not fully understood. Two major factors influencing this condition are genetics and environmental factors.

People with a family history of rosacea have an increased risk of developing this condition. Studies suggest that about 50% of rosacea patients have a family history of this condition². Another study has identified specific gene variants (also known as alleles) associated with rosacea. Three alleles of the human leukocyte antigen (HLA) gene and two specific mutations at this gene have been linked to rosacea. The authors of this study also noted that these HLA alleles are also associated with other conditions, such as type I diabetes mellitus and celiac disease³.

Another important factor influencing rosacea is the environment. Various environmental risk factors have been identified that can trigger or worsen rosacea symptoms. These include:

Drinking alcohol, hot drinks, coffee or tea
Eating spicy foods
Overexposure to sunlight
Anxiety
Emotional stress
Overheating, especially at night

Types of rosacea

Traditionally, rosacea has been classified into four subtypes:

Subtype 1: Erythematotelangiectatic Rosacea

Characterised by flushing, persistent redness, and visible blood vessels

Subtype 2: Papulopustular Rosacea (previously called acne rosacea)

With persistent and intermittent redness, bumps and pimples

Subtype 3: Phymatous Rosacea

Skin thickening, with a characteristic enlargement of the nose

Subtype 4: Ocular Rosacea

Which affects the eyes, causing dry eye, tearing and burning, swollen eyelids, and potential loss of vision.

In 2017, these subtypes classifications were reviewed due to the progression of some subtypes into another and because these subtypes can co-occur. The new proposed classification of rosacea changes from using “subtypes” to using “phenotypes. Under this classification, rosacea is diagnosed based on the presence of one diagnostic and two major phenotypes are present. See Table 1 for a list of the current phenotypes used for diagnosing rosacea.

Focus on: Microbiota and Rosacea

Our body is inhabited by billions of microorganisms, including bacteria, viruses, fungi and other groups. These microorganisms live inside our gastrointestinal tract, in our skin, scalp and inside our nose, mouth and genital tracts. One of the primary functions of the human microbiota is to protect our body from external pathogens, but they also have other functions. The skin and gut microbiota, for example, can influence the function of the immune system following interactions with certain environmental factors. For example, in a recent study, researchers showed that children exposed to natural settings develop a healthier skin microbiota and a stronger immune system. Read all about this study here.

Studies have identified specific microbial signatures in patients with rosacea, suggesting a potential role of these microbes in the pathogenesis of this disease. One study, for example, compared patients with rosacea, erythematotelangiectatic, papulopustular or both, against a healthy group⁴. Their finding showed that compared to controls:

The skin microbiota in erythematotelangiectatic rosacea was depleted for the bacteria Roseomonas mucosa.
Skin lesion affected by papulopustular rosacea has high levels of the bacteria Campylobacter ureolyticus, Corynebacterium kroppenstedtii, and the oral bacterium Prevotella intermedia.
Patients affected by both erythematotelangiectatic and papulopustular rosacea had the highest levels of the bacterium Corynebacterium kroppenstedtii in skin affected by rosacea.

Other studies report a potential role of gut microbes influencing the progression of rosacea. Patients with rosacea may experience different associated diseases. Many of them involve the gut (e.g., gastroesophageal reflux disease, gastritis, Crohn’s disease, ulcerative colitis, celiac disease, and small intestinal bacterial overgrowth [SIBO] syndrome). This association with gut-related diseases strongly suggests that a link exists between rosacea and the gut microbiota^6-8.

The gut microbiota (also known as the gut microbiome) has also been shown to influence skin homeostasis, either through maintenance of intestinal barrier function or through modulation of the immune system⁹.

Evidence of the importance of gut microbes in skin health has also been reported in studies showing that chemicals released by gut bacteria may be able to enter the bloodstream and reach the skin. One study found that two of these chemicals, free phenol and p-cresol, can enter the circulatory system and accumulate in the skin of mice⁵. These two metabolites can also influence the expression of certain genes found in keratinocytes, the most common type of skin cell. Alterations to the optimal function of keratinocytes affect the way the skin functions, potentially causing disease⁶. Learn more about how the skin microbiota affects our health. Please read our article on this topic.

Through the metabolites they produce, the link between gut microbes and skin health points towards another important concept: intestinal permeability.

Intestinal Permeability and Skin Health

The gastrointestinal epithelium functions as a protective barrier against invading pathogens from the outside world, while allowed passage to water and nutrients¹⁰. Pathogens that enter our body through the mouth and nose, and manage to avoid the gastric juices of the stomach, are usually prevented from entering the bloodstream by the concerted efforts of the physical barrier of the gastrointestinal linings and the bacteria inhabiting the gut.

However, sometimes, malfunctions in the gut, certain environmental factors, or genetic conditions can lead to increased intestinal permeability, which means pathogens and other potentially harmful substances can enter the bloodstream and reach any part of the body.

Some studies have found evidence that abnormal intestinal permeability may be linked with skin disorders. One study, for example, found that patients with acne reacted to the presence of a bacterial toxin called LPS, whereas healthy controls showed no reactions to the toxin¹¹. A positive reaction to the LPS toxin can be considered as evidence of significant intestinal permeability in acne patients. Similar mechanisms may exists linking intestinal permeability to vitiligo.

Diagnosis and treatment of rosacea

There is no specific test for rosacea. A clinician will make a diagnosed based on inspection of the skin and evaluation of your medical history, including all symptoms you have experienced. Some testing can be done to rule out other conditions with similar symptoms, such as psoriasis, eczema or lupus.

There is no treatment for curing rosacea. Instead, standard treatments are focused on controlling signs and symptoms of this disease. Some drugs can be prescribed to reduce the redness of the skin, by closing blood vessels. However, the effects of these drugs on the blood vessels is only temporary so medication might require regular use. Oral antibiotics and acne drugs can also be prescribed in some cases as well as laser-based therapies, which aim to reduce the redness of the skin.

Overall, the standard approach to treat rosacea is not able to cure the disease and is focused only on reducing the symptoms. Hence, there is a need to develop new and more effective treatments that target the underlying factors driving vitiligo. For a good overview of the standard treatment of rosacea, see this link.

Functional medicine in Australia: a more efficient approach to Rosacea

At the Australian Centre for Functional Medicine, we take a comprehensive look at all factors influencing and driving the development and worsening of rosacea. We employ a Modern approach to Functional Medicine, merging standard medical protocols with cutting edge, research-backed approaches, evidence-based natural treatments, and extensive diagnostic testing.

Optimal skin health requires a careful combination of multiple factors, including an optimal composition of the gut and skin microbiota, optimal immune function, reduced cellular stress and optimization of other factors. At the Australian Centre for Functional Medicine, we follow a constantly updated practice based on new and current research findings. Our goal with our approach to modern Functional Medicine is to understand the underlying factors affecting your skin and to apply the best research-backed treatments to restore the health of your skin (as well as your overall health). At the Australian Centre for Functional Medicine, our approach merges the best aspects of standard medical practice and modern functional medicine.

Our modern approach to Functional Medicine offers an effective alternative to the standard model of clinical practice. The Australian Centre for Functional Medicine employs leading clinical testing approaches, evaluating biomarkers found in your blood, stool, urine, and breath. Genomic-based tests, for example, are used to inform us about genetic susceptibilities, mutational defects or other factors that may influence treatment efficacy and health. We also test the composition of your gut and skin microbiota to identify any instances of dysbiosis. This is the comprehensive approach of modern Functional Medicine.

This comprehensive testing is used to obtain a solid understanding of your physical health and garner evidence of any malfunctions that potentially affect your health. All this information will ultimately allow us to design a personalised treatment based on your specific needs. This unique approach to Functional Medicine will guarantee the best possible treatment and the best possible outcomes for your condition.

What is it like to be a patient at the Australian Centre for Functional Medicine? If you seek treatment for rosacea or any other skin condition, one of the first treatment recommendations we will likely make involves your lifestyle. The diet you follow, your daily activity levels, and your sleep patterns will be evaluated, and an optimal plan will be proposed.

Following certain unhealthy diets, such as those rich in refined flour, excess fats and sugar, and industrial seed oils can increase inflammatory responses in the body, which can ultimately affect the skin. In Australia, national surveys have shown that there are significant deficiencies in micronutrients like Vitamin D, for which 23% of all Australians are deficient at this vitamin. Also, for iodine, 18.3% of child-bearing women were found deficient.

Switching to a diet rich in nutrient-rich foods and supporting the gut microbiome through the consumption of probiotic and prebiotic-rich foods is a proven way to improve your immune health and the health of your skin.

In addition to diet, changes to your sleep and exercise patterns will also be evaluated and improved. Exercising regularly and sleeping regular hours can help reduce inflammation and improve immune function.

On your path towards healthy skin and a healthier life with modern Functional Medicine.

To learn more about Functional Medicine and the many health conditions we treat, download our Gut Health e-Book now.

References

Rainer BM, Kang S, Chien AL. Rosacea: Epidemiology, pathogenesis, and treatment. Dermato-endocrinology. 2017 Jan 1;9(1):e1361574. Read it!
Aldrich N, Gerstenblith M, Fu P, Tuttle MS, Varma P, Gotow E, Cooper KD, Mann M, Popkin DL. Genetic vs environmental factors that correlate with rosacea: a cohort-based survey of twins. JAMA dermatology. 2015 Nov 1;151(11):1213-9. Read it!
Chang AL, Raber I, Xu J, Li R, Spitale R, Chen J, Kiefer AK, Tian C, Eriksson NK, Hinds DA, Tung JY. Assessment of the genetic basis of rosacea by genome-wide association study. Journal of Investigative Dermatology. 2015 Jun 1;135(6):1548-55. Read it!
Rainer BM, Thompson KG, Antonescu C, Florea L, Mongodin EF, Bui J, Fischer AH, Pasieka HB, Garza LA, Kang S, Chien AL. Characterization and analysis of the skin microbiota in rosacea: a case–control study. American Journal of Clinical Dermatology. 2020 Feb 1;21(1):139-47. Read it!
Miyazaki K, Masuoka N, Kano M, Iizuka R. Bifidobacterium fermented milk and galacto-oligosaccharides lead to improved skin health by decreasing phenols production by gut microbiota. Beneficial Microbes. 2014 Jun 1;5(2):121-8. Read it!
Rainer BM, Fischer AH, Da Silva DL, Kang S, Chien AL. Rosacea is associated with chronic systemic diseases in a skin severity–dependent manner: Results of a case-control study. Journal of the American Academy of Dermatology. 2015 Oct 1;73(4):604-8. Read it!
Egeberg A, Weinstock LB, Thyssen EP, Gislason GH, Thyssen JP. Rosacea and gastrointestinal disorders: a population‐based cohort study. British Journal of Dermatology. 2017 Jan;176(1):100-6. Read it!
Thompson KG, Rainer BM, Kang S, Chien AL. The skin microbiota as a link between rosacea and its systemic comorbidities. International Journal of Dermatology. 2020 Apr;59(4):513-4. Read it!
O’Neill CA, Monteleone G, McLaughlin JT, Paus R. The gut‐skin axis in health and disease: a paradigm with therapeutic implications. BioEssays. 2016 Nov;38(11):1167-76. Read it!
Ahmad R, Sorrell MF, Batra SK, Dhawan P, Singh AB. Gut permeability and mucosal inflammation: bad, good or context dependent. Mucosal immunology. 2017 Mar;10(2):307-17. Read it!
Juhlin L, Michaëlsson G. Fibrin microclot formation in patients with acne. Acta dermato-venereologica. 1983 Jan 1;63(6):538-40. Read it!