Bacterial Imbalance

Key Concepts About Small Intestinal Bacterial Overgrowth (SIBO)

Small Intestinal Bacterial Overgrowth (SIBO) and Rosacea

Italian investigators discovered the link between small intestinal bacterial overgrowth (SIBO) and rosacea (Parodi, et al., 2008). Of 113 consecutive rosacea patients, 52 exhibited a positive breath test for SIBO (vs. 3 of 60 controls). After SIBO eradication by rifaximin as determined by reversal of the breath test, rosacea cleared in 20 of 28 patients and greatly improved in an additional 6 patients. The following figure shows the clinical outcome in SIBO-positive and SIBO-negative rosacea patients treated with rifaximin. Patients treated with placebo remained unchanged (18/20) or worsened (2/20) (P<0.001).


(Figure adapted from Parodi et al., 2008)

The patients who were given placebo were subsequently switched to rifaximin. In these patients, SIBO was eradicated in 17 of 20 cases. Fifteen of these patients demonstrated a complete resolution of rosacea symptoms. Thirteen of 16 patients with negative breath tests for SIBO remained unchanged; this result differed from SIBO-positive cases (P<0.001). Eradication of SIBO induced a nearly complete regression of cutaneous lesions in these patients for at least 9 months. The authors suggested that chronic systemic inflammation causes inflammation of the skin.

A subsequent study (Weinstock and Steinhoff, 2013) reported that 63 patients who were seen by a gastroenterologist for colon cancer screening were diagnosed with rosacea. Of these, 57patients were diagnosed previously by a dermatologist, and 4 patients were referred after being diagnosed with ocular rosacea by an ophthalmologist (3 of these patients presented with concurrent facial rosacea). In addition to the cases of ocular rosacea, nine cases of papulopustular rosacea were observed, and the remainder of this patient population exhibited erythematous rosacea. Of these 63 patients, 32 (51%) had an abnormal (positive) breath test compared to 3/30 (10%) of completely healthy control subjects (relative risk = 5.0; 95% CI: 1.7–15.1; P<0.001). Of the 32 rosacea patients with a positive breath test, 28 were given rifaximin (1200 mg per day for 14 days). The results of this treatment are shown on the graph below.

In general, the papulopustular rosacea patients and the ocular rosacea patients demonstrated the best response to rifaximin. This was not a double-blinded study. Since this study was performed many other rosacea patients treated for SIBO in clinic have seen improvement in their skin, eyes and when associated, GI symptoms.

 

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Rosacea and Helicobacter Pylori

Infection of the stomach by Helicobacter pylori may lead to ulcers and cancer. Owing to the nature of chronic H. pylori infection with subtle systemic inflammation, concerns were raised in the past that this bacterium may cause rosacea. Rosacea has been associated with gastritis and hypochlorhydria. The Helicobacter pylori rosacea studies show conflicting results.

In some studies, rosacea patients who were infected with Helicobacter pylori were treated with multiple antibiotics, which seemed to lessen the severity of rosacea. A small study investigated ocular rosacea, and clinical and serological evidence of Helicobacter pylori infection showed significant improvement of rosacea symptoms. Helicobacter pylori treatment seems to be more effective for ocular rosacea than for cutaneous disease. Most dermatologists feel that association of rosacea and Helicobacter pylori is non-specific. In my review of this literature, I believe that two things are clear: an association of Helicobacter pylori with rosacea may exist based on the study by Szlachcic, et al in 1999 and 2002. This association may be applicable to only the subtype of Helicobacter pylori found in Poland. Alternatively, the antibiotics used in other Helicobacter pylori studies may have treated an infection in another location…such as the small intestine.

In the Poland experience, gastric Helicobacter pylori infection in 60 patients with rosacea having erythema and flushing on the face with visible papules and pustules was compared to 60 age- and gender-matched patients without any skin diseases. The effect of treatment on plasma interleukin (IL)-8 and tumor necrosis factor (TNF)-alpha was also determined after 1 week of treatment with omeprazole (20 mg), clarithromycin (500 mg), and metronidazole (500 mg), all twice daily. The Helicobacter prevalence in rosacea patients was approximately 88%, compared to 65% in control subjects. The incidence among rosacea patients of a more virulent form of Helicobacter (cytotoxin-associated gene A [CagA]-positive) was double that of controls. After antibiotic treatment of 53 rosacea patients, 51 had resolution of the Helicobacter pylori infection. Within 2 to 4 weeks, the symptoms of rosacea disappeared in 51 patients, markedly declined in 1 patient, and remained unchanged in the remaining treated patients. Plasma TNF-alpha and IL-8 were reduced significantly (72% and 65%, respectively) after the therapy. Differences in Helicobacter exist in populations around the world, and rosacea may be considered one of the major extra-gastric symptoms of certain infectious Helicobacter pylori induced systemic inflammatory proteins (cytotoxins and cytokines).

 

References

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