Rosacea patients complaining of gastrointestinal symptoms warrant clinical suspicion of disease because, while the pathogenic link between gastrointestinal disorders and rosacea remains a mystery, an association between the two is clear, according to a new study1.
Researchers conducted a nationwide cohort study of 49,475 patients with rosacea and more than 4,300,000 general population controls, to look at possible associations between rosacea and celiac disease, Crohn's disease, ulcerative colitis, Helicobacter pylori infection, small intestinal bacterial overgrowth and irritable bowel syndrome.
They found rosacea patients were 46% more likely than controls to have celiac disease; 45% more likely to have Crohn’s disease; 19% more prone to ulcerative colitis; and had a 34% higher rate of irritable bowel syndrome.
The co-occurrence of Helicobacter pylori infection and small intestinal bacterial overgrowth was significantly higher among patients with rosacea at baseline, but the risk of developing incident Helicobacter pylori infection or small intestinal bacterial overgrowth during follow-up was insignificant, the study’s lead author Alexander Egeberg, M.D., Ph.D., department of dermatology and allergy, Herlev and Gentofte Hospital, Hellerup, Denmark, tells Dermatology Times.
“This suggests that Helicobacter pylori infection and small intestinal bacterial overgrowth may precede the onset of rosacea (and may perhaps cause rosacea, but this is speculative); whereas, it does not appear that rosacea increases the risk of Helicobacter pylori infection or small intestinal bacterial overgrowth,” Dr. Egeberg says.
Implications for dermatologists
In dermatology practice, Dr. Egeberg says he and colleagues often see rosacea patients who complain of gastrointestinal ailments.
“Depending on what symptoms they present with, this may affect our choice of therapy (e.g. tetracycline [versus] doxycycline), and we sometimes refer our patients to gastroenterologists for further examinations and management,” he says.
It’s interesting to note, the dermatologist says, that some but not all studies have suggested rosacea improves following gastrointestinal disorders treatment.
“For example treatment of small intestinal bacterial overgrowth and Helicobacter pylori infections have in some studies resulted in a remarkably high remission rate of rosacea symptoms,” Dr. Egeberg says. “It may be relevant to consider a systemic approach, in particular in treatment-resistant cases of rosacea. However, further studies are still needed before specific recommendations can be made.”
Dermatologist Hilary Baldwin, M.D., former president of the American Acne and Rosacea Society and member of the National Rosacea Society medical advisory, tells Dermatology Times that when evaluating the clinical importance of the many reported systemic associations with rosacea, dermatologists need to remember that rosacea is a common condition affecting perhaps 16 million Americans or more.
“Therefore co-occurrence does not necessarily imply pathophysiologic association,” Dr. Baldwin says. “On the other hand, rosacea - like psoriasis - is a chronic inflammatory disease and an association between cardiovascular disease and psoriasis has been repeatedly reported. Inflammation surely plays a prominent role in atherosclerosis, inflammatory bowel disease, rheumatoid arthritis and many neurologic disorders; so, scientific rationale for purported association is evident.”
In the absence of definitive data, it is incumbent upon dermatologists to ask the appropriate questions. But what they do with the answers is less clear, according to Dr. Baldwin.
“The efficacy of doxycycline in the treatment of rosacea is well documented. Several reports have suggested that it may also be of benefit in the treatment and prevention of various cardiovascular ailments,” she says. “In my practice, concerns regarding antibiotic resistance leads me to prescribe sub-antimicrobial doses of doxycycline for my patients with rosacea. I believe that in the absence of conclusive data, it is prudent to treat rosacea patients with associated inflammatory disorders with anti-inflammatory doses of doxycycline.”
Dr. Egeberg and colleagues are planning experimental studies to elucidate the role of the gastrointestinal microbiome in rosacea. If successful, he says, such studies could potentially lead to the discovery of new treatment targets in the management of rosacea.
Dr. Egeberg has no conflicts of interest on this topic.
Dr. Baldwin is a Galderma consultant.
1 - Egeberg A, Weinstock LB, Thyssen EP, Gislason GH, Thyssen JP. Rosacea and gastrointestinal disorders: a population-based cohort study. Br J Dermatol 2016;176 (1):1365-2133.