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Rosaceans are rosacea sufferers

Chicken or the Egg? What do you think?

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Image courtesy of sodahead.com

Whenever the subject of demodex mites comes up there is the age old quandary, which came first the demodex or the rosacea? This question was first proposed by Frank Powell, M.D., in an article, Something to Blush About, in the Ivanhoe Newswire. [1]

The NRS published an article in July 2012 that states, “now there may be some evidence that the “chicken” —Demodex mites — and not the “egg” comes first, according to a recent scientific report.”  [2] This article comments on the work of “researcher Dr. F.M.N. Forton [who] has championed the mite as a key culprit behind the development of the condition, noting it may be the missing link in understanding the onset of subtype 2 (papulopustular) rosacea.”

David Pascoe  published an editorial on this subject where he states under the subheading, Dreaming, that “this theory is pretty far fetched.” [3]

While neither Powell or Forton dogmatically say whether the demodex or the rosacea is first, both are saying the evidence points to the demodex mites as coming first. No one really knows for sure.

The articles written about demodex and rosacea are prolific. [4]  There doesn’t seem to be any end to researchers writing about demodectic rosacea which, without a doubt, more will be coming down the pipeline for us to read about and comment on.

For example, recently there is a report that two proteins from B.oleronius found on demodex mites may cause an inflammatory response in rosacea patients. [5] So which comes first the bacteria or the mites?  Does it really make any difference?  Apparently to some which comes first is very important.

So while the jury is still out on this subject, What do you think?  Which comes first, the demodex or the rosacea? Does it even matter?  The point is that there is some evidence that demodectic rosacea needs to be ruled out.  So if you make a choice, which comes first, be careful. Being dogmatic on this subject might get some egg on your face.

 

image courtesy of sodahead.com

End Notes

[1] Powell is quoted as saying: “In other words, which came first: the mites or the rosacea?” study author Frank Powell, M.D., consultant dermatologist at Mater Misericordiae Hospital in Dublin, Ireland, was quoted as saying. “And now there is evidence that it might be the mites.”

Something to Blush About, Medical Breakthoughs, Ivanhoe Newswire, December 11, 2007

[2]  The Chicken, not the Egg?
National Rosacea Society, Thursday, July 5, 2012

[3] More Demodex Dreaming: Mites are the Chicken?
by David Pascoe, July 24th, 2012

[4] For a partial list of papers on demodex and rosacea click here

[5] Positive correlation between serum immuno-reactivity to Demodex-associated Bacillus proteins and Erythematotelangiectic Rosacea.
O’Reilly NMenezes NKavanagh K.
Br J Dermatol. 2012 Jun 18. doi: 10.1111/j.1365-2133.2012.11114.x.

Cathelicidin Peptide LL-37

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image courtesy of ION CHANNEL MEDIA GROUP LTD

In an article published in PLoS ONE [1] stated that “The cause of rosacea has been proposed as over-production of the cationic cathelicidin peptide LL-37.”  This statement is without a doubt  the result of the work of Gallo, et. al, at the University of San Diego that was initially published in Nature Magazine [2].

So what is cationic cathelicidin peptide LL-37?  It is an Antimicrobial peptide (AMP) which is part of our immune system that attack invading bacteria or other microbes to defend our body. There has been some evidence that rosacea may be a result of an immune system disorder. [3] Gallo, mentioned earlier, said in 2004, that rosacea may be an “abnormality in the innate immune system … caused by too much cathelicidin.”  He is also quoted as saying “if we believe that the disease is caused by too much cathelicidin, we could develop a strategy to block the effects of the cathelicidins by making molecules that mimic that protein but don’t have the same effects.” [4]

When reading these articles, one might conclude that the theory of what causes rosacea is over and that cathelicidin is the culprit. However, the article only said that the “cause of rosacea has been proposed as over-production of the cationic cathelicidin peptide LL-37.”  The jury is still out on what causes rosacea. [5]

However, it is important to note that as Dr. Gallo pointed out, “if we believe that the disease is caused by too much cathelicidin” then the treatment might be radically different.  Antibiotics are regularly used to treat rosacea and may be treating the wrong target. [6] So this new article published in PloS One by Zhang, et. al, “tested a new class of non-anticoagulant sulfated anionic polysaccharides, semi-synthetic glycosaminoglycan ethers (SAGEs)”  on mouse skin. The result:

“Topical application of a 1% (w/w) SAGE emollient to overlying injected skin also reduced erythema and PMN infiltration from intradermal LL-37.”

So we wait and see what will become of this new treatment for rosacea based on the theory that the cause is an overproduction of Cationic Cathelicidin Peptide LL-37.

End Notes

[1] Novel Sulfated Polysaccharides Disrupt Cathelicidins, Inhibit RAGE and Reduce Cutaneous Inflammation in a Mouse Model of Rosacea.
Zhang J, Xu X, Rao NV, Argyle B, McCoard L, Rusho WJ, Kennedy TP, Prestwich GD, Krueger G.
PLoS One. 2011 Feb 9;6(2):e16658.

[3] Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea
Kenshi Yamasaki1, Anna Di Nardo1, Antonella Bardan1, Masamoto Murakami2, Takaaki Ohtake3, Alvin Coda1, Robert A Dorschner1, Chrystelle Bonnart4,5, Pascal Descargues4,5, Alain Hovnanian4,5,6, Vera B Morhenn1 & Richard L Gallo1
Nature Medicine 13, 975 – 980 (2007)
Published online: 5 August 2007 | doi:10.1038/nm1616

[3] Innate Immune Response
post by Brady Barrows, Director of the RRDi

[4] Innate immunity: Role in rosacea?
Michelle Stephenson
Dermatology Times, June 1, 2004
posted at Rosacea Support Group

[5] Cause of Rosacea Revisited

[6] Dr. Gallo is quoted as saying, “Antibiotics tend to alleviate the symptoms of rosacea in patients because some of them work to inhibit these enzymes [STCE]. Our findings may modify the therapeutic approach to treating rosacea,since bacteria aren’t the right target.”
UCSD Researchers Discover Cause of Rosacea
By Debra Kain, University of California, San Diego, August 7, 2007

Image Credit
Image of  Solution structure of the LL-37 core peptide bound to detergent micelles courtesy of ION CHANNEL MEDIA GROUP LTD.


4% Quassia amara extract for Rosacea

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Image courtesy of TROPILAB® INC
Image courtesy of TROPILAB® INC

A new article released today on PubMed suggests 4% Quassia amara extract for Rosacea. The article concluded:

“Topical quassia extract could be a new, efficient, and safe weapon in the armamentarium for the management of rosacea.”

Click here for a copyrighted photo of Quassia.

Wikipedia says quassia amara is “used for the bitterwood or quassia, its heartwood, used as a febrifuge; this contains quassin, a bitter-tasting substance (it is, in fact, the bitterest substance found in nature). Extracts of Q. amara bark containing quassinoids are used as insecticides, being particularly useful against aphids on crop plants [1]. It is also used to flavor aperitifs and bitters which are added to cocktails.”

We will await anecdotal evidence in the online rosacea groups to confirm the effectiveness of quassia extract for rosacea.

More rosacea news:
http://www.rosaceans.com/news.php

PubMed source of article

Candidiasis

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A Spanish public research organisation has developed a monoclonal antibody that detects a protein of Candida famata. The antibody detects candidiasis and retinopathies in samples from blood, urine, aqueous humour, vitreous humour, and cerebral spinal fluid without interference from other species of Candida. The antibody is also useful for monitorization of antifungal treatments efficacy. Pharma and biotech companies are sought for exploitation under a patent license agreement.

Candidiasis has been reported to be linked to rosacea in at least one clinical paper. [1] There are some anecdotal reports that have been collected about this which you may be interested in reading. [2] There obviously needs to be more research on this subject. More info on this image is available at note number 3. Candidiasis is another rosacea mimic. [4]

[1] Candida Albicans and rosacea

[2] Anecdotal Reports

[3] Image courtesy of European Technologies

[4] http://rosaceans.com/rosacea_mimics.php

NRS Reports Form 990 for 2009

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The National Rosacea Society has reported the required Form 990 for 2009 which is late this year. The report stated that “additional time is required to compile all data necessary to file a complete and accurate return.”  This is understandable when you review the Form 990 for 2009 and compare it with previous returns, especially the one for 2008.  More information is included in the Form 990 for 2009, such as, the salaries for Glendale and Park Employees are included in the report for 2009 which amounted to a total of $183,491 while these salaries were not reported in Form 990 for 2008 by comparison.  What do the salaries of Glendale and Park have to do with the NRS?  These are private corporations that are reported on Form 990 used by the NRS as independent contractors which three of the board of directors of the NRS are employees of. [1] The Form 990 reports for 2005, 2006, and 2007 also reported these salaries, while reports previous to 2005 never mention these salaries (the report for 2008 also omits these salaries). The Internal Revenue Service obviously wants the NRS to report these salaries so the public can know how a non profit spends its donated funds.

The economy may have affected the NRS as the rest of us since revenues are down 20% from the previous year. The total revenue received by the NRS for 2009 is reported to be $633,576.  Of this total received the NRS spent $69,725 on rosacea research grants. This means that for every dollar donated to the NRS eleven cents was spent on rosacea research grants. Where did the rest of the donated funds go?  $449,824 of the total funds received which amounts to 74% went to the two independent contractors, Glendale and Park, both of which are owned by the director of the NRS (three of the board members of the NRS are also employees of Glendale and Park including the director of the NRS).  [1]

I have been following the NRS reports to the IRS by reading their Form 990 reports since 1998.  Over this period the NRS has received $9,177,103 in revenue and of this revenue $942,971 has been spent on rosacea research which is a twelve year run.  That means over the past twelve years for every dollar donated to the NRS a little over ten cents is spent on rosacea research. Where did all the rest go?  Basically over this same period 62.5% went to independent contractors that are owned by Sam Huff, Director of the NRS.  [2]

The NRS reports on Form 990 for 2009 that 22.73% of the donated funds are from public support, meaning not from private corporations, i.e., pharmaceutical companies. In 2008 this public support is reported to be 35.1% which shows that in 2009 this public support has dropped probably due to the economy. [3] The NRS web site reports $88,150 in ‘individual donations.’ [4] Rosaceans continue to support the NRS with substantial donations and usually have no clue about what the NRS reports on Form 990 which is public knowledge. If those who donate from the public would see how the NRS spends its funds for themselves and actually take a look at what the NRS reports to the Internal Revenue Service each year on Form 990, they might have some questions about how these donated funds are spent. It takes about ten minutes to take a cursory look at Form 990 to get an overall review of revenues and expenses but if you want a nut shell version of how the NRS has been doing for a twelve year period you can click here for a report.

If you want to do something about this click here.

References

[1] Sam Huff, Glendale & the NRS

[2] For a complete breakdown of revenue and expenses of the NRS from 1998 thru 2009 click here.

[3] Form 990 Report - Schedule A, page 2, Section C, 14, 15

[4] http://www.rosacea.org/about/financial.php

Do You Have a Gut Feeling?

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A new study confirms antibiotics mess with the gut.  The study, published in the Proceedings of the National Academy of Sciences, supports the common wisdom that antibiotics can damage the ‘good’ germs living in the body. [1]

Another article suggests five ways to kill bugs in your gut and one of these suggestions is to stop eating sugar which I have been saying for over eleven years will help your rosacea. Dr. Hyman, the writer of the article suggests that what is in your gut may be the problem for a number of health problems including skin diseases. [2]

Clearing up any unhealthy bugs and getting a healthy flora may improve not only the skin but also a number of other health issues and “relief from allergies, acne, arthritis, headaches, autoimmune disease, depression, attention deficit, and more–often after years or decades of suffering.”

Bacteria has been one of the theories postulated as the cause of rosacea but this has never been proven. If bacteria isn’t involved the question is always asked, then, why do antibiotics clear rosacea? The usual response is the anti-inflammatory role of antibiotics is what treats rosacea. There is now a very low dose antibiotic like Oracea used to treat rosacea. However, the long term risks of antibiotic treatment is something to consider which may include an upset stomach, antibiotic resistance and bacterial overgrowth.

But the question is whether do you have a gut feeling about rosacea?  And antibiotics without a doubt plays a role in the gut.  Do you feel that rosacea is somehow related to something going wrong in your gut?

Most rosaceans use  trigger avoidance in their treatment of rosacea and the subject of diet triggers ALWAYS comes up.  Rosaceans have a gut feeling that what they are eating and drinking may have something to do with their rosacea but can’t seem to get a handle on it.  While most rosaceans on the internet know that sugar is a potential rosacea trigger, the NRS still hasn’t added sugar to their ‘official trigger list.’

For more than eleven years my Rosacea Diet has been published explaining why sugar is a rosacea trigger and more rosaceans have confirmed that reducing sugar in the diet does indeed help control their rosacea. Sugar is feeding your rosacea which makes it warm, red, and glowing.

There has been some discussion of how treating IBS, SIBO and H Pylori has helped rosacea. You might want to read this interesting post by Nanobugs, especially the last part of the post. So maybe you have a gut feeling that your rosacea is related to what you are eating and drinking.  Maybe your gut is trying to tell you something.

For more information:

[1] Study confirms antibiotics mess with gut
ABC Science, Maggie Fox, Reuters, Tuesday, 14 September 2010
Original Article

[2] 5 Steps to Kill Hidden Bugs in Your Gut That Make You Sick
Mark Hyman, MD
The Huffington Post . September 30, 2010

More Info:

Rosacea 101: Includes the Rosacea Diet

H Pylori Controversy

SIBO and Rosacea

Update on the above article with more info

The Demodex Rosacea Controversy

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A new report says, “Because Demodex mites are ubiquitous, their potential as human pathogens has often been ignored. This contribution focuses on the growing body of evidence linking Demodex mites with various skin disorders. Histologically, spongiosis and lymphoid inflammation are regularly seen in follicles containing Demodex mites. In animals, they are well established as a cause of mange, and a human counterpart-demodectic alopecia-appears to exist. There is also a statistical association between Demodex mite density and rosacea, facial itching, and chronic blepharitis. Papulovesicular rosacealike lesions and spiny blepharitis often respond to agents that reduce Demodex numbers. Although these observations are not sufficient to fulfill Koch’s postulates, Koch’s postulates are also not fulfilled for the association between brown recluse spiders and dermal necrosis or the association between streptococci and guttate psoriasis. The evidence linking Demodex mites to human disease has implications regarding treatment.”  [1]

Demodex and its connection with rosacea is probably the most researched and reported topic other than reports on metronidazole. [2] Yet demodex remains a hot topic that is debated and discussed not only by rosaceans but also in the medical community. For example, a couple of noted rosacea online gurus have dismissed the role of demodex in rosacea. One such rosacea guru said, “Rosacea experts all agree that this mite plays no real role in the development of progression of rosacea (except for the odd pustule).”  [3] The other rosacea guru says, “I have always pushed the line that demodex mites have thus far only been proven to be innocent bystanders in rosacea symptoms.” [4]

While demodectic rosacea remains a controversy, it will continue to play a significant role in more research and discussion and the list of articles written on this subject by researchers all over the world will continue to grow.  [5]

Sources

Elston DM.
Department of Dermatology, Geisinger Medical Center, 100 N Academy Ave, Danville, Danville, PA 17822-5206, USA.
Clin Dermatol. 2010 September – October;28(5):502-504.
[2] For a partial list of research articles on demodex click here
[3] page 110 quote
Beating Rosacea Vascular, Ocular & Acne Forms
Geoffrey Nase, Ph.D.
Nase Publications 2001

[4] Mar 29, 2007 R-S post by David Pascoe

[5] For more information on demodectic rosacea click here

H Pylori Controversy in Rosacea

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Copyright 2010 • All Rights Reserved • July 2010 by Brady Barrows

Artist Depiction of H Pylori

H Pylori (Helicobacter Pylori) has been a controversy with rosacea for some time now.  Some experts dismiss H Pylori’s role in rosacea and yet it remains a controversy since other rosacea experts continue to discuss H Pylori as a possible factor in rosacea. A report in January 2010 states that “Helicobacter pylori infection is implicated in the pathogenesis of extradigestive diseases such as acne rosacea…” A report by Mc Leer, Lacey and Powell in 2009 listed H Pylori as a possible factor in the pathophysiology in rosacea. One report in 2003 suggests “some form of relationship between rosacea and H. pylori infection.” Two reports in 1996 suggested H Pylori’s role in rosacea with titles such as “Eradication of Helicobacter pylori as the only successful treatment in rosacea” and “Acne rosacea and Helicobacter pylori betrothed.” Rebora suggested in 1995 that the “role of H. pylori is more probable in erythrotic rosacea than in its papulopustular and granulomatous stages.” [1] These are just a few reports suggesting H Pylori as a factor in rosacea.

When you consider the fact that H Pylori was ‘officially’ discovered in 1986 by Drs Marshall and Warren in Australia who both won the Nobel Prize in 2005 for this discovery and changed the textbooks about how bacteria can survive in the human stomach and its relation to ulcers and other gastric problems and the fact that this gram negative bacteria is considered an infection that half the world’s population is carrying with most being totally asymptomatic it is a wonder that anyone can even connect H Pylori with rosacea at all.  Yet the reports on H Pylori and rosacea keep coming out despite the fact that many reports negate H Pylori’s role in rosacea.

While there are many older reports suggesting H Pylori having some role in rosacea, newer reports dismiss this role. For instance, the late Dr. Kligman noted H Pylori’s controversial role in rosacea in his 2003 report. [2]

A report released in 2002 mentions ‘promising recent reports of beneficial H. pylori eradication’ in many cutaneous skin diseases except rosacea. [3]

A study published in May 2010 concluded, “There is no association between Helicobacter pylori infection and rosacea in current study.” [4]

Nevertheless, there are reports of H Pylori associated with rosacea indicating that eradicating H Pylori clears rosacea and discuss the possible cutaneous pathology of H Pylori to an autoimmune mechanism. A report in 2009 says, a “few case reports have documented associations between Helicobacter pylori infection and rosacea.” [5]

What is H Pylori and how does it relate to rosacea?

H Pylori is a gram negative bacteria that is considered an infection and harmful to humans.

According to one report, “more than 50% of the human population have long-term Helicobacter pylori infection.” [3] Wikipedia says that the diagnosis of H Pylori is done with different tests that are not failsafe and sometimes results in false positives.  How anyone can know for sure that 50% of the human population is infected with H Pylori is quite suspect. The percentage of ‘infection’ of H Pylori, if indeed it is an infection, may be more or less than 50% .

According to Wikipedia, “Helicobacter pylori is a Gram-negative, microaerophilic bacterium that can inhabit various areas of the stomach, particularly the antrum. It causes a chronic low-level inflammation of the stomach lining and is strongly linked to the development of duodenal and gastric ulcers and stomach cancer. Over 80% of individuals infected with the bacterium are asymptomatic.”

So, if 80% of individuals are asymptomatic and they only discovered H Pylori in 1986 how do they know that H Pylori is a human pathogen?  There is an amusing article, “So, What’s Your Problem with Gram-Negative Bacteria??,” that gets you thinking. Do you really think that medical science knows everything about H Pylori in a little over twenty years?  Obviously sometimes H Pylori is a human pathogen and runs amuck causing us problems. But in 80% of individuals H Pylori is asymptomatic and obviously is in the stomach for some reason, possibly for some nefarious purpose such as an ulcer, but it is quite possible for some beneficial purpose as well.  Could it be possible that a gram negative bacteria serves some useful purpose that as yet hasn’t been discovered? For instance, E. coli can help people and animals to digest food and help in providing vitamins but sometimes runs amuck causing some serious food poisoning. Could H Pylori have some beneficial yet undiscovered function for humans yet sometimes cause issues like E. coli does?

Could H Pylori be asymptomatic because it is helping us for some reason yet undiscovered, and sometimes for some yet undiscovered reason turns into a monster that causes problems like ulcers and rosacea?

SIBO has been associated with rosacea with gram negative bacteria associated with it such as H Pylori. One report says, “Gastric acid suppresses the growth of ingested bacteria, thereby limiting bacterial counts in the upper small intestine. Diminished acid production (hypochlorhydria) is arisk factor for SIBO, and can develop after colonization with Helicobacter pylori or as a consequence of aging. [6]

Gram Negative Folliculitis, a rosacea mimic, is an acne condition caused by Gram-negative organisms which usually develops in patients who have received systemic antibiotics for prolonged periods. This is quite odd when you consider that eradicating H Pylori, a gram negative bacterium, clears rosacea in some cases. This certainly raises some questions about using long term antibiotic treatment for rosacea, doesn’t it?

Since eradicating H Pylori involves the use of antibiotics it would be difficult to really know if the H Pylori is truly a factor in rosacea since antibiotics have been used for many years to successfully treat rosacea.  If it were possible to eradicate H Pylori without using antibiotics and rosacea clears up, then, there would be some substantial evidence of H Pylori being a factor in rosacea

According to Wikipedia, “The standard first-line therapy is a one week “triple therapy” consisting of a proton pump inhibitors such as omeprazole, Lansoprazole and the antibiotics clarithromycin and amoxicillin. Variations of the triple therapy have been developed over the years…” Since antibiotics are usually used in the eradication of H Pylori you can see why it would be difficult to know whether the clearing of rosacea is due to the eradication of the H Pylori or simply because antibiotics have been used successfully to treat rosacea for over fifty years.

Nevertheless, there are anecdotal reports that treatment for gastric problems has cleared rosacea.

For instance, one anecdotal report suggests that after treating a patient with gastritis and evidence of GERD that the rosacea cleared. [7]  According to Wikipedia, “In 1999, a review of existing studies found that, on average, 40% of GERD patients also had H Pylori infection. The eradication of H. pylori can lead to an increase in acid secretion, leading to the question of whether H. pylori-infected GERD patients are any different than non-infected GERD patients.  A double-blind study, reported in 2004, found no clinically significant difference between these two types of patients with regard to the subjective or objective measures of disease severity.

A few other anecdotal reports have suggested digestive issues related to their rosacea. [8]

There may be other anecdotal reports suggesting H Pylori eradication clears rosacea which I plan on adding to this page. If you have thoughts on this subject I suggest you post them here. There is a long thread on the SIBO ROSACEA LINK at R-F that is interesting to read if you have the time.

Sources

[1] Helicobacter pylori infection and autoimmune disease such as immune thrombocytopenic purpura
Ohta M.
Kansenshogaku Zasshi. 2010 Jan;84(1):1-8

The pathophysiology of rosacea.
Mc Aleer MA, Lacey N, Powell FC
G Ital Dermatol Venereol. 2009 Dec;144(6):663-71.

Helicobacter pylori and rosacea.
Zandi S, Shamsadini S, Zahedi MJ, Hyatbaksh M
East Mediterr Health J. 2003 Jan-Mar;9(1-2):167-71.

Eradication of Helicobacter pylori as the only successful treatment in rosacea
Kolibásová K, Tóthová I, Baumgartner J, Filo V.
Arch Dermatol. 1996 Nov;132(11):1393.

Acne rosacea and Helicobacter pylori betrothed
Wolf R.
Int J Dermatol. 1996 Apr;35(4):302-3

May Helicobacter pylori be important for dermatologists?
Rebora A, Drago F, Parodi A.
Dermatology. 1995;191(1):6-8

[2] A Personal Critique on the State of Knowledge of Rosacea
Albert M. Kligman, M.D., Ph.D.

[3] Helicobacter pylori infection in skin diseases: a critical appraisal.
Wedi B, Kapp A.
Am J Clin Dermatol. 2002;3(4):273-82.

[4] Risk factors associated with rosacea.
Abram K, Silm H, Maaroos HI, Oona M.
J Eur Acad Dermatol Venereol. 2010 May;24(5):565-71. Epub 2009 Oct 23.

[5] Helicobacter pylori infection and dermatologic diseases.
HERNANDO-HARDER AC, BOOKEN N, GOERDT S, SINGER MV, HARDER H.
Eur J Dermatol. 2009 Sep-Oct;19(5):431-44. Epub 2009 Jun 15.

[6] Small Intestinal Bacterial Overgrowth: A Comprehensive Review
Andrew C. Dukowicz, MD, Brian E. Lacy, PhD, MD, and Gary M. Levine, MD
Gastroenterology & Hepatology Volume 3, Issue 2 February 2007

[7] ice2meetyu’s report July 4, 2010

[8] Rosacea and digestive problems

Classification of Rosacea Remains Controversial

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A report by the new ROSIE [ROSacea International Expert] Group reports that, “Classification of rosacea into stages or subgroups, with or without progression, remained controversial.”  This new group is comprised of “European and US rosacea experts.”  Two of the experts in the group are MAC members of the RRDi,  Dr. Draelos and Dr. Jensen. The report, Rosacea – global diversity and optimized outcome: proposed international consensus from the Rosacea International Expert Group, was released by J Eur Acad Dermatol Venereol. 2010 Jun 23.

This is not a new controversy.  The late Albert Kligman, a noted expert on rosacea, stated in 2003 about the NRS classification of rosacea into four subtypes and one variant:

” In my view this is a vast oversimplification which will not solve the diagnostic dilemmas that confront us. I see no reason not to give equal nosologic status to granulomatous rosacea, rosacea conglobata, rosacea inversa (formerly called pyoderma faciale), rosacea fulminans, edematous rosacea (a devastating variety) or combinations with seborrheic dermatitis, lupus erythematosus, acne vulgaris, and still other variants. Reducing the classification to four sub-types does little to clarify and eliminate the inherent complexities of this mysterious disease.”  [1]

Another report released after the ROSIE group report mentioned above had this remark about how a ‘proper standardization’ is needed:

“It is to be remarked that the quality of most studies evaluating rosacea treatment is rather poor, mainly due to a lack of proper standardization. For a major breakthrough to occur in the management of rosacea, we need both a better understanding of its pathogenesis and the adherence of future clinical trials to clearly defined grading and inclusion criteria, which are crucial for investigators to correctly compare and interpret the results of their work.” [2]

This controversy is based upon the fact that the NRS classification is based not on nosology but rather on symptoms. No doubt this controversy will continue until more is known about the cause of rosacea. Until then, diagnosis of rosacea sometimes results in misdiagnosis.

[1] A Personal Critique on the State of Knowledge of Rosacea
Albert M. Kligman, M.D., Ph.D.

[2] Rosacea Treatments: What’s New and What’s on the Horizon?
Gallo R, Drago F, Paolino S, Parodi A.
Am J Clin Dermatol. 2010;11(5):299-30

Cause of Rosacea Revisited

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Copyright 2010 by Brady Barrows

If you were around in August 2007, there were headlines such as, Scientists unmask the cause of rosacea, [1] and UCSD Researchers Discover Cause of Rosacea [2] not to mention all the other headlines which created quite a stir in all the online rosacea groups and brought a lot of hope for rosacea sufferers. These articles seemed to conclude that rosacea’s mystery is resolved and within time a treatment would be found to eradicate rosacea. These startling headlines were the result of a paper published by researchers at UCSD associated with Richard L Gallo, et.al, in a study published by  Nature Medicine [3]. This paper concluded:

“These findings confirm the role of cathelicidin in skin inflammatory responses and suggest an explanation for the pathogenesis of rosacea by demonstrating that an exacerbated innate immune response can reproduce elements of this disease.”  More info on cathelicidins.

If you will notice in the above statement that the findings suggest an explanation for the pathogenesis of rosacea. Gallo, et.al, never said they found the cause of rosacea.  The newspapers came to the conclusion that now all the mystery of rosacea is over and we now have the cause nailed down. All we have to do is wait for the treatment. This is not exactly the truth.  While the research of Gallo, et.al, at UCSD is remarkable and insightful, the jury is still out on what causes rosacea. And while the jury is still out, there is more news worth mentioning that may be related to cathelicidin, peptides or antigenic proteins.

According to The Irish Times, Irish Scientists blame bacteria as the cause of rosacea according to a different study. This study is the result of researcher Dr Kevin Kavanagh, a senior lecturer in biology at NUI Maynooth. According to The Irish Times, “Working with the Mater hospital, the researchers previously identified a Bacillus bacterium inside Demodex mites. The bacteria release two proteins that trigger an inflammation in patients with facial rosacea.” [4]

At least one type of bacteria is associated with demodex mites and rosacea. This bacteria is Bacillus oleronius according to an NRS press release [5] which quotes Dr. Kavanagh as saying, “This indicates that the Bacillus bacteria found in the Demodex mite produce an antigen that could be responsible for the tissue inflammation associated with papulopustular rosacea.”  A study released in September 2007 by Dr. Frank Powell, et.al, also concluded, “Antigenic proteins related to a bacterium (B. oleronius), isolated from a D. folliculorum mite, have the potential to stimulate an inflammatory response in patients with papulopustular rosacea.” [6] Another study released in January 2010 also said, “The strong correlation provides a better understanding of comorbidity between Demodex mites and their symbiotic B oleronius in facial rosacea and blepharitis.”  [7]

In the recent past, a couple of noted rosacea online gurus have dismissed the role of demodex in rosacea. One such rosacea guru said, “Rosacea experts all agree that this mite plays no real role in the development of progression of rosacea (except for the odd pustule).”  [8] The other rosacea guru says, “I have always pushed the line that demodex mites have thus far only been proven to be innocent bystanders in rosacea symptoms.” [9] However, the NRS continues to sponsor research into demodex and the RRDi just released a paper by Dr. Kosta Y. Mumcuoglu and Dr. Oleg E. Akilov on demodex’s role in rosacea. [10] In fact, there is probably not many other type research with as many papers on the subject of demodex except for a scarce few. [11]

Another theory on the cause of rosacea is that irritable bowel syndrome is related to rosacea. “Rosacea may be a symptom of an unhealthy gastrointestinal system and healing the entire gastrointestinal system may be the basis for eliminating rosacea. Many people with rosacea also have been diagnosed with Irritable Bowel Syndrome (IBS), Crohn’s Disease or some for of Colitis.”  [12]

This theory also is related to bacteria in the gut and that using antibiotics clears rosacea. An article in the St. Louis Dispatch [13] says that one doctor has been prescribing Xifaxan, an antibiotic for gastric problems and reports clearing of rosacea. Previously to this report a study in Italy published that eradicating the bacteria in the gut had improved rosacea. [14]

Another theory that has come up is that SIBO is related to rosacea. The previously mentioned rosacea online guru had this to say about SIBO and rosacea:

“This sort of abstract just make me shake my head. If you read quickly you will think that this abstract suggests that Small Intestinal Bacterial Overgrowth (SIBO) causes rosacea. What this abstract is saying that is that rosacea sufferers seem to have a higher incidence of SIBO than non rosacea sufferers.” [15] “The link between SIBO and the papules and pustules of rosacea is still a mystery.” [16] For more information on rosacea and SIBO click here.

There is also a continuing controversy as to whether H Pylori is a factor in rosacea and I have written an article on this subject for your interest.

So in conclusion, the jury is still out on what causes rosacea but it appears that the jury hasn’t ruled out demodex quite yet, despite what the rosacea gurus tell you. The headlines may one day come to another ’cause’ of rosacea or highlight the ones discussed above. Whatever happens, keep an open mind, since we still don’t know what causes rosacea. We may be surprised one day to actually read a headline that says truthfully what the cause of rosacea is.

For more information on the cause of rosacea and other theories on this subject click here.

[1] Scientists unmask the cause of rosacea
August 06, 2007|Alison Williams, Los Angeles Times Staff Writer

[2] UCSD Researchers Discover Cause of Rosacea
UCSD News Center

[3] Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea
Kenshi Yamasaki1, Anna Di Nardo1, Antonella Bardan1, Masamoto Murakami2, Takaaki Ohtake3, Alvin Coda1, Robert A Dorschner1, Chrystelle Bonnart4,5, Pascal Descargues4,5, Alain Hovnanian4,5,6, Vera B Morhenn1 & Richard L Gallo1
Nature Medicine 13, 975 – 980 (2007)
Published online: 5 August 2007 | doi:10.1038/nm1616

[4] Study finds cause of rosacea
Claire O’Connell
The Irish Times – Tuesday, July 14, 2009

[5] New Study Shows Role for Bacteria in Development of Rosacea Symptoms
NRS Press Release, May 3, 2004, Suzanne Corr / Barbara Palombo

[6] Mite-related bacterial antigens stimulate inflammatory cells in rosacea.
Lacey N, Delaney S, Kavanagh K, Powell FC.
Department of Biology, National University of Ireland, Maynooth, Co. Kildare, Ireland
Br J Dermatol. 2007 Sep;157(3):474-81

[7] Correlation between Ocular Demodex Infestation and Serum Immunoreactivity to Bacillus Proteins in Patients with Facial Rosacea,
Li J, O’Reilly N, Sheha H, Katz R, Raju VK, Kavanagh K, Tseng SC.
Ophthalmology. 2010 Jan 14,

[8] page 110 quote
Beating Rosacea Vascular, Ocular & Acne Forms
Geoffrey Nase, Ph.D.
Nase Publications 2001

[9] Mar 29, 2007 R-S post by David Pascoe

[10] The Role of Demodex Mites in the Pathogenesis of Rosacea and Blepharitis and Their Control
Kosta Y. Mumcuoglu, Ph.D., Oleg E. Akilov, M.D., Ph.D.
Journal of the Rosacea Research & Development Institure, Vol.1, No.1

[11] For a partial list of Demodex in rosacea and acne click here.

[12] Dr. David Dahlman, a Chiropractic Physician with a degree in Nutrition

[13] New way to treat skin disorder
By Cynthia Billhartz Gregorian, St. Louis Post Dispatch, 04/29/2010

[14] Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication.
Parodi A, Paolino S, Greco A, Drago F, Mansi C, Rebora A, Parodi A, Savarino V.
Department of Internal Medicine, Gastroenterology Unit, University of Genoa, Genoa, Italy.
Clin Gastroenterol Hepatol. 2008 Jul;6(7):759-64

[15] SIBO eradication clears rosacea: are you serious ?
May 7th, 2008, by David Pascoe

[16] Gut Bacteria and Xifaxan get some press coverage
April 30th, 2010, by David Pascoe

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