Rosacea and Low Stomach Acid by Jeffrey Dach MD

Jim has "Rosacea" of the face for many years, and has accumulated a lengthy list of dermatologists and treatments over the years including various topical creams, gels, and tetracycline antibiotics.  Nothing has really helped.  Lately a new topical gel (Mirvaso brimonidine ) seems to be helping the most , although the facial redness is still present.(see upper left image).
Rosacea is a common problem I see every day in the office affecting 10 million Americans. The appearance is distinctive.  For images of faces with Rosacea, click here.

What causes Rosacea ? 

Mainstream medicine will shrug their shoulders raise their hands and say "we don't know".   As you will read below, we actually do know.
Left image courtesy of National Rosacea Society.

Association with low stomach acid.

Thanks to Jonathan Wright MD who mentions the connection between Rosacea and low stomach acid in his book, Why Stomach Acid Is Good for You.  Dr Wright mentions the work of Dr Brown and others who studied gastric secretions in patients with rosacea.(1-3)  An excellent summary of this research was published by Norman Epstein MD in the 1931 Cal West Med Journal.(4)
Here is the link to the full pdf file: ROSACEA_Hypochlorhydria_Acid_Dr.Epstein_1931
Dr. Norman Epstein found that 75% of his patients with Rosacea had either absent or subnormal stomach acid.  See his data chart below:

CHART 2.- Gastric Secretion Studies         cases    percent total
Achlorhydria- No free HCl . .                          7 cases   29.1%
Marked hypochlorhydria-(Free HCl under 10)  4 cases  16.6%
Hypochlorhydria-(Free HCl under 20) ..           7 cases  29.1%
Lower limits of normal-(Free HCl under 30) ..  3 cases    12.5%
Normal free HC1, (30-45) . .                           3 cases  12.5%
Results: 75 per cent of Rosacea Patients had Low stomach acid

Treatment with Food Enzymes - with Betaine HCL

Dr Wright reports that in his experience, Rosacea resolves in most patients by taking gastric acid (HCL) supplements with meals.  He also recommends digestive enzymes and probiotics as well.  These are available without a prescription at the health food store.  These are widely available on Amazon. Click Here for: Betaine HCL with Pepsinon Amazon.
In the office, we usually use the Food Enzymes from Nature's Sunshine , as this has a good track record and is well tolerated.  We also add in the Probiotic 11 with this.

Mainstream Medicine Ignores this Association

If you are suffering from Rosacea, this information may be new to you, since mainstream dermatologists ignore the association between low gastric acid secretion and continue to treat Rosacea with antibiotics and other drugs which may provide temporary improvement, without addressing the underlying cause.

What Causes Low Stomach Acid ? H Pylori


Low acid production is frequently associated with some form of gastritis or inflammation of the stomach lining which may lead to atrophic gastritis.   A common gastric bacterial infection called H. Pylori has been associated with gastritis and gastric ulcer.   In addition, H. Pylori infection has been associated with Rosacea, and eradication of H Pylori with triple therapy treatment has been reported to "cure" Rosacea.(5-12)   We routinely test for H Pylori and provide treatment with Triple Therapy when this is found.

This article is part three of a series.
for part one: click here
for part two click here.
Link to this article

Jeffrey Dach MD
7450 Griffin Road, Suite 190
Davie, Fl 33314
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Links and References

Rosacea and gastric analysis
1) http://archderm.jamanetwork.com/article.aspx?articleid=503981
AYRES, SAMUEL. "Gastric secretion in psoriasis, eczema and dermatitis herpetiformis." Archives of Dermatology and Syphilology 20.6 (1929): 854-859.
2) http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2133.1935.tb09852.x/abstract
BROWN, W. HERBERT, Mary S. Smith, and ALLISON D. McLACHLAN. "Fractional gastric analysis in diseases of the skin: Further observation in 316 cases, with special reference to rosacea." British Journal of Dermatology 47.5 (1935): 181-190.
3) Ryle, J. A., and H. W. Barber. "GASTRIC ANALYSIS IN ACNE ROSACEA." The Lancet 196.5076 (1920): 1195-1196.
4) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1657916/
Cal West Med. Aug 1931; 35(2): 118–120.
ACNE ROSACEA WITH PARTICULAR REFERENCE TO GASTRIC SECRETION by Norman Epstein and David Susnow
*From the Department of Dermatology of the University of California Medical School, and the Mount Zion Hospital in San Francisco.
5) http://archderm.jamanetwork.com/article.aspx?articleid=558369
Eradication of Helicobacter pylori as the Only Successful Treatment in Rosacea. Klaudia Kolibášová, MD, PhD; Ingrid Tóthová, MD; Jan Baumgartner, MD; Viliam Filo, MD, PhD
Arch Dermatol. 1996;132(11):1393.
6) http://www.ncbi.nlm.nih.gov/pubmed/10695558
J Physiol Pharmacol. 1999 Dec;50(5):777-86.
Helicobacter pylori and its eradication in rosacea.
Szlachcic A1, Sliwowski Z, Karczewska E, Bielański W, Pytko-Polonczyk J, Konturek SJ.
Rosacea is a common condition of unknown etiology usually accompanied by gastrointestinal symptoms and favorably responding to the treatment with antibiotics. This study was designed to examine the prevalence of gastric Helicobacter pylori (Hp) infection verified by 13C-UTB-test, CLO, Hp culture and serology (IgG) in patients with rosacea. Gastroduodenoscopy was combined with pentagastrin secretory test and antral and fundic biopsy samples were taken for histological evaluation (the Sydney system). Blood samples were also taken for the determination of plasma gastrin using RIA and plasma interleukin (IL)-8 and tumor necrosis factor alpha (TNFalpha) using ELISA. This study was performed in 60 patients, 31-72 year old, with visible papules and pustules associated with erythema and flushing on the face and on 60 age- and gender-matched patients without any skin diseases but with similar as in rosacea gastrointestinal symptoms but without endoscopic changes in gastroduodenal mucosa (non-ulcer dyspepsia - NUD). The Hp prevalence in rosacea patients was about 88 % as compared to 65% in control NUD patients. Among rosacea patients, 67% were cytotoxin associated gene A (CagA) positive, while in NUD patients only 32% were CagA positive. Rosacea patients showed gastritis with activity of about 2.1 in antrum and 0.9 in the corpus of the stomach while those with NUD only mild gastritis with activity of approximately 1.0) confined to the antrum only. Following initial examination, typical 1 wk anti-Hp therapy including omeprazole (20 mg bd.), clarithromycin (500 mg bd.) and metronidazol (500 mg bd.) was carried out. After eradication, 51 out of 53 treated rosacea patients became Hp negative. Within 2-4 weeks, the symptoms of rosacea disappeared in 51 patients, markedly declined in 1 and remained unchanged in 1 other subject. A dramatic reduction in activity of gastritis (to 0.3 in antrum and to 0.1 in corpus) was observed. Basal plasma gastrin decreased from 48 +/- 5 pM before to 17+/-3 pM after eradication, while pentagastrin-induced maximal (MAO) declined, respectively, from about 16.6 +/- 4.2 to 8.5 +/- 1.8 mmol/h. Plasma TNFalpha and IL-8 were reduced after the therapy by 72% and 65%, respectively. We conclude that: 1) Rosacea is a disorder with various gastrointestinal symptoms closely related to gastritis, especially involving the antrum mucosa, with Hp expressing cagA in the majority of cases and elevated plasma levels of TNFalpha and IL-8; 2) The eradication of Hp leads to a dramatic improvement of symptoms of rosacea and reduction in related gastrointestinal symptoms, gastritis, hypergastrinemia and gastric acid secretion; and 3) Rosacea could be considered as one of the major extragastric symptoms of Hp infection probably mediated by Hp-related cytotoxins and cytokines.
7) http://archderm.jamanetwork.com/article.aspx?articleid=477886
Effect of Treatment of Helicobacter pylori Infection on Rosacea FREE   Joel T. M. Bamford, MD; Robert L. Tilden, DrPH, MPH; Janet L. Blankush, RN; David E. Gangeness, PharmD
From the Department of Dermatology (Dr Bamford) and the Division of Education and Research (Drs Tilden and Gangeness and Ms Blankush), St Mary's–Duluth Clinic Health System, Duluth, Minn.
Arch Dermatol. 1999;135(6):659-663. doi:10.1001/archderm.135.6.659.
Conclusions  Rosacea abated in most participants in this study, whether they were in the treatment or the control cohort. There was no statistical difference when the results of active treatment were compared with those of placebo. Treating H pylori infection has no short-term beneficial effect on the symptoms of rosacea to support the suggested causal association between H pylori infection and rosacea.
8) http://www.ncbi.nlm.nih.gov/pubmed/12890101
Int J Dermatol. 2003 Aug;42(8):601-4.
Incidence of anti-Helicobacter pylori and anti-CagA antibodies in rosacea patients.  Argenziano G1, Donnarumma G, Iovene MR, Arnese P, Baldassarre MA, Baroni A.
1Department of Dermatology, Faculty of Medicine and Surgery, II University of Naples, Naples, Italy.
In recent years some authors have reported a possible correlation between Helicobacter pylori (Hp) and dermatological diseases such as rosacea. In this study we evaluated serum IgG and IgA anti-Hp in a group of 48 patients with rosacea. IgG antibodies were present in 81% of the rosacea patients with dyspepsia and 16% of the rosacea patients without dyspeptic symptoms. Serum IgG and IgA anti-Hp were detected by means of an enzymatic immunoabsorption test (enzyme-linked immunosorbent assay: ELISA). In addition, an evaluation of the anti-CagA antibodies by means of an immunoenzymatic method was carried out (ELISA, RADIM). IgA anti-Hp was present in 62% of patients with dyspepsia and in 6% of patients with no upper gastrointestinal symptoms. Anti-CagA antibodies were seen to be present in 75% of patients with both rosacea and gastric symptomatology, and were prevalent in patients affected by rosacea with papular symptoms in respect to rosacea with erythematous symptoms. The data that emerge from our case studies appear to confirm the hypothesis put forward by scientists who propose a correlation between the two clinical presentations rather than an inverse hypothesis of total independence.
9) J Eur Acad Dermatol Venereol. 2002 Jul;16(4):328-33.
The link between Helicobacter pylori infection and rosacea.
Szlachcic A.    Department of Physiology, Jagiellonian University Medical College ul Grzegórzecka 16, Kraków, Poland.
Rosacea is a common condition of unknown aetiology that is usually accompanied by gastrointestinal symptoms and responds favourably to treatment with antibiotics.
AIMS/METHODS: This study was designed to examine the prevalence of gastric Helicobacter pylori (Hp) infection verified by 13C-UBT, CLO-test, Hp culture and serology (IgG and IgA) and the presence of Hp in the oral cavity evidenced by CLO-test, Hp culture and saliva anti-Hp antibodies (IgG and IgA). During gastroduodenoscopy antral and fundic biopsy samples were taken for histological evaluation (the Sydney system). This study was performed on 60 subjects 30-70 years old with visible cutaneous rosacea symptoms and 60 age- and gender-matched controls without skin diseases but with dyspeptic symptoms similar to those of rosacea and without endoscopic changes in gastroduodenal mucosa (non-ulcer dyspepsia--NUD).
RESULTS:The Hp prevalence in rosacea patients was about 88%, compared to 65% in the NUD controls. A noticeable number of rosacea patients showed chronic active gastritis predominantly in antrum but also in the corpus while those with NUD showed only mild gastritis confined to the antrum only. Following the initial examination, a typical 1 week systemic anti-Hp therapy, induding omeprazole (2 x 30 mg), clarithromycin (2 x 500 mg) and metronidazole (2 x 500 mg), plus gargling and application of metronidazole paste in the case of Hp oral cavity infection. After the application of the systemic and local therapy in the oral cavity, Hp was eradicated from the stomach in 97% and from the oral cavity in 73% of treated patients. Within 2-4 weeks, the symptoms of rosacea disappeared or decreased markedly in 51 subjects.
SUMMARY:We conclude that: (1) rosacea is a disorder with various gastrointestinal symptoms closely related to gastritis, especially involving the antrum mucosa; (2) the eradication of Hp leads to improvement of symptoms of rosacea and reduction in related gastrointestinal symptoms; (3) the lack of improvement of cutaneous symptoms in rosacea after eradication of Hp from the gastric mucosa could depend on bacteria in the oral cavity; and (4) rosacea could be considered as one of the extragastric symptoms of Hp infection probably mediated by Hp-related cytotoxins and cytokines.
10) http://www.ncbi.nlm.nih.gov/pubmed/10071314
J Am Acad Dermatol. 1999 Mar;40(3):433-5.
Helicobacter pylori eradication treatment reduces the severity of rosacea.  Utaş S1, Ozbakir O, Turasan A, Utaş C.
A higher prevalence of Helicobacter pylori infection in rosacea patients than in healthy controls has been reported.
OBJECTIVE:The aim of this study was to investigate the effect of H. pylori eradication therapy in patients with rosacea.
METHODS:Twenty-five rosacea patients and 87 age- and sex-matched healthy controls were included in this study. We detected IgG and IgA antibodies against H. pylori in both groups. An upper gastrointestinal endoscopy and a rapid urease test were performed on the 13 patients with rosacea who accepted this procedure. Amoxicillin 500 mg 3 times daily, metronidazole 500 mg 3 times daily, and bismuth subcitrate 300 mg 4 times daily were administered to patients positive for H. pylori. The severity of rosacea was scored before and after treatment.
RESULTS:There was no statistical difference in seropositivity in either group. In H. pylori-positive rosacea patients there was a significant decrease in the severity of rosacea at the end of the treatment as compared with the initial scores.
CONCLUSION:Our findings suggest that H. pylori may be involved in rosacea and that eradication treatment may be beneficial.

Jeffrey Dach MD
7450 Griffin Road, Suite 190
Davie, Fl 33314
954-792-4663

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