⚠ Evidence warning: Clinical trials or other evidence do not support the claim that H. pylori increases reactive oxygen species and nitric oxide and so promotes the vascular dilation of rosacea. This page keeps it as a report of what people, websites or other media say.

Rosacea

Rosacea — scientific infographic poster

Table of Contents

Rosacea at a Glance

Rosacea is a chronic inflammatory skin condition that primarily affects the central face — the cheeks, nose, chin, and forehead. It is characterized by persistent redness, visible blood vessels, and in some cases, acne-like bumps and skin thickening. A 2018 review of 32 studies covering more than 26 million people estimated that about 5.46% of adults worldwide have rosacea; estimates were higher in questionnaire studies than in studies where a doctor examined the skin.

From a naturopathic perspective, rosacea is far more than a surface-level skin condition. It is a systemic inflammatory disorder with deep connections to the gut, immune system, and vascular health. While conventional treatment focuses primarily on symptom suppression, naturopathic medicine seeks to identify and address the underlying drivers of inflammation, immune dysregulation, and microbial imbalance that fuel this condition.

Rosacea typically begins after age 30 and follows a progressive course if left unaddressed. Early signs include a tendency to flush or blush easily, followed by persistent redness that does not resolve. Over time, visible blood vessels, papules, pustules, and in some cases, tissue overgrowth may develop.

Subtypes of Rosacea

The 2002 National Rosacea Society system classified rosacea into four main subtypes, though many patients show features of more than one subtype at the same time. In 2017 the society's expert committee replaced these subtypes with a classification based on phenotypes: a person is described by the features they actually have (such as persistent redness, flushing, bumps, thickened skin or eye signs), because research showed that one shared disease process lies under all of these features. The four 2002 subtypes are described below.

1. Erythematotelangiectatic Rosacea (ETR)

This is the most common subtype and is characterized by:

ETR reflects underlying vascular instability and heightened neurovascular reactivity. The blood vessels in rosacea-affected skin are abnormally responsive to stimuli that would not cause visible flushing in unaffected individuals.

2. Papulopustular Rosacea

Often mistaken for acne, this subtype involves:

This subtype involves a stronger immune and inflammatory component, with elevated levels of cathelicidin antimicrobial peptides and matrix metalloproteinases in the skin.

3. Phymatous Rosacea

The least common but most disfiguring subtype, characterized by:

Rhinophyma, the bulbous enlargement of the nose, was historically and incorrectly attributed to excessive alcohol consumption. While alcohol can worsen rosacea, rhinophyma is a result of chronic rosacea-driven tissue remodeling.

4. Ocular Rosacea

This subtype affects the eyes and can occur independently of skin symptoms:

Ocular rosacea is frequently underdiagnosed. Up to 50% of rosacea patients may have some degree of eye involvement. In severe cases eye involvement can damage the cornea and affect vision.

Who Rosacea Affects

A 2018 review of 32 studies estimated that rosacea affects about 5.46% of adults, women (5.41%) somewhat more often than men (3.90%), and mostly people aged 45 to 60. Groups reported to be at higher risk include:

Causes and Theories

The exact cause of rosacea remains incompletely understood, but research has identified several interconnected factors that contribute to the disease.

Demodex Mites

Demodex folliculorum and Demodex brevis are microscopic mites that live in human hair follicles and sebaceous glands. While present on most healthy adults, rosacea patients harbor significantly higher densities of Demodex — often 5 to 10 times more than unaffected skin. The mites contribute to rosacea through several mechanisms:

Cathelicidin and LL-37

Cathelicidin is an antimicrobial peptide produced by the innate immune system. In rosacea, there is an overproduction of cathelicidin and its active fragment LL-37. The enzyme kallikrein 5 (KLK5) cleaves cathelicidin into LL-37 at abnormally high levels in rosacea skin. LL-37 is a potent promoter of:

This cathelicidin dysregulation is considered one of the central pathological mechanisms in rosacea.

Vascular Dysfunction

Rosacea involves abnormalities in the blood vessels and nerves of the facial skin:

The Gut Connection

The gut-rosacea connection is one of the most compelling areas of emerging research:

H. pylori — Helicobacter pylori is a stomach bacterium. H. pylori increases the production of reactive oxygen species and nitric oxide, promoting vascular dilation. A 2017 review that pooled 14 studies (928 people with rosacea and 1,527 without) found a weak link between the infection and rosacea that did not reach statistical significance overall (odds ratio 1.68, P = 0.052); the link was significant only in studies that tested with the urea breath test (odds ratio 3.12). Some individual studies reported rosacea improvement after the infection was cleared, but pooled across seven studies, clearing it had no significant effect on rosacea symptoms (risk ratio 1.28). The authors wrote that whether the infection causes rosacea, or simply marks other factors, remains unknown.

Small Intestinal Bacterial Overgrowth (SIBO) — A 2008 Italian study found small intestinal bacterial overgrowth in 52 of 113 people with rosacea (about 46%) compared with 3 of 60 healthy controls (5%). Among those whose overgrowth was cleared with the antibiotic rifaximin, the skin cleared in 20 of 28 and greatly improved in 6 of 28, while of 20 people given a placebo, 18 stayed the same and 2 got worse. The two dermatologists who judged the skin knew which treatment each person had received, which is a weakness of the study. The proposed mechanism involves bacterial endotoxins entering the bloodstream through a compromised gut lining and triggering the inflammatory cascade that manifests as rosacea.

Common Triggers

Rosacea flares are often provoked by identifiable triggers. Many people with rosacea keep a trigger diary to find their own triggers. Common triggers include:

Environmental Triggers

Dietary Triggers

Lifestyle Triggers

Conventional Treatments

Topical Medications

Oral Medications

Laser and Light Therapy

Natural and Naturopathic Approaches

A naturopathic approach to rosacea addresses the underlying inflammation, immune dysregulation, microbial imbalance, and gut dysfunction that drive the condition.

Azelaic Acid

Azelaic acid occupies a unique position as both a conventional and natural treatment. It is a naturally occurring dicarboxylic acid found in grains such as wheat, rye, and barley. At concentrations of 10-20%, it reduces inflammation, kills Demodex-associated bacteria, and normalizes keratinocyte proliferation. It is well-tolerated and safe for long-term use.

MSM (Methylsulfonylmethane)

MSM is an organic sulfur compound with anti-inflammatory and antioxidant properties. Practitioners use it both by mouth (1-3 g daily) and on the skin for rosacea, and report that MSM helps reduce redness, hydrate the skin, and support the structural integrity of blood vessels; the study evidence named here is for a topical cream. A topical cream containing MSM and silymarin (from milk thistle) has been studied with positive results for rosacea.

Omega-3 Fatty Acids

Eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) are potent anti-inflammatory agents that help resolve the chronic inflammation underlying rosacea. They reduce pro-inflammatory eicosanoids, support vascular health, and may help with ocular rosacea symptoms. Naturopathic practitioners commonly use 2,000-3,000 mg of combined eicosapentaenoic acid/docosahexaenoic acid daily from fish oil or algal sources.

Probiotics

Given the strong gut-rosacea connection, probiotics are a foundational part of the naturopathic approach. Specific strains that have shown benefit include Lactobacillus rhamnosus, Lactobacillus plantarum, and Saccharomyces boulardii. Probiotics help restore gut barrier integrity, reduce endotoxemia, modulate the immune response, and may help address underlying small intestinal bacterial overgrowth and dysbiosis.

Zinc

Zinc supports immune function, wound healing, and has anti-inflammatory properties. Low zinc status has been associated with rosacea. Zinc supplementation at 25-30 mg daily (as zinc picolinate or bisglycinate) may help reduce papules and pustules. Topical zinc preparations can also soothe irritated skin.

B Vitamins

Riboflavin (B2) and niacinamide (B3) are particularly relevant for rosacea. Niacinamide at 500-750 mg daily or applied topically (4-5%) improves skin barrier function, reduces transepidermal water loss, decreases redness, and has anti-inflammatory effects. Niacin (nicotinic acid) is different: it commonly triggers flushing, while niacinamide does not.

Aloe Vera

Aloe vera gel applied topically provides cooling, anti-inflammatory, and hydrating benefits. It contains compounds that inhibit cyclooxygenase and reduce prostaglandin production. Practitioners describe pure aloe vera gel (without added fragrances or alcohol) as a soothing agent and moisturizer for rosacea skin.

Green Tea

Green tea polyphenols, particularly epigallocatechin gallate (EGCG), have significant anti-inflammatory, antioxidant, and anti-angiogenic properties. A topical cream containing green tea extract has been shown to reduce pustule count and redness in rosacea. Oral consumption of 3-4 cups daily provides systemic anti-inflammatory benefits. Green tea also inhibits the activity of MMP-2 and MMP-9, enzymes involved in rosacea-related tissue damage.

Licorice Root Extract (Topical)

Licorice root (Glycyrrhiza glabra) contains glycyrrhizin and licochalcone A, compounds with potent anti-inflammatory and anti-redness properties. Topical preparations containing licorice extract have been shown to reduce erythema, irritation, and itching. Licochalcone A specifically inhibits NF-kB signaling and reduces pro-inflammatory cytokine production in the skin.

Niacinamide (Topical)

Topical niacinamide at 4-5% concentration is one of the most versatile and well-tolerated ingredients for rosacea-prone skin. Benefits include strengthened skin barrier, reduced sensitivity, decreased redness, improved hydration, and anti-inflammatory effects. It can be used in combination with other topical treatments and is safe for long-term daily use.

Small Intestinal Bacterial Overgrowth Treatment Protocol

Given the strong association between small intestinal bacterial overgrowth and rosacea, testing for and treating small intestinal bacterial overgrowth is an important component of the naturopathic approach.

Testing

A lactulose or glucose breath test measures hydrogen and methane gases produced by bacteria in the small intestine. Elevated levels indicate bacterial overgrowth. Newer tests also measure hydrogen sulfide, a third gas now recognized as a small intestinal bacterial overgrowth subtype.

Herbal Antimicrobial Protocol

Herbal antimicrobials have been shown to be as effective as the antibiotic rifaximin for small intestinal bacterial overgrowth eradication. A typical protocol includes a combination of the following, taken for 4-6 weeks:

Prokinetics

After small intestinal bacterial overgrowth treatment, practitioners use prokinetic agents to prevent relapse by supporting the migrating motor complex (MMC), the cleansing wave that sweeps bacteria from the small intestine between meals:

Gut Healing for Rosacea

Beyond small intestinal bacterial overgrowth treatment, comprehensive gut healing is often necessary for lasting rosacea improvement.

Remove

The first step of this practitioner framework removes factors thought to damage the gut: food sensitivities (common culprits include gluten, dairy, and eggs), excess alcohol, nonsteroidal anti-inflammatory drugs (NSAIDs), and unnecessary antibiotics. Some practitioners also test for H. pylori and treat it if present (see the 2017 review above on how much clearing it changes rosacea).

Replace

Support adequate digestive function with digestive enzymes if needed, and ensure sufficient stomach acid production. Low stomach acid (hypochlorhydria) contributes to small intestinal bacterial overgrowth by failing to sterilize incoming bacteria. Betaine HCl with pepsin may be appropriate for some patients.

Reinoculate

Restore a healthy microbiome with probiotics (as discussed above) and prebiotic foods such as garlic, onions, asparagus, and artichokes. Prebiotics may at first worsen symptoms in people with small intestinal bacterial overgrowth, so practitioners usually introduce them slowly.

Repair

Support gut lining repair with nutrients including:

Anti-Inflammatory Diet

Dietary modification is a powerful tool in rosacea management. An anti-inflammatory diet reduces systemic inflammation, supports gut health, and minimizes dietary triggers.

Foods Featured in Anti-Inflammatory Diets

Foods People Report as Triggers

Gentle Skincare for Rosacea

Rosacea-affected skin has a compromised barrier and heightened sensitivity. Skincare guidance for rosacea generally describes a minimal, gentle routine.

Cleansing

Moisturizing

Sun Protection

Ingredients Reported to Irritate Rosacea Skin

Cautions and Considerations

Key Research Papers

  1. Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors. J Am Acad Dermatol. 2015;72(5):749-758. — PubMed PMID: 25890455
  2. Two AM, Wu W, Gallo RL, Hata TR. Rosacea: part II. Topical and systemic therapies in the treatment of rosacea. J Am Acad Dermatol. 2015;72(5):761-770. — PubMed PMID: 25890456
  3. Yamasaki K, Di Nardo A, Bardan A, et al. Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea. Nat Med. 2007;13(8):975-980. — doi:10.1038/nm1616
  4. Stein L, Kircik L, Fowler J, et al. Efficacy and safety of ivermectin 1% cream in treatment of papulopustular rosacea: results of two randomized, double-blind, vehicle-controlled pivotal studies. J Drugs Dermatol. 2014;13(3):316-323. — PubMed PMID: 24595578
  5. Parodi A, Paolino S, Greco A, et al. Small intestinal bacterial overgrowth in rosacea: clinical effectiveness of its eradication. Clin Gastroenterol Hepatol. 2008;6(7):759-764. — doi:10.1016/j.cgh.2008.02.054
  6. Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: report of the National Rosacea Society Expert Committee on the classification and staging of rosacea. J Am Acad Dermatol. 2002;46(4):584-587. — doi:10.1067/mjd.2002.120625
  7. Tan J, Berg M. Rosacea: current state of epidemiology. J Am Acad Dermatol. 2013;69(6 Suppl 1):S27-S35. — doi:10.1016/j.jaad.2013.04.043
  8. Del Rosso JQ, Thiboutot D, Gallo R, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 5: a guide on the management of rosacea. Cutis. 2014;93(3):134-138. — PubMed PMID: 24738094
  9. Forton FMN, De Maertelaer V. Two consecutive standardized skin surface biopsies: an improved sampling method to evaluate Demodex density as a diagnostic tool for rosacea. Acta Derm Venereol. 2017;97(2):242-248. — doi:10.2340/00015555-2528
  10. Egeberg A, Hansen PR, Gislason GH, Thyssen JP. Clustering of autoimmune diseases in patients with rosacea. J Am Acad Dermatol. 2016;74(4):667-672. — doi:10.1016/j.jaad.2015.11.004
  11. Schwab VD, Sulk M, Seeliger S, et al. Neurovascular and neuroimmune aspects in the pathophysiology of rosacea. J Investig Dermatol Symp Proc. 2011;15(1):53-62. — doi:10.1038/jidsymp.2011.6
  12. Mikkelsen CS, Holmgren HR, Kjellman P, et al. Rosacea: a clinical review. Dermatol Reports. 2016;8(1):6387. — doi:10.4081/dr.2016.6387
  13. Jørgensen AR, Egeberg A, Gideonsson R, et al. Rosacea is associated with Helicobacter pylori: a systematic review and meta-analysis. J Eur Acad Dermatol Venereol. 2017;31(12):2010-2015. — PubMed PMID: 28543746
  14. Gether L, Overgaard LK, Egeberg A, Thyssen JP. Incidence and prevalence of rosacea: a systematic review and meta-analysis. Br J Dermatol. 2018;179(2):282-289. — PubMed PMID: 29478264
  15. Gallo RL, Granstein RD, Kang S, et al. Standard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78(1):148-155. — PubMed PMID: 29089180
  16. Stein-Gold L, Kircik L, Draelos ZD, et al. Topical Oxymetazoline Cream 1.0% for Persistent Facial Erythema Associated With Rosacea: Pooled Analysis of the Two Phase 3, 29-Day, Randomized, Controlled REVEAL Trials. J Drugs Dermatol. 2018;17(11):1201-1208. — PubMed PMID: 30500142
  17. Gold LS, Del Rosso JQ, Kircik L, et al. Minocycline 1.5% foam for the topical treatment of moderate to severe papulopustular rosacea: Results of 2 phase 3, randomized, clinical trials. J Am Acad Dermatol. 2020;82(5):1166-1173. — PubMed PMID: 32004648

Historical Background

Rosacea was first described in the 14th century by the French surgeon Guy de Chauliac, who called it "goutterose" (French for "pink droplet"). The English dermatologist Thomas Bateman provided the first detailed clinical description in 1812. The modern classification into four subtypes was established by the National Rosacea Society Expert Committee in 2002, led by Jonathan Wilkin, and was replaced by a phenotype-based classification in the committee's 2017 update. The discovery of elevated cathelicidin LL-37 in rosacea skin by Richard Gallo and colleagues in 2007 was a landmark finding that reshaped understanding of the disease's pathophysiology.

PubMed Topic Searches

Curated PubMed topic searches of peer-reviewed literature on Rosacea. Each link opens a live PubMed query so you always see the most current studies.

  1. PubMed: Rosacea pathogenesis
  2. PubMed: Ivermectin and Demodex
  3. PubMed: Topical brimonidine
  4. PubMed: Low-dose doxycycline
  5. PubMed: IPL and laser therapy
  6. PubMed: Rosacea and SIBO
  7. PubMed: H. pylori and rosacea
  8. PubMed: Dietary triggers
  9. PubMed: Ocular rosacea
  10. PubMed: Azelaic acid therapy
  11. PubMed: Rhinophyma treatment
  12. PubMed: Cathelicidin and inflammation

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Connections

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