Rosacea and Low Stomach Acid by Jeffrey Dach MD

Rosacea and Low Stomach Acid by Jeffrey Dach MDRosacea 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.

Rosacea2Left 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.

Click Here for: Betaine HCL with Pepsin/  on Amazon.

Click here for probiotic Lactobacillus GG Culturelle on Amazon.

Click Here for  Pure Encapsulations Digestive Enzyme Ultra with HCL.

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 ? Association of Rosacea with 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.(5-13)   We routinely test for H Pylori and provide treatment with Triple Therapy when this is found.

Ivermectin Cream  for Rosacea Caused by Parasitic Mite

One school of thought is that Rosacea is caused by a parasitic mite, the Demodex folliculorum mite. If so, then the anti-parasitic drug ivermectin would be indicated. In 2016, Dr Ekert treated 34 cases of rosacea with 1% ivermectin topical cream.  She a good response for most

“All patients were treated with topical IVM 1% carbohydrate cream base, which was prescribed once a day at night-time, to be applied in a thin layer without rubbing it in for 2 months….The best responses were found in patients with moderate to severe rosacea, with improvement being produced in both the vascular component as well as with papulopustular rosacea ….In our experience topical IVM (Ivermectin) cream can be an effective treatment for rosacea. Our series demonstrates better results with moderate to severe papulopustular rosacea as in the cases studied in trials. Nevertheless, we have also observed some response in mild cases of erythemato telangiectatic rosacea as well. Tolerance of ivermectin cream is high and produces quick results.”(14)

The latest dermatology literature places topical Ivermectin Cream as the most effective of the various creams in the dermatology armamentarium.(15)  Whether the mode of action (MOA) is anti-parasitic, or anti-inflammatory is yet to be determined.(16-19)

Local Pharmacy Availability of Ivermectin topical Cream Soolantra (r)

Conclusion: Rosacea treatments depend on prevailing thought as to the etiology.  The various treatments are listed above.  Replacing low gastric acid with a supplement and applying topical Ivermectin cream seem the most promising therapies.

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

Links and References

Rosacea and gastric analysis

AYRES, SAMUEL. “Gastric secretion in psoriasis, eczema and dermatitis herpetiformis.” Archives of Dermatology and Syphilology 20.6 (1929): 854-859.

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.

Cal West Med. Aug 1931; 35(2): 118–120.
*From the Department of Dermatology of the University of California Medical School, and the Mount Zion Hospital in San Francisco.

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.

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.

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.

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.

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.

11)  The Whole Journey Stomach Acid Balance and Acne

12) Jonathan Wright Newsletter: Stomach Acid and Rosacea

13) DIAZ, CAMILO, et al. “Rosacea: A Cutaneous Marker of Helicobacter pylori Infection? Results of a Pilot Study.” Acta Derm Venereol 83 (2003): 282-286. Rosacea Cutaneous Marker Helicobacter pylori Infection Acta Derm Venereol DIAZ CAMILO 2003

14) Mendieta Eckert, Marta, and Nerea Landa Gundin. “Treatment of rosacea with topical ivermectin cream: a series of 34 cases.” Dermatology online journal 22.8 (2016). Treatment of rosacea with topical ivermectin cream 34 cases Mendieta Eckert Dermatology 2016

15) Husein‐ElAhmed, Husein, and Martin Steinhoff. “Efficacy of topical ivermectin and impact on quality of life in patients with papulopustular rosacea: A systematic review and meta‐analysis.” Dermatologic Therapy.
This meta‐analysis gives strong evidence that IVM 1% cream is the most effective topical treatment above other alternatives and it satisfies the impairment of social and working life with a sustained better QoL

16)  Ebbelaar, Chiel Cristiano F., Aalt W. Venema, and Maria R. Van Dijk. “Topical ivermectin in the treatment of papulopustular rosacea: A systematic review of evidence and clinical guideline recommendations.” Dermatology and therapy 8.3 (2018): 379-387.

17) Dall’Oglio, Federica, et al. “Clinical and erythema-directed imaging evaluation of papulo-pustular rosacea with topical ivermectin: a 32 weeks duration study.” Journal of Dermatological Treatment (2019): 1-5.
Background: Ivermectin (IVM) 1% cream represents an emerging therapy for papulo-pustular rosacea (PPR) and erythema-directed photography is a useful tool for evaluation of patient’s erythema. Objective: The aim of our study was to assess the efficacy of IVM in PPR in achieving clear status at 8 weeks or at 20 weeks followed by respectively 24 and 12 weeks follow-up, using clinical/instrumental evaluation. Methods: Twenty patients with PPR were instructed to apply IVM for 8 weeks. At week 8, in case of complete response the therapy was stopped and a follow-up period up to 24 weeks was carried out, whereas in case of improvement the treatment was extended for additional 12 weeks followed by a 12 weeks follow-up. Instrumental evaluation was performed by erythema-directed digital photography (VISIA-CRTM- RBXTM). Results: At week 8, complete response was observed in 31.6% of cases along with a significant decrease of erythema degree. During treatment extension, additional improvement in terms of complete response, respectively at 12 (42%), 16 (47%) and 20 (58%) weeks, and reduction of erythema degree was observed. Conclusions: IVM is a valuable therapeutic option in mild/moderate PPR. Erythema-directed digital photography enhances erythema changes visualization compared to clinical observation alone.
18) Del Rosso, James Q. “Topical Ivermectin: Data Supporting Dual Modes of Action in Rosacea.” The Journal of clinical and aesthetic dermatology 10.9 (2017): 39.

IVM may provide direct biologic effects that are anti-inflammatory in rosacea and are unrelated to its anti-parasitic properties1

19) De Ménonville, Séverine Thibaut, et al. “Topical treatment of rosacea with ivermectin inhibits gene expression of cathelicidin innate immune mediators, LL-37 and KLK5, in reconstructed and ex vivo skin models.” Dermatology and therapy 7.2 (2017): 213-225.

Ivermectin 10 mg/g cream, indicated for the treatment of inflammatory lesions of rosacea, is reported to have dual anti-parasitic and anti-inflammatory properties. However, the exact mechanism of action of ivermectin cream in the treatment of rosacea is unknown.

Leaky Gut in Rosacea patients- Elevated Zonulin Levels

Yüksel, Mavişe, and Gözde Ülfer. “Measurement of the serum zonulin levels in patients with acne rosacea.” Journal of Dermatological Treatment 33.1 (2022): 389-392.

Objective: Although the etiopathogenesis of acne rosacea has not yet been clearly elucidated, it has been discussed over the years that autoimmunity may play a role. Genetic and environmental factors are known to have combined effects in the background of autoimmunity, but it has recently been emphasized that an impaired intestinal barrier system is also involved in the development of the disease. Zonulin is a protein that reversibly increases intestinal permeability. This study aimed to evaluate the zonulin levels in acne rosacea.

Methods: A total of 61 individuals, 30 diagnosed with acne rosacea and 31 healthy controls, were included in this study. There was no difference between the two groups in terms of age, gender, and body mass index. Zonulin was studied using the enzyme-linked immunosorbent assay.

Results: The serum zonulin levels were found to be significantly higher in the patient group than in the control group (18.5 ± 2.9 ng/ml and 13.2 ± 2.7 ng/ml, respectively; p < .001).

Conclusion: This is the first study in the literature to demonstrate that the serum zonulin levels are increased in patients with acne rosacea.

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

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Rosacea and Low Stomach Acid by Jeffrey Dach MD
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6 thoughts on “Rosacea and Low Stomach Acid by Jeffrey Dach MD

  1. Great three part series, Dr. Dach. Very insightful — what test do you use in the office to diagnose H. pylori? And do you find eradication helps increase and recover acid production? I’m also assuming AFTER you treat the H. Pylori you then add the probiotic and enzymes? And how long would they need the enzymes (forever or you wean them off gradually?. Sorry for all the questions — insightful articles do that to us researchers! Thanks again for the cool insight.
    Dan Purser MD

  2. Pingback: Acid Reflux Medication Pantoloc Drug Study | Natural Remedies for Acid Reflux

  3. Pingback: How to Balance Stomach Acid and Improve Acne & Rosacea FAST! | The Whole Journey

  4. Suzie from Wichita

    Hi Dr. Dach I read your article on Rosacea and low stomach acid that my naturopath gave me. I showed it to my dermotologist who noted the 1931 publishing date. We want to know if
    there is a more current case study done to support this article? She has never heard of this connection at any of the Rosacea clinics she has attended. I am testing this out for myself by taking HCL 3x a day before meals. I’ve been doing this for 2 weeks. I’m using Metronidazole
    gel (a prescription) 2x a day after cleansing with Vanicream soap. When should I expect results in using HCL? Thank you for responding to my inquiry. Susie ( please:

    Did you read the email I sent or just send a generic reply? I was not asking for medical advice. I wanted to know if there had been a more recent case study done on HCL and rosacea. I would think that you could answer that question. Please reply if you can answer the question thank

    • Hi Susie,

      You can tell your dermatologist that the results of the 1931 study are just as valid in 2017.

      Maxwell’s equations of electromagnetism were published in the 1800’s .

      Does this mean electricity is outdated and we no longer use it? of course not.

      That is rubbish.

      Same with medical studies that are based on human physiology.

      Human physiology in 1931 is the same human physiology in 2017. The idea that these studies are somehow discredited is rubbish.

      regards, dr d

  5. Hi Dr. Dach,
    After reading this article and a few others with a similar message I have started taking HCL slowly working my way up. I noticed you also recommended taking a digestive enzyme and a probiotic. Do you recommend taking them at the same time?
    In the event that my stomach acid level is normal could the enzyme and probiotic help on there own?

    Thanks for everything

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