Latest news with #rosacea
Medscape
7 days ago
- Health
- Medscape
Gut Health in Rosacea: Diet, Probiotics, and the Microbiome
Growing evidence suggested that the skin and gut may be more closely linked than once thought — especially in chronic inflammatory conditions like rosacea. In a comprehensive review recently published in Biomolecules , Marco Manfredini, MD, from the Department of Dermatology at the University of Modena and Reggio Emilia, Modena, Italy, and colleagues explored the evolving science around how diet, gut microbiota, and probiotics may influence rosacea pathogenesis and symptom severity. While more clinical studies are needed, the review highlighted new pathways linking gastrointestinal dysbiosis to cutaneous inflammation. The authors proposed that specific dietary modifications and the use of probiotics could support traditional treatment approaches for certain patients. Pathogenesis of Rosacea: A Multifactorial Inflammatory Process Rosacea arises from a complex interplay of multiple contributing factors. 'The pathogenesis of rosacea continues to be a subject of investigation,' the authors wrote, involving 'dysregulation of the innate immune response and neuropeptide activity, microbial involvement, environmental factors, dietary triggers, and skin barrier dysfunction.' Central to these mechanisms is the innate immune system. In rosacea, elevated levels of kallikrein-5 trigger excessive processing of antimicrobial peptides into proinflammatory fragments such as LL-37. These fragments promote oxidative stress, cytokine release, and blood vessel changes, contributing to the inflammation and vascular symptoms seen in the disease, according to the authors. Neurovascular dysregulation is also a hallmark of the disease. The authors noted, 'activation of TRPV1 [Transient Receptor Potential Cation Channel Subfamily V Member 1] and related channels by environmental triggers like heat and UV [ultraviolet] radiation exacerbate flushing and erythema by promoting vasodilation and neurogenic inflammation.' These channels are hypersensitive in patients with rosacea, contributing to enhanced symptom severity. While the skin microbiome — particularly Demodex folliculorum and its associated Bacillus oleronius — has long been considered a contributing factor, recent attention has turned to the gut. 'Emerging evidence suggests that while microorganisms may not be central causative factors… alterations in the skin microbiome across multiple rosacea subtypes may act as trigger factors or potentiate inflammation,' the review authors wrote. 'Gastrointestinal dysbiosis, including conditions such as Helicobacter pylori infection and small intestinal bacterial overgrowth (SIBO),' they noted, 'has been hypothesized as a potential contributor to rosacea development.' Gut Dysbiosis and the Skin: The Available Evidence The concept of a gut–skin axis describes the bidirectional relationship between intestinal microbiota and skin inflammation. In rosacea, this relationship is supported by associations with conditions like SIBO, H pylori infection, and inflammatory bowel diseases, as highlighted in the Manfredini review. Asked to comment on this emerging topic, Rajani Katta, MD, clinical professor of dermatology at the McGovern Medical School, University of Texas, Houston, noted, 'We have strong evidence linking gut dysbiosis to rosacea, but it is important to note that this applies only to certain patients. In other words, only a subset of patients with rosacea seems to have gut dysbiosis, and in those patients, there appears to be a link.' Rajani Katta, MD Katta added that the most compelling mechanisms relate to inflammation. 'Patients with SIBO may have higher levels of inflammatory mediators, such as tumor necrosis factor alpha. In other studies, gut dysbiosis can lead to the activation of specific inflammatory pathways like the kallikrein-kinin pathway. Activation of these pathways has multiple downstream effects, which may ultimately increase neurogenic inflammation in the skin.' The review by Manfredini and colleagues supported these theories, citing studies that show improvement in rosacea symptoms following SIBO eradication, although the benefit of H pylori treatment is less clear. 'The association between Helicobacter pylori infection and rosacea remains complex and influenced by several confounding factors,' the authors wrote. 'The antibiotic treatment required for H pylori eradication represents an important confounding factor.' The authors caution that without large-scale prospective studies examining the gut microbiome before and after intervention, firm conclusions about causality remain elusive. Dietary Triggers: What the Evidence Supports Dietary factors may influence rosacea by promoting vasodilation, activating sensory receptors, or altering the gut microbiome. Yet, data on specific triggers remain mixed, according to the authors. Asked to comment on dietary triggers in rosacea, Lauren Kole, MD, associate professor of dermatology at the University of Alabama at Birmingham, said that 'the best data for dietary triggers for rosacea are for alcohol and hot beverages. Alcohol may induce peripheral vasodilation, promote inflammation, modulate the immune system, and may trigger histamine release. Hot beverages may cause direct vasodilation and trigger other pathways that lead to flushing, stinging, and sensitive skin.' Katta also noted that alcohol and hot beverages 'are common triggers, likely because they lead to vasodilation, which causes flushing.' She also highlighted spicy foods as a culprit. 'Foods that contain capsaicin may result in vasodilation and thus flare rosacea, so avoiding spicy foods may be helpful.' Another category included foods that contain cinnamaldehyde — a compound found in cinnamon, tomatoes, and citrus —which may trigger flushing in sensitive individuals, according to Katta. Katta recommended a practical approach for patients. 'For most patients, a 6-week trial of eliminating the most commonly reported food triggers in rosacea is a good first step… I tell patients that it can take 6 weeks of avoiding these foods to see if it will be helpful, and I recommend a food diary.' Interestingly, certain foods may offer benefits. Dairy products have been associated with reduced rosacea severity in some populations, potentially because of their anti-inflammatory effects. High-fiber diets may support gut microbial diversity and caffeine — despite its reputation — has been inversely associated with rosacea in large observational studies, cited in the Manfredini review. Probiotics: Potential but Preliminary Probiotics are another area of growing interest. These live microorganisms may influence rosacea by rebalancing the gut microbiome, reducing inflammatory cytokine production, and enhancing skin barrier function, according to the authors. 'Dietary probiotics may help normalize skin dysbiosis in rosacea and may limit substance P-induced skin inflammation,' said Kole. She referenced a study that found improved skin barrier function and reduced sensitivity with oral probiotic use alongside doxycycline therapy. Katta said that she has not used probiotics for rosacea in her practice. 'Preliminary results appear intriguing, but there are still many questions about the optimal strain of probiotics as well as dose and duration,' she told Medscape Medical News . She added that the current evidence is 'too preliminary to recommend specific strains or delivery routes, although some have shown benefit,' referencing studies on strains of Bifidobacterium , Lactobacillus , and Escherichia coli Nissle included in the Manfredini review. Topical formulations are also being explored with promising results, and a product containing Vitreoscilla filiformis has shown reductions in facial erythema and Demodex density while improving transepidermal water loss, according to the review's authors. However, mirroring Katta's sentiment, the authors concluded that 'despite promising results, the evidence supporting the use of probiotics in the treatment of rosacea remains relatively limited. Further clinical trials are necessary to evaluate and compare the effectiveness of various probiotic strains and different methods of delivery, such as oral ingestion and topical use.' Looking Ahead: Clinical Considerations and Research Needs While the current research is promising, more rigorous studies are needed. 'One of the research areas that I'd love to see more of,' Katta said, 'is measuring rates of gut dysbiosis in patients with rosacea, with prospective studies examining gut microbiome composition before and after treatment, and how that correlates to rosacea severity.' For now, clinicians may consider an individualized approach, she said, and asking about gastrointestinal symptoms, evaluating for common dietary triggers, and discussing a food elimination trial can be helpful strategies. Although formal probiotic guidelines for rosacea are lacking, some patients may benefit from a monitored trial of supplementation — particularly if they also have gut-related complaints, she added. 'There are many gaps in our understanding of the gut–skin axis,' Katta emphasized. 'But it's an exciting area of dermatologic research.'
Medscape
21-05-2025
- Health
- Medscape
Lasers Designed for Acne and Aging Effective for Rosacea
ORLANDO, Fla. — For decades, pulsed dye laser (PDL) has been an established treatment for rosacea, with intense pulsed light (IPL) emerging as a more recent alternative. But new energy-based approaches also appear promising, especially for hard-to-treat disease subtypes. At The American Society for Laser Medicine and Surgery (ASLMS) 2025 Annual Meeting, specialists shared experimental strategies for treating rosacea and other vascular skin conditions, including rare presentations and severe subtypes. Several of the treatment strategies involved energy-based devices designed for other indications. Acne-Targeting Laser for Papulopustular and Phymatous Rosacea Dermatologist Hyemin Pomerantz, MD, who practices in Wellesley, Massachusetts, presented results from an observational study using a 1726 nm laser, which is designed to treat acne by selectively targeting sebaceous glands, in patients with mild to severe papulopustular rosacea. In this disease subtype, papules and pustules occur alongside redness and inflammation. The idea for the study, Pomerantz said at the meeting, came from her observations of treating patients with acne using the device. 'It works well for inflammatory papules in acne vulgaris,' she noted. And in a small, unpublished split-face study using the device in patients with acne, Pomerantz and her colleagues saw that inflammatory symptoms also improved on the untreated side. 'We were wondering if there might be a systemic influence of the device in lowering inflammation,' she said. 'We then wondered if it would help the inflammatory aspect of papulopustular rosacea.' The five patients in Pomerantz's study ranged in age from 31 to 50 years; three were women. Four had failed oral antibiotics or topical therapies, and one responded to these therapies but wanted to avoid medication because she was pregnant. Patients underwent 1-3 laser treatments spaced 1 month apart. While the oldest patient saw less improvement than the rest, all experienced visible improvement, Pomerantz reported. This argument, she said, called for further investigation of the 1726 nm laser as a treatment for rosacea. While some sebaceous gland involvement is thought to occur in all rosacea, phymatous rosacea is characterized by the overgrowth of these glands, often on the nose (rhinophyma). This growth can also affect other areas of the face. Usual treatment involves surgery, which may result in more severe scarring and other adverse effects in patients with disease in areas besides the nose. At the meeting, David Hashemi, MD, who practices dermatology in Neptune, New Jersey and New York City, presented two cases using the 1726 nm laser in two men, aged 62 and 60 years, with severe, disfiguring phymatous rosacea. The first patient underwent electrosurgery on the nose, followed by 1726 nm laser treatment on the cheeks and chin. Similar to what Pomerantz observed in her inflammatory acne pilot study, the patient saw improvement in an untreated area — the forehead. The second patient, treated with the laser only, experienced halted progression and clinical improvement. In an interview, Hashemi said he had also used the device on a patient with the more common erythematotelangiectatic subtype of rosacea, which is characterized by redness and flushing, and the benefit was less pronounced. Still, he noted, papulopustular rosacea 'is almost as common as the redness type. And then when it starts to get into the phymatous category, that's where we see the most significant results' from the 1726 nm laser. Phymatous presentations are rare, Hashemi said, but can be difficult to treat. 'The eye, the chin, the cheeks, the forehead — you don't necessarily want to be doing electrosurgery in those areas.' Commenting on the findings by Hashemi and Pomerantz, dermatologist Paul M. Friedman, MD, who practices in Houston and is a past president of the ASLMS, praised them as an example of 'utilizing existing technology outside of the box to target and go after challenging conditions.' Tightening Laser Shows Surprise Benefit Against Redness A 1550 nm laser with 'focal point' technology, designed to promote skin tightening in all skin types, also works on facial erythema, according to results presented by Dieter Manstein, MD, PhD, of the Cutaneous Biology Research Center at Massachusetts General Hospital in Boston. 'Typically, you wouldn't pick a 1550 nm laser for treatment of vascular lesions,' Manstein said at the meeting. But in a prospective study enrolling 31 patients with facial erythema (ages 22-66 years; 71% women; Fitzpatrick skin types I-IV), Manstein found that erythema was reduced by a mean 30% after an average of four treatments with the device ( P < .05), administered at 4- to 6-week intervals. Blinded evaluations of pre- and posttreatment photos were used to determine treatment effect, and the improvement was sustained at 3-month follow-up. The device used in the study creates a conical shape that allows for less involvement of the epidermis while delivering high energy deeper into the dermal layers. Although the 1550 nm wavelength has no selectivity for blood vessels, as with the PDL, the focal point laser can seal small blood vessels by generating a pattern of coagulation zones within the dermis. In an interview following his presentation, Manstein said his results 'serve as a reminder that for the treatment of abnormal blood vessels, we might want to also consider concepts other than the classic 'selective photothermolysis,' he said, referring to the established laser treatment model using wavelengths that selectively target hemoglobin. 'To use a nonselective laser for treatment of blood vessels is a game changer.' In a separate presentation, Roy Geronemus, MD, of NYU Langone Health, New York City, who also has a private practice in New York City, showed the case of an older adult woman patient with a severe port wine stain he successfully treated using the 1550 nm focal point laser. Port wine stains are a type of vascular lesion that can begin as a birthmark and thicken and redden over time. These, too, are usually treated with PDLs. In an interview, Geronemus said that he has been using the device experimentally for treatment-resistant port wine stains and seeing success. 'We are working right now on a case series, a retrospective analysis of our efforts to improve port wine stains that haven't responded as well as we'd like to laser treatment, and also some of the hypertrophic or thicker stains that are more difficult to treat,' he said. The laser 'is helping a variety of vascular [skin] conditions. This is a sort of an accidental finding,' Geronemus added, noting that his own investigations were inspired by findings from Manstein's group. 'There's a lot to explore there.' PDL: An Option for Refractory Ocular Rosacea Rosacea blepharitis, also known as ocular rosacea, occurs when inflamed facial blood vesselsrelease proinflammatory cytokines that propagate to the eyelids, disrupting the function of the eye's meibomian glands and causing dry eye symptoms. Though cases have been treated successfully with IPL, a team of dermatologists at the Naval Medical Center, San Diego, presented results from a split-face placebo-controlled trial using a 595 nm PDL. They chose this approach, they said, because it had the advantages of a smaller handpiece to maneuver, no need for pretreatment anesthesia, easier cleanup, and possible therapeutic benefits over standard treatment. Monica Borza, DO, presented findings from five patients referred to the hospital's dermatology service from ophthalmology. Four were treated with PDL on one side of the face, including the periocular area, cheek, and forehead, and received sham treatment on the opposite hemiface, while one patient was treated on both sides. Treatment was performed every month for 4 months, and intraocular metal eye shields were used in all patients. Borza reported that the PDL treatment was safe and well tolerated and that all patients had significant improvement on the treated side, according to assessments by ophthalmologists using a validated disease scoring tool. She noted that this was the first time PDL had been investigated in patients with rosacea blepharitis and may offer a more practical option for dermatologists over IPL. Commenting in an interview on the study by Borza and her colleagues, Manstein said he found the results intriguing for a different reason. 'For years, we have treated rosacea with the idea that skin improves only where you directly aim the laser,' he said. 'Here we saw that treating the skin adjacent to the eye reduced an inflammation of the eye. I would like to know whether this represents the kind of anti-inflammatory 'field effect' we are seeing in the other studies.' What the findings from the conference collectively show, Manstein continued, 'is that we still don't know everything about rosacea and that a paradigm change may be underway.' Geronemus disclosed financial relationships (consulting, contract research, and/or speaker fees) with Accure, Allergan, AbbVie, Avava, BellaMia Technologies, Inc., Candela Medical, Cynosure Lutronic, Cytrellis Biosystems, Inc., Galderma, Novoxel, Sofwave Medical, Solta Medical, and the New York Stem Cell Foundation. Friedman disclosed financial relationships with Acclaro, Allergan, Candela Medical, Cytrellis Biosystems, Inc., Merz Aesthetics, R2, and Solta Medical. Manstein is a co-founder of Blossom Innovations, the company that manufactures the AVAVA (1550 nm) device used in his study, and reported relationships with German Medical Engineering, R2, Shiseido, and IPG Photonics. Pomerantz is a consultant for Accure.
