Rosacea is a chronic, inflammatory skin condition that primarily affects approximately 5% of adults over the age of 30, impacting both men and women. It most commonly appears on the central areas of the face, including the cheeks, nose, chin, and forehead. The presentation of rosacea can vary, with symptoms often flaring up and subsiding unpredictably. This condition is also associated with various gastrointestinal issues, such as inflammatory bowel conditions, small intestinal bacterial overgrowth (SIBO), and Helicobacter pylori infection. A nationwide cohort study in Denmark reported that people with rosacea have a 46% increased risk of developing celiac disease, a 45% increased risk of Crohn’s disease, and a 19% increased risk of ulcerative colitis.
Rosacea is divided into four distinct subtypes: erythematotelangiectatic rosacea (ETR), papulopustular rosacea (PPR), phymatous rosacea, and ocular rosacea. In the early stages, rosacea often presents as ETR, but as the condition progresses, individuals may develop more severe symptoms such as papules, pustules, visible blood vessels (telangiectasia), and skin thickening, particularly around the nose (rhinophyma).
Subtypes of Rosacea
Erythematotelangiectatic Rosacea (ETR) is the most common form. It is characterized by persistent redness (erythema) and visible blood vessels (telangiectasia) on the central face. Flushing is common and usually manifests as sudden episodes of warmth and redness in the skin. This subtype is typically seen in the early stages of rosacea, where inflammation is more widespread and less localized.
Papulopustular Rosacea (PPR) involves the appearance of papules and pustules, resembling acne vulgaris, but without clogged pores (comedones). Like ETR, it is accompanied by persistent facial redness and visible blood vessels. Lesions often appear around the eyes and nose, and unlike acne vulgaris, PPR lacks comedones, which helps differentiate it from acne.
Phymatous Rosacea is marked by skin thickening, primarily due to sebaceous gland enlargement and connective tissue proliferation. This stage is most commonly seen in the nose, where it is referred to as rhinophyma, but it can also affect other areas, including the chin, forehead, cheeks, and ears. Phymatous changes indicate a later-stage manifestation of rosacea.
Ocular Rosacea affects the eyes and occurs in over 50% of rosacea patients. Symptoms include dryness, irritation, light sensitivity (photophobia), conjunctivitis, and blepharitis (inflammation of the eyelids). In severe cases, ocular rosacea can lead to corneal inflammation and vision impairment. This subtype is often underdiagnosed because its symptoms can be subtle or mistaken for other eye conditions.
Diet and Nutritional Support
The gut microbiota plays a significant role in the development of rosacea. Dysbiosis (microbial imbalance), SIBO, Helicobacter pylori infection, and dysfunctions in the innate immune system all contribute to the condition. Certain dietary factors, such as hot beverages, alcohol, spicy foods, and histamine-rich foods, may trigger symptoms by promoting vasodilation. For example, alcohol metabolites like acetaldehyde and acetic acid can release histamine, exacerbating redness and swelling. Similarly, cinnamaldehyde found in foods like cinnamon, tomatoes, carrots, and chocolate may activate vasodilation and worsen rosacea symptoms.
Histamine-rich foods, including fermented products, spinach, tomatoes, and some fruits, can promote vasodilation and inflammation, especially in individuals with histamine intolerance. In these cases, reduced activity of diamine oxidase leads to a buildup of histamine, resulting in heightened sensitivity. Additionally, niacin (vitamin B3), found in liver, tuna, and peanuts, can trigger flushing and potentially worsen rosacea. Reducing histamine-producing and heat-inducing foods, while improving gut health, may help manage symptoms.
Skin Microbiota and Probiotics
Maintaining a healthy skin microbiome, with probiotics and gentle skincare routines, can help mitigate these responses. Certain strains of Lactobacilli have been shown to inhibit substance P-induced skin inflammation and improve skin barrier function, reducing sensitivity. Probiotics can also reduce transepidermal water loss and enhance skin hydration.
Environmental and Genetic Triggers
Environmental factors, such as heat and UV radiation, can exacerbate rosacea by promoting vasodilation and neurogenic inflammation. These triggers often worsen flushing and erythema (redness), which are hallmark symptoms of rosacea. Stress is another factor that can trigger or worsen rosacea, as it may activate an abnormal immune response in both the gut and skin.
Conclusion
Rosacea is a complex condition influenced by genetic, environmental, and immune factors. While there is no single cause, a combination of gut microbiota imbalance, dietary triggers, and skin microbiota disturbances likely play key roles in its development. A multifaceted approach, like what naturopathic medicine provides, includes gut health improvement, dietary modifications, stress reduction, and gentle skin care, can significantly reduce symptoms and improve quality of life for those affected by this chronic condition.
References
Manfredini, M., Barbieri, M., Milandri, M., & Longo, C. (2025). Probiotics and Diet in Rosacea: Current Evidence and Future Perspectives. Biomolecules, 15(3), 411. https://doi.org/10.3390/biom15030411
Parhizkar, E., Vosough, P., Baneshi, M., Keshavarzi, A., Lohrasbi, P., Taghizadeh, S., & Savardashtaki, A. (2025). Probiotics and gut microbiota modulation: implications for skin health and disease management. Archives of microbiology, 207(3), 68. https://doi.org/10.1007/s00203-025-04267-6
