The time has come to move beyond only thinking of rosacea as a skin-based disease, according to an international expert.
While presenting at the Australasian Society for Cosmetic and Procedural Dermatologists Symposium last month, Professor Firas Al-Niaimi put a question to the audience: is rosacea a systemic disease?
Professor Al-Niaimi argued that rosacea could be viewed as a systemic type of low-grade inflammation, not unlike cardiometabolic syndrome or psoriasis.
As a result, rosacea can be linked to a variety of other systemic diseases where inflammation is thought to play a role, including hypertension, gastrointestinal disorders and migraines, as well as anxiety and depression.
Professor Al-Niaimi explored two of these links in greater depth.
Rosacea and the gut
“There is definitely a gut link, but with two conditions,” Professor Al-Niaimi said, referencing his review on this topic that was published in the Australasian Journal of Dermatology. “[The first is] with Helicobacter pylori [infection], which causes gastrin-induced flushing, and [the second] is small intestinal bacterial overgrowth.”
These conditions affect gut symbiosis, with the resulting dysbiosis worsening rosacea symptoms and limiting treatment effectiveness due to dysregulation of the innate immune system. Probiotics can be beneficial, but antibiotics should only be used in sub-microbial doses to limit the wider impact on the symbiosis of the gut microbiome.
Professor Al-Niaimi recommended rosacea patients who also report symptoms of bloating or IBS should be referred to a gastroenterologist and undergo testing for H. pylori or SIBO.
“[But] if you do want to treat it, I recommend going with a fiber-rich diet and a one-week course of rifaximin at a dose of 550mg, twice a day,” he told delegates.
Unpublished data from Professor Al-Niaimi’s own patients indicated he had tested 36 rosacea patients who reported bowel symptoms for gut involvement over a three-year period. Of these, 26 had SIBO, 16 had H. pylori and 12 had both, but all patients reported improved roseacea control once their gut symptoms had been treated.
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Rosacea and migraine
“It is pretty much accepted now that there is a link between rosacea and migraine through a common pathway, which is the calcitonin gene-related peptide receptors,” Professor Al-Niaimi went on to say, citing a systematic review and meta-analysis from 2018 that explored the relationship between the two conditions and discussed potential pathophysiological mechanisms.
CGRP is involved in the cascade of events that lead to the onset of migraine, making them an attractive target for anti-migraine treatments. A recent cross-sectional study conducted in Denmark found elevated plasma levels of CGRP in rosacea patients, adding further evidence to the possibility of a common pathogenetic mechanism.
“There is a neurologist who I collaborate with who is very comfortable in prescribing oral anti-CGRPs for patients with refractory, severe migraines if they [also] have flushing or rosacea,” Professor Al-Niaimi said. “So, next time you see someone with rosacea who’s in tears and saying, ‘I get headaches and migraines’, just think that there is something called the anti-CGRPs.”
The 2026 ASCPD Symposium was held in Melbourne from 20 to 22 March.
