Anti-Inflammatory Diet

All health care starts with diet. My recommendations for a healthy diet are here:
Anti-Inflammatory Diet and Lifestyle.
There are over 190 articles on diet, inflammation and disease on this blog
(find topics using search [upper left] or index [lower right]), and
more articles by Prof. Ayers on Suite101 .

Monday, September 28, 2009

Paradoxical Inflammation

Anti-inflammatory Treatments Cause Inflammation in Some Diseases, e.g. Rosacea

I thought that the anti-inflammatory diet and lifestyle I outlined on this blog would be a general purpose starting point for the treatment of all diseases. Inflammation is the foundation for allergies, autoimmune diseases and cancer. Inflammation is a basic defense against infectious diseases and many tissues require signaling components integral to inflammation for their normal function, so it is possible to overdo anti-inflammatory treatment and produce immuno-suppression. But that is unusual. What I am talking about here is inflammation caused by vitamin D, omega-3 oils, potentially low carbs and inhibitors of NFkB, such as tumeric. This is Paradoxical Inflammation.

Rosacean Inflammation Is Paradoxical

The obvious example of a paradoxical inflammatory disease is rosacea. Rosacea seems to be a large group of diseases that manifest in facial inflammation. Excessive flushing of the face can become persistent and form pustules and swelling. The triggers for rosacean inflammation are legion and idiosyncratic. They include mundane social interactions, numerous foods, temperature extremes and, paradoxically, just about everything that I recommend to decrease chronic inflammation.

Bacteria in Tissue and Gut Biofilms Are Candidates

Why do otherwise anti-inflammatory foods and exercise make rosaceans red in the face? Even vagal stimulation that is uniformly calming to inflammation, can make a rosacean flush. This is very inconvenient. I can only invoke the typical players: cryptic bacteria, biofilms, vagus nerve stimulation and response, lymphocytes/macrophages, cytokines and neurotransmitters.

All rosaceans have demonstrated facial inflammation and have had long term exposure to antibiotics and NSAIDs. That combination suggests that bacteria have been transported from a leaky gut (NSAIDs) to the site of inflammation (the face). It is likely that cryptic bacteria inhabit the dermis near the blood vessels and resident lymphocytes/mast cells. This is also the location for axons from vagus nerves. Thus, vagus stimulation may result in the release of neurotransmitter acetylcholine to stimulate lymphocytes/mast cells with subsequent release of cytokines. In this case the cytokines are inflammatory.

Other sources of inflammatory cytokines are lymphocytes/mast cells activated by endotoxin release from cryptic bacteria triggered by immunological attack. In this case, the immunological attack can be initiated by disruption of the stasis invoked by the cryptic bacteria.

Activated Cryptic Bacteria Are Source of Inflammation

It is hypothesized that the cryptic bacteria remain in tissue, because they are able to induce a hibernation-like physiology in the tissue. Disruption of the hibernation would initiate an immunological assault. Disrupting agents typically include vagal stimulators, such as activators of the hot or cold sensors, e.g. capsaicin, castor oil or menthol. Interestingly, the cryptic bacteria require a residual level of inflammation to acquire nutrients from the host. Anti-inflammatories that inhibit NFkB may destabilize the bacterial/host interaction and result in an immunological attack on the bacteria. All of the attacks on the cryptic bacteria release inflammatory endotoxin.

Gut Biofilms Store Bacteria Recruited to Become Cryptic in Inflamed Tissue

During the course of the disease and following numerous antibacterial treatments, bacteria can be continually recruited from safe havens, such as gut biofilms. Antibiotic treatment of biofilms converts the biofilm community to antibiotic resistance through activated horizontal gene transfer. Moreover, harsh treatment of biofilm communities initiates shedding of bacteria that could migrate across the leaky gut adjacent to the gut biofilms and provide new emigrants into the inflamed face tissue. A likely resident would be Chlamydia pneumonia, which has been demonstrated to be carried by macrophages and offloaded at distant sites of inflammation.

How the Vagus Becomes Inflammatory

This brings up the question of why vagal stimulation shifts from anti-inflammatory to inflammatory in rosaceans. I don’t think that the vagus nerves change in either their activation or in the neurotransmitters that are released as a result of stimulation. This means that the cells that respond to the vagal acetylcholine must be changed. I think that the change is a depletion of Treg cells and the result is that acetylcholine receptors on the remaining T cells cause a release of inflammatory cytokines. These cytokines cause the release of NO by endothelial cells and vasodilation. Leaking of endotoxin from the resident cryptic bacteria causes persistent dilation and restructuring of the vasculature.

Helminth and Il-2 Therapy Reestablish Tolerance and Reverse Vagal Inflammation

Since I have been forced to explain paradoxical inflammatory diseases, I might as well speculate on exotic approaches that already suggest potential treatments. Ingesting parasitic worm eggs (helminth therapy) has proven successful in the treatment of inflammatory diseases such as asthma, allergies and IBDs. Interleukin 2 (Il-2), usually used as a complex with an anti-Il2 antibody, is also a productive treatment. In both of these cases, the treatment stimulates the proliferation of Treg cells, which appear to be deficient in many of the inflammatory diseases. These treatments should also lead to a lowering of inflammation in the gut and suppression of inflammation as a result of vagal stimulation. Inhibitors of acetylcholine receptors, e.g. scopolamine patches, might also be interesting to test to see if they inhibit rosacean flushes in response to typical vagal stimulants such as castor oil or menthol.

Addendum:  Another possibility associated with the heavy use of antibiotics by rosaceans is intestinal (biofilm?) candidiasis.  Yeast infections are common after prolonged antibiotic treatment.  Interestingly, Candida produces resolvins from omega-3 fatty acids and the resolvins suppress neutrophil activity that would attack the yeast.  Thus, many of the anti-inflammatory treatments would actually aggravate yeast infections and contribute to rosacea.  Treatment for candidiasis (keeping in mind that yeast may be protected by biofilms) helps many rosaceans.  Stripping biofilms may be useful if pro- and pre-biotics are used to displace Candida.


Cupcakes said...

Very interesting indeed.

Appreciate the insight.


Angela said...

Great post.

Maybe I'll try the scopolamine patches... Not so sure about the helmint eggs ^^U

Daniel said...

Where does the idea that Rosacea can result from overdoing anti-inflammatory measures come from?

I have had Rosacea in the past (and never used NSAIDs or antibiotics for long periods of time) that was treated into remission.

I started vitamin D, fish oil, turmeric, etc about 8 months ago and actually did experience another (very monor) bout of Rosacea for the first time in 10 years.

I chalked it up to increased vasodilation resulting from a few things I had included in my regimen. When I removed niacin & piperine (came with the turmeric), the Rosacea went away.

Dr. B G said...

Dr. A,

Very interesting! Rosacea involves gut-related organisms on the face... That makes TOTAL sense! Ok... there has been some associations made betw H. pylori and rosacea and that appears to jive with your insights.

What I have found helped H.pylori related dyspepsia (post-eradication) also has independently helped rosacea:
--low carb diet (ala Peter's post Helicobacter and Hydrogen
--gluten avoidance (and sometimes dairy)
--the anti-inflammatories that you mentioned (!!)
--digestive enzymes (my patients like the NOW brand SUPER ENZMES)

Most colonized with H.pylori experience a high re-lapse rate after triple therapy and often take acid-suppression medications indefinitely (which only exacerbates the root cases).


Dr. Art Ayers said...

But my point is that some rosaceans respond to fish oil or vit.D or topical menthol or low carb diets, with red-faced inflammation. Any vagal stimulation causes inflammation. All of the typical anti-inflammatory interventions are met with initial inflammation. That is why I invoke the chronic deficiency of tolerance generating regulatory T cells. Thus, vagal release of acetylcholine results in subsequent release of inflammatory cytokines instead of suppression of inflammation by regulatory T cells.

Rosaceans are a very diverse group representing many different stages of multiple diseases.

Thanks for your comments.

Dr. B G said...


Are you saying there are specific subsets? With vagal stimulation are these experiencing let's rhinitis (non-allergic) or even stimulated by eating/food with cholinergic stimuli?

Thank you for your thoughts,

Peter said...

Hi Art,

My wife is moving from immunology to pathology and is very interested in the the potential link between meticulous cat worm treatment and feline asthma syndrome. Do you have the links to hand for papers on helminth therapy for allergic diseases, in any species? They would be much appreciated.

Nice post


Anonymous said...


I'm a long-term rosacea sufferer.

Is there any evidence for the claims you make in this post?

For example, you state that rosaceans have had long-term exposure to antibiotics/NSAIDS. That wasn't true in my case when the condition began (although I was a smoker; I wonder if there are some equivalent immunosuppressive effects here). I've been on a rosacea board for a couple of years, and prior use of anti-inflammatories isn't a commonality; not at all.


Angela said...

Dr. B.G.,

Are you suggesting that HP erradication may help some rosaceans? I looked into that when I first recoognized the "rash" as rosacea (at first it looked like acne perioralis), but all the references I gathered are in my computer in Tenerife...

My case has been exactly as Art has layed out: three months after going the antiflammatory way with low carb, high dose D3, fish oil, no grains, probiotics (homemade kefir and Douglas laboratories) exercise and fasting... Bang!

No history of long term use of NSAIDs or antibiotics (I'm a med student and hate to take meds). But... I have supposedly benign MS since my teens... So leaky gut, yes of course!

I am currently using topical metronidazol (with little success), after a bad experience with mino (depersonalization and derealization syndrome - psychiatric adverse effects are NO fun) i don't really want to take tetracyclines.

Dr. Art Ayers said...

Your wife's project sounds interesting.
There is a lot of info on Wikipedia under "Helminth Therapy."

Dr. Art Ayers said...

NSAID use may have just been a generalization that I got from looking at testimonials. I bow to anyone with information. The points of NSAID use was subsequent leaky bowel.

I am just trying to make molecular sense of the observations of rosaceans and others, and the biomedical literature. I hope that these insights lead to improved treatments and reduce the frustrations that many rosaceans experience with typical medical approaches.

Thanks for the perspective of someone who has been there.

Dr. Art Ayers said...

Dr. B.G.,
H.pylori and rosacea is an interesting relationship. The use of molecular hydrogen, H2, by Hp is fascinating. It is interesting that increasing rate of transit through the gut and thereby decreasing H2 production, decreases symptoms for some rosaceans. From the histories that I have heard, I would say that Hp is common among rosaceans. Dietary adjustments may control Hp contribution to symptoms.

Some rosaceans do report heighten rhinitis under conditions that suggest vagal stimulation.

Thanks for your perspective.

Angela said...

"Some rosaceans do report heighten rhinitis under conditions that suggest vagal stimulation."

I know I doo.

Peter said...

Thanks Art, got it


Dr. B G said...


Thanks for your reply. Your posts always trigger my thoughts (when I get them) -- I appreciate the immunological aspects b/c I think they seem to bring a lot of understanding to explain our modern diseases -- dyspepsia, GERD, H.pylori (+) PUD, leaky gut, and now *haa* maybe gut flora on our FACES.

Anonymous med student,

Are you getting enough vitamin A? Do you get occ organ meats? When we increase Vit D can imbalance the other fat-soluble vitamins apparently. Is your Vitamin D excessive (blood 25OHD > 80 ng/ml)? Those with gluten-enteropathy (again which leads to gut flora overgrowth, fungal overgrowth and opportunistic aerophilic organisms that love the glucose that the yeast drive like Hp) are ALL notoriously low on vitamin A.

Vit A requires as Dr. Ayers freq discusses happy and healthy gut flora for conjugation and ultimately absorption. Some bile acids are good too.

Vit A alone helps some rosacea (retinoids are in the medical literature).

As the gut is healing, my sister and I have read about and seen something called 'yeast die off'. I wonder if this is related to rosacea after people improve their gut health like what you've experienced?

I'd strongly consider the value of some source Vit K2 too as well. Many report baby clear soft skin after using K2-rich supplements like butter-oil (casein-free, grassfed from fast-growing clover). Great stuff (but chunky). Fermented cod liver oil is awesome too.

Good luck!

Angela said...

Hi Dr. BG (I'm a big fan of your blog andd your work with Dr. Davis),

I think I am the "anon med student".

Regarding A and K that's what I thought at first. D supplementation quickly depletes the liver's reserve of vit A and if you are already low... And vit K, is essential to blood vessels.

I have been supplementing with Green pastures' fermented CLO to get enough A (while eating lots of carotenoids) and also butter oil to cover my K (I also eat lots of fine Spanish and italian old cheeses, very rich in menaquinones). So far it's not working. I also did a dairy and solenaceae free trial, with no noticeable success.

I am starting to think my rosacea is mainly related to stress... And if Dr. Ayers ir right, at least the flare up might mean that I'm doing everything right regarding multiple sclerosis (which is my main concern).

Thanks for your suggestions!!

Nick said...

Hello Art,

Thank you for providing another post that is personally very helpful to my journey with regard to inflammation and diet.

I had significant facial redness for some years, particularly after golfing on windy or sunny days. I also had facial swelling including in my eyes, ears and nose. I thought is was part of my allergies and have never heard of rosacea until now. When I began eliminating foods to manage blood sugar and lose 10 pounds, the inflammation and redness in my face receded. I honestly didn't know I had the inflammation until it resolved within days of my dietary changes. My allergies also went away, something else I didn't expect. It was very odd to reach up and feel like I was touching someone else's eyes and nose. For fear of people thinking I had lost it, I didn't tell anyone that I could see and hear better. While not totally resolved, the reduced inflammation in my throat mitigated my sleep apnea somewhat also.

I'm not really clear on what caused the rosacea but it appears to be beyond gluten. Interestingly, I just took a trip to Chile and didn't want ketosis breath (or effects), so allowed myself to eat potatoes and rice and found that my allergies returned. I also allowed myself a bite of gluten in a dessert (still a bit of denial on my part) and had a severe stomach reaction.

As a teen I took antibiotics for years for acne. I used NASIDS daily for many years at bedtime as well. After reading Stephan's post on k2 some time ago, I began taking butter oil daily and noticed an immediate change in my skin - it became much softer and smoother.

I owe a great deal to you, Stephan, Peter, Jenny and Dr Eades for my vastly improved health and well-being.

Dr. Art Ayers said...

Your comments are great motivators for my research and writing. It is rewarding to hear that my insights can help others to be healthier and enjoy life more.

Thank you for reading, acting and commenting. said...

"Ingesting parasitic worm eggs?"

For some reason, I don't think the "Parasitic Worm Eggs Cure" has the potential to be a bestselling book.

Angela said...

Hey Art,

I have stopped applying lip balm with mentol since I read your post. At that time I was on topical metronidazol, but it had no effect. After changing the lip balm my rosacea is WAY better: less red, smaller papulae... Almost normal! I am even enjoying coffee and red wine in moderate amounts. No chili for me though :D

Thank you!

MasK said...


just wanted to add about the low carb diet.
I stuck with this diet, because if I eat even a small amount of carbs, let's say oat bran (I did recently), I experience very bad flushes, especially in the nose, that becomes swollen and bright red. I also feel quite dizzy.
My GP prescribed my CDSA tests (stool analysis), and the results came showing a very low amount of beneficial bacterias (lactobacillii and bifidobacteria), and an overgrowth of pseudonomas aeruginosa.
So he put me on high dosages probiotics, with prebiotics (inuline and FOS), and with these prebiotics I have no problem of flushes (slithly bloated but that's normal).

So it makes perfect sense to me that carbs are triggering an inflammatory response.

I have to add that my face become red even if I'm eating a cold meal. So I really FEEL the vagal stimulation inducing a slight flush, coming from the stomach region.

I'm thus trying to replenish the flora, I use supplements of EPA/DHA, and avoid totally carbs and sugars. I'm living on some fats, and feel quite fine with them. I also take 4000 UI's of Vit D3 a day.
My face is much less irritated and my skin's softer. But sometimes some itching pimples are showing on my face. I hope that when the balance will be done in the GI tract, my symptoms will subside...

Best regards,

Dr. Art Ayers said...

Your observations are valuable. They show that feeding an overgrowing intruder in the gut flora and cause inflammation, presumably by release of LPS, to which the lining of the gut responds.

It is interesting that some rosaceans experience just the opposite reaction to starch. If they don't maintain a high carb diet, they get flushes. Presumably they have an overgrowth of a different bacterial species that dies back and releases LPS if not fed adequate starch.

You must be taking low doses of vit.D, because that is the max that you can take without flushing. Have you checked your serum vit.D? I would expect it to be quite low. Are you going to try high dose vit.D?

Thanks for your important observations and let me know how you progress.

MasK said...

Dear Dr Ayers,

I had my 25(OH)D levels checked some months ago in august, and I was very deficient, at 10,1ng/ml. My doc prescribed me 25000 UI dose once a week, and I took it during 3 months without any problem.
New test in december, 31ng/ml, which is still low. So I started to take 1000 IU a day during some weeks and increased the dosage by 1000 IU's slowly. I'm now on 4000 IU and do not feel too much problems. My skin is sometimes redder, but I can say it is ok. I also take EPA/DHA capsules as my levels were very low.

I will make a blood test maybe tomorrow to see how it goes.
I want to add that I have IBS (constipation), in fact it is more a slow transit problem. I started kefir and it improved things a lot.
I suffered too from GERD for many years and was on omeprazole during ten years, so I ended with dysbiosis, leaky gut, ...
My itchy scalp and face started with the IBS some months ago, so this is definitely connected. I can't wait for my gut to heal. I'm taking a powder with glutamine, licorice and aloe vera also for that.

I'm pretty sure omeprazole created a lot of my problems. My GERD is now almost gone, since I'm taking some supplements to enhance gastric acid production (bitters, TMG, zinc,...).

I must add that my sister is suffering from mild rosacea, and other skin problems (mostly eczema patches on face, dryness of the hands) that are eventually resolving since I advised her to start a hig fat/low carb diet along with omega 3. She has leaky gut problems too.

I was wondering about the family link in rosacea. I don't like the genetic idea because it means no cure. But as I suspected my sister has also gut issues, so maybe the link is there. But why?

Best regards.


Dr. Art Ayers said...

I think that the reason for most family associations with disease is not genetic, but rather dietary. People tend to eat like their family eats.

Since most chronic inflammation is dietary and diet-based inflammation involves disruption of gut flora and the immune system based in the gut, it is no surprise that many inflammatory diseases run in families and can be cured by changing the diet. People in the same family also tend to swap gut flora.

Changing the diet sounds simple, and it is, since most people can change their food preferences just by exposure to a new food for three weeks. People are, however, very resistant to changes in what they eat and there are complex psychological barriers to diet changes. Also, much of the current medical advice on diet is incorrect and inflammatory, so the medical industry is contributing to modern disease patterns.

From what I have heard in those who have low serum vit.D, it takes a lot of initial vit.D3 supplement to raise the serum levels and then there is a breakthrough as the bodywide levels of vit.D start to suppress inflammation. At that point it takes less supplement to maintain the serum vit.D and sun exposure contributes more.

I would also expect that as your serum vit.D level rises, you may see more facial flaring. It is good that you are also able to tolerate omega-3s, but remember to eat enough saturated fats for uptake and to compete with inflammatory responses to the omega-3s.

Keep me posted on your progress.

caphuff said...

Hi Doc,

Your site is a great resource and I appreciate the time and energy you put into it; as well as your thoughtful responses to readers' comments.

On that note, here is more food for thought. My wife (with a history of rosacea and interstitial cystitis) recently had a fainting episode which unfortunately required a trip to the emergency room to make sure everything was alright from the bump and cut she got on her head when she fainted. Luckily the cut was superficial, and EKG and MRI-wise everything checked out OK.

On follow-up her PCP diagnosed vasovagal syncope, as she has had similar, if infrequent, fainting spells in the past (luckily without injury).

According to wikipedia the mechanism of vasovagal syncope is that "the nucleus tractus solitarius of the brainstem is activated directly or indirectly by the triggering stimulus, resulting in simultaneous enhancement of parasympathetic nervous system (vagal) tone and withdrawal of sympathetic nervous system tone."

Of course this brought to mind your posts on rosacea, paradoxical inflammation and the vagus nerve connection. Could be just free association, but it made me wonder if any of your other rosacean readers have had similar experiences.

Dr. Art Ayers said...

Hi Caphuff,
Vasovagal syncope seems to be too much of a good thing. It is sort of the opposite of stress or too much of the nervous system suppression of immune system inflammation. Wasn't there a victorian fashion for young women to wear decorative containers of smelling salts to revive them from faints? Perhaps this signaled a prevalence of estrogen-based suppression of chronic inflammation that led to vasovagal syncope.

Practitioners of vagal stimulation can lower heart beat and blood pressure and vasovagal syncope frequently has triggers that are tied into the vagal output.

That would suggest that vasovagal syncope is rosacea of the heart, i.e. nervous hypotension or extending the Vagus nerve reflexes to the parallel enervation of the face. If I knew more about cardiology, I could also probably include cardiovascular symptoms that parallel the involvement of gut interactions and cryptic bacterial infections of rosacea.

You have provided some interesting insights.

caphuff said...

re victorian era, yeah when I first read the descriptions of vasovagal syncope it sounded like a fancy term for the "vapors".

Maybe in those days just normal levels of estrogen were enough to trigger it, what with the layers of clothes people wore back then and the lack of AC.

Anonymous said...

Dr. Art,

Thanks for all your hard work regarding Rosacea and inflammation. I have been a diagnosed rosacean for 10 years or so with a history of chronic antibiotic use. I also was prescribed 3 doses of accutane over a 15 year period.

I am dealing heavily with your principle of paradoxical inflammation. I can confirm anecdotally that some, if not all, of the anti-inflammatory remedies you've mentioned (ie, Vit D, Omega-3, etc) exacerbate my rosacea.

So, what are my options at this point to lower inflammation? Am I to isolate and attack candidiasis first, and then go back and slowly introduce natural anti-inflammatories.

Very frustrated here. Rosacea has literally ruined my life socially, career-wise, and financially.

Thank you.


Dr. Art Ayers said...

I have heard of the terrible suffering of numerous rosaceans. It is a very difficult group of diseases.

I think that making sure that candidiasis is not a limiting condition, is a good start. In the absence of candidiasis and of course antibiotics, I think that it will be possible to start building up a gut flora and expanding food tolerance.

With candidiasis under control it may be possible to cut back on carbs in the diet and incorporate saturated fats. That will also make it possible to eliminate grains that may be contributing to many deficiency problems due to poor absorbance. The presence of more saturated fats will permit the uptake and utilization of omega-3 fish oils and vit.D3.

I see rosacea as a kind of Gordian knot that needs to be approached in the proper way. The therapeutic magic bullet would be a topical face treatment to block a facial flare, so that other parts of the syndrome in the gut, for example, could be attacked without huge damage to the face. That bullet is still missing, because rosacea is still poorly understood and only proprietary compounds are tested, instead of simple potential remedies such as topical heparin, PEG or berberine.

Some severe rosaceans rely on high carb diets, presumably to stimulate intestinal candidiasis and systemically suppress neutrophil action to stop attacks in facial skin. Clearly, this kind of approach will have many health ramifications.

I think that patiently building up a normal gut flora with a high fat diet is the first major step to curing rosacea.

Let me know how you progress.

Anonymous said...

Thanks, Dr Art, for your reply.

My head is spinning a little as I try to piece all the information together in my approach to paradoxical inflammation. Would you be willing to respond with a "do's" and "don't's" list with regard to diet, supplementation, exotic therapies, etc for the short, intermediate, and long terms for those of us facing paradoxical inflammation?


Dr. Art Ayers said...

I am afraid that I remain baffled in finding an approach to a cure for rosaceans who have progressed to paradoxical inflammation. So, the ease of recovery depends on how compromised the immune and digestive systems are.

The list of do's and don'ts for this situation is empirical and individual. It is going to reflect the history of treatments that contributed to the aggravation of the rosacea. Accutane for example, probably causes permanent damage to stem cells in the skin and is an extreme treatment. Pulsed laser is another extreme treatment equivalent to surgery. These and other treatments provide cosmetic benefits, but cause lasting damage.

Facial damage is compounded by an attack on the digestive tract with antibiotics. The antibiotics eliminate gut bacteria that control the development of the immune cells that regulate inflammation in the facial skin. Without these cells, the attack of neutrophils in facial skin goes on unchecked and is readily inflamed by cytokines and bacterial products from the gut triggered by food.

Absence of gut flora also produces constipation that also leads to restructuring of the large bowel. This will take months to years to return to normal.

I don't think that the approach to curing this type of rosacea can be addressed with a lists of things to avoid or do, because the steps have to be tailored to the responses that are observed.

For those who can tolerate a high fat, low carb diet and start to increase vit.D and omega-3 oils, it should be possible to suppress some of the facial inflammation with diet and increase vit.D to therapeutic levels.

If it is difficult to shift to eating saturated fats and replace carbs in the diet, then that might indicate that Candida is a problem.

So, I think the things to start with are tests for Candida and serum vitD. Disruption of gut flora also may lead to numerous deficiencies in vitamins and minerals. This is beyond me to sort through and others are much better at it.

Cure candidiasis, increase dietary saturated fats and reduce carbs (basic anti-inflammatory diet), then increase serum vit.D to at least 30ng/ml. This also assumes that antibiotics are no longer used. Note the recommendations on supplements in previous posts. That would be the first step.

The second step would be to start probiotics and start to reconstruct gut flora (fruit/vegetables with pectin and inulin) to achieve normal bowel movements with hydrated, shaped stools.

The third step might be to gradually increase serum vit.D to >80 ng/ml to start to cure the face.

I don't know how speculative this approach is, and of course it also assumes some means of controlling flare ups during all of the changes in gut flora.

I think that gut flora transplants should be considered as a reasonable short cut to reconstruction of the very compromised gut flora of rosaceans.

I hope that this is helpful.

Anonymous said...

Dr. Art,

This is very helpful. It's at the very least a starting "big picture" roadmap, even though I realize you are having to speculate quite a bit.

My full facial history includes chronic antibiotic use as a teenager for acne, 3 doses of accutane over the past 25 years, and then also 16 IPL treatments over the past 10 years. I am thankful for your feedback concerning IPL's. It's been about 5 years since my last IPL and I was thinking about going back to see if the swelling could be alleviated with another round of IPL treatments. I guess, from your comments about IPL, that you would most likely discourage that.

I can easily handle a low carb, high fat diet. I have done it in the past for weight control, not for ant-inflammatory purposes. While on this diet, should I avoid dairy products? I seem to have read that dairy can be inflammatory, especially for paradoxicals like me. Also, will I just have to fight through the hopefully initial and temporary paradoxical inflammation when my system is starved for carbs. I have noticed, as you have stated elsewhere on this site, that rosacea seems to get a slight reprieve when a meal or two has a high carb content. And, I love steel cut oats in the morning, so these will be hard to quit. I need to get the Dr Eades book and find some breakfast replacements. By the way, it was their book "Protein Power" that got me started on the low-carb lifestyle 11 years ago, but after initially losing 30 pounds, I never really stuck to it consistently. I can assure you, though, that bad Rosacea is a huge motivator, and if the diet helps with my face issues, I will stay on it for life!

For all the other rosaceans out there, although my rosacea is still bad, it has improved somewhat after quitting the diet pop and alcohol.

Thanks again for your kind and thorough responses. If the MD's that had "treated" me over the years with anti-biotics, accutane, and IPL's had been so thoughtful, I might not be in this mess. By the way, there is a like-minded MD by the name of Dr Ben Johnson at who is also advocating a healthy gut flora system. He has come out with (and sells) topicals to control the inflammation supposedly, that I am going to try. He thinks that willow herb extract is a great natural alternative to topical steroids. Maybe you all could work together on the "magic bullet" you alluded to earlier in a previous post to control the rosacea symptoms while getting the gut and inflammation under control?

Anyway, thanks again for everything.


Anonymous said...

By the way, Dr. Art, I have been taking Loratadine daily for the past 2 years that seems to help tremendously. After doing some "lay" internet research, it seemed that a non-drowsy anti-histamine could help the redness produced my histamines from allergies, whether food or environmental. I notice that whenever I stop the Loratadine for a few days that my Rosacea worsens. Of course this could be coincidental given the array of triggers out there.

Any thoughts about long term Loratadine usage? A dermatologist suggested there was no long term harm with Loratadine, but I'd like your thoughts, if possible.


Dr. Art Ayers said...


I would suggest that with your familiarity with the Drs Eades diets, that you contemplate the Six Week Cure, not for weight loss, but for diet/gut flora shifting. That approach may also make you aware of sensitivities to grains/starch/dairy, because they are deleted at different times. I would be interested on your views of using that approach for treating some rosaceans.

I don't understand problems with eating dairy. After all, milk is supposed to be the safest diet for the most immunologically compromised, the neonate. Milk also contains proteins, such as lactoferrin in whey, that are potent at eliminating problem gut microbes. I can understand lactose intolerance and allergies to particular milk proteins, but otherwise, I don't get it. Milk should be a health food.

I think that histamine reactions in the gut and face are very important in rosacea. Loratadine is a blocker of the histamine receptor. That will inhibit responses to histamine produced by mast cells, but it won't minimize the damage caused by the other mast cell chemicals and enzymes released along with the histamine. You might look into mast cell stabilizers and especially some that might be used topically on the face. Mast cells also release heparin that is important in the GI tract, and proteases that may be damaging skin in the face.

I was just thinking about the Candida problem and the role of omega-3 fish oils that the yeast converts into resolvins that block neutrophil attack. Since neutrophils seem to be a problem in rosacean facial tissue, I wonder if anyone has tried topical application of EPA and aspirin (not salicylate). That should also produce resolvin, but in that case it should stop facial inflammation. Just a thought. Perhaps that's the magic bullet.

Let me know how it goes.

Anonymous said...

Thanks, Dr Art. Just bought the Eades book. I'll let you know how I progress after implementing their ideas.

You know, with milk, it's interesting that humans are the only species that drinks milk past the age of infacy, and we are the only species that drinks other species' milk!!!!! From what I can tell from my reading, one of the primary benefits to drinking milk as a neonate is the introduction of healthy flora from one's mother. With these thoughts in mind, it makes one wonder about the need for drinking cow's milk past the age of infancy, doesn't it, especially with how easily antibiotics filter into cow's milk from the veterinarian? This bout of increased inflammation I am enduring right now may be the omega-3, vitamin D, or the yogurt that I was consuming to increase gut flora, but I am almost certain that milk products are not good for me.

By the way, apple cider vinegar seems to help me, but I am not sure, empiracally speaking. Any thoughts about apple cider vinegar? Also, is an acidic or alkaline gut environment best for growing flora and killing yeast overgrowth, in your opinion? I have read differing views.


Dr. Art Ayers said...

My point about milk, was not about traditional practices of drinking milk, but rather about the evolutionary advantages to newborns that should also apply to adults. The question is not whether milk consumption is necessary for health, since it is not, but rather why would it be a health risk? Why would it cause digestive problems or contribute to rosacean flares? I am interested in the molecular basis of these problems, if they exist.

I think that drinking apple cider vinegar has nothing to do with altering the acid environment of the gut, since acetic acid is a weak acid and would not alter the pH below 4.5. I don't think that food has any impact on the pH of the digestive system and trying to have an acid or basic gut doesn't make sense. From my perspective, all that counts is the food composition of fats, proteins, carbs and phytochemicals. The carbs are either readily converted to glucose (sugar, starch, HFCS, honey) or used as a nutrient by lower gut flora (soluble fiber, e.g. pectin, inulin.) Lactose and soluble fibers require bacteria that can metabolize them. The products of the bacteria growing on soluble fiber are short chain fatty acids, e.g. acetic acid, butyric acid.

I think that transmission of hormones and antibiotics through milk are of minimal consequence.

Thanks for the questions.

Anonymous said...

Thanks, again, Dr Art.

I don't really undestand a lot of the scientific jargon or priciples that you refer to, so forgive me.

My comment about milk was to make a carryover implication that as humans we tend to do and eat things that were not meant to be done and eaten, and therefore cause us a lot of harm.

I'll stay in touch regarding the Eades book outcomes for me.


Anek Dodl said...
This comment has been removed by the author.
skyricho said...

Father has success using helminth therapy to treat his son's autism via Seth Roberts blog

Sarah said...

I have had three severe episodes of depression over the years. Around the time of the last and worst, I started having rosacea. I finally got better from that episode, but have been fragile as far as mood goes ever since. Recently I found out I have mild diabetes. I have been on a low carb diet for two months and seem to be doing pretty well with it now. I decided to drop grains, too, to see if that helped on moods. The diet works well for lowering blood sugar, and I've noticed other positive changes. I have had frequent allergy symptoms over the last year or two, mostly nonstop sneezing marathons. I have had less allergy symptoms on the low carb diet, except I notice that some foods such as such as eggplant and mango bring on allergy symptoms. I was reading something about the possibility that cytokines cause depression. Do you have any thoughts on that?
My biggest concern is of course the depression. I have tried taking omega 3 supplements in the past on three or four different occasions and each time I would become depressed. Maybe paradoxical inflammation would explain this paradoxical reaction.
Another thing I was curious about is this. Could the tiny amounts of mold toxins in wheat and other grains play into this whole unhealthy gut flora thing?

Sarah said...

This is something I read about cytokines and depression.

wormgirl1 said...

Hello, Dr. Ayers--

I tried helminthic therapy (HT) for an unrelated life-threatening condition called hereditary angioedema III, which vastly improved, but also have a "rosacea-like dermatitis" which actually worsened considerably during treatment, progressing to mucus membrane inflammation, or a "Sjogren's like" state (but not a Sjogren’s diagnosis, antibody negative).

IMO, this lends credence to the idea that some forms of rosacea are caused by an underlying infection of some kind, which could theoretically worsen with helminthic immunomodulation, perhaps in a manner akin to what you describe as "paradoxical inflammation." In my understanding, cathelcidins, known to be elevated in rosacea patients, are triggered by infection, so this *might* be a good thought process, but I would love to hear your take on it.

Helminth eradication has had no effect on improving things—rarely, helminths have been associated with vasculitis, but I suspect they are in themselves harmless, and this only occurs when another factor, I’m guessing infection, is present.

Others who have rosacea have not had any reported problems using HT, but it is my misfortune to be deficient in IgA and lacking half of my genetic material—as you might imagine, this complicates life. :)

I theorize that downregulation of certain cytokines like IL6, IL1 and also TNF-alpha, which are what helminths do best, might perhaps exacerbate extant infection…

Candida or other fungi have been raised as a possibility by my integrative med physician, who has suggested a long-term course of nystatin (this after trying low dose doxycycline and minocycline, and several rounds of azithromycin as prescribed by my dermatologist). Sarcoidosis has been a word recently thrown around in my case, but interestingly, all roads seem to lead to Rome, as sarcoid has long been posited to be caused by mycobacteria.

I came across this part of your site today and was dismayed to find that I’ve been doing several of the things that you state precipitate inflammation in rosacea patients, low-carb, EPA/DHA supplementation, etc.
I’m convinced that gut microbiome alteration is at the root of everything… I’m grateful to no longer be suffering from acute hereditary angioedema of the larynx as a result of HT. Now if we can only surmount the current issue…

All thoughts appreciated.

wormgirl1 said...

Hello, Dr. Ayers--

I tried helminthic therapy (HT) for an unrelated condition which vastly improved, but also have a "rosacea-like dermatitis" which actually worsened considerably during treatment, progressing to mucus membrane inflammation, or a "Sjogren's like" state (but not a Sjogren’s diagnosis, antibody negative).

IMO, this lends credence to the idea that some forms of rosacea are caused by an underlying infection of some kind, which could theoretically worsen with helminthic immunomodulation, perhaps in a manner akin to what you describe as "paradoxical inflammation." In my understanding, cathelcidins, known to be elevated in rosacea patients, are triggered by infection, so this *might* be a good thought process, but I would love to hear your take on it.

Helminth eradication has had no effect on improving things—rarely, helminths have been associated with vasculitis, but I suspect they are in themselves harmless, and this only occurs when another factor, I’m guessing infection, is present.

Others who have rosacea have not had any reported problems using HT, but it is my misfortune to be deficient in IgA and lacking half of my genetic material—as you might imagine, this complicates life. :)

I theorize that downregulation of certain cytokines like IL6, IL1 and also TNF-alpha, which are what helminths do best, might perhaps exacerbate extant infection…

Candida or other fungi have been raised as a possibility by my integrative med physician, who has suggested a long-term course of nystatin (this after trying low dose doxycycline and minocycline, and several rounds of azithromycin as prescribed by my dermatologist).

Sarcoidosis has been a word recently thrown around in my case, but interestingly, all roads seem to lead to Rome, as sarcoid has long been posited to be caused by mycobacteria.

I came across this part of your site today and was dismayed to find that I’ve been doing several of the things that you state precipitate inflammation in rosacea patients, low-carb, EPA/DHA supplementation, etc.

I’m convinced that gut microbiome alteration is at the root of everything…

I would like to add that I’m grateful to no longer be suffering from acute "hereditary" angioedema of the larynx as a result of HT. Now if we can only surmount the current issue…

Unknown said...

I suffered from Rosacea flare ups for over a decade, using trigger avoidance and Oracea (1.5 ys) to keep it in check. (I also had been treated for H.pylori and been on omepramzole long-term during that 10 yr period, then dx with celiac.) That said, my real question is this: While undergoing chemotherapy this past year (T/A/C - 6x) for breast cancer, my rosacea cleared up and stayed away until the third month or so after finishing. My skin was gorgeous (ironic, I know). What do you see as the link between chemo and rosacea abatement, if any, and, how might this influence a protocol for beginning treatment of rosacea again? Thank you

Dr. Art Ayers said...

Prior antibiotic treatment is what compromised your immune system to begin with and contributed to your rosacea and probably also your cancer. It was the regulatory part of your immune system that was damaged by killing off gut bacteria, e.g. Clostridium sp., that are needed for development of Treg cells in the lining of the gut. The result is autoimmune attack by the remaining aggressive part of your immune system that contributes to rosacea. Since other bacteria are needed for the development of the aggressive part of the immune system, treatment with additional antibiotics can even wipe out the rest of the immune system and reduce the symptoms of rosacea. Most popular treatments for rosacea reduce symptoms by further damaging the body.

Many people with rosacea also have constipation, which is a loss of gut flora that is so severe that there is not enough bacteria to form normal, hydrated stools and the ability to digest common types of soluble plant fibers is so reduced that they have food intolerances. The obvious cure would be to introduce healthy gut flora and a healthy diet, but this can only be done with a fecal transplant from a healthy (non-familial) donor. Probiotics could provide temporary relief by supplying perhaps a half dozen of the missing one hundred species of different bacteria. Hygiene is the major impediment here, because we simply do not eat food that contains enough live bacteria with the diversity needed to repopulate our gut. What is needed is a medical study to develop a good source of gut flora, e.g. feces or compost or soil, that has hundred of bacterial species that a needed, but without pathogens and parasites.

A simple cure for disable gut flora could dramatically reduce national healthcare budgets and provide a cure for many chronic diseases. Unfortunately, it would reduce the need for most healthcare facilities and produce a doctor surplus.

Until a simple gut cure is available, it will be necessary to avoid antibiotics and gradually build up your gut flora by following the Anti-inflammatory diet that I recommend, along with finding a source for the myriad species of gut bacteria that you lack. It will also help to augment the gut flora of the people and animals with whom you are in contact. Most of the new bacteria will get into your gut by clinging as dirt on uncooked vegetables.

Just eating a healthy diet will not improve your health, without providing a source of healthy bacteria. The healthy diet is also food for your gut flora. Healthy gut flora should be able to provide most of your vitamin needs and will lower chronic inflammation that will permit you to produce vitamin D in your skin.

Let me know if this was helpful.

Unknown said...

Thank you for your speedy response.I also should have mentioned that before I first got my celiac diagnosis, I was shown to be osteopenic. That was a head-scratcher since I live in AZ where vit. D deficiency isn't so typical. So the order of dx was: H.pylori & GERD - Rosacea - osteopenia- Breast Cancer (hr +). All traceable back to the gut. I was just about to start back on Oracea when I read your comment about avoiding antibiotics. Whew. So I've been drinking Kefir, taking add'l pro-biotics, and digestive enzymes, and in the last week I've been feeling energetic and strangely at peace. My rosacea-eye symptoms reduced. (One of the supplements I got has lamb intestine concentrate-- not sure what that is for, but it sounds icky enough to give me a placebo-effect at the very least) I'm not a chemist, and I struggle to understand the science, but I do think your research has convinced me to stay focused on the gut. Oh ya, and continue my lifelong relationship with the oncologist. Thanks again

Dr. Art Ayers said...

You are correct to focus on your gut flora and the damage caused by taking antibiotics.

Fermented foods can supply a few of the bacteria that are missing, but needed for the normal function of your immune system, i.e. to suppress the attack on your own tissues and add to inflammation.

Most of the needed bacteria use soluble fiber from vegetables, so you have to eat lots of different leafy vegetables, onion/garlic/leeks, and pectin-rich fruits to make sure that you are providing food for new bacteria.

But -- You also need to eat the missing bacteria. Some of those bacteria are found in soil/compost clinging to the vegetables. You are probably lacking dozens of different species of bacteria not found in common fermented foods, e.g. Clostridia. Just eating dairy will not resolve your problems.

Other signs of missing gut bacterial species are food intolerances and constipation.

Unknown said...

Dr. Ayers,
This study, summarized in the NYT, seems to validate the need to see the gut biome as the command center for our immune system-- you're probably well aware of this, but here's the link for your readers if you want.

pattyf said...

I really have no idea what I am talking about but, as a rosacean who with low vitamin d yet gets worse with vitamin d supplementation, I'd love to understand what is going on, so I'm gonna put myself out here. I saw these two articles--this one indicating that some lactobacilli stimulate the vagus nerve while some bifidobacterium (all?) do not And I also saw this article on Treg cell enhancement by vitamin a In my own experience, high vitamin a helps my rosacea but I fear that I am further driving down my vitamin d levels which can't be good. They are already low. Plus the Dr. Cannell at the Vitamin D Council thinks Vitamin A is extremely dangerous and should not be supplemented in the U.S. at least where, he claims, hardly anyone has Vitamin A deficiency. But could it be that high Vitamin A can help straighten out the rosaceans wacky immune system so that it vitamin D may some day help it? Could certain probiotics be better than others for a vagus nerve that doesn't want to be stimulate? Oh it's so confusing, and my limited understanding of the science isn't helping. But then I found this blog.... :-) Thanks for your thoughts on the rosacea puzzle.

Anonymous said...

How do you think Dr. Martin Pall's NO/ONOO cycle fits into this picture? The Human Genome project also discovered genetic polymorphisms (A1298C and C677 are probably the most common) in the methylation process. I highly suspect that many Rosaceans have some issues with their methylation process as there are numerous SNP's that can malfunction and cause issues that just might contribute to this inflammatory process. I would be VERY interested in hearing your thoughts on this.

Anonymous said...

My rosacea seems to have disappeared following treatment for under-methylation which is associated with a high build up of histamines in the body. In retrospect it's clear to me that I've had a methylation defect for some time as a few years ago I ended up having a trip to A&E after taking a standard dose of niacin which interacted with the histamine I had accumulated resulting in severe whole body flushing - I felt like my whole body was on fire, I was covered in hives and my legs started to turn blue within ten minutes of taking the niacin supplement. Under-methylators have trouble with phase II liver detoxification which results in toxins accumulating in the body.
An anti-inflammatory low toxin diet is very helpful but doesn't actually address the methylation issue, it merely helps seemingly by reducing the demand for methyl donors. Trying to replenish beneficial gut flora following treatment for blastocystis helped somewhat but not as much as the methylation cycle treatment. Richard Van Konynenburg's supplement protocol was particularly beneficial.

Anonymous said...

I find this really interesting. I've struggle with digestive issues for about 8 years and take probiotics. I'm really careful about what I eat. About a year ago I started getting acne & rosacea (in my late 30s after a lifetime of clear skin). I stumbled upon this product: which, like you, posits that rosacea is caused by bacteria, and kills them with a bacteriophage. I've been using it for about a month and it seems to be helping. It's not yet available in the US, but I had a friend who lives in the UK order it for me and then they shipped it to me.

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