You might want to wash your hands before reading this. Start by placing your fingertip to your cheek. Go ahead, really. Now slowly move it toward your lips and into your mouth, paying attention to the uninterrupted inward turn of skin as it changes from cheek to lip to mucous membrane. You probably never thought about this (and may wish you never had), but your skin continues right into your mouth, down your esophagus, into your stomach, and on through intestines (both small and large), rectum, and anus before turning skin-side out again. It’s continuous.
Picture a hollow cylinder, skin on the outside and gastrointestinal tract on the inner wall. Just keep in mind why some clever gastroenterologist once remarked about his profession, “We’re all really just internal dermatologists, aren’t we?”
Various fields of alternative medicine (naturopathic medicine, traditional Chinese medicine, homeopathy) have always considered skin health and intestinal health to be intimately connected. Skin inflammation such as acne or rosacea will always be connected to something “off” with digestion. In fact most people with chronic skin conditions quickly discover that certain foods exacerbate (or improve) their skin situation.
Until recently, though, conventional dermatologists and gastroenterologists were not in communication much. But some fresh research about the very difficult-to-treat skin condition rosacea has changed this.
Rosacea’s connection to mites
You know what rosacea looks like, ranging from the mild flush on the cheek of a fetching Irish lass (rosacea has been called “the Celtic curse”) to the unfortunate nose of a W.C. Fields-type tippler. For years doctors knew that steroid creams helped (by reducing inflammation), as did an anti-parasite medication applied topically (metronidazole). So did the antibiotics used for acne, especially clindamycin. They also knew that many people with Crohn’s disease had rosacea but didn’t understand why.
What exactly was going on?
Some recent research has shown that to a greater or lesser extent, our skin is inhabited by an organism called a skin mite, a tiny little microscopic thing living around our hair follicles, eyelashes, and eyebrows. We’ve all got these mites, and their population increases as we get older. They’re called Demodex (their Latin name) and for most of us they’re harmless fellow travelers, just like many of the countless microbes we carry with us. Under a microscope, the Demodex mite looks like this.
If you’ve got rosacea, your dermatologist might prescribe the anti-parasite drug metronidazole to reduce your Demodex population, sometimes adding an antibacterial antibiotic, which doesn’t kill the mites but does seem to help.
Here’s why: like all of us, the Demodex mite has its own wee digestive system. After it eats (a teeny little bit of you), just like you it needs to empty its intestines. And just as you have a lot of bacteria in your bowel movement, so does Demodex. You have your e. Coli, Lactobacillus, and Bifidobacter. Your Demodex mite excretes small but significant amounts of the bacterium Bacillus oleronius, among others. And for certain susceptible individuals (Celts, people who drink too much alcohol, people under stress), this bacterium causes an inflammatory reaction on the skin that we know as rosacea.
If the metronidazole isn’t working against the mites, taking an antibiotic like Clindamycin kills off the B. oleronius and your rosacea improves. But the result is only temporary, and the meds often don’t work as well as they should. Why the rosacea keeps returning has been a puzzle. But science is solving it.
Given that we’re all singularly unhygienic, prone to rubbing our eyebrows and then putting our fingers in our mouths, we inadvertently swallow some of the B. oleronius from the Demodex bowel movement and down it travels, into our intestines. There, in utter darkness, endless moisture, and with lots to eat, it grows like crazy. And it seems that this endless cycle of Demodex emptying its intestinal contents and you guiding them into your own intestines allows the rosacea to return after what originally seemed to be a successful treatment.
How did researchers figure this out?
Stay with me here. Scientists recently discovered that the rosacea-linked B. oleronius is one of several bacteria responsible for a not-uncommon digestive condition called “small bowel intestinal overgrowth,” SIBO for short. In a healthy small intestine, there really should be no bacteria, but sometimes people with chronic digestive symptoms do have bacterial overgrowth. SIBO is diagnosed by finding excessive amounts of hydrogen or methane gas in your breath using the unsurprisingly named “Hydrogen/Methane Breath Test,” in which a sample of your breath is collected in a vacuum tube and sent to a lab for analysis. We do this test at WholeHealth Chicago, but your insurance won’t cover it (“experimental,” they say). The cost is about $150.
What’s important here is that people with SIBO almost always have an abnormal breath test. But the big news is that recent studies have shown that rosacea patients–even with no digestive symptoms at all–have the same abnormal breath test as SIBO patients. In other words, the symptoms on the skin and the symptoms in the small intestine have the same source: a bacterium from the intestines of the Demodex mite.
Now tell me that isn’t interesting!
This is all good news for people with rosacea, a group usually quite unhappy with the state of their skin. It means that an antibiotic specifically designed for SIBO should theoretically clear their rosacea. And it does.
Xifaxan (rifaximin) is an intestinal antibiotic that works only within your intestine—it’s not absorbed into your bloodstream. And when Xifaxan is given to rosacea patients, it does indeed clear most, though not all, skin lesions. Why not all? Because Xifaxan doesn’t kill certain species of bacteria from the Demodex mite intestine. In this situation, you need metronidazole for complete coverage.
On the down side, while the results can be dramatic they may not be permanent. It’s virtually impossible to clear every remaining mite, and once you stop taking the metronidazole, the mites do start proliferating again, having their little mite bowel movements. Predictably, the B. oleronius starts proliferating too. But since Xifaxan is quite safe (it seems to let good-guy gut bacteria alone), when rosacea flares patients can start new courses of Xifaxan and metronidazole.
Now you’ve got to admit that even though you may not have rosacea, the idea that the bacteria in the bowel movement of a mite living near the hair follicles of your eyebrows and eyelashes could be responsible not only for a chronic skin condition but also for a chronic digestive condition is an interesting idea. Something you’d hear on “House.”
Isn’t it interesting?
Really, isn’t it?
Be well,
David Edelberg, MD
I have been sick since 2006 with what they thought was Sarcoidosis because of the granulomas and scarring in my small airways and skin problems. It is now 2022 and I have Ocular Rosacea, they say, but I say I have these mites all over inside and outside. Mt pcp was on the right track but Long Covid forced her to retire last year and I do have a derma that treats the rosacea with IvermectinCream and Minocylcline(50mgs) daily. This is not even stopping any of it but my skin looks better so she keeps me on these. Since Covid, we have lost many dr’s in out small rural area and I haveto use urgent cares for when I have a “flare” and this is a nightmare because they just think it is scabies and give me a small amount of Ivermectin tabs (enough for 2 treatments). This does slow things but with a few weks I am back to itching and swelling and now even pooping and peeing these critters!! I see my gastro next month if I am still sane, I just pray he is enlightened. I told his office I am dealing with a parasite and need to be seen asap, but they do not “get it” and told me to go to ER if it is that bad. I did this once and not only did I not even get any blood tests, fecal or urine, again a small amount of Ivermectin and sent home …HELP ME PLEASE!!! In the last year I have been to 5 urgent cares and one ER trying to get some help ….
Nancy Oyen
Hi Nancy,
We see patients with parasites and many of them have a story much like yours. We are so sorry that you are going through this! Give our office a call at 773-296-6700 and we can figure this out with you. In fact, we would be happy to help!
WholeHealth Chicago
Hi Doc,
very interesting. So does a person take the Xifaxan AND metronidazole at the same time or finish one and then start the other? Also, is this safe to take concurrently with Doxycycline ? Thanks
Antonio
Hi Antonio,
Please feel free to give us a call at 773-296-6700 so we can answer some of these questions for you.
Thank you,
WholeHealth Chicago
I was so pleased to find your article online! I’ve suffered from Demodex mites constantly for nearly 6 months now, and then on and off before that for 4-5 months. This seemed to worsen under the care of a wonderful nutritionist who found all my allergies, and put me on a protein, veg (some fruit) diet, with supplements too. But even though doing all the right things improved my heart health (especially cholesterol), i suffer terribly from the Demodex mites. I totally keep them under control in the day with my bathing habits (with mostly tea tree oil) but have a terrible time at night, even though it takes me an hour and a half with hygiene, when I understand the males become active to mate. It’s as though they’ve becoming resilient to what I’m using as nighttime is getting worse.
The nutritionist did not wish to do the SIBO tests for some reason, but would prescribe the Xifaxan. However, the insurance would not approve a $2,000+ medication and needed more info from the dr. The nutritionist/nurse practitioner referred me to my general practitioner, but I’m on Medicare and will pay for this anyway as the cost will take me into the prescription cost “doughnut hole.” Apparently there is no longer a generic version.
Is there anything else that you can recommend in place of Xifaxan if I do go to another doctor and have the SIBO test?
Thank you again for this article – I wish dermatologists throughout the US knew about this!
Alice
My doc said he would prescribe a SIBO but he could not figure out how to prescribe it. I looked on google and it appears that there are lots of options for this test such as methane or hydrogen (H2) or both & lactose, fructose, lactalose, etc. He is clueless and I am too. Which one do you typically recommend for your patients? Thanks! Anna
Anna Burns
Anna. At WholeHealth Chicago, we use a SIBO test utilizing hydrogen and methane.
Dr. R
Hi Anna
Regular use of tea tree oil soap and shampoo will keep the Demodex under control. In addition use immune building herbs to improve your resistance. Lastly get the breath test for SIBO
Dr E
Great article Dr. Edelberg! I have an interesting situation. I have an overgrowth of demodex over my entire upper body. I use sulfur cream to keep it down, but I still have bug bites and sometimes scaling, also on my face. Also, in the past, I had pylori and I think that I have SIBO.
I’m wondering if the pylori is back. I have asked my doc for the breath test for both, waiting on the prescription for that. On top of everything, I have a b cell deficiency ( CVID), which really makes me a sitting duck for these parasites. I have tried pyrethrin cream as well as oral ivermectin. They were not much help at all. I eat low carb, high healthy fat, lots of veggies diet. I supplement. Not sure what else might help. The mites are really bothering me a lot. Any suggestions? thanks, Anna B
Anna B
But how do you get your doctor to order Xifaxan!? They would have to be familiar with this information, which I’m willing to bet that most typical general physicians, GI and even derms are not. And even if they were, they want to do the hydrogen breath test. I have rosacea, digestive problems (chronic diarrhea) and dry eyes. I have felt for a couple of years that I have SIBO. I think this would benefit me greatly.
Coco GH
Coco GH. I would recommend trying to find a doctor more familiar with functional and integrative medicine. You might google the Institute for Functional Medicine and click on their “Find a Physician” link to find a more like-minding doc.
Dr. R
Hi Navin
You can order the Hydrogen Breath Test directly from Genova lab (or the lab can refer you to a doctor in your area who can order it for you
If the test is “positive,” then a course of Xifaxan (mentioned above) would clear the abnormal bacteria (and hopefully the mites)
Dr E
Since last one and half year I have suffered from démodé mites and seen doctors and no one believes, but l would like solution to my sickness. I have scalp folliculities itchy skin and rash. I have used permethrin cream and tea tree oil but only little relief
Navin
I had food poisoning 10 years ago in the Dominican & within a year a small mark came up on my skin which has got bigger and bigger and I have had many different diagnosis such as BCC, Actinic Keratosis and even being told I just have Bad Skin, 8 years later with pain in my stomach I went to a new doctor who gave me a test and found H.Pylori which was eradicated, this was 2 years ago but still in pain I had an endoscopy 3 months later which found I had Erosive Gastitiis all over my stomach. I have also had excruciating migraines from bright lights and dry eyes and my dermatoloist has given me a final diagnosis of Granular Rosacea and as my scar is now very big and growing in to my eyebrow he has broached the idea of Cosmetic Surgery and said he will bring this up at a meeting with other drs and a plastic Surgeon to see if this can be done. I’m glad I have a name and information to fight this with now but WOW who would think a little bug could lead to all this and do so much damage and since reading up on this nasty little ailment I’m never more than 3 feet away from antibiotic wipes lol.
Joanne Ahrendt
I do have all theses sympto,s since three months ago, I can stopped the itching in my face the burning red checks and the feeling that so,etching is rolling under my skin. I started thes symptoms while I was i. The third day of taking metronidazole .i was taking in as I normally I do every 3 years to kill any possible intestine parasite. And boom this itching and swelled face started. And now is in my lips and burns and I can’t stop it. I need help where I can go ? I’m traveling all over USA now I’m in the state of Iowans going to minnesota thanks if you can give me some advise
Mariana griffith
What is SIBO? Would like more comments.
alice enichen
Please refer to the paragraphs below this heading in the article above. “How did researchers figure this out?”
Dr. R
The Fast Track Diet for IBS is having tremendous success in helping people with GERD, IBS, and SIBO control, including reduction in Rosacea and Ocular rosacea! You need to control specific foods that have a high fermentation potential by these bacteria but the diet is VERY doable and in many ways seems much easier than GAPS, SCD, FODMAP and other “gut healing” diets. I hope this helps someone. It is really helping me with my SIBO symptoms
MK
I read recently that there’s also a connection between rosacea and h-pylori. I was diagnosed with both over 10 years ago. Four dermotologists yet nothing ever helped the rosacea but I was treated for h-pylori. I have also suffered with severe itching from head to toe for close to 15 years. I’ve taken zydec daily to keep it under control all these years. I’ve been experiencing excessive indigestion and heartburn over the past few weeks and will be seeing my GI Dr next week. Maybe I’ll get lucky and find that all my ailments are related and they will all be treated and go away! Thanks for the great article!
Kathy
Does it spread from one person to other. I am from india.
I have rosacea, also can you please tell me that movement under skin is also one of its symptoms.
kishor
Yes, it’s not only interesting but quite amazing! And I thank you for bringing that discovery to my attention and explaining it in a way my wee brain can understand.
Lisa Romano
Can this mite affect follicles? I get horrible brow/lash inflammation and sores that makes them fall out. It also causes anxiety. I have colitis and dysbiosis, so i wonder if there is a correlation. Is there? How would this be treated? Are RX drugs necessary, or are there natural methods?
stacy
To Bee
A healthy diet is always a good idea
To Joanne
It might be worthwhile trying a rosacea treatment for you
Dr E
This is so interesting. I’m wondering about my dry eyes, which they say is caused by blockage in my meibomian glands, (this is also linked to people with roascea), if trying this course of treatment will help?
Joanne Boylan
What is a natural approach that can be taken? I refuse to take any antibiotics…they have destroyed my health and my gut. And I react poorly to supplements
If u eat a healthy, plant-based diet, u can change ur gut flora back to optimal, sans antibiotics and supplements.
Do u advocate a diet similar to Dr Fuhrman’s Eat to Live? The results from his nutritional research and testimonials is outstanding!
Bee