019: SIBO-Rosacea Connection w/ Dr. Leonard Weinstock

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A lot of people with rosacea are struggling to understand what is causing it. It’s a condition that can make you feel self-conscious and frustrated. My personal experience has taught me that to understand rosacea, you need to understand its underlying causes. One of the major causes, we’re learning, is small intestine bacterial overgrowth (SIBO). My guest today, Dr. Leonard Weinstock, is an expert on this and I am so happy he joins us to help break it all down.


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Dr. Weinstock is board certified in gastroenterology and internal medicine with his own private practice. He’s also an associate professor in clinical medicine and surgery at Washington University School of Medicine. He has published numerous articles, book chapters, abstracts, and editorials on the subject of gastroenterology. His particular research focuses on SIBO and mast cell activation syndrome (MCAS).

When inflammatory chemicals leave the gut and end up where they don’t belong, so many other problems can occur, such as rosacea. It’s crucially important for anyone with rosacea to listen to all their body’s symptoms, not just the ones on the skin. That way they can address the root cause of the problem.

Have you seen a link between SIBO and rosacea? Leave a comment!


In this episode:

  • How SIBO can cause rosacea
  • Understanding that a problem in the gut, like SIBO, will manifest as a problem elsewhere
  • What to consider when taking medication for GI issues and rosacea



“It all comes down to what’s happening in the lining of the intestine, what kind of cells are being attracted.” [4:40]

“It is important to consider both with and without GI symptoms that your GI tract is the trigger.” [9:55]

“Gut health is important. Not only is it diet related, because if you have this increase in intestinal permeability because of bacterial overgrowth, you want healthy products that heal the gut linings.” [14:46]



Find Dr. Weinstock online

Rosacea and small intestinal bacterial overgrowth: Prevalence and response to rifaximin

Do I Have SIBO? article on JenniferFugo.com


“Gut health is important. Not only is it diet related, because if you have this increase in intestinal permeability because of bacterial overgrowth, you want healthy products that heal the gut linings.”

019: SIBO-Rosacea Connection w/ Dr. Leonard Weinstock FULL TRANSCRIPT

Jennifer:                              Hi everyone. Welcome back to The Healthy Skin Show . Today I have a very special guest with me who I will admit I kind of stalked online and then finally got in touch with him and he is here to talk to you today about the connection between rosacea and SIBO and if you don't recall what SIBO is, you can go back and check out one of those previous podcasts. I'll put in the show knows that I did on SIBO, what is it and its connection to skin issues, but we're going to focus today specifically on rosacea. My guest today is Dr. Leonard Weinstock. He is a board certified gastroenterologist as well as being board certified in internal medicine. He is an associate professor of clinical medicine and surgery at Washington University School of Medicine and has also has a private practice. Dr Weinstock is an active lecturer and has published more than 85 articles, abstracts, editorials and book chapters. He is researching the role of small intestinal bacterial overgrowth and mast cell activation syndrome in a variety of syndromes. Thank you so much for joining us.

Dr Weinstock:                    My pleasure, Jen. Thank you.

Jennifer:                              Well. So as I said, I kind of did a little bit of stalking. It wasn't my fault though. I mean you wrote a really fascinating article and it wasn't even an article. It's actually a journal article. So that was, I was perusing the science and I came across this really interesting article called Rosacea and Small Intestinal Bacterial Overgrowth, Prevalence and Response to Rifaximin. And I was like, Whoa, I need to find the person that co authored this.

Dr Weinstock:                    Ah, funny. All right.

Jennifer:                              It was really great because a lot of people are struggling with rosacea. They don't understand why they have it and they become incredibly frustrated and even self-conscious because it's hard to wear makeup. It's hard to cover that up. And ultimately it's my belief that there's something underlying a lot of these things. It's not just necessarily your skin that is the problem. And at least that has been my experience with my own personal skin issues as well as working with clients. So how did you end up making this connection initially between rosacea and SIBO?

Dr Weinstock:                    Well in particular, I read a journal article that the Italians came out with in 2008 and they made the connection, but I've been looking for connections of bacterial overgrowth and many extra intestinal manifestations including restless leg syndrome and chronic pain disorders and pelvic pain disorders. And so I look everything related to bacterial overgrowth because I thought that a disruption of your microbiome would have a great deal to do with inflammation and not only could it account for symptoms outside my regular old Crohn's patients, but patients with irritable bowel, with bacterial overgrowth. So I saw this great article and I thought it was fantastic. I showed it to friends of mine and patients of mine who are physicians and dermatologists and even though it was a excellent randomized, double blind placebo controlled study, they just said, well, it needs more work. And so I decided I was going to do the work and try to reproduce it in my own patients and also look at rosacea and some inflammatory patients of my own, namely those with Crohn's disease.

Jennifer:                              Interesting. So you've been looking at rosacea for quite a while now because this are, this article I found is from 2013.

Dr Weinstock:                    Right. Well, it takes a little while to get going and we had a preliminary article or presentation in 2011 so it started fairly rapidly. But it requires time getting approval from the investigational review board to do the studies and so forth.

Jennifer:                              So why do you think it is that there is even a connection between SIBO so bacteria where it should not be in the small intestine should be in the large intestine, but for any number of reasons, it has moved upwards in the wrong direction. What do you think is the connection? Is rosacea essentially, could that be considered almost like a symptom of the SIBO or are they just sort of two separate conditions that can occur together?

Dr Weinstock:                    Okay, great question. Well, it all comes down to what's happening in the lining of the intestine, what kind of cells are being attracted? So when there's a bacterial overgrowth and you've got this load of bacteria, namely usually colonic bacteria in the small intestine, it's toxic. It creates inflammation. It breaks down the lining of the gut, increasing intestinal permeability and so-called leaky gut. With that you get excitation of inflammatory cells, mass cells, lymphocytes. So some of our patients will get hives because the mass cells get activated and release histamine. But there are many chemicals that are released, these cytokines C, Y, T, O, K, I, , N, E, S, cytokines, and those things circulate in the bloodstream. So for my IBS patients, I was seeing patients with chronic fatigue, muscle pain, brain fog. And it wasn't just because their gut was abnormal, it was because there's circulating factors that cause symptoms outside of the gut.

Dr Weinstock:                    And so when I read that article by the Italians and it was combination of GI and dermatologists that got together and they had done a number of studies on irritable bowel and bacterial growth, I thought, wow, this is yet another example of inflammatory chemicals derived from the gut coming out into this body. Going to the bloodstream, going to the skin, causing inflammation, vascular changes. So this flushing that's going on, well there are chemicals that come out that are released by mass cells in the gut and that are vasoactive and that can cause flushing. And so that's a very common sign of somebody who's got mast cell activation syndrome flushing. So that's a big part of rosacea. And then there's the inflammation with the papules and painful and tender skin. And those could certainly be things that are going on with inflammatory cells in the skin and yet chemicals that go via the bloodstream to the skin.

Jennifer:                              So essentially what you're saying is that in conventional medicine, you know, my dad's a doctor, so you know, I, I understand he deals with eyes and so typically they're like everybody deals with their own region. But what you're essentially saying for everyone listening who's maybe new to this concept, that everything is connected in some way, shape, or form. You've got so much going on in the gut, essentially that's where the problem initiates and then it floods out essentially and shows up elsewhere. It's specifically in this condition on your skin.

Dr Weinstock:                    Absolutely. so much is going on. For instance, in my Crohn's disease patients, you know, to ulcerate in condition of the intestine, I looked at 60 patients, three of them had significant skin problems with rosacea and when they were active with their inflammatory bowel disease, their skin was active. When I could get their skin better with one technique or another, whether it be antibiotic or anti-inflammatory drugs, their skin got better. So it really is a telltale sign. And these were just classic rosacea patients.

Jennifer:                              And one of the thing that was really interesting to me, and yes, I know it, the, the article that I was looking at is from 2013, so perhaps with now more experience clinically you've seen these numbers fluctuate, but at least what I thought was interesting was that you had observed a relationship where 46% of the prospective patients with rosacea had SIBO. That's like almost 50% of people.

Dr Weinstock:                    Right.

Jennifer:                              And the sad thing is that when skin clients come to me saying, Oh, I want to address my skin, they ignore or write off every other symptom that's happening someplace else in their system. So should this be a wake up call to anyone listening to this who has rosacea that they need to start tuning in to all the symptoms that they are experiencing throughout the body instead of just fixating on their skin?

Dr Weinstock:                    Absolutely. Now, not everybody who's got a condition related to small intestinal bacterial overgrowth such as rosacea or restless leg syndrome, have GI symptoms. But in particular, do you have bloating, gas to distension, trap gas, abdominal discomfort, altered bowel habits as a chronic problem? Usome of my patients who get this have had,uan infection, like they went to Mexico or to a bad restaurant and had a diarrheal disease. And then that creates an inflammatory pathway going on in the gut, which then can be followed by symptoms outside of the gut. So it is important to consider both with and without GI symptoms. Could your GI tract be the trigger?

Jennifer:                              Interesting. And in this case. So when a patient comes to you with rosacea, cause it's interesting your specialty is gastroenterology, but you've really, you've actually created this very interesting bridge that we don't often see. But I would love to see more and more in conventional medicine of bridging these gaps and connecting the systems because it's so important and people really I think tend to improve quick more quickly and get help. But so in this study you use Rifaximin, Which is a pretty typical non absorbing oral antibiotic that people use with SIBO sometimes if they can get their hands on it. Do you feel like in the cases that you've seen now with all the experience, obviously a number of years later, do you feel like that's still the right treatment to consider? Are there other things that people who are listening should consider or think about or talk to their doctor about?

Dr Weinstock:                    Well with respect to insurance companies who dictate what you can get and what you can't, it comes down to this. If you have irritable bowel syndrome with diarrhea and you've tried a couple of different classic treatments, which generally don't work well anyway and you failed that, you're a good candidate for Rifaximin. So as long as you have irritable bowel syndrome with diarrhea, your insurance company will approve it. That's a problem if you don't. Now, if you test.

Jennifer:                              So if you're more constipated, then it's a problem

Dr Weinstock:                    Right now in that setting, you also have to look at what we call a lactulose breath test to see if you have hydrogen and methane. Because if it's just hydrogen, usually it's bloating, gas and diarrhea. If it's methane, it could be constipation or a mix of both diarrhea and constipation. And I do want to say that herbal antibiotic therapy, is it an alternative for those people who can't get the Rifaximin don't want to use other antibiotics because actually Rifaximin is unique in the regard that it does not get absorbed by virtually any means. 0.4% gets absorbed. And so it stays in the gut, works in the gut, and it's directed towards the small bowel where it's bile solvent and doesn't get into the colon to create havoc and cause complications of antibiotics. So it's unique in that regard. But once again, insurance companies are only gonna approve this antibiotic if you've got irritable bowel syndrome and failed treatment. So someday, hopefully, you know, studies will be done, more studies will be done. I on Rifaximin and rosacea, and for those, let's say, who have a positive test for bacterial overgrowth, the insurance will cover it because it's a two week course. In the study by the Italians, they did not have any relapses for nine months, so they were treating. Whereas with irritable bowel, the average relapses three to four months where you'll need another course of the antibiotic.

Jennifer:                              That's really fascinating that that was creating such a major impact that they no longer had. I mean, just such an extensive period of time, they were free of those symptoms and rosacea and maybe other GI issues. It's just so cool. And you know, I think this, this underscore I, this is actually one of the cool things that I love about this particular podcast is that we're looking at ways, we're looking at one issue except we're finding another way into it. You know, finding another path or solution that is in a sense novel and different and outside of the box. But it's because you're connecting the dots between the two. Instead of just saying, oh, we have to look at the skin, that's all there is. We know that that's not true. And I know that you also use low dose naltrexone as well, the LDN. Do you ever use that with any of your rosacea patients?

Dr Weinstock:                    If they don't have SIBO than I'll give them a try and I've seen some benefit, but I haven't had enough patients to be able to say, okay, that's great. LDN, low dose naltrexone has been helping my patients with psoriasis and various autoimmune conditions that affect the skin. So I love it in that regard. Basically it increases the endorphins which reduce T and B cell function and reduces cytokines, the inflammatory chemicals. So it's been very good for my patients with inflammatory bowel disease or autoimmune conditions in general. I do also want to emphasize that gut health is important. Not only is it diet related because again, if you've got this increased intestinal permeability because of the bacterial overgrowth, you do want to attend towards healthy products that heal the gut lining. So I use a lot of zinc. L-Glutamine does a product called bovine immune globulin that I use as well. But, you know, healing the gut lining after your treat with antibiotics I think also plays an important role.

Jennifer:                              I agree with that. I mean, I found with so I beyond my scope of practice is like the whole antibiotic and medication space, which I can get into and I'll usually encourage clients to go back to their doctor, a physician like yourself to get help. But if we do work with botanicals that's always has to be a big piece of it, right? Because you can't just expect the gut to go back to normal. You have to do some work afterwards to help it find balance, to “reseal”, so to speak in air quotes and get the inflammation to come down and, and let your body just get used to that new balanced level. You know, and there's this idea that like to swing back to homeostasis if you've been sick a long time, it wants to stay where it's been unfortunately in a state of imbalance.

Jennifer:                              And so you've got to do some work to get it back to a healthier spot and really support it to stay there. So I just want to thank you so much. This has been a fascinating conversation and I would love to have you back to talk more about the low dose naltrexone and how you've been working with psoriatic patients. I think that would be absolutely fascinating if you would be so kind to indulge us. And I also to want to invite every single person listening to this to go check out your website. You've got two separate sites are kind of one in the same, but there's two ways to get there. You can go to gidoctor.net or rosacearescue.com and I promise everyone I will put those two links in the show notes. So if you're listening, don't worry about writing stuff down. Just come to this podcast and everything will be there for you so that you can easily find and get in touch with Dr Weinstock. Thank you so much for joining us.

Dr Weinstock:                    My pleasure.