Cruel rosacea robbed Janet of her looks. Antibiotics and creams failed her – then doctors tried a game-changing new treatment and she has clear skin for the first time in decades

For decades, Janet Atkins would start each day inspecting her face in the mirror in the hope that the flushing and spots spread across her cheeks had improved overnight.

Inevitably, she was disappointed.

Janet, 62, had suffered with acne from the age of 16 but in her forties developed rosacea, resulting in an angry rash, a red, inflamed nose and spots that were both unsightly and painful.

‘The condition of my skin dominated my life for years – often it was all I could think about,’ says the medical secretary and mother-of-one. ‘I only felt comfortable going out if my face was caked in foundation,’ adds Janet, who lives with husband Nigel, 65, a retired research scientist, in Worthing, Sussex.

‘It took me 45 minutes to apply every morning, I wouldn’t even pop to the shops without it on.

‘When I first met my husband, by which time I had the rosacea, I wouldn’t let him see me make-up free. But even with foundation on, there have been many times when I have pulled out of social events because my skin was so bad and I felt horribly self-conscious.’

The only thing that tamed it was a course of antibiotics, and Janet would have to take these for months on end to see any improvement. Yet, she now has a clear complexion for the first time since childhood – and hasn’t needed antibiotics in almost two years.

Janet has been following a new approach to rosacea and other skin problems recommended by an increasing number of experts that involves not only caring for the skin, but the gut, too.

Rosacea is an inflammatory condition, and the theory is that the make-up of the microbiome – the community of microbes in the gut – plays a crucial role in it.

As Holly Wilkinson, senior lecturer in wound healing and the microbiome at the University of Hull, explains, an imbalance in the microbiome fuels inflammation, ‘as it can lead to the release of bacterial toxins or bacteria into the bloodstream’.

The inflammation can damage the outermost layer of the skin which, in turn, makes the skin more sensitive to rosacea triggers such as sunlight.

It has long been accepted that there is a link between rosacea and certain gut complaints.

A study in the British Journal of Dermatology in 2018, for instance, found those with rosacea were more likely to have inflammatory gut disorders such as IBS and coeliac disease.

But the microbiome is now specifically being investigated as a potential target for various skin complaints including rosacea.

In a recent review of 97 previous studies, published in Biomolecules, researchers at the University of Modena in Italy concluded that using probiotics – or ‘good’ bacteria – to alter the make-up of the microbiome ‘could represent an effective and innovative strategy’ for managing rosacea.

They added high-fibre diets – which feed beneficial bacteria – may also help, though research is in the early stages.

As many as three million people in the UK have rosacea and currently there is no cure.

It typically first develops between the ages of 45 to 60 and, although genetics are involved, the exact cause is unclear.

However, research (including a study in the Journal of Investigative Dermatology in 2021) has found a protein called LL 37 – which helps with wound healing – is overly active in people with rosacea and destabilises the outer skin barrier, making it sensitive to triggers. 

This includes skincare products. Indeed, the popularity of anti-ageing products among young people explains why more of them are now seeking help for rosacea, says Dr Justine Hextall, a consultant dermatologist at University Hospitals Sussex NHS Foundation Trust and the private Tarrant Street Clinic in Arundel.

‘Younger people think they need to hammer their skin with acids and retinols [to reduce signs of ageing] but there is only so much the skin barrier can take,’ she explains.

Another factor may be microscopic demodex mites that we all have on our skin but are more prevalent in those with rosacea.

And this is where the skin microbiome – the 4,000 or so different types of bacteria that live on the skin – may play a part, adds Holly Wilkinson.

She says: ‘With rosacea, it’s thought the bacteria carried by the demodex mites are implicated’ – as compounds released by the bacteria trigger the inflammation and flushing that is a hallmark of the condition. Standard NHS rosacea treatment involves topical creams such as azelaic acid to reduce inflammation but severe flare-ups need antibiotics for four months or more.

(Symptoms tend to be exacerbated by triggers such as spicy food, alcohol and stress.)

‘Around 60 per cent of moderate to severe cases rely on long-term antibiotics to control symptoms,’ says Dr Hextall.

While antibiotics might reduce flare-ups, side effects can include stomach upsets – and once treatment stops another flare-up often follows. ‘I’ve lost count of how many courses of antibiotics I took over the years,’ says Janet. ‘And I began to worry about the effect it was having on my body – I was getting regular tummy upsets which weren’t pleasant.’

And while they got rid of the painful pustules, ‘my skin would still flush’, she says.

After one course of antibiotics lasted eight months, Janet came across the new approach to rosacea. Dr Hextall, one of the UK experts pioneering this approach, is running a study involving around 200 patients at her private clinic.

Among other measures, they might be advised to try a course of probiotics and to follow a healthy diet with plenty of prebiotic foods – such as leeks, broccoli, apples and bananas – which help feed the beneficial microbes.

‘When the microbiome is healthy, this leads to the production of short chain fatty acids [a by-product produced when gut bacteria feed on fibre],’ says Dr Hextall.

‘These are really important for the skin as they help reduce inflammation, and support a healthy skin barrier.’

Her approach targets the gut, but also looks at restoring the skin barrier – patients are advised to use products containing moisture retaining ingredients such as ceramides (fats naturally found in the skin), ‘rather than using harsh products, containing alcohol for example, that strip the skin of oil which many people with blemish-prone skin think they should be using’, says Dr Hextall.

Patients also use anti-inflammatory creams, such as azaleaic acid and ivermectin, ‘which are standard, but previously maybe didn’t work, yet in conjunction with everything else, will now’, says Dr Hextall.

More surprisingly, perhaps, patients are also advised to wear sunscreen throughout the year.

‘Studies suggest up to 85 per cent of people with rosacea have sun sensitivity,’ says Dr Hextall.

‘People underestimate how much of a trigger the sun is for rosacea – even going for a walk on a sunny day in winter is a big trigger for some.’ She also encourages patients to get enough sleep and reduce stress. Antibiotics are a last resort.

Dr Hextall says her approach is about ‘making multiple small gains’ rather than there being a single cure. Triggers like stress are less of a problem, she says, when ‘you reduce inflammation and improve the condition of the skin barrier’.

Angela Tewari, a consultant dermatologist at the HCA Lister Hospital in Chelsea, London, who also works in the NHS, is using a similar holistic approach.

‘The evidence is that if gut health is even slightly out of balance it can contribute to inflammatory skin conditions such as rosacea,’ she says.

She also tries rosacea patients on vitamin D and omega 3 supplements, as these can help control inflammation.

Janet was treated by Dr Hextall, whose advice included stopping using exfoliators and toners – and to moisturise instead, plus an SPF. ‘Before I wasn’t doing much moisturising – if you have pustules you don’t think of putting grease and moisture on your skin,’ says Janet. ‘And I would expose my face to the sun whenever I could, because I thought it would dry it out.’

Within six months, her skin was clear which ‘was like some kind of miracle’, she says. ‘I can go to social events without months of planning. I go swimming, which I couldn’t before as I didn’t want to be seen without make up. It is no exaggeration to say that this has changed my life.’

Dr Hextall recommends talking to your GP about topical treatments and suitable moisturisers, while taking steps to improve gut health – such as increasing fibre intake.

‘I have seen such a transformation in patients with this – some of whom have had rosacea for years – and I feel really passionate about it,’ she says.

But Dr Tewari warns: ‘Not every case can be helped by addressing the gut because the amount it contributes to the rosacea varies from patient to patient’.