Helicobacter Pylori Treatment and Rosacea

Helicobacter Pylori Treatment and Rosacea Running title: Helicobacter Pylori Treatment and Rosacea Parviz Saleh1, Mohammad Naghavi-Behzad2, Hamdieh Herizchi3, Fatemeh Mokhtari3, Mohammad Mirza-Aghazadeh-Attari2 , Reza Piri4* 1- Chronic Kidney Diseases Research Center, Tabriz University of Medical Sciences, Tabriz, Iran 2- Students Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran 3-Department of dermatology, Tabriz University of Medical Sciences, Tabriz, Iran 4- Medical Philosophy and History Research Center, Tabriz University of Medical Sciences, Tabriz, Iran Effects of Helicobacter pylori Treatment on Rosacea: a Single Arm Clinical Trial Study Abstract: Rosacea is a chronic dermatologic disease. Helicobacter pylori has been discussed as one of its causative factors. In this clinical trial study, it was tried to evaluate the effect of H. pylori standard eradication protocol on the rosacea clinical course. In this single-arm clinical trial, patients with approved H. pylori infection based on serological studies were assessed to examine rosacea existence. Then, the patients with concurrent rosacea and H. pylori infection were included in the study and underwent a standard Helicobacter pylori eradication therapy. Rosacea was evaluated using Duluth rosacea grading score at beginning, 2 months later, and at the end of the trial (day 180). Of 872 patients with positive H. pylori, 167 patients (19.15%) manifested the clinical features of rosacea. The patients with concurrent rosacea were younger (p Keywords: Rosacea, Helicobacter pylori, Prevalence, Eradication, Treatment Effects of Helicobacter pylori Treatment on Rosacea Introduction: Rosacea is a chronic dermatological disorder mostly affects facial convexities, which is characterized by telangiectasia, flushing and papulopustular changes (1, 2). These findings tend to be in cluster patterns, which allow identification of different subgroups of patients. In other words, rosacea includes a wide spectrum of dermatological manifestations with different severities (3-5). Pathogenesis of rosacea is thought be related to vascular changes, but the main process of pathogenesis for rosacea is still unknown. A combination of dermal connective tissue damage and vascular dysfunction consisting endothelial damage, impaired reactivity, and autonomic dysfunction has been proposed (5-9). So researchers have always tried to reveal the pathophysiology process by proposing possible pathogenic factors such as solar irradiation, sensitivity to noxious stimuli, change in redox status, and the presence of parasitic mites (Demodex folliculorum) (10-14). The role of Helicobacter pylori related gastritis in the pathogenesis of rosacea has been also a subject of controversy. Diverse prevalence of H. pylori infection has been reported among rosacea patients (15-21), ranging from zero to 100%. Some studies have suggested that rosacea could be considered as an extra-gastric symptom of H. pylori infection or reported improved rosacea clinical course post H. pylori eradication (22) (23), while others concluded no significant relationship between H. pylori infection and rosacea (24, 25). Based on our literature review, no confident and precise conclusion has been made about any change in the clinical course of rosacea after H. pylori eradication yet today. So the present clinical trial aimed to evaluate changes in the clinical course of rosacea after H. pylori eradication by standard treatment protocol. Subjects and Methods Study design In this single-arm clinical trial which was conducted in clinical-educational centers of Tabriz University of Medical Sciences (Tabriz, Iran) from May 2013 to November 2015, patients with proved H. pylori infection based on serological study were screened for evaluation of concurrent rosacea disease. Then, the patients with concurrent rosacea clinical presentation and H. pylori infection were enrolled into the study. Considering sample number limitation, sampling was performed during a year to calculate sample size, then study power was calculated 0.85 according to that number of samples. Rosacea severity was graded using Duluth rosacea grading score (26) before and after H. pylori eradication protocol. Finally, the patients were examined 2 and 6 months after medication, to compare dermatological findings of rosacea with primary findings. All participants were provided an informed written consent, and the study protocol was in compliance with the Helsinki Declaration and was approved by the Ethics Committee of Tabriz University of Medical Sciences. In all stages of study patients information were anonymous and based on codes and patients could refuse to take part in the study at any stage. This study is registered at Iranian Registry of Clinical Trials (IRCT2015051418946N3). Study population All patients who were 20-65 years old, with confirmed H. pylori infection and active rosacea, attending clinical-educational centers of TUMS were included in the study. Prior H. pylori eradication treatment, the existence of any other dermatologic problem, allergy to clarithromycin or omeprazole, antibiotic therapy within past 2 months, topical treatment of rosacea in past 3 weeks, history of hospitalization in past 6 months, pregnancy and breastfeeding, patients were considered as exclusion criteria of the study. H. pylori infection evaluation H. pylori stool antigen test was implicated to confirm H. pylori infection before enrolling the patients into this study (day 0) and to confirm H. pylori eradication (day 60). Stool samples were collected in a standard container. In the laboratory, using an applicator stick 4-5 mm of stool was transferred in a diluent vial, then it was vortexed for 20 seconds. Then, 4 drops of vial were dispensed in ImmunoCard STAT HpSA kit (Meridian Diagnostics, Inc., OH, USA); positive predictive value of this test was 89.3% based on literature (27). The positive and negative results were concluded based on the manufacturers recommendation. Rosacea evaluation Rosacea severity was evaluated using Duluth rosacea grading score (26) at beginning (day 0), 2 months later (day 60), and at end of the trial (day 180). Dermatology team examined rosacea based on detecting primary and secondary signs and symptoms of rosacea and graded them as absent, mild, moderate, or severe (0-3), based on the Duluth scoring system. Primary features of rosacea included: flushing (transient erythema), non-transient erythema, papules and pustules, telangiectasia. Secondary features included: burning or stinging, plaques, dry appearance, edema, ocular manifestations, peripheral location (present or absent), phymatous changes. Finally, rosacea condition was compared in day 0, day 60, and day 180 by the same team. H. pylori treatment Standard two-week triple therapy was administered to eradicate H. pylori, including metronidazole 500 mg orally twice per day, clarithromycin 500 mg orally twice per day, and pantoprazole 40 mg orally per day. Primary and secondary outcomes The primary outcome was the severity of rosacea before and after H. Pylori eradication. Secondary outcomes were H. Pylori eradication rate and prevalence of rosacea among patients with H. Pylori and demographic differences between H. Pylori positive patients with rosacea and without rosacea. Demographic and outcome measurement All demographic information was collected at patients enrollment time. Patients rosacea stage was evaluated on day 0, 60, and 180, then they were compared. Same dermatology team reevaluated clinical course of rosacea to decrease inter-observer error. Statistical methods Statistical analysis was performed by SPSS software package, version 16.0, for windows (SPSS Inc.). Quantitative data are presented as mean  ± standard deviation (SD), while qualitative data are demonstrated as frequency and percent (%). Paired sample t-test, chi-square, and Friedman test were used for analysis of data. Mann-Whitney U test was used to compare between groups and Wilcoxon ranked sum test was used to compare within groups. Probable confounding factors were considered as inclusion and exclusion criteria. However, some factors which could have been confounding factors were analyzed using multivariate analysis but they were not presented in results the section. P value less than 0.05 was considered statistically significant. Normal distribution of data was assessed using Kolmogorov-Smirnov test. Results In the present study 872 patients with positive H. pylori stool antigen were assessed by dermatologists team. Of 872 patients, 167 patients had clinical features of rosacea. Some demographic information about patients is shown in Table 1; of all patients with a positive test for H. pylori, patients diagnosed with rosacea had lower ages (p>0.001) and the difference in gender composition was also statistically significant (p=0.034); in this conclusion, multivariate analysis was used. Based on the results, rosacea prevalence among patients with positive H. pylori stool antigen was 19.15% (167/875). Of 167 patients with positive H. pylori stool antigen and rosacea, 17 patients rejected to take part in the study while 150 patients agreed. Of 150 patients who underwent H.pylori eradication therapy, 138 (92%) had negative H. pylori stool antigen (successful treatment) at the end of the trial. Rosacea Duluth score at day 0, 60 and 180 was 15.55 ±4.34, 14.11 ±3.96 and 12.57 ±3.62, respectively; the differences between all stages were statistically significant (p Based on Wilcoxon signed-rank test, comparison of primary and secondary features of rosacea between stages of study is shown in table 3; Of secondary rosacea features, burning or stinging, plaques, dry appearance edema and ocular manifestations the difference between two stages of study were mostly significant; but the differences for peripheral involvement and phymatous change were mostly not statistically significant. Discussion Rosacea as a chronic dermatological disease, with an almost unknown pathogenesis process so far, has been the subject of many studies. One of the proposed pathogenic processes attributed to rosacea is gastric infection with H. pylori, so many researchers have tried to examine this association by trying to investigate the correlation between H. pylori infection and rosacea or by observing changes of rosacea after H. pylori eradication. Based in the present study, Prevalence of rosacea among H. Pylori positive patients was 19.15% in this study, which seems as twice as the highest reported rate in other populations, ranging from 1-10% (2, 28-31). This different has been correlated to various variables including race, culture and diet of these. In a study by Argenziano et al. potential association between rosacea and serological evidence of H. pylori infection was investigated and they concluded that there is a significant association between rosacea and H. pylori infection (32), while A bram et al. evaluated several suspected risk factors for rosacea and concluded that there was no statistically significant differences between rosacea patients and those of control group (33). Patients with rosacea and H. pylori infection had female gender predominance and lower age in comparison to those suffering only H. pylori infection. H. pylori cure rate after routine triple therapy was 92%. During 6 months of follow-up, H. pylori eradication among those who had rosacea and H. pylori infection led to a significant improvement in rosacea condition based on Duluth score grading. There was a significant decrease in intensity of almost all primary and secondary criteria except phymatous changes, telangiectasia, and peripheral involvement; this difference in phymatous changes, telangiectasia, and peripheral involvement might be due to the more time taking nature of these criteria to be resolved. Based on the literature, diverse conclusions have been made regarding rosacea resolution after H. pylori eradication. In a study by Szlachcic et al. investigating the link between Helicobacter pylori infection and rosacea, it was concluded that after H. pylori eradication therapy among patients with rosacea and H. pylori infection, H. pylori cure rate was 97%, and in 85% of patients the symptoms of rosacea decreased markedly or disappeared within 2-4 weeks (22); although H. pylori cure rate in the present study is less than that reported in this study, the effect of H. pylori eradication on rosacea is similar in both of the studies. In another study conducted by Rojo et al. on the role of H. pylori in rosacea and chronic urticarial, it was concluded that H. pylori eradication led to a significant improvement both in rosacea (75.6%) and urticarial (85.7%) when compared with control group (22%) in 4 weeks (34); results of that study is similar to what was concluded in the present study, although no precise description of clinical features of rosacea was presented after treatment. On the hand, Bamford et al. in a study investigating effect of treatment of H. pylori infection on rosacea concluded that rosacea was significantly improved after H. pylori eradication, although this improvement was also significant in control group, the difference between the improvement of rosacea was not statistically significant between intervention and control group (35); this fact that both groups had significant improvement in rosacea totally undermined the association of H. pylori infection and rosacea which was concluded in the present study, also in this article the improvement was attributed to probable placebo effect. In another study by Herr et al. relationship between H. pylori and rosacea was examined by evaluating the response of patients with rosacea to H. pylori eradication, and they concluded that there was no statistically significant change in rosacea condition both in intervention and control group, although papulopustules had significantly decreased in interven tion group comparing baseline and follow-up (36), which is the only improvement detected after H. pylori eradication in this study, but in the present study besides improvement of papulopustules, almost all the other clinical manifestations of rosacea had improved. In a study by El-khalawany evaluating the effect of H. pylori eradication in rosacea subtypes it was concluded that H. pylori eradication led to a significant improvement in rosacea, where papulopustular subtype improved significantly more than erythematotelangiectatic subtype (37); these results are similar to the results of present study, since in the present study almost all clinical manifestations of rosacea had decreased while no statistically significant change was shown about telangiectasia. According to the mentioned literature, different conclusions have been derived from studies about the efficacy of H. pylori eradication in rosacea treatment; ranging from significant improvement in rosacea (22) or significant improvement between baseline and follow-up but not when compared to control group (35) to no significant improvement in rosacea. One of the reasons which might be responsible for these diverse conclusions is multifactorial nature of rosacea where ethnic group, bacterial subtypes or genetics might be other confounding factors. One of the main limitations of this study was lack of control group, so it might have affected this study to prevent coming to a precise and confident conclusion, also this might have led to undermining probable placebo effect of administered treatment. The main thought behind not including a control group was not willing to deprive patients of H. pylori treatment where their H. pylori infection had already been proved. Another factor which could have resulted in a more precise and reliable conclusion was including possible confounding factors such as gender, ethnic groups, and occupational environment status and analyzing rosacea improvement while taking confounding factors into account. 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J Korean Med Sci 2000: 15: 551-554. 37.El-khalawany M, Mahmoud A, Mosbeh A-S, et al. Role of Helicobacter pylori in common rosacea subtypes: A genotypic comparative study of Egyptian patients. The Journal of Dermatology 2012: 39: 989-995. Tables: Table 1. Demographic information about patients with positive H. pylori stool antigen (%) Variables Patients with* P value + HPA without rosacea (N=705) +HPA with rosacea (N=167) Age (years old) 54.38 ±10.71 43.21 ±9.84 Gender 337 (47.81%) female, 368 (52.19%) male 95 (56.89%) female, 72 (43.11%) male 0.03 Marital status Single, Divorced or widowed (643(91.2%)), Married (62(8.8%)) Single, Divorced or widowed (145 (86.82%)), Married (22 (13.18%)) 0.1 +HPA: Positive H. pylori antigen * U Mann-Whitney test was used. **Data are shown as Mean  ± Standard Deviation and number (%) Table 2. Rosacea Duluth grading of patients at day 0, 60 and 180 of trial (N=138)*. Variables Day 0 ** Day 60** Day 180** P value Primary Features Flushing 2.28  ± 0.71 2.02  ± 0.51 1.82  ± 0.52 Non-transient erythema 2.34  ± 0.54 1.9  ± 0.64 1.42  ± 0.72 Papules and pustules 1.8  ± 0.59 1.71  ±0.51 1.58  ± 0.52 Telangiectasia 1.78  ± 0.93 1.72  ±0.67 1.74  ± 0.84 <