- Author: Bhairavi Kharod-Dholakia, MD; Chief Editor: Hampton Roy, Sr, MD more...
Rosacea is a common inflammatory dermatologic condition that affects the midface and eyes.[1, 2, 3, 4] Although the etiology of rosacea is not fully understood, an augmented response of the innate immune system and neurovascular pathways to certain triggers are considered to be major factors in the chronic inflammatory process associated with this condition. The nose, cheeks, forehead, chin, and glabella are the most commonly affected areas. Clinical features include flushing, telangiectasias, erythema, papules and pustules, and rhinophyma. More than 50% of patients with rosacea have ocular manifestations.
See the image below.
Manifestations of ocular rosacea range from minor irritation, foreign body sensation, dryness, and blurry vision to severe ocular surface disruption and inflammatory keratitis. Patients frequently describe a gritty feeling, and they commonly experience Blepharitis and conjunctivitis. Other ocular findings include lid margin and conjunctival telangiectasias, eyelid thickening, eyelid crusts and scales, chalazia and hordeolum, punctate epithelial erosions, corneal infiltrates, corneal ulcers, corneal scars, and vascularization. Sight-threatening disease is rare with rosacea; however, keratitis can result in sterile corneal ulceration and eventual perforation if not treated aggressively.[6, 7]
Ocular rosacea is most frequently diagnosed when patients also suffer from cutaneous disease. However, ocular signs and symptoms may occur prior to cutaneous manifestations in 20% of patients with rosacea. No correlation exists between the severity of ocular disease and the severity of facial rosacea.
The symptoms of rosacea can be treated effectively; however, rosacea is a chronic condition with exacerbations and remissions, which requires long-term therapy to maintain symptomatic control.
The precise pathophysiology of rosacea remains unclear[8, 9] but is comprised of both vascular dysregulation and altered immune system responses and inflammatory changes. Recent research has shown an upregulation of proinflammatory and vasoregulatory genes in rosacea patients. Alterations in the innate immune system responses include an overabundance of cathelicidin (an antimicrobial peptide), along with kallikrein-5, an enzyme involved in processing cathelicidin. Moreover, toll-like receptor 2 activity in the innate immune system is increased in patients with rosacea.
A variety of rosacea triggers have been described including skin colonization with Demodex mites (along with bacteria in their gut) and Staphyloccocus epidermidis. Eradication of Helicobacter pylori has been shown to improve rosacea in some patients, and the organism may play a role in the pathogenesis of inflammation of inflammation in rosacea.
Four distinct rosacea subtypes have been described: erythematotelangiectatic rosacea, papulopustular rosacea, phymatous rosacea, and ocular rosacea.
More than 10% of the general population exhibits dermatologic characteristics of rosacea; of these, up to 60% experience ocular complications.
An epidemiological study in Sweden showed a 10% prevalence of rosacea. A study in Estonia showed a 22% prevalence rate of rosacea, as determined by the American National Rosacea Society Expert Committee (NRSEC) classification.
While rosacea is not a life-threatening disease, it is a source of much morbidity because of pruritus, burning, and psychosocial impairments. Approximately 5% of patients with rosacea manifest corneal disease, which can rarely be severe and lead to blindness via corneal ulceration, perforation, secondary infections, or corneal opacification from complete vascularization.
Rosacea is recognized much more commonly in fair-skinned, white patients than in dark-skinned patients. However, because dark skin tones may mask erythema of rosacea, its incidence in this population is likely underreported.
Women are affected with the papulopustular and erythematotelangiectactic rosacea subtypes twice as often as men; however, the phymatous rosacea subtype develops much more frequently in men. Ocular rosacea affects both sexes equally.
All ages can be affected, including pediatric patients. Peak incidence occurs in the fourth to seventh decades.
Buechner SA. Rosacea: an update. Dermatology. 2005. 210(2):100-8. [Medline].
Knox CM, Smolin G. Rosacea. Int Ophthalmol Clin. 1997 Spring. 37(2):29-40. [Medline].
Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24. 352(8):793-803. [Medline].
Wilkin J, Dahl M, Detmar M, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. 2002 Apr. 46(4):584-7. [Medline].
Del Rosso JQ. Advances in understanding and managing rosacea: part 1: connecting the dots between pathophysiological mechanisms and common clinical features of rosacea with emphasis on vascular changes and facial erythema. J Clin Aesthet Dermatol. 2012 Mar. 5(3):16-25. [Medline]. [Full Text].
Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. 1997 Nov. 104(11):1863-7. [Medline].
Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol. 1986 Nov-Dec. 31(3):145-58. [Medline].
Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol. 1994 Mar. 130(3):359-62. [Medline].
Tisma VS, Basta-Juzbasic A, Jaganjac M, et al. Oxidative stress and ferritin expression in the skin of patients with rosacea. J Am Acad Dermatol. 2009 Feb. 60(2):270-6. [Medline].
Sobottka A, Lehmann P. Rosacea 2009 : new advances in pathophysiology, clinical staging and therapeutic strategies. Hautarzt. 2009 Dec. 60(12):999-1009. [Medline].
Jarmuda S, O'Reilly N, Zaba R, Jakubowicz O, Szkaradkiewicz A, Kavanagh K. Potential role of Demodex mites and bacteria in the induction of rosacea. J Med Microbiol. 2012 Nov. 61(Pt 11):1504-10. [Medline].
Whitfeld M, Gunasingam N, Leow LJ, Shirato K, Preda V. Staphylococcus epidermidis: a possible role in the pustules of rosacea. J Am Acad Dermatol. 2011 Jan. 64(1):49-52. [Medline].
Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol. 1989. 69(5):419-23. [Medline].
Abram K, Silm H, Oona M. Prevalence of rosacea in an Estonian working population using a standard classification. Acta Derm Venereol. 2010 May. 90(3):269-73. [Medline].
Chamaillard M, Mortemousque B, Boralevi F, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol. 2008 Feb. 144(2):167-71. [Medline].
Viso E, Rodriguez-Ares MT, Gude F. Prevalence of and associated factors for dry eye in a Spanish adult population (the Salnes Eye Study). Ophthalmic Epidemiol. 2009 Jan-Feb. 16(1):15-21. [Medline].
Icasiano E, Latkany R, Speaker M. Chronic epiphora secondary to ocular rosacea. Ophthal Plast Reconstr Surg. 2008 May-Jun. 24(3):249. [Medline].
Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol. 2010 May. 24(5):565-71. [Medline].
Breton AL, Truchetet F, Veran Y, et al. Prevalence analysis of smoking in rosacea. J Eur Acad Dermatol Venereol. 2011 Sep. 25(9):1112-3. [Medline].
Modi S, Harting M, Rosen T. Azithromycin as an alternative rosacea therapy when tetracyclines prove problematic. J Drugs Dermatol. 2008 Sep. 7(9):898-9. [Medline].
Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani P. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol. 1993 Jul 15. 116(1):88-92. [Medline].
Alikhan A, Kurek L, Feldman SR. The role of tetracyclines in rosacea. Am J Clin Dermatol. 2010. 11(2):79-87. [Medline].
Barnhorst DA Jr, Foster JA, Chern KC, Meisler DM. The efficacy of topical metronidazole in the treatment of ocular rosacea. Ophthalmology. 1996 Nov. 103(11):1880-3. [Medline].
Tanghetti E, Del Rosso JQ, Thiboutot D, Gallo R, Webster G, Eichenfield LF, et al. Consensus recommendations from the American Acne & Rosacea Society on the management of rosacea, part 4: a status report on physical modalities and devices. Cutis. 2014 Feb. 93(2):71-6. [Medline].
Torresani C. Clarithromycin: a new perspective in rosacea treatment. Int J Dermatol. 1998 May. 37(5):347-9. [Medline].