Ocular Rosacea Treatment & Management
- Author: Bhairavi Kharod-Dholakia, MD; Chief Editor: Hampton Roy, Sr, MD more...
Rosacea is caused by inherent defects in the body's immune system and vasoregulatory processes. Treatment is directed toward symptomatic control and disease prevention rather than cure.
When treating ocular rosacea, a stepwise approach can be undertaken, using first lid hygiene and artificial tears, followed by topical and oral anti-inflammatory medications, with late surgical intervention as required.
Hot compresses applied to the eyelid margins can help to liquefy the thick meibomian gland secretions and, thus, facilitate their expression. Mild, nonirritating cleaning solutions, such as dilute baby shampoo or commercially prepared eyelid scrubs, can also be applied to the eyelids to remove clogging debris. Additionally, light pressure applied to the eyelids can aid in gland expression. Thermal pulsation to the eyelid (Lipiflow) is an emerging technique in the treatment of blepharitis.
Because of the frequency of application, nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.
Patients with ocular rosacea who are asymptomatic and without worsening eye disease should not be placed on oral antibiotics.
Tetracyclines (eg, tetracycline, doxycycline, minocycline) [21, 20, 22]
- Tetracyclines represent the most common and most effective treatment regimen for rosacea. These drugs are believed to be effective not primarily as antibiotics but rather through a secondary effect that they exert on the meibomian glands. Tetracyclines decrease bacterial lipase, thereby altering the fatty acid composition of the meibomian gland secretions and improving their solubility. These medications also inhibit collagenase; therefore, they are effective in protecting the cornea from impending perforation secondary to inflammatory responses.
- Adverse effects are predominantly GI, including diarrhea and, rarely, pancreatitis and pseudomembranous colitis. In these patients, enteric-coated tetracyclines such as Doryx (a form of enteric-coated doxycycline) are a promising option. The special coating prevents the medication from dissolving in the stomach where it may induce GI upset. Instead, the medication is broken down in the small intestine from where it readily enters the blood stream. More severe but much less common adverse effects include benign intracranial hypertension and renal tubular damage (Fanconi syndrome) from outdated medications. Additionally, tetracyclines cross the placenta and can cause permanent discoloration of teeth as well as fetal bone growth retardation.
- Tetracyclines generally are effective for rosacea in doses much lower than those given for antibiotic effect, and, once the disease has come under control, the dose may be tapered to a lower, suppressive dose and maintained indefinitely. Because of the chronic, relapsing nature of rosacea, the medication may be used chronically at suppressive doses or discontinued and restarted if and when symptoms recur.
- Among this class of medications, tetracycline and doxycycline are most commonly used. The 2 medications are quite similar in their mechanism of action, adverse effect profile, and efficacy, but slight differences do exist. Tetracycline has a shorter half-life and, thus, is dosed 4 times per day, as opposed to doxycycline, which is given twice per day or once per day. Frucht-Pery et al reported a more rapid therapeutic response to tetracycline; however, no difference was found at 6 months.
- In 2006, the first FDA-approved oral treatment for rosacea became available: a controlled-release form of doxycycline called Oracea (Galderma Laboratories L.P). The 40-mg tablet is a combination of 30 mg of immediate-release and 10 mg of delayed-release doxycycline. The low dose enables the medication to have anti-inflammatory properties without exerting significant antibacterial properties, allowing for a more improved side effect profile and decrease rates of bacterial resistance.
- Topical azithromycin eye drops have also gained popularity in the treatment of ocular rosacea. Ocular rosacea often results in severe and recalcitrant blepharitis. Azasite (azithromycin 1%, Inspire Pharmaceuticals) currently FDA approved only to treat bacterial conjunctivitis has found an off label use in the treatment of meibomian gland dysfunction.
- Erythromycin can be taken orally for patients intolerant to, or too young for, tetracyclines. Erythromycin ointment applied to the lid margins once or twice daily can provide lubrication for the eye and reduce the bacterial overgrowth contributing to lid margin disease.
- Clarithromycin has shown efficacy in treating rosacea. This compound exhibits anti-inflammatory effects as well as activity against H pylori. Torresani compared clarithromycin and doxycycline and found equivalent therapeutic responses and a milder adverse effect profile for clarithromycin.
- Metronidazole exhibits antimicrobial (antibacterial and antiparasitic), anti-inflammatory, and immunosuppressive properties and has been found to be effective against rosacea. In fact, oral metronidazole has been advocated as first-line therapy. Adverse effects include gastrointestinal irritation and a disulfiramlike action; thus, abstinence from alcohol is required.
- Topical metronidazole is quite effective in treating skin lesions in rosacea. While not approved for ophthalmic use, in a pilot study, Barnhorst et al found the topical compound to be safe and effective in treating eyelid involvement in ocular rosacea.
Topical steroids can prove useful for short-term exacerbations of lid disease and management of inflammatory keratitis. However, steroids should be used cautiously and discontinued as soon as possible to prevent corneal melting. Topical steroids may lead to rosacea exacerbations and should be avoided if possible.
Vitamin A derivatives, such as oral isotretinoin and topical tretinoin, have been found effective in reducing the inflammatory lesions in rosacea. This appears to be accomplished via the suppression of sebum production and a subsequent reduction in sebaceous follicle size. Additionally, tretinoin may help restore sun-damaged skin through the increased production of type 1 collagen in damaged regions. Both compounds can actually cause severe erythema and blepharoconjunctivitis, worsen telangiectasias, and lead to severe keratitis. Additionally, retinoids are extremely teratogenic and, thus, must never be used during pregnancy. Therefore, the use of retinoids is commonly reserved for cases in which multiple agents have failed.
H pylori plays an as yet undetermined role in rosacea, and some have advocated H pylori eradication in the treatment of rosacea. Thus, in some cases of rosacea, antiulcer combination regimens, such as amoxicillin or clarithromycin, metronidazole, bismuth, and an H2 antagonist, have been used with varying efficacy.
Other treatments in the treatment of rosacea include intense pulsed light therapy, ablative lasers, and electrosurgical loop.
See the list below:
Treatment of dry eye - Punctal occlusion can be accomplished via permanent silicone plugs or punctal cauterization.
Amniotic membrane - Amniotic membrane has anti-inflammatory properties and promotes reepithelization of the cornea. It can be used to reconstruct the corneal surface in severe cases of rosacea when a nonhealing epithelial defect, corneal ulceration, or limbal stem cell deficiency are present.
Treatment of corneal perforations
- Cyanoacrylate tissue adhesive
- Lamellar keratoplasty
- Penetrating keratoplasty
Restoration of vision from corneal disease
- Penetrating keratoplasty
- The success rate for graft survival is generally much lower than for noninflammatory conditions because of the increased vascularization of the host cornea.
Treatment of limbal stem cell deficiency - Limbal stem cell transplant
A dermatology consult is essential for the optimal management of rosacea.
Avoidance of triggers, such as hot, spicy foods, alcohol, and heated beverages, can reduce symptomatic episodes.
Avoidance of sunlight can be beneficial for some patients.
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].