eMedicine Specialties > Ophthalmology > Dermatologic Disorders

Ocular Rosacea: Treatment & Medication

Author: J Bradley Randleman, MD, Associate Professor, Department of Ophthalmology, Section of Cornea, External Disease and Refractive Surgery, Emory University School of Medicine; Director of Cornea, External Disease and Refractive Surgery Fellowship, Emory University; Physician Member, Section of Ophthalmology, The Emory Clinic
Coauthor(s): Evan S Loft, MD, Staff Physician, Department of Ophthalmology, Emory University; C Diane Song, MD, Chief of Ophthalmology, Asheville Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: Feb 20, 2009

Treatment

Medical Care

Rosacea is an enigmatic disease with multiple exacerbations and remissions, and, unfortunately, treatment is directed toward symptomatic control rather than cure. Ocular rosacea can manifest as minor ocular irritation or severe corneal compromise; thus, medical therapy is chosen based on the severity of presentation. When possible, 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.

As can be implied by the number and variety of treatment options available for rosacea, no one therapeutic regimen has been found effective in all cases, and many cases of rosacea are recalcitrant to multiple therapies. Therefore, treatment always must be tailored to each individual, and various options must be explored until symptoms begin to respond favorably.

• Lid hygiene: 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, also can be applied to the eyelids to remove clogging debris. Additionally, light pressure applied to the eyelids can aid in gland expression.
• Artificial tears: 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.
• Antibiotics (Patients with ocular rosacea who are asymptomatic and without worsening eye disease should not be placed on oral antibiotics.)
  • Tetracyclines (eg, tetracycline, doxycycline, minocycline)^12,13
    • 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 gastrointestinal, including diarrhea and rarely pancreatitis and pseudomembranous colitis. 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 retardation of fetal bone growth.
    • 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.¹² Additionally, the adverse effect profile is slightly more favorable for doxycycline.
  • 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.¹⁴
  • Metronidazole
    • 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.¹⁵
• 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.
• Retinoids: 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 actually can 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.
• Antiulcer therapy: 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.

Surgical Care

• 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

Consultations

 A dermatology consult is essential for the optimal management of rosacea.

Diet

Avoidance of triggers, such as hot, spicy foods, alcohol, and heated beverages, can reduce symptomatic episodes.

Activity

Avoidance of sunlight can be beneficial for some patients.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Antibiotics

Anti-inflammatory effect helps to ameliorate meibomian gland disease.

Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor.

Doxycycline (Vibramycin, Doryx)

DOC; inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor.

Clarithromycin (Biaxin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Effective through secondary, anti-inflammatory action.

Metronidazole (Flagyl)

Has anti-inflammatory and immunosuppressive activity.

Erythromycin ophthalmic ointment (E-Mycin)

Used to decrease meibomian gland bacterial overgrowth.

Retinoids

Decrease sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.

Isotretinoin (Accutane)

Reduces sebum production and sebaceous follicle size.

Tretinoin (Avita, Retin-A, Retin-A Micro)

Structurally related to vitamin A. Reduces sebum production and sebaceous follicle size. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. May help restore sun-damaged skin. Long-term, low-dose therapy may be suitable for selected patients.
Inhibits microcomedo formation and eliminates lesions present. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.

Steroids

Topical steroids occasionally are needed to help suppress inflammatory changes in the cornea.

Prednisolone acetate (Pred Forte, Econopred)

Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability.

Immunomodulators

These agents regulate key regulatory steps responsible for inflammation.

Cyclosporine (Restasis)

Used to relieve dry eyes caused by suppressed tear production secondary to ocular inflammation. Thought to act as partial immunomodulator. Exact mechanism of action is not known.

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