History

Facial symptoms may include the following:

Recurrent flushing episodes
Persistent and/or recurrent midfacial erythema
Papular and pustular lesions

Ocular symptoms may include the following:

Dry eyes,^[16]irritation, redness, itching, burning, foreign body sensation, and photophobia
Recurrent chalazia
Recurrent eye infections

Facial findings

Facial findings are as follows:

Telangiectasias
Papules and pustules (without comedones)
Rhinophyma (hypertrophy of sebaceous glands leading to bulbous deformity of the nose)
See the image below

Typical findings of rosacea, including papules, pustules, and rhinophyma.
View Media Gallery

Ocular findings

Ocular findings are as follows:

Eyelid (most common)^[17]
- Eyelid telangiectasias as depicted below
  
  Ocular rosacea. Eyelid telangiectasias with inspissated meibomian glands.
  View Media Gallery
- Blepharitis
- Meibomian gland dysfunction
- Thick viscous plugging of meibomian gland orifices
- Hordeola/chalazia
Conjunctivitis
- Usually chronic, diffuse hyperemia
- Can lead to cicatrization in rare, severe cases
Corneal findings
- Punctate epithelial keratopathy (PEK), usually in the inferior one third of the cornea
- Marginal corneal infiltrates
- Corneal neovascularization
- Superficial, wedge-shaped (spade-like) peripheral vascularization with its base at the limbus
- Can progress to frank corneal neovascularization and eventual opacification as shown below
  
  Ocular rosacea. Extensive corneal neovascularization and opacification.
  View Media Gallery
- Corneal thinning as depicted below, ulceration, and perforation
  
  Ocular rosacea. Extensive corneal pannus with thinning.
  View Media Gallery
Secondary bacterial keratitis
Episcleritis, scleritis (rare)

Causes

Flushing triggers: These include alcohol, hot beverages, tobacco, spicy foods, vasodilating medications, and emotional stress.

UV light: This is postulated to decrease the competence of already dilated cutaneous vasculature, increasing persistent erythema and telangiectasias.

Demodex: This mite, which is part of the skin's normal flora, leads to stimulation of the innate immune system. Bacteria in the gut of Demodex may be the inciting factor rather than the Demodex itself.^[11]

S epidermidis: Hyper-reactivity of the innate immune system in rosacea patients makes them sensitive to this normal skin flora.^[12]

H pylori: This is postulated to be strongly correlated with rosacea. This is possibly due to a flush-inducing toxin present in H pylori.

Positive family history: Some studies have shown a higher rate of positive family history of rosacea in patients with this dermatologic disorder than in skin-healthy controls.^[18]

Smoking: Some studies have shown an increased history of smoking in patients with rosacea as compared with skin-healthy controls.^{[18, 19]}

Complications

Complications include corneal vascularization, ulceration, perforations, secondary bacterial infections, and, ultimately, decreased vision.

Differential Diagnoses

Buechner SA. Rosacea: an update. Dermatology. 2005. 210(2):100-8. [QxMD MEDLINE Link].
Knox CM, Smolin G. Rosacea. Int Ophthalmol Clin. 1997 Spring. 37(2):29-40. [QxMD MEDLINE Link].
Powell FC. Clinical practice. Rosacea. N Engl J Med. 2005 Feb 24. 352(8):793-803. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link]. [Full Text].
Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. 1997 Nov. 104(11):1863-7. [QxMD MEDLINE Link].
Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol. 1986 Nov-Dec. 31(3):145-58. [QxMD MEDLINE Link].
Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol. 1994 Mar. 130(3):359-62. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Sobottka A, Lehmann P. Rosacea 2009 : new advances in pathophysiology, clinical staging and therapeutic strategies. Hautarzt. 2009 Dec. 60(12):999-1009. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol. 1989. 69(5):419-23. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Chamaillard M, Mortemousque B, Boralevi F, et al. Cutaneous and ocular signs of childhood rosacea. Arch Dermatol. 2008 Feb. 144(2):167-71. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Icasiano E, Latkany R, Speaker M. Chronic epiphora secondary to ocular rosacea. Ophthal Plast Reconstr Surg. 2008 May-Jun. 24(3):249. [QxMD MEDLINE Link].
Abram K, Silm H, Maaroos HI, Oona M. Risk factors associated with rosacea. J Eur Acad Dermatol Venereol. 2010 May. 24(5):565-71. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Gao YY, Di Pascuale MA, Elizondo A, Tseng SC. Clinical treatment of ocular demodecosis by lid scrub with tea tree oil. Cornea. 2007 Feb. 26 (2):136-43. [QxMD MEDLINE Link].
Schechter BA, Katz RS, Friedman LS. Efficacy of topical cyclosporine for the treatment of ocular rosacea. Adv Ther. 2009 Jun. 26 (6):651-9. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Alikhan A, Kurek L, Feldman SR. The role of tetracyclines in rosacea. Am J Clin Dermatol. 2010. 11(2):79-87. [QxMD MEDLINE Link].
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. [QxMD MEDLINE Link].
Luchs J. Azithromycin in DuraSite for the treatment of blepharitis. Clin Ophthalmol. 2010 Jul 30. 4:681-8. [QxMD MEDLINE Link]. [Full Text].
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. [QxMD MEDLINE Link].
Torresani C. Clarithromycin: a new perspective in rosacea treatment. Int J Dermatol. 1998 May. 37(5):347-9. [QxMD MEDLINE Link].

Media Gallery

Typical dermatologic findings of rosacea, including midfacial papules, pustules, and rhinophyma.
Typical findings of rosacea, including papules, pustules, and rhinophyma.
Ocular rosacea. Eyelid telangiectasias with inspissated meibomian glands.
Ocular rosacea. Peripheral corneal pannus.
Ocular rosacea. Extensive corneal pannus with thinning.
Ocular rosacea. Extensive corneal neovascularization and opacification.

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Author

Jitander Dudee, MD, MA(Cantab), FACS, FRCOphth Ophthalmologist, Medical Vision Institute, PSC

Jitander Dudee, MD, MA(Cantab), FACS, FRCOphth is a member of the following medical societies: American Academy of Ophthalmology, Kentucky Medical Association, Royal College of Ophthalmologists

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Christopher J Rapuano, MD Professor, Department of Ophthalmology, Sidney Kimmel Medical College of Thomas Jefferson University; Director of the Cornea Service, Wills Eye Hospital

Christopher J Rapuano, MD is a member of the following medical societies: American Academy of Ophthalmology, American Ophthalmological Society, American Society of Cataract and Refractive Surgery, Contact Lens Association of Ophthalmologists, Cornea Society, Eye Bank Association of America, International Society of Refractive Surgery

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: AAO; OMIC; American Society of Ophthalmic Trauma (ASOT); Avellino, Baxis; Bio-Tissue; Celularity; Dompe; Emmecell; Glaukos; Kala; Oyster Point; Sun Ophthalmics; Tarsus; TearLab<br/>Serve(d) as a speaker or a member of a speakers bureau for: Glaukos; Dompe; Bio-Tissue<br/>Received research grant from: Glaukos<br/>Received income in an amount equal to or greater than $250 from: AAO; OMIC; Baxis; Bio-Tissue; Cellularity; Dompe; Glaukos; Kala; Sun Ophthalmics; TearLab<br/>stock options for: RPS, Fount Bio.

Chief Editor

Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC Professor, Department of Ophthalmology and Vision Sciences, Sunnybrook Hospital, University of Toronto Faculty of Medicine; Incoming Chair of Ophthalmology, University of Alberta Faculty of Medicine and Dentistry, Canada

Edsel B Ing, MD, PhD, MBA, MEd, MPH, MA, FRCSC is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, American Society of Ophthalmic Plastic and Reconstructive Surgery, Canadian Medical Association, Canadian Ophthalmological Society, Canadian Society of Oculoplastic Surgery, Chinese Canadian Medical Society, European Society of Ophthalmic Plastic and Reconstructive Surgery, North American Neuro-Ophthalmology Society, Ontario Medical Association, Royal College of Physicians and Surgeons of Canada, Statistical Society of Canada

Disclosure: Nothing to disclose.

Additional Contributors

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

J Bradley Randleman, MD is a member of the following medical societies: Alpha Omega Alpha, International Society of Refractive Surgery, Cornea Society, American Academy of Ophthalmology, American Society of Cataract and Refractive Surgery

Disclosure: Nothing to disclose.

C Diane Song, MD Chief of Ophthalmology, Asheville Veterans Affairs Medical Center

C Diane Song, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology, American Society of Cataract and Refractive Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Evan S Loft, MD Clinical Assistant Professor, Department of Ophthalmology, Emory University

Evan S Loft, MD is a member of the following medical societies: American Academy of Ophthalmology, American Medical Association, American Society of Cataract and Refractive Surgery, Association for Research in Vision and Ophthalmology, Phi Beta Kappa

Disclosure: Nothing to disclose.

Bhairavi Kharod-Dholakia, MD North Georgia Eye Clinic

Disclosure: Nothing to disclose.

Sheetal M Shah, MD Assistant Professor of Ophthalmology in Cornea and External Diseases, Department of Ophthalmology, Emory Eye Center and Emory Vision, Emory University School of Medicine

Sheetal M Shah, MD is a member of the following medical societies: American Academy of Ophthalmology, Association for Research in Vision and Ophthalmology

Disclosure: Nothing to disclose.

Joshua A Zeichner, MD Assistant Professor, Director of Cosmetic and Clinical Research, Mount Sinai School of Medicine; Chief of Dermatology, Institute for Family Health at North General

Joshua A Zeichner, MD is a member of the following medical societies: American Academy of Dermatology, National Psoriasis Foundation

Disclosure: Received consulting fee from Valeant for consulting; Received grant/research funds from Medicis for other; Received consulting fee from Galderma for consulting; Received consulting fee from Promius for consulting; Received consulting fee from Pharmaderm for consulting; Received consulting fee from Onset for consulting.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the assistance of Ryan I Huffman, MD, with the literature review and referencing for this article.