Pediatric and Teen CL Care
Rosacea: Not Just for Adults
By Christine W. Sindt, OD, FAAO
Rosacea is a common condition, affecting about 14 percent of women and 6 percent of men (Berg, 1989). Often described as “adult acne,” it is a chronic, inflammatory skin condition, frequently associated with ocular manifestations. Rosacea is characterized by flushing, nontransient erythema, papules/pustules, telangiectasia, and sebaceous gland dysfunction of the face, neck and shoulders. Ocular signs include chalazia, blepharoconjunctivitis, conjunctival hyperemia, keratitis, and corneal ulcers while symptoms include photophobia, burning, itching, and reduced vision (Crawford, 2004).
While adult rosacea is one of the most common dermatologic diagnoses, pediatric rosacea is less defined and is often overlooked. Childhood rosacea may be under-diagnosed because ocular manifestation may be present before or in the absence of associated skin changes (Donaldson, 2007; Bamford, 2006).
Periorificial dermatitis (pustules around the mouth, nose and eyes) may be present along with ocular signs (mainly recurrent chalazia and blepharitis) (Hong, 2009), but unlike adult rosacea, the use of topical corticosteroids on the face rarely precipitates disease exacerbation in children.
Chronic pediatric rosacea and blepharokeratoconjunctivitis are not benign (Jones, 2007). Watch children who have blepharitis closely for corneal scarring, neovascularization, and refractive changes, especially in light of potential amblyopia development.
In a study evaluating children who have blepharitis-related keratitis, blepharitis treatment improved visual acuity in 70 percent of affected eyes (Jones, 2007).
Treatment options for pediatric rosacea include topical and systemic treatments, among others. Topical treatments include warm compresses, ofloxacin 0.3%, topical steroids, and possibly autologous serum eye drops (Mavrakanas, 2010). Warm compresses are thought to melt meibum and increase circulation to help resolve inflammation. Topical ofloxacin provides broad-spectrum, gram-positive coverage, while topical steroids reduce inflammation. Autologous serum is believed to enhance corneal epithelial healing and to reduce the corneal inflammatory and immune response (Mavrakanas, 2010), but it has limited description in the literature for children.
Systemic treatments for periorificial dermatitis and rosacea in children use oral erythromycin (Cetinkaya, 2006) and omega-3 fatty acids. Tetracyclines are often considered to be the best systemic therapy for ocular rosacea in adults but are contraindicated in young children because they can stain and weaken tooth enamel (Kroshinsky, 2006).
Erythromycin lengthens tear film breakup time and helps resolve corneal staining by improving meibomian gland dysfunction (Mavrakanas, 2010). It is effective against common gram-positive organisms that cause blepharokeratoconjunctivitis and may inhibit proinflammatory bacterial enzymes (Mavrakanas, 2010). Therapeutic dosage has been suggested at 30mg/kg/day to 50mg/kg/day for three months or longer to prevent serious ocular sequelae (Hong, 2009).
Oral omega-3 fatty acids provide an anti-inflammatory effect, but the long-term use of flaxseed oil in children has not been evaluated and is not supported by the FDA (Jones, 2007).
For children who are in the amblyopia-producing years, treating blepharokeratoconjunctivitis is vitally important in order to prevent vision loss. While not nearly as common as adult rosacea, consider pediatric rosacea anytime a child has recurrent chalazia or significant chronic blepharitis. CLS
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Dr. Sindt is a clinical associate professor of ophthalmology and director of the contact lens service at the University of Iowa Department of Ophthalmology and Visual Sciences. She is also the 2010-2011 Chair of the AOA Cornea and Contact Lens Council. She is a consultant or advisor to Alcon, Ciba Vision, and Vistakon and has received research funds from Alcon. You can reach her at firstname.lastname@example.org.