Rosacea The Dermatologic Connection
WILLIAM L. MILLER, OD, PHD, FAAO
often associate cases of recurrent conjunctival injection and symptomatic ocular
irritation with dry eye syndrome or allergic ocular disease. But careful attention
to the facial skin
may reveal the real culprit rosacea. Rosacea is a chronic cutaneous syndrome
affecting the regions of the face with waxing and waning of the disease process.
The prevalence of rosacea in the United States is around 13 million
or approximately 1 in every 20 individuals. It can occur in any ethnicity, but more
frequently in patients of northern European descent or in those who have fair skin.
It affects more females than males (3:1) and occurs typically between the fourth
and sixth decades of life. Rosacea patients who have ophthalmic rosacea may range
from 3 percent to 58 percent.
Signs and Symptoms
Common primary facial signs to look for include telangiectasia,
flushing (transient erythema), nontransient erythema, papules, pustules, edema and
rhinophyma. Any one of the first four signs indicates rosacea. Patients may also
experience burning or stinging, red elevated skin plaques and dry scaly skin.
Ophthalmic signs, which may occur before dermatological signs
in up to 20 percent of patients, can include conjunctival hyperemia and lid inflammation.
Patients may also suffer from frequent bouts of hordeola and chalazia. Severe
cases may demonstrate corneal vascularization, corneal infiltrates and episcleritis/scleritis.
Rosacea is classified into four subtypes and one variant with
each ranging from mild to moderate to severe (Wilkin et al, 2002). Ocular rosacea
falls under subtype 4, following subtypes erythematotelangiecatic, papulopustular
and phymatous. Patients who have ocular rosacea exhibit interpalpebral hyperemia,
foreign body sensation, burning or stinging, dryness, itching, photophobia, blurred
vision, telangiectases of conjunctiva and lid margin and/or lid and periocular
erythema. Patients may also have blepharitis, conjunctivitis or irregular eyelid
margins. An inflamed eyelid with telangiectasia may be a key determinant for diagnosis.
Treatment of the ocular manifestations of rosacea will target
the eyelid and ocular surface. Treat blepharitis and meibomian gland dysfunction
with lid hygiene and oral antibiotics such as doxycycline or minocycline (100 mg,
b.i.d.). Over-the-counter tear supplements can prevent ocular surface drying. Cyclosporine
(Restasis, Allergan) may help alter aqueous tear production and target ocular surface
Fit affected contact lens wearers into low-water-content lenses,
preferably silicone hydrogels, which move well on the eye. A more frequent replacement
schedule minimizes contact lens surface deposits.
You can coordinate with your patient's physician or dermatologist
to provide other systemic treatments. In addition to the oral antibiotics mentioned
earlier, metronidazole (Flagyl) in a topical cream or gel can be used. For female
patients who are pregnant, topical clindamycin (Cleocin) is a suitable alternative
to the cyclines and metronidazole. Other second line treatments include Accutane
or topical tretinoin. Patients can prevent facial flushing by avoiding triggers
such as sunlight and alcohol or through the use of low dose clonidine (Catapres;
0.05mg b.i.d.). Azelaic acid (Finacea) as a 15% gel is approved to combat facial
redness and pustules.
To obtain references for this article, please visit
and click on document #132.
Dr. Miller is on the faculty
at the University of Houston College of Optometry. He is a member of the American
Optometric Association and serves on its Journal Review Board. You can reach him
Contact Lens Spectrum, Issue: November 2006