Dry Eye Diagnosis and Treatment in Rosacea: From Skin to Eye

Overview

Rosacea and dry eye disease share multifactorial inflammatory and autoimmune mechanisms, often overlapping when rosacea affects the ocular surface as ocular rosacea. Diagnosis can be challenging due to variable symptom presentation and underrecognition, especially in darker-skinned populations. Treatment ranges from lifestyle modifications and omega-3 supplementation to topical and systemic therapies, with a need for evidence-based guidelines.

Background

Rosacea is a chronic inflammatory condition affecting approximately 5.5% of adults globally, with ocular involvement occurring in 10% to 15% of cutaneous cases and sometimes independently. It manifests with facial erythema, vascular abnormalities, and ocular signs including blepharitis, conjunctivitis, dry eye, and meibomian gland dysfunction. Both rosacea and dry eye disease share inflammatory, autoimmune, and neurological roots and are often underdiagnosed. Recognizing ocular rosacea is critical for effective management of dry eye symptoms in affected patients.

Data Highlights

Rosacea prevalence: ~5.5% of global adults
Ocular rosacea prevalence: 10%-15% of cutaneous rosacea cases
Common ocular features: blepharitis, conjunctivitis, dry eye, meibomian gland dysfunction, lid telangiectasias
Severe ocular complications: keratitis, corneal neovascularization, scarring, ulceration, anterior uveitis

Key Findings

• Rosacea and dry eye disease share multifactorial inflammatory, autoimmune, and neurological mechanisms with overlapping triggers including microbes and environmental factors.
• Ocular rosacea can present with blepharitis, conjunctivitis, dry eye, meibomian gland dysfunction, and lid telangiectasias, sometimes without skin involvement.
• Rosacea is often underdiagnosed in darker-skinned individuals due to masking of erythema and vascular signs by melanin pigmentation.
• Treatment options include lifestyle modifications, omega-3 supplementation, topical therapies for mild symptoms, and systemic antibiotics or immunomodulators for moderate to severe disease.
• Light- and heat-based therapies such as intense pulsed light and thermal pulsation show promise but lack standardized dosing and treatment duration guidelines.
• Collaboration between dermatologists and eyecare providers is essential for comprehensive management of patients with both cutaneous and ocular rosacea.

Clinical Implications

Clinicians should maintain a high index of suspicion for ocular rosacea in patients with dry eye symptoms, especially when facial rosacea signs are present. Early identification and multidisciplinary management involving dermatology and eyecare specialists can improve patient outcomes. Treatment should be individualized, combining lifestyle changes, topical and systemic therapies, and emerging light-based modalities while awaiting consensus guidelines.

Conclusion

Ocular rosacea represents a significant overlap between dermatologic and ophthalmic disease requiring integrated diagnostic and therapeutic approaches. Enhanced awareness and collaboration among healthcare providers are critical to effectively manage the complex manifestations of rosacea and associated dry eye disease.

References

1. van Zuuren et al, 2021 -- Rosacea: new concepts in classification and treatment
2. Schaller et al, 2020 -- Recommendations for rosacea diagnosis, classification and management
3. Mohamed-Noriega et al, 2025 -- Ocular rosacea: an updated review
4. Kaur et al, 2023 -- Practice patterns and clinician opinions for treatment of ocular rosacea
5. Zhai et al, 2024 -- Meta-analysis of the efficacy of intense pulsed light and pulsed-dye laser therapy in rosacea
6. Shergill et al, 2024 -- A review of intense pulsed light in the treatment of ocular rosacea