What is the recommended treatment for rosacea in children?

Treatment of Rosacea in Children

For pediatric rosacea, initiate treatment with topical metronidazole or azelaic acid for mild cases, and add oral erythromycin (not tetracyclines) for moderate to severe disease, as tetracyclines are contraindicated under age 8 due to tooth staining. 1

Key Diagnostic Considerations in Children

Rosacea in children presents differently than in adults and is frequently misdiagnosed:

• Ocular symptoms often precede cutaneous manifestations, leading to chronic recurrent blepharokeratoconjunctivitis, punctate erosions, peripheral keratitis, meibomian gland disease, or recurrent chalazia before facial findings appear 1
• Children typically present with corneal involvement and asymmetric ocular disease with potential for sight-threatening visual impairment including corneal melting/perforation 1
• Facial rosacea is less frequent in children, and associated atopy is common 1
• Diagnosis is challenging because telangiectasia and facial flushing may be subtle or absent initially 1
• Phymatous subtypes do not occur in pediatric rosacea 2

Treatment Algorithm for Pediatric Rosacea

Mild Disease (Facial Involvement Only)

First-line topical therapy:

• Topical metronidazole 0.75% or 1.0% once daily is a well-established first-line option 1, 3
• Topical azelaic acid 15% gel or foam is equally effective for inflammatory lesions 4, 5
• Topical ivermectin 1% cream once daily shows superior efficacy (84.9% achieving "clear" or "almost clear" vs 75.4% with metronidazole) and longer remission periods 4, 5

Moderate to Severe Disease or Ocular Involvement

Combination therapy is required:

• Topical agent (ivermectin, metronidazole, or azelaic acid) PLUS oral erythromycin 1
• Oral erythromycin is the systemic antibiotic of choice in children under 8 years because tetracyclines cause permanent tooth staining 1
• For children ≥8 years, oral doxycycline or minocycline may be substituted, though erythromycin remains safer 1

Dosing considerations:

• Oral erythromycin can be given daily and adjusted based on clinical response 1
• Treatment can be intermittently discontinued and reinstated based on severity and tolerance 1

Ocular Rosacea Management

Stepwise approach based on severity:

• Mild cases: Lid hygiene measures 4
• Moderate to severe cases: Oral erythromycin (or doxycycline if ≥8 years) combined with lid hygiene 1, 4
• Consider topical cyclosporine for ocular surface inflammation 3
• High index of suspicion is critical as ocular involvement can lead to corneal scarring and vision loss 1

Persistent Erythema (if present)

• Topical brimonidine tartrate 0.33% gel once daily provides rapid vasoconstriction with maximal effects at 3-6 hours 4, 5
• Topical oxymetazoline HCl 1% cream once daily is an alternative α1-receptor agonist 4
• Warning: Brimonidine causes paradoxical erythema in 10-20% of patients 4

Critical Pitfalls to Avoid

Tetracycline use in young children:

• Never use tetracyclines (doxycycline, minocycline, tetracycline) in children under 8 years due to permanent tooth staining and enamel impairment 1, 2
• Minocycline can additionally stain skin, nails, sclera, conjunctiva, tongue, and bone 1

Overlooking ocular involvement:

• Always examine for ocular signs (recurrent chalazia, blepharitis, keratitis) as these may be the presenting feature 1
• Untreated ocular rosacea can progress to corneal melting/perforation 1

Inadequate treatment duration:

• Improvement typically requires 3-4 weeks for topical treatments 4
• Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued 4, 5

Maintenance and Long-Term Management

• Long-term maintenance with topical agents is essential to prevent relapses 4, 5
• Identify and avoid personal triggers (spicy foods, extreme temperatures, though evidence is limited in children) 4
• Sun protection with SPF 30+ and gentle cleansers are essential adjuncts 5
• Treatment can be tapered after clinical improvement but often requires intermittent reinstatement 1

Special Pediatric Considerations

• Associated atopy is common in children with rosacea 1
• Children with history of styes have increased risk of developing adult rosacea 1
• Granulomatous variants and idiopathic facial aseptic granuloma are pediatric-specific subtypes 2, 6
• Demodicosis is very rare in immunocompetent children, unlike adults where Demodex plays a significant role 2