What is the best course of treatment for a patient with rosacea (acne rosacea) and associated eye symptoms, possibly indicating ocular rosacea?

Treatment of Ocular Rosacea

For patients with rosacea and associated eye symptoms, initiate eyelid hygiene and artificial tears immediately, and refer to ophthalmology for any symptoms beyond mild burning/stinging that don't respond to these basic measures within 2-4 weeks. 1, 2

Initial Assessment and Recognition

Ocular rosacea affects approximately 75% of patients with cutaneous rosacea and can present before skin manifestations, particularly in children. 1 Key ocular features to identify include:

• Blepharitis with eyelid margin telangiectasias 1
• Meibomian gland dysfunction with inspissation and excessive sebum secretion 1
• Chronic conjunctival injection and hyperemia 1
• Foreign body sensation, photophobia, tearing, and blurred vision 1, 2
• Evaporative dry eye 1
• Chalazia (often recurrent) 1

Critical pitfall: In children, ocular symptoms frequently appear before cutaneous manifestations, leading to misdiagnosis. 1 Asymmetric ocular disease and corneal involvement are more common in pediatric cases and carry risk of sight-threatening visual impairment. 1

Treatment Algorithm by Severity

Mild Ocular Rosacea (Does Not Bother Patient Significantly)

First-line approach:

• Eyelid hygiene daily - warm compresses, lid scrubs, and meibomian gland expression 2
• Artificial tear substitutes for burning/stinging 1, 2
• General eye care and trigger avoidance 1, 2

This represents the only level of ocular rosacea that dermatologists can manage without ophthalmology referral. 1

Moderate Ocular Rosacea (Cannot Be Controlled with Lid Hygiene)

Refer to ophthalmology AND initiate:

• Oral doxycycline as first-line pharmacological treatment 2, 3
  • Standard dose: 50-200 mg daily (antibiotic activity) 2
  • Modified-release: 40 mg daily (anti-inflammatory activity without antibiotic effect in some regions) 2
  • Treatment duration: 6-12 weeks minimum before declaring failure 2, 4

The 2024 systematic review found oral antibiotics achieved complete or partial response in 89% of patients (525/580). 3 This represents the highest quality evidence for pharmacological intervention.

Severe Ocular Rosacea (Significant Inflammation or Corneal Involvement)

Immediate ophthalmology referral for:

• Brief course of topical corticosteroids for severe eyelid or ocular surface inflammation 2
  • Must be tapered once inflammation controlled 2
  • Avoid long-term corticosteroid therapy due to risk of glaucoma and cataracts 1, 2
• Topical cyclosporine 0.05% for posterior blepharitis 2, 3
  • Achieved 87% response rate (40/46 patients) in systematic review 3
• Continuation of oral doxycycline 2

Combination Therapy Approach

Multiple ocular features require simultaneous treatment with multiple agents. 1 The 2024 systematic review found combination treatments achieved 90% response rate (69/77 patients). 3

Effective combinations include:

• Lid hygiene + artificial tears + oral doxycycline 2, 3
• Topical cyclosporine + oral antibiotics 3, 5
• Topical azithromycin or tacrolimus + systemic therapy 5

Maintenance Therapy

Use the minimum treatment necessary to maintain control. 1, 2 Without maintenance therapy, up to two-thirds of patients relapse when treatment is discontinued. 4

Maintenance approach depends on:

• Initial treatment modality used 1, 2
• Patient preference for ongoing therapy 1, 2
• Severity of initial presentation 1

Critical Contraindications and Warnings

Tetracyclines (including doxycycline) are contraindicated in:

• Pregnancy 2
• Nursing women 2
• Children under 8 years 2
• Patients with hypersensitivity 2

For pediatric cases requiring systemic therapy, alternative agents must be selected by ophthalmology. 1

When to Refer to Ophthalmology

Dermatologists should refer for:

• Any ocular symptoms beyond mild burning/stinging 1, 2
• Symptoms not controlled with lid hygiene alone 1, 2
• Blurred vision, photophobia, or foreign body sensation 1
• Recurrent chalazia or hordeola 1, 6
• Any corneal involvement 1
• Pediatric patients with ocular symptoms 1

Do not attempt to treat moderate-to-severe ocular rosacea without ophthalmology involvement - corneal complications including ulceration, scarring, neovascularization, and rarely perforation can occur. 1, 7

Emerging Evidence

Intense pulsed light (IPL) therapy achieved 89% partial response rate (97/109 patients) in the 2024 systematic review, representing a promising adjunctive treatment for refractory cases. 3 However, this requires specialized equipment and ophthalmologic expertise.