What causes dry symptoms, particularly in adults with a history of autoimmune disorders?

Causes of Dry Symptoms in Adults with Autoimmune Disorders

Dry symptoms in adults with autoimmune disorders are most commonly caused by Sjögren's syndrome, which affects approximately 10% of patients with clinically significant dry eye and is characterized by lymphocytic infiltration of exocrine glands, leading to both ocular and oral dryness. 1

Primary Autoimmune Causes

Sjögren's Syndrome

• Sjögren's syndrome is the leading autoimmune cause of dry symptoms, presenting with both dry eyes (keratoconjunctivitis sicca) and dry mouth (xerostomia) due to lymphocytic infiltration and destruction of lacrimal and salivary glands. 1, 2, 3
• This condition predominantly affects women with a 20:1 female-to-male ratio and typically presents in perimenopausal or postmenopausal years. 2, 4
• Primary Sjögren's syndrome occurs alone, while secondary Sjögren's develops in association with other autoimmune diseases such as rheumatoid arthritis, systemic lupus erythematosus, or scleroderma. 4, 3
• Approximately 5% of Sjögren's patients develop lymphoid malignancy, representing a critical complication requiring lifelong rheumatologic surveillance. 1, 2, 4

Other Systemic Autoimmune Diseases

• Rheumatoid arthritis is independently associated with dry eye disease in multiple studies. 1
• Systemic lupus erythematosus, scleroderma, and autoimmune thyroid disease can disrupt the lacrimal functional unit and cause dry symptoms. 1
• Graft-versus-host disease (GVHD) following hematopoietic stem cell transplantation causes severe dry eye through T-cell-mediated infiltration and fibrosis of lacrimal glands and conjunctiva. 1

Medication-Induced Dry Symptoms

Medications represent a major modifiable cause of dry symptoms, with an estimated 62% of dry eye and dry mouth symptoms in the elderly attributable to medication side effects. 5

High-Risk Medication Classes

• Antihistamines (including cetirizine) disrupt tear film maintenance and are strongly associated with increased dry eye risk. 1, 6
• Antidepressants and antianxiety medications are significant risk factors identified in population studies. 1
• Oral corticosteroids increase dry eye risk, though topical corticosteroids are used therapeutically for short-term management. 1
• Diuretics contribute to both dry eye and dry mouth symptoms through systemic dehydration effects. 1, 5
• Topical antiglaucoma medications, particularly those containing benzalkonium chloride preservative, are established risk factors. 1

Protective Medications

• Angiotensin-converting enzyme (ACE) inhibitors, such as ramipril, are associated with a lower risk of dry eye disease and should be continued. 1, 6

Hormonal and Age-Related Factors

• Older age and female gender are major risk factors for dry eye disease. 1
• Hormone replacement therapy, particularly estrogen use alone, is associated with increased risk of clinically diagnosed dry eye in postmenopausal women. 1
• Androgen hormone deficiency contributes to lacrimal functional unit dysfunction. 1

Metabolic and Systemic Conditions

Diabetes Mellitus

• Poorly controlled diabetes shows a 17.5% prevalence of dry eye, with poor metabolic control being a particularly significant risk factor. 1, 6

Infiltrative Diseases

• Lymphoma, sarcoidosis, hemochromatosis, and amyloidosis can cause aqueous tear deficiency through infiltration and replacement of lacrimal gland secretory acini. 1

Viral Infections

• Chronic viral infections including hepatitis C, HIV/AIDS, and Epstein-Barr virus can cause Sjögren's-like illness with sicca symptoms. 1, 2
• Dry eye was diagnosed in 21% of patients with AIDS. 1

Dermatologic and Inflammatory Conditions

• Rosacea exacerbates dry eye symptoms through meibomian gland dysfunction, causing evaporative dry eye, and is often overlooked, especially in darker-skinned individuals and children. 1
• Ocular mucous membrane pemphigoid and Stevens-Johnson syndrome produce tear deficiency through inflammation, scarring, and destruction of conjunctival goblet cells. 1

Environmental and Lifestyle Factors

• Reduced humidity, increased wind, air conditioning, and heating exacerbate ocular discomfort in susceptible individuals. 1
• Prolonged visual efforts with decreased blink rate (reading, computer use) worsen symptoms. 1
• Smoking and exposure to second-hand smoke are associated with increased dry eye risk. 1
• Air travel and sitting near air conditioner vents trigger symptom flares. 1

Surgical and Iatrogenic Causes

• Keratorefractive surgeries (LASIK, SMILE) that disrupt trigeminal afferent sensory nerves cause dry eye. 1
• Cataract surgery and other anterior segment procedures commonly result in dry eye symptoms, with approximately one-third of patients experiencing persistent symptoms beyond 3 months postoperatively. 1
• Eyelid surgeries (ptosis repair, blepharoplasty, entropion/ectropion repair) can contribute to dry symptoms. 1

Pathophysiologic Mechanisms

• Decreased tear secretion and clearance initiates an inflammatory cascade on the ocular surface involving both soluble and cellular mediators. 1
• Tear film instability is more common than isolated aqueous tear deficiency, with most patients having multiple contributing factors. 1
• Disruption of the ocular surface microenvironment—formed by tissues, cells, matrices, and the ocular surface microbiome—leads to loss of homeostasis and dry eye disease. 1