With Ocular Rosacea, Two Clinicians Are Better Than One

How do you diagnose ocular rosacea? Are there clinical findings that are specific on exam or is it just the history? Does the patient have to have facial rosacea also or can it be a stand alone diagnosis? 

Sara Weidmayer, OD: Ocular rosacea is a diagnosis made based on clinical findings, primarily findings on the eyelids. These ultimately do impact surrounding structures like the ocular surface, but the key for diagnosis is to look at the eyelids, particularly the eyelid margins. The hallmark features of ocular rosacea include meibomian gland dysfunction (MGD), eyelid margin keratinization, and especially eyelid margin telangiectasias. It’s also most typically accompanied by other indications of blepharitis, like erythema and debris on the eyelid margin and lashes as well.

MGD and keratinization, and certainly the symptoms of discomfort that patients experience in rosacea can be seen in all different subtypes of the dry eye spectrum, but telangiectasias are pretty pathognomonic for ocular rosacea. Ocular rosacea can be, and often is, a standalone diagnosis, but there are several different subtypes of rosacea, and combinations of rosacea. We most often do see them in combination. There is erythematous, telangiectatic, papulopustular, phymatous, but ocular rosacea actually is its own subtype. So, it can be seen alone. But most often, it’s with another flavor of facial rosacea, and I feel like in my practice, I most often see it in people who have phymatous facial findings or telangiectatic facial findings, or sometimes just standalone.

Is there anything patients can do to prevent rosacea from developing or worsening? What can be done to lessen the appearance of facial telangiectasias? 

Rebecca Baxt, MD: The answer is no, rosacea is genetic. You either have it or you don’t have it. There are some families and ethnicities where it’s extremely common. I would say it is less common in darker skin types, but I have seen rosacea in all skin types. It is very common in fair-skinned people, particularly of Northern European descent, but  there’s nothing you can do to prevent it from coming.

Once you have it, there’re lots of things you can do to prevent it from getting worse. So, rosacea can be triggered by lots of things, such as stress, such as weather changes. Some people get rosacea flares from wind. Some people get rosacea flares from sun. Some people get rosacea flares from extreme heat in their face, so to the extent that you can control it, managing the temperature of the environment around you is helpful.

Foods are a big factor for rosacea on the skin, so there’s a whole list of foods that are commonly seen as triggers. Common ones can be hot foods, spicy foods, alcohol, nuts, chocolate, sometimes dairy, sometimes citrus, it’s different for different people, so I typically will give rosacea patients a list and have them check and say, ‘is this a problem for you? You usually know within about a day or so of eating something. Every single time you have chocolate, you break out, well, then that’s a trigger for you, and you can reduce your rosacea by avoiding your triggers.’

So, there are obviously some things that are hard to avoid, like stress, right? I always tell people, ‘I’d love to give you a prescription for no stress, and I’ll take that one, too!’ But to the extent that you can, learn to minimize your stress. Whatever that takes, whether it’s exercise or meditation or walks in nature or getting good sleep, taking good care of your body, reducing the things that trigger your rosacea can prevent it from worsening.

I would also say to avoid hot water. I always tell patients with rosacea, ‘things that make you red will continue to make you red, and will make your face redder and redder and redder, so washing your face in hot water is always a bad idea. I always recommend cool water. Scrubbing your face is a bad idea, so mild cleansers, fingertips, cool water, those are things to help prevent it from getting worse.’

What over-the-counter options can patients use to manage facial telangiectasias and erythema?

Rebecca Baxt, MD: I would say there are 3 main things to do for those. One, in the last number of years, we’ve gotten creams that are prescriptions that are — the brand names are Mirvaso® and Rhofade®. They are vasoconstrictors, so if you have health insurance, and your insurance company will cover them, you can use those creams every morning, or if you’re going to a special event in the evening, and it will give you a certain amount of relief — 6 hours, 8 hours, whatever it may be. The problem is, they’re very expensive, a lot of people don’t have health insurance, and insurance companies often don’t cover it, because while we know rosacea is a medical condition, a lot of insurance companies feel that the erythema and the flushing and the blushing is a cosmetic issue.

So, if you can get those creams, they can be very helpful on a temporary basis. The things that are more helpful on a more long-term basis are lasers and intense pulsed light treatment. There are a few different types of lasers. Pulsed dye lasers, KTP lasers, any laser that works on red things. Usually it’s the hemoglobin in the blood vessel, and the laser energy gets absorbed, it damages those blood vessels, and then your body heals and reabsorbs those damaged vessels. It does usually take more than 1 treatment. It can cause a little bit of discomfort. It can cause swelling, occasionally bruising, and then there’s intense pulsed light, which is a little bit gentler than the lasers. It is multiple wavelengths, instead of just 1 wavelength like a laser, and the intense pulsed light also can reduce redness. It is also absorbed on a similar spectrum to the lasers, it’s just a little bit milder, so I find that intense pulsed light works a little bit better for background erythema, background redness, flushing, and blushing, and that the lasers will work better on individual larger blood vessels. A lot of my patients will do a combination of both of those treatments.

In treating the patients, are you trying to rid them of the disorder or do they need ongoing treatment? Can the treatment be intermittent as they have symptoms, or do they need to use a medication, such as Restasis®, all the time?

Dr Weidmayer: I wish I were ridding these patients of this problem, but rosacea is just such a chronic problem, so treatment really is geared at getting the patient comfortable, and then trying to maintain it. These patients are really in it for the long haul, and it can be really difficult to treat, but despite the problem being ever-present, a lot of times, the symptoms do wax and wane, so sometimes, we intentionally intensify treatment just intermittently to get them through a symptomatic rough patch, and for some people, it might be like in the summer, when a lot of sun exposure is exacerbating their rosacea, or for other patients, it might be in the winter, when there’s less environmental humidity, at least in our region, so evaporative dry eye symptoms tend to worsen a lot.

By and large, though, this is a full-time problem. Most medications that we use to treat ocular rosacea really are safe long-term, but as with any medication, certainly, there are risks as well. You had mentioned Restasis. Restasis is cyclosporine, and that’s an immunosuppressant, so while this helps an inflammatory dry eye, certainly, it can increase the risk of ocular infections on the surface, so these patients really should be monitored, and they need to know that they should follow up A.S.A.P. in the case of red eyes or injuries or other similar problems to be evaluated.

Another class of medications that we tend to use a lot here is steroids. Steroids make almost everything feel better, but these do pose a very long-term risk of complications, like cataract formation, and elevated intraocular pressure, actually, in about 20% of people that use steroids, so these are generally not preferred for ongoing long-term everyday treatment in these rosacea patients, but they sure can be helpful, at least for a time.

For oral medications, like doxycycline, which we love for rosacea patients, long-term use is generally safe if the patient isn’t getting any adverse GI symptoms, but we certainly should periodically be monitoring the patient’s liver and kidney function if they’re on it long-term.

When dermatologists perform intense pulsed light therapy for facial rosacea, are they including the eyelids?

Dr Baxt: We do not, as dermatologists. When we’re doing intense pulsed light, we really are very, very careful to shield the eyes, because one of the side effects of laser and light treatment can be eye damage. I have never seen it in my office, because we take eye protection very seriously, so we are all wearing special goggles, and the patient is wearing eye shields, so we do not treat the eyelids at all in my practice, and in most dermatology practices. In order to treat the eyelids, I feel that the person probably needs eye drops to anesthetize the eye, and an internal eye shield, which there are some dermatologists, probably, who would do that. I am not one of them, but that is an area where there could be probably better cooperation between the 2 specialties, but I don’t know how to do that, I’ve never been taught how to do that, I wouldn’t feel comfortable doing that, so we shield the eyes and we do not treat the eyelids, but we treat the rest of the face.

Are oral tetracyclines the best — or only — approach, or do other oral drug classes meaningfully help with facial rosacea?

Dr Baxt: For rosacea, tetracyclines really do work incredibly well. The one that we typically use is doxycycline — 50 mg, 100 mg, maximum dose would be 100 twice a day. Sometimes, we will use a very, very low dose, like a 20-milligram twice a day, or even a 40-milligram long release once a day, so doxycycline, which is a tetracycline, works really well, but it has 2 main problems.

One is that it can cause a lot of GI upset and upset the stomach, so I always recommend that patients take it with food, and the other is that it can cause a lot of sun sensitivity, which is a real issue for fair-skinned patients, especially certain seasons, or especially in certain areas, if you live in a sunny place, so sometimes, doxycycline is not optimal.

My second line therapy would be minocycline, which is a cousin of doxycycline, which is also a tetracycline, but it has much less GI upset and much less sun sensitivity. So, minocycline can have other side effects. Obviously, anyone can be allergic to any of these drugs, but if doxycycline is not working well or is not optimal for that patient, my second line would be minocycline, which is again, a tetracycline.

There can be other antibiotics that are used. They typically don’t work as well, but if someone is allergic or cannot tolerate the tetracyclines and they need an oral antibiotic, I will sometimes use Bactrim®. Bactrim is a cheap, very effective generic available antibiotic. It is not that popular, because it can cause severe allergic reactions, but again, if someone doesn’t have health insurance, and they need something inexpensive, or they cannot tolerate tetracyclines, Bactrim would be another option. I don’t use it very often, but I would say yes, there are other options if a patient cannot tolerate a tetracycline.

What is the management protocol for ocular rosacea with oral doxycycline? 

Dr Weidmayer: I love to put ocular rosacea patients on oral doxycycline, and I love it even more, actually, when their dermatologist has them on it for facial rosacea so that they’re doing the management, and I’m reaping the ocular benefits.

For ocular rosacea, there’s really not a standard protocol that everybody uses across the board as far as dosage. I typically use 50 mg a day, and I have them use it for at least 3 months, and assess their symptoms at that point. If the patient was really symptomatic, sometimes, I’ll start them on a higher dose for a week or 2, perhaps even up to 100 mg twice a day, before dropping them down to the 50 mg per day. That pulse can be a pretty helpful jumpstart, but sometimes, it really can backfire, because at those higher doses, patients are more likely to get GI symptoms, and then they’re hesitant to continue on with it, so I most often actually just put people on 50 mg right out of the gate.

Some doctors prefer 20 mg or 40 mg per day, and those are actually a very expensive branded dosage of doxycycline, but our hospital formulary has 100 mg tablets readily available, less expensively available, so I order that, along with the pill splitter, and find that it works really well.

After the 3-month trial, I talk with to the patient. There are certainly clinical, measurable outcomes, but treatment really is very much symptom-driven. Some patients prefer to stay on it long-term if they’re doing well, and some people prefer to do 3-month pulses as needed.

Are there other treatment options other than cyclosporine and oral doxycycline?

Dr Weidmayer: There are a lot of things that we can try for ocular rosacea. Since this is a primarily eyelid-based problem, treatment, though, we should always include eyelid-based therapy. Good eyelid hygiene to remove proinflammatory debris and overgrowth of our normal flora is always really important, and even just regular consistent warm compresses for several minutes at a time on a really consistent basis can also help with the meibomian gland inspissation that we tend to see with these patients.

I love a really good eyelid margin ointment. You just put the ointment right at the base of the problem, right at the source. I often just use erythromycin ophthalmic ointment and apply it to the base of the eyelids and lashes at nighttime, again, to just kind of cut down on that eyelid flora, to really target those meibomian glands, but sometimes, I’ll reach for a combination antibiotic steroid ointment like Maxitrol® — that one has dexamethasone, and it works really very well.

To address the ocular discomfort that results from the imbalance in the tear film, again, this is primarily from inadequate meibome from the meibomian glands, increased ocular surface osmolarity, pro-inflammatory cytokines, the like. Various artificial tear supplements actually can be really, really helpful as well. Restasis and Xiidra® can be useful in these patients, but really never as standalone, because again, we always need to deal with the eyelids as the root of the problem, not just the ocular surface, so they can be helpful, but make sure you’re also doing some eyelid therapy as well.

Autologous serum drops, which are actually made by drawing the patient’s blood and centrifuging it, that can be really, really helpful in severe cases as well, and another therapy that I actually really love for ocular rosacea patients is intense pulsed light therapy. I’m sure all in dermatology are really familiar with this for facial rosacea, where it can really help with erythema and telangiectasias and papules, but it really can help with the eyelids as well, so this is another great option.

How can dermatology and optometry be more collaborative in managing ocular and facial rosacea?

Dr Baxt: Doctors of all varieties, and doctors and non doctors and healthcare professionals really just need to take the time to pick up the phone and call each other. It’s very difficult in the busy day of a healthcare professional to find the time to call somebody, but that’s really what I think needs to happen on complicated cases and difficult management issues of patients, so I would say a phone call is the best way to do it. You pick up the phone, leave a message, leave your cell phone, try to talk to the other practitioner about that particular patient. 

Also, I will sometimes send notes, so I’ll have just, like, a blank pad in all my exam rooms with my practice name and phone number and website and everything on it, and I will often write a note and have the patient give it to their doctor, because there are particular specialties that are notoriously very hard to get in touch with, like an OB/GYN, very hard to get in touch with them, they’re always so busy in the hospital delivering babies. 

I’ll give the patient a note to send to their doctor and ask them to give me a call, or to send me a note back. Sometimes, I’ll get a note back, and I will also always do that if I have a patient who was referred by a doctor, I will send them a consultant note, where some people will send a copy of their note and report, so it needs to be communication, whether it’s a phone call, whether it’s sending something through snail mail. Sometimes, maybe email, you know, if you’re working in a large healthcare system and everybody can see each other’s notes, because they’re all on the same electronic medical record, that becomes much easier to see and message somebody, but for those of us in private practice, that doesn’t usually happen, so it requires a phone call or a note.

Sara Weidmayer, OD is an optometrist at the VA Ann Arbor Healthcare System in Ann Arbor, Michigan and is a clinical assistant professor with the department of ophthalmology and clinical science for the University of Michigan’s Kellogg Eye Center. 

Rebecca Baxt, MD, MBA, FAAD is a board certified dermatologist with Baxt CosMedical in Paramus, NJ where she provides both medical and cosmetic dermatological care.