Dr. Shalita

"It is a problem that dermatologists should be aware of," says Alan Shalita, M.D., distinguished teaching professor and chairman, department of dermatology, State University of New York, Downstate, Medical Center, Brooklyn, N.Y.

"Patients generally tell you that they have an eye problem, and most of the time, they see an ophthalmologist as well," he says.

Dr. Webster

"A short course of corticosteroids or anti-inflammatory medications can be prescribed, but they should not be used for the long term, because you might get rebound," he says.

In the majority of instances — about 70 percent of the time — patients will respond adequately to lower doses of doxycycline, Dr. Shalita says. When patients are refractory to that management approach, stronger doses of doxycycline or minocycline are required.

"That is the exception rather than the rule," he says.

There isn't a relationship between the severity of rosacea and the appearance of ocular rosacea, Dr. Shalita tells Dermatology Times.

Patients who need stronger doses than low-dose doxycycline would be taking doses of 100 mg or 200 mg daily, says Guy Webster, M.D., Ph.D., clinical professor, Jefferson Medical College, Philadelphia, and a staff member at Wills Eye Hospital, Philadelphia.

Ocular rosacea can present independently of generalized rosacea of the skin, but it typically presents in conjunction with generalized rosacea of the skin, Dr. Webster says. Rosacea of the skin usually initially presents in the late twenties, he says.

"Many patients are not aware that they have the problem," Dr. Webster says. "They just figure their eyes are irritable, and that they have styes. It's actually often the case that they have ocular rosacea."

Clinical results

A study that Dr. Webster and colleagues published in the Journal of the American Academy of Dermatology in 2007 found that 40 mg of sustained-released doxycycline in capsule form, administered once daily for 16 weeks, was found to be both effective and safe in treating skin rosacea.

The impetus to investigate the safety and efficacy of low-dose doxycycline in treating a condition such as rosacea has been the challenge of compliance with chronic systemic tetracyclines that have represented the mainstay of treating rosacea.

The adverse events that have been reported with the use of Oracea are no greater than those that have been reported with placebo, Dr. Webster says.

Doxycycline does the trick in most case of ocular rosacea, but that doesn't mean there isn't space in the dermatologist's armamentarium for more therapeutic options, Dr. Webster says.

Of note, low-dose isotretinoin has been used in cases of severe ocular rosacea refractory to antibiotic treatment.

Future treatments

"As we understand the pathogenesis of ocular rosacea and look at the pathways of the condition, we will better understand the therapeutic angles that we can approach and develop drugs that shut down the disease in a different way," Dr. Webster says.

Dr. Webster notes that the expression of matrix metalloproteinases plays a role in the development of the condition, so exploration of their expression may represent an avenue for future research.

Collaboration between ophthalmologists and dermatologists is likely to produce an optimal outcome in cases of ocular rosacea, but such collaboration is likely the exception rather than the rule, according to Dr. Webster.

Disclosures: Dr. Shalita is a consultant and investigator for Galderma, Medicis and Stiefel. Dr. Webster is a consultant for Galderma, Medicis and Stiefel.