Rosacea

What is Rosacea

Rosacea is a chronic, inflammatory skin condition primarily affecting the central face — nose, cheeks, chin, and forehead. It is characterized by persistent redness, visible blood vessels, inflammatory papules and pustules, and in advanced cases, phymatous skin changes (tissue thickening). Importantly for oculoplastic surgeons, ocular involvement is common, occurring in roughly 30–70% of patients with cutaneous rosacea depending on the study, causing eyelid and ocular surface disease that can threaten vision if untreated.

Subtypes of Rosacea

The National Rosacea Society has historically classified rosacea into four subtypes, which may coexist in the same patient (the Society moved to a phenotype-based framework in 2017, but the subtypes remain a useful clinical shorthand):

• Subtype 1 — Erythematotelangiectatic (ETR): Persistent central facial redness, flushing, visible telangiectasias. Most common form. Sensitive skin prone to stinging. Treated with topical brimonidine (Mirvaso), oxymetazoline (Rhofade), laser, and IPL.
• Subtype 2 — Papulopustular: Acne-like papules and pustules on a background of central facial erythema. Often confused with acne vulgaris — distinguished by the absence of comedones (blackheads/whiteheads) in rosacea. Treated with metronidazole gel, azelaic acid, ivermectin cream (Soolantra), doxycycline.
• Subtype 3 — Phymatous: Skin thickening with irregular surface changes; most commonly affects the nose (rhinophyma). Caused by sebaceous hyperplasia and fibrosis. Treated surgically with CO₂ laser resurfacing or surgical debulking.
• Subtype 4 — Ocular Rosacea: Eye and eyelid involvement — covered in detail below.

Ocular Rosacea

Ocular rosacea is the most clinically significant subtype from an oculoplastic perspective. It can precede, accompany, or follow cutaneous manifestations — and some patients have isolated ocular rosacea without obvious skin involvement, making diagnosis challenging.

Eyelid Manifestations

• Chronic blepharitis: Persistent eyelid margin inflammation, crusting, and telangiectasias of the lid margin
• Meibomian gland dysfunction: MGD is nearly universal in ocular rosacea — inspissated secretions, plugged orifices, and progressive meibomian gland atrophy
• Chalazia: Recurrent chalazia are a hallmark of rosacea-associated MGD
• Hordeola (styes): Recurrent external styes from associated anterior blepharitis
• Periocular telangiectasias: Visible dilated vessels at the eyelid margin and periocular skin

Ocular Surface Manifestations

• Conjunctivitis: Hyperemia, discharge; may be papillary
• Dry eye: From MGD-related tear film instability and lipid deficiency
• Keratitis: Corneal involvement ranging from superficial punctate keratopathy to peripheral vascularization, infiltrates, and — in severe cases — corneal thinning (keratolysis) and perforation. Ocular rosacea keratitis is a leading cause of vision loss in rosacea.
• Episcleritis and scleritis (less common)

Diagnosis

Diagnosis of rosacea is clinical. Ocular rosacea is diagnosed based on:

• History of characteristic eyelid symptoms (burning, tearing, foreign body sensation, recurrent chalazia)
• Slit lamp findings: telangiectatic lid margin vessels, plugged meibomian orifices, inspissated secretion, reduced tear break-up time, corneal staining
• Skin examination: central facial erythema or telangiectasias, even if mild
• Exclusion of other causes of blepharitis (staphylococcal, Demodex, seborrheic)

Meibography reveals progressive gland dropout in chronic cases.

Treatment

Treatment of rosacea requires simultaneous management of cutaneous and ocular disease. Oculoplastic surgeons manage ocular rosacea; dermatologists manage skin manifestations — often in shared care.

Ocular Rosacea Treatment

• Eyelid hygiene: Warm compresses, lid massage, lid scrubs — the foundation of MGD management. Daily routine.
• Oral doxycycline: First-line systemic treatment for ocular rosacea, working through an anti-inflammatory effect on meibomian gland function independent of antibiotic activity. Because that benefit is anti-inflammatory rather than antibacterial, a sub-antimicrobial dose — 20 mg twice daily, or 40 mg modified-release (Oracea) — is often preferred and reduces antibiotic-resistance risk; a conventional 50–100 mg daily course is an alternative. Azithromycin is an alternative agent.
• Topical cyclosporine (Restasis, Cequa): Reduces ocular surface inflammation; indicated for associated dry eye and keratitis.
• Topical azithromycin (AzaSite): Lid margin application reduces meibomian gland inflammation.
• Intense Pulsed Light (IPL): Applied to the periocular skin, IPL reduces periocular telangiectasias, decreases Demodex burden, and improves meibomian gland function. Emerging evidence supports IPL as an effective adjunct treatment for ocular rosacea and MGD. Series of 3–4 treatments.
• LipiFlow or thermal pulsation: Meibomian gland expression to clear obstructed glands.
• Topical steroids / cyclosporine: For acute flares with keratitis or conjunctivitis; used short-term under physician supervision with monitoring for elevated intraocular pressure and cataract, and avoided when infectious keratitis is suspected.

Cutaneous Rosacea Treatment

• Topical treatments: Metronidazole 0.75–1% gel/cream; azelaic acid 15% gel (Finacea); ivermectin 1% cream (Soolantra — reduces Demodex colonization); brimonidine 0.33% gel (Mirvaso) or oxymetazoline 1% cream (Rhofade) for erythema/flushing.
• Oral antibiotics: Doxycycline (40–100 mg) or azithromycin for papulopustular rosacea.
• Vascular laser / IPL: KTP (532 nm), pulsed dye laser (595 nm), or Nd:YAG (1064 nm) for telangiectasias and diffuse erythema. IPL provides broad-spectrum treatment of redness and pigment.
• CO₂ laser / surgical debulking: For rhinophyma — ablative resurfacing or tangential excision to restore nasal contour.
• Isotretinoin (Accutane): For severe, refractory papulopustular rosacea; significantly reduces sebaceous activity. Can cause or worsen ocular surface dryness and meibomian gland dysfunction. Requires strict pregnancy prevention.

Triggers and Lifestyle

Rosacea has no cure — management focuses on symptom control and trigger avoidance. Common triggers that worsen flushing and inflammation:

• Sun exposure — UV radiation is a very common trigger; daily broad-spectrum SPF 30+ sunscreen is strongly recommended
• Heat (hot beverages, saunas, hot showers)
• Spicy foods, alcohol (especially red wine)
• Exercise and emotional stress
• Certain topical products — alcohol-based products, fragrances, irritants
• Certain medications — niacin, topical steroids (which cause rebound flushing)

A gentle, fragrance-free skincare routine with physical (mineral) sunscreen is recommended for all rosacea patients.