Clinical and laboratory study of ocular rosacea in northern Greece

Diagnostic Challenges of Ocular Rosacea

OBJECTIVE

This study aims to address the issues surrounding the diagnosis of ocular rosacea and to evaluate the development of the patients’ condition after treatment, as well as to distinguish between healthy and diseased patients using a glycomic analysis of tears.

METHODOLOGY

A prospective study was conducted to assess a total of 68 eyes in 34 patients over a six-week period. These patients were diagnosed with ocular rosacea based on subjective symptoms and clinical examination. The study monitored the development of objective and subjective values. The difference between patients with the pathology and healthy controls was established by means of analysis of glycans in tears.

RESULTS

Skin lesions were diagnosed in 94% of patients with ocular rosacea, with the most commonly observed phenotype being erythematotelangiectatic (68.8%). The mean duration of symptoms was 29.3 months (range 0.5–126 months) with a median of 12 months. Throughout the study, an improvement in all monitored parameters was observed, including Meibomian gland dysfunction, bulbar conjunctival hyperemia, telangiectasia of the eyelid margin, anterior blepharitis, uneven and reddened eyelid margins, and corneal neovascularization. The study also observed improvements in subjective manifestations of the disease, such as foreign body sensation, burning, dryness, lachrymation, itching eyes, photophobia, and morning discomfort. The analysis of glycans in tears partially separated tear samples based on their origin, which allowed for the differentiation of patients with rosacea from healthy controls. In the first sample, the pathology was determined in a total of 63 eyes (98.4%) of 32 patients, with further samples showing a change in the glycomic profile of patients’ tears during treatment.

CONCLUSION

The study demonstrated objective and subjective improvements in all the patients. Tear sampling and analysis could provide a means of timely diagnosis of ocular rosacea.

Autoimmune Disease-Related Dry Eye Diseases and Their Placement Under the Revised Classification Systems: An Update

Dry eye disease (DED) is a chronic and progressive disorder involving the ocular surface, characterized by disturbances in tear film composition, instability of the tear film, and inflammation of the ocular surface. There are two forms of DED: aqueous-deficient dry eye (ADDE) and evaporative dry eye (EDE). Autoimmune diseases are systemic disorders involving multiple organs, including the eyes, and have a significant impact on DED. There have been multiple studies demonstrating the relation between autoimmune diseases and DED. This article reviews the current knowledge regarding the epidemiological characteristics, pathogenesis, and treatments of autoimmune disease-related DED.

Rosacea: The eyes have it

Rosacea is a chronic inflammatory dermatosis typically affecting the facial skin but also the eyes. With its chronic course with fluctuating episodes of flashing, redness, papulopustules, and nodules it poses a severe psychologic burden to the affected individuals. In addition to the facial changes, more than half of the patients have ocular involvement ranging from blepharitis and conjunctival hyperemia to more severe ophthalmic damage, and even blindness. Clinically, the ocular involvement in rosacea includes meibomian gland dysfunction with relapsing hordeola and chalazia, diffuse hyperemic conjunctivitis, photophobia, episcleritis, or kerato-conjunctivitis, and in rare cases, corneal ulcers. These are mainly observed in adult patients but can also occur in children. Depending on the degree of cutaneous or ocular findings, patients with rosacea may present first to the dermatologist or to the ophthalmologist. Both specialists should be aware of the potential oculocutaneous involvement. Any ocular complaints expressed by the patient in the setting of a dermatologist's office should be referred promptly for an ophthalmologic examination. Conversely, signs suggestive of rosacea in the eye should lead the ophthalmologist to consider underlying skin disease. A timely interdisciplinary collaboration is paramount for the earlier diagnosis and treatment, thus preventing permanent eye impairment in this chronic dermatosis.

Skincare in Rosacea from the Cosmetologist's Perspective: A Narrative Review

Rosacea is a common skin disease that affects about 5% of the general population. Its symptoms include telangiectasia, persistent erythema, burning/stinging sensation, dry skin sensation, and pruritus. It is characterized by a chronic course with frequent exacerbation. It often coexists with anxiety and depression, reducing the quality of life of affected patients. The etiopathogenesis of rosacea is complex and not fully elucidated; hence, there is no causative effective treatment. In this review, we highlight the role of a cosmetologist in the treatment of rosacea and the maintenance of remission. As part of medical treatment, patients are advised to introduce lifestyle changes and use proper skin care; a cosmetologist can help educate patients affected with rosacea, create effective home care programs for skin care, and support them with treatments in beauty salons. Proper skin care is essential, including the use of dermocosmetics, cleansing of the skin, and frequent visits to beauty salons for tailored apparatus procedures. A cosmetologist is more accessible to patients and can help implement healthy daily habits, including skin care and eating habits, as well as support and mediate good communication between the patient and the patient's treating physician, thereby improving compliance and ensuring long-term satisfactory outcomes.

Development of an animal model for rosacea‑like skin lesions caused by Demodex

To develop an animal model of rosacea-like skin lesions caused by Demodex mites, a suspension of Demodex mites was injected into the skin of Japanese rabbits. The pathology of the skin lesion was assessed using H&E staining after 4 weeks of modeling. The skin lesions observed after 4 weeks were further treated with the recombinant bovine basic fibroblast growth factor (rbFGF) gel. Untreated lesions in the same rabbit were considered as the blank control. Erythema papules were observed in the model rabbit skin and could be observed most clearly in the 2nd week. Lumpy foreign bodies, telangiectasia and granuloma-like structure were observed in the model rabbit in the 1st, 2nd, and 3rd weeks, respectively. An organized granuloma-like structure was observed in the 4th week. The color of the skin lesions became lighter than that of the self-control after 4 weeks of rbFGF treatment. In conclusion, the model of Demodex-induced rosacea-like skin lesions can be developed through intradermal injection of suspension of Demodex mites into Japanese rabbits. The model can mimic the phenotype of skin lesions and histopathological manifestations in the Demodex mite-positive patient with rosacea.

S2k guideline: Rosacea

This updated and upgraded S2k guideline deals with the diagnosis and treatment of rosacea, which is a common, chronic inflammatory skin disease mostly affecting the face. Initially, rosacea is characterized by recurrent erythema, telangiectasia and flushing. Later, the inflammatory component predominates, with persistent erythema with follicular papules, papulopustules and pustules. The development of phyma, which usually occurs on the acral localizations, is the most severe manifestation. For the treatment of rosacea, the interdisciplinary guideline committee, with representatives of the German Dermatological Society (DDG), the Professional Association of German Dermatologists (BVDD), the German Opthalmological Society (DOG), the Society for Dermopharmacy (GD), the Swiss Society for Dermatology and Venereology (SGDV) and the German Rosacea Aid e. V., recommends the avoidance of trigger factors and topical applications of metronidazole, azelaic acid or ivermectin. For symptomatic treatment of persistent centrofacial erythema, the topical vasoconstrictors brimonidine or oxymetazoline can also be used. Systemic therapy is recommended for therapy-resistant and severe forms of rosacea papulopustulosa. The drug of choice is low-dose doxycycline. Alternatively, low-dose isotretinoin can be recommended. Ocular rosacea should be treated with lid margin hygiene. For topical treatment, ciclosporin eye drops, azithromycin, ivermectin or metronidazole are suggested.

Case Series: Underdiagnosis of Ocular and Oculocutaneous Rosacea in an African American Pediatric Population

SIGNIFICANCE

As the global multiracial population grows, this case series highlights the current under- and misdiagnosis of ocular and oculocutaneous rosacea and the importance of properly identifying the condition in a darkly pigmented pediatric population.

PURPOSE

This series aims to report the clinical presentation of ocular and oculocutaneous rosacea and adverse sequelae of misdiagnosis in two pediatric African American patients.

CASE REPORT

One 11-year-old male and one 10-year-old female, both darkly pigmented African American patients, presented with a history of chronic ocular irritation. The male patient was seen by an eyecare provider eight times over the past seven years for recurrent anterior ocular inflammation. The female patient presented to the clinic with chronic anterior segment ocular inflammation for one year. Both patients were previously treated for their acute signs and symptoms. The male patient was diagnosed with ocular rosacea and the female patient was diagnosed with oculocutaneous rosacea. Both patients were subsequently treated for their underlying inflammatory condition, yielding an improvement in their ocular health.

CONCLUSIONS

These two cases bring attention to the under- and misdiagnosis of ocular and oculocutaneous rosacea in pediatric patients with darkly pigmented skin. Timely and accurate diagnosis is critical to minimize the risk of significant visual and dermatological sequelae.

Prevalence of Helicobacter pylori Infection Among Rosacea and Chronic Spontaneous Urticaria Patients in a Tertiary Hospital in Riyadh, Saudi Arabia

BACKGROUND

The multifactorial nature of rosacea and chronic spontaneous urticaria (CSU) pathogenesis complicates the achievement of satisfactory treatment outcomes. 13C urea breath test (UBT) has been identified as an accurate, non-invasive, and quick procedure to detect the presence of Helicobacter pylori (H. pylori) with high sensitivity and specificity.

OBJECTIVE

In this study, we aim to assess the correlation between H. pylori infection and rosacea and CSU patients.

METHODS

A cross-sectional, observational study was conducted on patients with rosacea and CSU in the dermatology clinic at King Khalid University Hospital in Riyadh, Saudi Arabia. History and physical examination were performed by a dermatologist. H. pylori 13C-UBT detection was performed in all subjects.

RESULTS

In total, 114 patients were included in this current study, with 41 rosacea and 73 urticaria patients. The vast majority of our subjects were females (96.5%). The mean (±SD) age was 42.3 (±12.7). More than half (58.8%) of the examined samples were positive for 13C-UBT; however, positive results were significantly higher in the rosacea patients (73.2%) compared to the urticaria group (50.7%), with a p-value of 0.019.

CONCLUSION

Our findings underline the significant association of H. pylori with rosacea and CSU regardless of the presence or absence of gastrointestinal symptoms. We thus recommend the inclusion of H. pylori testing in the routine workup of CSU and rosacea patients.

Myeloid differentiation factor 88 expression in eyelid specimens of rosacea

Purpose: Rosacea is a common cause of ocular surface disease. Specific immunologic features have been implicated in its pathogenesis, including toll-like receptors, mitogen-associated kinase, and nuclear factor kappa-B. Myeolid differentiation factor 88 (MYD88) has been associated with these elements, suggesting a role for this protein in rosacea. This study was designed to compare the expression of MYD88 in the eyelids of patients with and without this disease.Methods: Western blotting for MYD88 was performed in 14 control patients and 15 patients with rosacea. Bands were quantified and normalized to actin. Immunohistochemical staining for MYD88 was performed in a different cohort of 12 patients with rosacea and 12 controls, and positively-staining cells were counted across five consecutive 40x fields. Statistical analyses compared the differences between the two groups via a dedicated software package.Results: On western blotting, the mean ratios of MYD88 to actin were 13.8 (standard deviation = 14.1) and 44.3 (standard deviation = 39.6) in control and rosacea patients, respectively (p = .002). On immunohistochemistry, the mean numbers of positively-staining cells were 12.1/40x field (standard deviation = 9.61/40x field) and 27.4/40x (standard deviation = 18.7/40x field) in control and rosacea patients, respectively (p = .0438).Conclusions: MYD88 is enriched in eyelid specimens of rosacea. This finding further implicates the innate immune system in the pathogenesis of rosacea, and is consistent with previous reports regarding the role of this protein in ocular surface disease and the previously-implicated cellular features of the disease. Inhibition of MYD88 may be a successful treatment strategy to manage rosacea.

Ocular manifestations of rosacea: A clinical review

Ocular rosacea is a chronic inflammatory condition that can occur in the absence of cutaneous features. The most common ocular features are chronic blepharoconjunctivitis with eyelid margin inflammation and meibomian gland dysfunction. Corneal complications include corneal vascularization, ulceration, scarring and, rarely, perforation. Diagnosis is largely based on clinical signs, although it is often delayed in the absence of cutaneous changes, particularly in children. It can also be associated with systemic disorders such as cardiovascular disease. Management ranges from local therapy to systemic treatment, depending on the severity of the disease. In this review, we describe the epidemiology, pathophysiology, clinical features and treatment of rosacea and ocular rosacea.

Nuclear Factor Kappa-B Is Enriched in Eyelid Specimens of Rosacea: Implications for Pathogenesis and Therapy

PURPOSE

To assess the role of nuclear factor kappa-B (NFKB) in cutaneous specimens of rosacea and unaffected tissue.

METHODS

Immunohistochemical staining was performed for the activated, phosphorylated variant of NFKB (pNFKB) in eyelid specimens of rosacea (n = 12) and normal, healthy tissue (n = 12). The numbers of positively staining cells/40× microscopic field were counted across 5 consecutive fields. Additionally, quantitative Western blotting was carried out for pNFKB and NFKB in specimens of rosacea (n = 15) and normal controls (n = 14). Statistical comparisons were performed via a dedicated software package.

RESULTS

The mean number of cells/40× microscopic field that stained positively for pNFKB was 18.4 (standard deviation = 15.3) for control patients and 39.3 (standard deviation = 16.9) for rosacea patients, and the difference between the 2 groups was statistically significant (P = .0024). On Western blotting, the mean ratios of pNFKB:NFKB for control and rosacea patients measured 0.58 (standard deviation = 0.81) and 3.11 (standard deviation = 3.53), respectively. The 2 groups were statistically significantly different (P = .0002).

CONCLUSIONS

The activated form of NFKB is enriched in rosacea, indicating a role for this pathway in the pathogenesis of this disease. Interference with NFKB signaling may represent a novel therapy for rosacea as clinical agents become available. NOTE: Publication of this article is sponsored by the American Ophthalmological Society.

[Ophthalmic Rosacea: etiopathogenesis and modern treatment methods]

Rosacea is a multifactorial chronic inflammatory disease with various clinical manifestations. Primarily it is seen as a dermatological condition, but it's not uncommon for it to develop ophthalmological implications affecting eyelids, cornea and conjunctiva. The article describes main aspects of its etiopathogenesis, variations in its clinical course and treatment approaches. There is currently no universal treatment strategy for the disease due to its varying clinical manifestation, particularly of its ophthalmological form, differing severity of the pathological process, lack of knowledge about its etiology and pathogenesis. Leading role in its pathological process belongs to disturbance of regulatory mechanisms of the vascular, immune and nervous systems. Additionally, higher levels of metalloproteinases and vascular endothelial growth factor (VEGF) can be observed. Possible influence of a range of micro-organisms also hasn't been excluded. Basic therapy involves both systemic and topical drugs. The first include tetracycline antibiotics. A new direction in Rosacea treatment that aims at structural and functional restoration of vascular endothelium, improvement of microcirculation and recovery of rheological properties of blood is angioprotector therapy, in particular with Calcium Dobesilate (Doxi-Hem). Aside from systemic drugs, the ophthalmological forms of Rosacea are treated topically with anti-inflammatory preparations, immunosuppressants and artificial tears that are chosen depending on the symptoms' severity. In cases with heavy corneal damage, various types of keratoplasty can be performed. Collaboration between ophthalmology and dermatology specialists is necessary in order to choose adequate strategy for Rosacea treatment.

The Rosacea-specific Quality-of-Life instrument (RosQol): Revision and validation among Chinese patients

Rosacea is a common chronic facial disorder that affects patients' health-related quality of life; the only questionnaire designed specifically for rosacea is the Rosacea-specific Quality-of-Life instrument (RosQol). However, the questionnaire has not been validated among Chinese patients. This study aimed to validate the Chinese version of the RosQol. First, we translated the questionnaire into Chinese. Then, rosacea patients completed the RosQol and Dermatology Life Quality Index, indicating the disease's impact on their lives. We also collected patients' demographic and clinical data, including symptom self-evaluation scores and rosacea severity scores. Internal consistency was determined by using Cronbach's alpha, test-retest reliability, and Spearman's correlation. Criterion-related validity and internal construct validity were also determined. Most RosQol items showed good internal consistency. However, items 13 and 19 were not sufficiently sensitive for use in the Chinese population; we deleted them and constructed the adjusted Chinese-version RosQol, which had good reliability and validity. When patients' clinical symptoms changed, the scores on the relevant dimensions of the adjusted RosQol also changed. Some RosQol items were not suitable for use in the Chinese sample. The adjusted Chinese-version RosQol was easy to complete, well received by patients, and demonstrated acceptable validity and reliability.

Prevalence of rosacea in the general population of Germany and Russia - The RISE study

BACKGROUND

There is an unmet need for general population-based epidemiological data on rosacea based on contemporary diagnostic criteria and validated population survey methodology.

OBJECTIVE

To evaluate the prevalence of rosacea in the general population of Germany and Russia.

METHODS

General population screening was conducted in 9-10 cities per country to ensure adequate geographic representation. In Part I of this two-phase study, screening of a representative sample of the general population (every fifth person or every fifth door using a fixed-step procedure on a random route sample) was expedited with use of a questionnaire and algorithm based on current diagnostic criteria for rosacea. Of the subjects that screened positive in the initial phase, a randomly selected sample (every third subject) t`hen underwent diagnostic confirmation by a dermatologist in Part II.

RESULTS

A total of 3052 and 3013 subjects (aged 18-65 years) were screened in Germany and Russia respectively. Rosacea prevalence was 12.3% [95%CI, 10.2-14.4] in Germany and 5.0% [95%CI, 2.8-7.2] in Russia. The profile of subjects with rosacea (75% women; mean age of 40 years; mainly skin phototype II or III, majority of subjects with sensitive facial skin) and subtype distribution were similar. Overall, 18% of subjects diagnosed with rosacea were aged 18-30 years. Over 80% were not previously diagnosed. Within the previous year, 47.5% of subjects had received no rosacea care and 23.7% had received topical and/or systemic drugs. Over one-third (35% Germany, 43% Russia) of rosacea subjects reported a moderate to severe adverse impact on quality of life.

CONCLUSION

Rosacea is highly prevalent in Germany (12.3%) and Russia (5.0%). The demographic profile of rosacea subjects was similar between countries and the majority were previously undiagnosed.

Corneal and conjunctival sensitivity in rosacea patients

Purpose

To assess corneal and conjunctival sensitivity in rosacea patients.

Methods

A total of 55 patients with rosacea and 37 control subjects participated in the study. Corneal and conjunctival sensitivity was determined by Cochet-Bonnet esthesiometer. Subjective symptoms of ocular dryness were evaluated using Ocular Surface Disease Index (OSDI). Schirmer’s I test (ST), tear breakup time (tBUT) and ocular surface staining with fluorescein were carried out to measure objective signs.

Results

The mean corneal and conjunctival sensitivity did not differ significantly between rosacea patients and controls (all p > 0.05). Schirmer’s I test and tBUT were significantly reduced (p = 0.004 for OD and p < 0.001 for OS) and grade of ocular surface staining was significantly high (p = 0.018 for OD and p = 0.038 for OS) in rosacea patients. Corneal and conjunctival sensitivity did not show significant correlation with ST, tBUT, ocular surface staining (Oxford Schema), duration of rosacea and OSDI score.

Conclusions

Corneal and conjunctival sensitivity did not change significantly in rosacea.

Development and Evaluation of a Rosacea Screening Instrument (Rosascreen)

Background:

There are no current instruments to facilitate population screening for rosacea.

Objective:

To develop and evaluate a screening instrument for rosacea applicable for population surveys.

Methods:

A rosacea-specific screening instrument (Rosascreen), consisting of a subject-completed questionnaire and screening algorithm, was developed based on current diagnostic criteria for rosacea. Three iterations were pilot tested and refined for clarity and sensitivity in adult outpatients with and without rosacea.

Results:

Three subject groups were consecutively evaluated with iterations of the questionnaire at each centre (overall N = 121). The final version had a sensitivity of 93% to 100% for key diagnostic criteria, and use of the algorithm had a sensitivity of 100% for detection of rosacea and specificity of 63% to 71%. Most subjects found the questionnaire easy to understand and complete.

Conclusion:

Rosascreen, a subject-completed questionnaire and diagnostic algorithm, is a highly sensitive screening instrument that may facilitate estimation of rosacea prevalence in general populations.

Rosacea: part I. Introduction, categorization, histology, pathogenesis, and risk factors

Rosacea is a chronic inflammatory skin condition that affects approximately 16 million Americans. Four distinct subtypes of rosacea have been recognized, with transient and nontransient facial flushing, telangiectasia, and inflammatory papules and pustules being among the more commonly recognized features. Although the exact pathogenesis of rosacea is unknown, dysregulation of the innate immune system, overgrowth of commensal skin organisms, and aberrant neurovascular signaling may all have a role in promoting the clinical features of rosacea.

Rosacea: prevalence, pathogenesis, particular features of clinical manifestations

This literature review examines principal aspects of rosacea prevalence in the Russian Federation and abroad, shows present-day opinions about the pathogenesis and histological picture of rosacea and presents actual classification and a number of key clinical forms of the disease.

Treatment of ocular rosacea: comparative study of topical cyclosporine and oral doxycycline

AIM

To compare the effectiveness of topical cyclosporine A emulsion with that of oral doxycycline for rosacea associated ocular changes and dry eye complaints.

METHODS

One hundred and ten patients with rosacea were screened. Thirty-eight patients having rosacea associated eyelid and ocular surface changes and dry eye complaints were included in the study. Patients were randomly divided into two groups: nineteen patients were given topical cyclosporine twice daily and nineteen patients were given oral doxycycline 100 mg twice daily for the first month and once daily for the following two months. Symptom and sign scores, ocular surface disease index questionnarie and tear function tests were evaluated at baseline and monthly for 3mo. Three months after results were compared with that of baseline.

RESULTS

Mean values of symptom, eyelid sign and corneal/conjunctival sign scores of each treatment group at baseline and 3mo after treatments were compared and both drugs were found to be effective on rosacea associated ocular changes (P<0.001). Cyclosporine was more effective in symptomatic relief and in the treatment of eyelid signs (P=0.01). There was statistically significant increase in the mean Schirmer score with anesthesia and tear break up time scores in the cyclosporine treatment group compared to the doxycycline treatment group (P<0.05).

CONCLUSION

Cyclosporine as a topical drug can be used in the treatment of rosacea associated ocular complications because it is more effective than doxycycline. In addition ocular rosacea as a chronic disease requires long term treatment and doxycycline has various side effects limiting its long term usage.

Interventions for rosacea

BACKGROUND

Rosacea is a common chronic skin condition affecting the face, characterised by flushing, redness, pimples, pustules and dilated blood vessels. The eyes are often involved and thickening of the skin with enlargement (phymas), especially of the nose, can occur in some people. A range of treatment options are available but it is unclear which are most effective.

OBJECTIVES

To assess the efficacy and safety of treatments for rosacea.

SEARCH METHODS

We updated our searches, to July 2014, of: the Cochrane Skin Group Specialised Register, CENTRAL in The Cochrane Library (2014, Issue 6), MEDLINE (from 1946), EMBASE (from 1974) and Science Citation Index (from 1988). We searched five trials registers and checked reference lists for further relevant studies.

SELECTION CRITERIA

Randomised controlled trials in people with moderate to severe rosacea.

DATA COLLECTION AND ANALYSIS

Study selection, data extraction, risk of bias assessment and analyses were carried out independently by two authors.

MAIN RESULTS

We included 106 studies, comprising 13,631 participants. Sample sizes of 30-100 and study duration of two to three months were most common. More women than men were included, mean age of 48.6 years, and the majority had papulopustular rosacea, followed by erythematotelangiectatic rosacea.A wide range of comparisons (67) were evaluated. Topical interventions: metronidazole, azelaic acid, ivermectin, brimonidine or other topical treatments. Systemic interventions: oral antibiotics, combinations with topical treatments or other systemic treatments, i.e. isotretinoin. Several studies evaluated laser or light-based treatment.The majority of studies (57/106) were assessed as 'unclear risk of bias', 37 'high risk ' and 12 'low risk'. Twenty-two studies provided no usable or retrievable data i.e. none of our outcomes were addressed, no separate data reported for rosacea or limited data in abstracts.Eleven studies assessed our primary outcome 'change in quality of life', 52 studies participant-assessed changes in rosacea severity and almost all studies addressed adverse events, although often only limited data were provided. In most comparisons there were no statistically significant differences in number of adverse events, most were mild and transient. Physician assessments including investigators' global assessments, lesion counts and erythema were evaluated in three-quarters of the studies, but time needed for improvement and duration of remission were incompletely or not reported.The quality of the body of evidence was rated moderate to high for most outcomes, but for some outcomes low to very low.Data for several outcomes could only be pooled for topical metronidazole and azelaic acid. Both were shown to be more effective than placebo in papulopustular rosacea (moderate quality evidence for metronidazole and high for azelaic acid). Pooled data from physician assessments in three trials demonstrated that metronidazole was more effective compared to placebo (risk ratio (RR) 1.98, 95% confidence interval (CI) 1.29 to 3.02). Four trials provided data on participants' assessments, illustrating that azelaic acid was more effective than placebo (RR 1.46, 95% CI 1.30 to 1.63). The results from three studies were contradictory on which of these two treatments was most effective.Two studies showed a statistically significant and clinically important improvement in favour of topical ivermectin when compared to placebo (high quality evidence). Participants' assessments in these studies showed a RR of 1.78 (95% CI 1.50 to 2.11) and RR of 1.92 (95% CI 1.59 to 2.32),which were supported by physicians' assessments. Topical ivermectin appeared to be slightly more effective than topical metronidazole for papulopustular rosacea, based on one study, for improving quality of life and participant and physician assessed outcomes (high quality evidence for these outcomes).Topical brimonidine in two studies was more effective than vehicle in reducing erythema in rosacea at all time points over 12 hours (high quality evidence). At three hours the participants' assessments had a RR of 2.21 (95% CI 1.52 to 3.22) and RR of 2.00 (95% CI 1.33 to 3.01) in favour of brimonidine. Physicians' assessments confirmed these data. There was no rebound or worsening of erythema after treatment cessation.Topical clindamycin phosphate combined with tretinoin was not considered to be effective compared to placebo (moderate quality evidence).Topical ciclosporin ophthalmic emulsion demonstrated effectiveness and improved quality of life for people with ocular rosacea (low quality evidence).Of the comparisons assessing oral treatments for papulopustular rosacea there was moderate quality evidence that tetracycline was effective but this was based on two old studies of short duration. Physician-based assessments in two trials indicated that doxycycline appeared to be significantly more effective than placebo (RR 1.59, 95% CI 1.02 to 2.47 and RR 2.37, 95% CI 1.12 to 4.99) (high quality evidence). There was no statistically significant difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse effects with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence). There was very low quality evidence from one study (assessed at high risk of bias) that doxycycline 100 mg was as effective as azithromycin. Low dose minocycline (45 mg) was effective for papulopustular rosacea (low quality evidence).Oral tetracycline was compared with topical metronidazole in four studies and showed no statistically significant difference between the two treatments for any outcome (low to moderate quality evidence).Low dose isotretinoin was considered by both the participants (RR 1.23, 95% CI 1.05 to 1.43) and physicians (RR 1.18, 95% CI 1.03 to 1.36) to be slightly more effective than doxycycline 50-100 mg (high quality evidence).Pulsed dye laser was more effective than yttrium-aluminium-garnet (Nd:YAG) laser based on one study, and it appeared to be as effective as intense pulsed light therapy (both low quality evidence).

AUTHORS' CONCLUSIONS

There was high quality evidence to support the effectiveness of topical azelaic acid, topical ivermectin, brimonidine, doxycycline and isotretinoin for rosacea. Moderate quality evidence was available for topical metronidazole and oral tetracycline. There was low quality evidence for low dose minocycline, laser and intense pulsed light therapy and ciclosporin ophthalmic emulsion for ocular rosacea. Time needed to response and response duration should be addressed more completely, with more rigorous reporting of adverse events. Further studies on treatment of ocular rosacea are warranted.

Ocular rosacea: an underdiagnosed cause of relapsing conjunctivitis-blepharitis in the elderly

Red eye and relapsing conjunctivitis-blepharitis are among the most common ocular disease in elderly patients. In these cases the search for causes is difficult and frustrating. We report the case of a 79-year-old woman with a long history of red eye and relapsing conjunctivitis-blepharitis caused by ocular rosacea. In this patient the proper diagnosis was performed after 10 years of ocular disease, and repeated evaluations by general practitioners and clinical specialists, only after the appearance of facial signs of erythematotelangiectatic rosacea. Adequate therapy with oral doxycycline led to the improvement of the clinical picture that previously had shown a poor response to several topical treatments. The possibility of ocular rosacea should be considered in evaluating an elderly patient with persistent red eye and relapsing conjunctivitis-blepharitis. Making the proper diagnosis is crucial because ocular rosacea does not respond as expected to topical therapy and may lead to severe corneal involvement.

Ocular rosacea: common and commonly missed

Rosacea is a prevalent disorder that may be disfiguring and cause significant ocular morbidity, if not diagnosed and managed appropriately. Ocular rosacea, in particular, is often left undiagnosed as no specific test is available to confirm the diagnosis. Accurate diagnosis is further complicated because symptoms of ocular rosacea are not always specific to the disorder alone. Other ophthalmic disorders may present with similar findings. Further challenges exist because the severity of ocular symptoms is often not related to the severity of cutaneous findings in rosacea. Isolating a disease marker may facilitate earlier diagnosis and treatment, and could also contribute to better understanding of disease pathogenesis. The glycomics of tear fluid and saliva in patients with rosacea shows promise as an initial step in the search for a biomarker specific to the disease. We have previously found potentially important disease biomarkers in roseatic tear and saliva samples. Further investigation should prove important in the early stages of developing a set of markers for accurate disease identification.

Rosacea: current state of epidemiology

Case definitions are critical in epidemiologic research. However, modern disease indicators must now consider complex data from gene-based research along with traditional clinical parameters. Rosacea is a skin disorder with multiple signs and symptoms. In individuals, these features may be multiple or one may predominate. While studies on the epidemiology of rosacea have previously been sparse, there has been a recent increase in research activity. A broader body of epidemiological information that includes a greater variety of countries beyond Northern Europe and general population-based demographics is needed. As there are operational issues in current case definitions of rosacea subtypes--rationalization and standardization--universal consistent applications in future research is also imperative. Further improvement in disease definition combining new research information along with clinical pragmatism should increase the accuracy of rosacea case ascertainment and facilitate further epidemiological research.