CORNEA 26 EWAP JUNE 2022 for rosacea. However, he said that one problem is that a lot of clinicians don’t realize that sometimes steroids may make acne rosacea worse. For ocular rosacea, steroids and doxycycline systemically have good results, he said, but if the patient has another form of rosacea, which is not uncommon, steroids are a double-edged sword. “I like to limit steroids to patients who just have the ocular form of rosacea,” he said. Dr. Perry added that ivermectin and metronidazole are effective treatments. You can combine this with the tetracycline family of antibiotics, including doxycycline and minocycline and minimize corticosteroid use. Dr. Perry said he has been using BlephEx and microblepharoexfoliation for the last 5 years with good results. He added that many use tea tree oil and Cliradex (Bio-Tissue) as well. There is some evidence that diets high in omega-3 essential fatty acids may be beneficial in rosacea, Dr. de Luise said, adding that there are several oral and topical options for rosacea, with variable degrees of efficacy. Dr. de uise noted a number of other treatment options (see sidebar). Dr. de Luise also mentioned the “interesting relationship” between Demodex mite infiltration of the eyelid margin. “Studies have been done to determine if this is correlative or causative,” he said. “To that end, Tarsus Pharmaceuticals is developing TP-03 (lotilaner), a mite-specific A A antagonist, for topical use on the eyelids and facial skin as a treatment for anterior blepharitis due to Demodex and is also testing a TP-04 formulation as a treatment for rosacea.” He said that AiViva BioPharma is testing an intradermal delivery of its pipeline molecule AIV001 in subjects with papulopustular rosacea. CAGE Bio is testing its pipeline gel CGB-400 for inyammatory rosacea. Allergan is developing AGN-199201 oxymetazoline cream for topical use and evaluating utility in subjects with erythema and rosacea. Contraindications In terms of contraindications, Dr. de Luise said that topical ophthalmic corticosteroids should be used with great caution in the management of rosacea. “It turns out that rosacea keratitis is extremely sensitive to topical corticosteroids, and corneal ulceration, descemetocele formation, and perforation have been reported to occur,” he said. “If topical corticosteroids are to be used in the management of rosacea keratitis, an ester steroid such as loteprednol etabonate is preferred, and careful, close follow-up is strongly recommended.” Dr. Cheung noted that certain oral antibiotics may have tolerability issues. Topical corticosteroid use needs to be monitored as certain eyes may be susceptible to corneal melts, he added. “I would avoid corticosteroids if infectious keratitis is suspected until properly treated.” Dr. Cheung said he cautiously uses topical corticosteroids for acute conjunctival/corneal disease to help quiet the eye. For dryness and chronic aspects Dr. de Luise shared details on several treatment options for rosacea: • Oral minocycline or oral doxycycline: This is a commonly employed strategy, especially in a modified release {0-mg formulation of doxycycline. These various oral cyclines should not be used for longer than 3–4 months at a time followed by a hiatus. Side effects of the cyclines are well known and include gastroenteritis, vaginal candidiasis, and dermal skin rashes. • Topical ivermectin 1% cream: This is used with fairly good success in several of the subtypes of rosacea. It directly targets Demodex folliculorum and Demodex brevis. • Topical brimonidine in a 0.33% gel: This targets vasomotor dysregulation in rosacea. Topical brimonidine is sometimes used in concert with topical potassium titanyl phosphate to address persistent facial erythema in rosacea. • Topical oxymetazoline: This is an imidazole whose mechanism of action is as an alpha 1A and alpha 2A adrenoreceptor agonist that induces vasoconstriction of dilated vessels in rosacea. • Topical isotretinoin: This has some degree of efficacy. • Another imidazole, metronidazole: These have been used in a topical formulation in facial rosacea. An ophthalmic formulation has been tested but is not available. • Intense pulsed light therapy: This has had some degree of success in rosacea. of the disease, corticosteroids may be used initially as bridge therapy while nonsteroidal anti-inyammatories such as cyclosporine or lifitegrast are taking their effect. EWAP Reference 1. allo R , et al. -tandard classification and pathophysiology of rosacea: The 2017 update by the National Rosacea Society Expert Committee. J Am Acad Dermatol. 2018;78:148–155. Editors’ note: Dr. Cheung practices at Virginia Eye Consultants, Norfolk, Virginia, and declared no relevant finanVial interests° r° de Õise is Assistant Clinical Professor of Ophthalmology, Yale University School of Medicine, New Haven, Connecticut, and deVlared no releÛant finanVial interests° Dr. Perry is Chief of the Cornea Service, NuHealth Medical Center, East Meadow, New York, and has interests with Alcon, Allergan, Azura, AXIM, Bausch + Lomb, BlephEx, NovaBay, Novaliq, Noveome, Omeros, Sol-Gel, and Tarsus.
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