|
Related Articles | Blepharitis, Adult
Central Sterile Corneal Ulceration
Chalazion
Chlamydia
Cicatricial Pemphigoid
Conjunctivitis, Allergic
Conjunctivitis, Bacterial
Conjunctivitis, Viral
Corneal Erosion, Recurrent
Dermatitis, Atopic
Dry Eye Syndrome
Episcleritis
Keratitis, Bacterial
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Sicca
Ulcer, Corneal
|
| Patient Education |
|
Click here for patient education.
|
|
You are in: eMedicine Specialties >
Ophthalmology > DERMATOLOGIC DISORDERS
Ocular Rosacea
Article Last Updated: May 14, 2007
AUTHOR AND EDITOR INFORMATION
Section 1 of 11  
Author: J Bradley Randleman, MD, Assistant Professor, Department of Ophthalmology, Cornea, External Disease, and Refractive Surgery Section, Emory University School of Medicine
J Bradley Randleman is a member of the following medical societies: Alpha Omega Alpha, American Academy of Ophthalmology, American College of Surgeons, American Medical Association, and American Society of Cataract and Refractive Surgery
Coauthor(s):
Evan Loft, MD, Resident Physician, Department of Ophthalmology, Emory University;
C Diane Song, MD, Assistant Professor, Department of Ophthalmology, Emory University
Editors: Fernando H Murillo-Lopez, MD, Department of Ophthalmology, Instructor, Private Ophthalmology Unit at C.E.M.E.S; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Christopher J Rapuano, MD, Professor, Department of Ophthalmology, Jefferson Medical College; Co-Chairman of the Cornea Service, Co-Chairman of Refractive Surgery Department, Wills Eye Hospital; Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri; Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Author and Editor Disclosure
Synonyms and related keywords:
rosacea, adult acne, inflammatory keratitis, corneal ulceration, corneal perforation
Background
Rosacea is a dermatologic condition that affects the midfacial region (in the form of telangiectasias, erythema, papules and pustules, and rhinophyma). More than 50% of patients with rosacea have ocular manifestations. Ocular rosacea is most frequently diagnosed when cutaneous signs and symptoms of the condition are also present. However, ocular signs and symptoms may occur prior to cutaneous manifestations in 20% of patients with rosacea. No correlation exists between the severity of ocular disease and the severity of facial rosacea.
Ocular manifestations are essentially confined to the eyelids and ocular surface. Problems range from minor irritation to potentially severe ocular surface disruption and inflammatory keratitis. Sight-threatening disease is rare with rosacea; however, keratitis can result in sterile corneal ulceration and eventual perforation if not treated aggressively.
The symptoms of rosacea can be treated effectively; however, rosacea is a chronic condition with exacerbations and remissions, which requires long-term therapy to maintain symptomatic control.
Pathophysiology
The precise pathophysiology of rosacea remains unknown. Rosacea manifests itself primarily as a cutaneous vascular disorder; however, inflammatory changes are a hallmark of severe rosacea. Thus, rather than a specific disease entity, rosacea may be thought of as a disease spectrum with 2 primary etiologic components, vascular and inflammatory. The earliest manifestations of the disease are cutaneous vascular dilatory changes with subsequent increased blood flow in the form of telangiectasias and erythema. Sunlight-induced small vessel damage may contribute to this underlying vascular instability.
The later stages of rosacea are marked by inflammatory changes in the form of papules and pustules in the midface, rhinophyma (bullous nose), blepharitis and meibomitis, and corneal vascularization. A type 4, cell-mediated hypersensitivity reaction has been hypothesized as a possible mechanism. Demodex mites also have been implicated as a possible inflammatory stimulus. Additionally, Helicobacter pylori has been postulated to be a causative factor in a subset of patients. Whatever the underlying mechanism, there is a fundamental abnormality in the sebaceous glands of the face and eyelids, which leads to the inflammatory changes exhibited.
Frequency
United States
More than 10% of the general population exhibits dermatologic characteristics of rosacea; of these, up to 60% experience ocular complications.
Mortality/Morbidity
Rosacea is not a life-threatening disease. Approximately 5% of patients with rosacea manifest corneal disease, which may be severe and can lead to blindness via corneal ulceration, perforation, secondary infections, or corneal opacification from complete vascularization.
Race
Rosacea is recognized much more commonly in fair-skinned white patients but also occurs in other populations and actually may be underreported, rather than less prevalent, in races with increased skin pigmentation.
Sex
Females are affected with rosacea twice as often as males; however, disease manifestations, especially rhinophyma, are frequently more severe in males than in females. The occurrence of ocular manifestations is approximately equal between men and women.
Age
All ages can be affected, including pediatric patients. Peak incidence occurs in the fourth to seventh decades.
History
- Facial symptoms
- Recurrent flushing episodes
- Persistent and/or recurrent midfacial erythema
- Acne (adult onset)
- Ocular symptoms
- Dry eyes, irritation, redness, itching, burning, foreign body sensation, and photophobia
- Recurrent styes
- Recurrent eye infections
Physical
- Facial findings
-
- Telangiectasias
-
- Papules and pustules (without comedones)
-
- Rhinophyma (hypertrophy of sebaceous glands of the nose leading to bullous tissue hyperplasia)
-
- Ocular findings
-
- Eyelid (most common)
- Eyelid telangiectasias
- Blepharitis
- Meibomian gland dysfunction
- Thick viscous plugging of meibomian gland orifices
- Hordeola/chalazia
-
- Conjunctivitis
- Usually chronic, diffuse hyperemia
- Can in rare, severe cases lead to cicatrization
-
- Corneal findings
- Punctate epithelial keratopathy (PEK) usually in the inferior one third of the cornea
- Marginal corneal infiltrates
- Corneal neovascularization
- Superficial, wedge-shaped peripheral vascularization with its base at the limbus
- Can progress to frank corneal neovascularization and eventual opacification
- Corneal thinning, ulceration, and perforation
-
- Secondary bacterial keratitis
-
- Episcleritis, scleritis (rare)
-
Causes
- Flushing triggers - Alcohol, hot beverages, tobacco, spicy foods, and stress
- Sunlight - Postulated to decrease the competence of already dilated cutaneous vasculature
- Demodex - Postulated to increase the inflammatory reaction of the sebaceous glands
- H pylori - Postulated to be correlated strongly with rosacea (This possibly is due to a flush-inducing toxin present in H pylori.)
Blepharitis, Adult
Central Sterile Corneal Ulceration
Chalazion
Chlamydia
Cicatricial Pemphigoid
Conjunctivitis, Allergic
Conjunctivitis, Bacterial
Conjunctivitis, Viral
Corneal Erosion, Recurrent
Dermatitis, Atopic
Dry Eye Syndrome
Episcleritis
Keratitis, Bacterial
Keratoconjunctivitis, Atopic
Keratoconjunctivitis, Sicca
Ulcer, Corneal
Lab Studies
- Rosacea is a clinical diagnosis; therefore, additional laboratory, imaging, and other studies are neither necessary nor useful in establishing the diagnosis.
Histologic Findings
Skin and conjunctival specimens have shown a nonspecific collection of inflammatory cells, increased vascular dilatation, and occasionally granulomatous changes. None of these changes are specific for rosacea.
Medical Care
Rosacea is an enigmatic disease with multiple exacerbations and remissions, and, unfortunately, treatment is directed toward symptomatic control rather than cure. Ocular rosacea can manifest as minor ocular irritation or severe corneal compromise; thus, medical therapy is chosen based on the severity of presentation. When possible, a stepwise approach can be undertaken, using first lid hygiene and artificial tears, followed by topical and oral anti-inflammatory medications, with late surgical intervention as required. As can be implied by the number and variety of treatment options available for rosacea, no one therapeutic regimen has been found effective in all cases, and many cases of rosacea are recalcitrant to multiple therapies. Therefore, treatment always must be tailored to each individual, and various options must be explored until symptoms begin to respond favorably.
- Lid hygiene: Hot compresses applied to the eyelid margins can help to liquefy the thick meibomian gland secretions and, thus, facilitate their expression. Mild, nonirritating cleaning solutions, such as dilute baby shampoo or commercially prepared eyelid scrubs, also can be applied to the eyelids to remove clogging debris. Additionally, light pressure applied to the eyelids can aid in gland expression.
- Artificial tears: Because of the frequency of application, nonpreserved artificial tears are recommended for use. Tears should be applied liberally throughout the day, and, if necessary, a lubricating ointment may be used at night. This ointment may contain an antibiotic preparation.
- Antibiotics (Patients with ocular rosacea who are asymptomatic and without worsening eye disease should not be placed on oral antibiotics.)
- Tetracyclines (eg, tetracycline, doxycycline, minocycline)
- Tetracyclines represent the most common and most effective treatment regimen for rosacea. These drugs are believed to be effective not primarily as antibiotics but rather through a secondary effect that they exert on the meibomian glands. Tetracyclines decrease bacterial lipase, thereby altering the fatty acid composition of the meibomian gland secretions and improving their solubility. These medications also inhibit collagenase; therefore, they are effective in protecting the cornea from impending perforation secondary to inflammatory responses.
- Adverse effects are predominantly gastrointestinal, including diarrhea and rarely pancreatitis and pseudomembranous colitis. More severe but much less common adverse effects include benign intracranial hypertension and renal tubular damage (Fanconi syndrome) from outdated medications. Additionally, tetracyclines cross the placenta and can cause permanent discoloration of teeth as well as retardation of fetal bone growth.
- Tetracyclines generally are effective for rosacea in doses much lower than those given for antibiotic effect, and, once the disease has come under control, the dose may be tapered to a lower, suppressive dose and maintained indefinitely. Due to the chronic, relapsing nature of rosacea, the medication may be used chronically at suppressive doses or discontinued and restarted if and when symptoms recur.
- Among this class of medications, tetracycline and doxycycline most commonly are used. The 2 medications are quite similar in their mechanism of action, side effect profile, and efficacy, but slight differences do exist. Tetracycline has a shorter half-life and, thus, is dosed 4 times per day, as opposed to doxycycline, which is given twice per day or once per day. Frucht-Pery et al reported a more rapid therapeutic response to tetracycline; however, no difference was found at 6 months.1 Additionally, the side effects profile is slightly more favorable for doxycycline.
- Erythromycin can be taken orally for patients intolerant to, or too young for, tetracyclines. Erythromycin ointment applied to the lid margins once or twice daily can provide lubrication for the eye and reduce the bacterial overgrowth contributing to lid margin disease.
- Clarithromycin has shown efficacy in treating rosacea. This compound exhibits anti-inflammatory effects as well as activity against H pylori. Torresani compared clarithromycin and doxycycline and found equivalent therapeutic responses and a milder side effect profile for clarithromycin.2
- Metronidazole
- Metronidazole exhibits antimicrobial (antibacterial and antiparasitic), anti-inflammatory, and immunosuppressive properties and has been found effective against rosacea. Oral metronidazole has in fact been advocated as first-line therapy. Adverse effects include gastrointestinal irritation and a disulfiramlike action; thus, abstinence from alcohol is required.
- Topical metronidazole is quite effective in treating skin lesions in rosacea. While not approved for ophthalmic use, in a pilot study, Barnhorst et al found the topical compound to be safe and effective in treating eyelid involvement in ocular rosacea.3
- Topical steroids can prove useful for short-term exacerbations of lid disease and management of inflammatory keratitis. However, steroids should be used cautiously and discontinued as soon as possible to prevent corneal melting.
- Retinoids: Vitamin A derivatives, such as oral isotretinoin and topical tretinoin, have been found effective in reducing the inflammatory lesions in rosacea. This appears to be accomplished via the suppression of sebum production and a subsequent reduction in sebaceous follicle size. Additionally, tretinoin may help restore sun-damaged skin through the increased production of type 1 collagen in damaged regions. Both compounds actually can cause severe erythema and blepharoconjunctivitis, worsen telangiectasias, and lead to severe keratitis. Additionally, retinoids are extremely teratogenic and, thus, must never be used during pregnancy. Therefore, the use of retinoids commonly is reserved for cases in which multiple agents have failed.
- Antiulcer therapy: H pylori plays an as yet undetermined role in rosacea, and some have advocated H pylori eradication in treatment of rosacea. Thus, in some cases of rosacea, antiulcer combination regimens, such as amoxicillin or clarithromycin, metronidazole, bismuth, and an H2 antagonist, have been used with varying efficacy.
Surgical Care
- Treatment of dry eye - Punctal occlusion can be accomplished via permanent silicone plugs or punctal cauterization.
-
- Treatment of corneal perforations
-
- Cyanoacrylate tissue adhesive
-
- Lamellar keratoplasty
-
- Penetrating keratoplasty
-
- Restoration of vision from corneal disease
-
- Penetrating keratoplasty
-
- The success rate for graft survival generally is much lower than for noninflammatory conditions due to the increased vascularization of the host cornea.
-
- Treatment of limbal stem cell deficiency - Limbal stem cell transplant
-
Consultations
A consult with dermatology is essential for optimal management of rosacea.
Diet
Avoidance of trigger foods and beverages can reduce symptomatic episodes.
Activity
Avoidance of sunlight can benefit some patients.
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Drug Category: Antibiotics
Anti-inflammatory effect helps to ameliorate meibomian gland disease.
| Drug Name | Tetracycline (Sumycin) |
|---|
| Description | Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor. |
|---|
| Adult Dose | 250 mg PO qid |
|---|
| Pediatric Dose | <8 years: Not recommended
>8 years: 25-50 mg/kg/d (10-20 mg/lb) PO divided q6h |
|---|
| Contraindications | Documented hypersensitivity; use with caution in patients with renal impairment |
|---|
| Interactions | Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants |
|---|
| Pregnancy | D - Unsafe in pregnancy
|
|---|
| Precautions | Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines |
|---|
| Drug Name | Doxycycline (Vibramycin, Doryx) |
|---|
| Description | DOC; inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s). Has anti-inflammatory activity. Also a potent collagenase inhibitor. |
|---|
| Adult Dose | 100 mg PO qd/bid; can taper to 50 mg PO qd or qod |
|---|
| Pediatric Dose | 2.2 mg/kg PO qd/bid |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; concurrent use of vitamin A has been associated with increased intracranial pressure; antacids decrease the absorption of tetracyclines |
|---|
| Pregnancy | D - Unsafe in pregnancy
|
|---|
| Precautions | Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines; caution in patients with hepatic insufficiency |
|---|
| Drug Name | Clarithromycin (Biaxin) |
|---|
| Description | Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest. Effective through secondary, anti-inflammatory action. |
|---|
| Adult Dose | 250-500 mg PO bid |
|---|
| Pediatric Dose | 7.5 mg/kg PO bid |
|---|
| Contraindications | Documented hypersensitivity; coadministration of pimozide |
|---|
| Interactions | Toxicity increases with coadministration of fluconazole and pimozide; clarithromycin effects decrease and GI adverse effects may increase with coadministration of rifabutin or rifampin; may increase toxicity of anticoagulants, cyclosporine, tacrolimus, digoxin, omeprazole, carbamazepine, ergot alkaloids, triazolam, and HMG CoA-reductase inhibitors; plasma levels of certain benzodiazepines may increase, prolonging CNS depression; arrhythmias and increase in QTc intervals occur with disopyramide; coadministration with omeprazole may increase plasma levels of both agents |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Coadministration with ranitidine or bismuth citrate is not recommended with CrCl <25 mL/min; give half dose or increase dosing interval if CrCl <30 mL/min; diarrhea may be sign of pseudomembranous colitis; superinfections may occur with prolonged or repeated antibiotic therapies |
|---|
| Drug Name | Metronidazole (Flagyl) |
|---|
| Description | Has anti-inflammatory and immunosuppressive activity. |
|---|
| Adult Dose | 250-500 mg PO bid/qid |
|---|
| Pediatric Dose | 7.5 mg/kg PO bid/qid |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | Concurrent use with warfarin results in increased warfarin activity; concurrent use with cimetidine results in increased metronidazole levels; concurrent use with disulfiram results in combined toxicity |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Extended use has been associated with the development of peripheral neuropathy, seizures, pancreatitis, leukopenia, and Clostridium difficile colitis |
|---|
| Drug Name | Erythromycin ophthalmic ointment (E-Mycin) |
|---|
| Description | Used to decrease meibomian gland bacterial overgrowth. |
|---|
| Adult Dose | Apply to eyelid margins qhs/bid |
|---|
| Pediatric Dose | Apply as in adults |
|---|
| Contraindications | Documented hypersensitivity |
|---|
| Interactions | None reported |
|---|
| Pregnancy | B - Usually safe but benefits must outweigh the risks.
|
|---|
| Precautions | Prolonged use may result in overgrowth of
nonsusceptible organisms, including fungi; discontinue use at first appearance of a skin rash or any other sign of hypersensitivity reaction |
|---|
Drug Category: Retinoids
Decrease sebaceous gland size and sebum production. May inhibit sebaceous gland differentiation and abnormal keratinization.
| Drug Name | Isotretinoin (Accutane) |
|---|
| Description | Reduces sebum production and sebaceous follicle size. |
|---|
| Adult Dose | 0.5-1 mg/kg/d PO divided bid |
|---|
| Pediatric Dose | <12 years: Not recommended
>12 years: Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; females of childbearing age (has been shown to cause major fetal abnormalities) |
|---|
| Interactions | Concurrent use with tetracyclines results in an increased risk for the development of pseudotumor cerebri; contraindicated with concurrent use of other topical acne medications |
|---|
| Pregnancy | X - Contraindicated in pregnancy
|
|---|
| Precautions | Do not donate blood while taking medication or within 30 d of discontinuing its use to prevent possible exposure for pregnant women; has been shown to cause corneal opacities and potentially severe blepharoconjunctivitis; has been shown to cause nosebleeds; can result in significant GI disturbances leading to discontinuation of use; exhibits cross-sensitivity with other vitamin A derivatives |
|---|
| Drug Name | Tretinoin (Avita, Retin-A, Retin-A Micro) |
|---|
| Description | Structurally related to vitamin A. Reduces sebum production and sebaceous follicle size. Makes keratinocytes in sebaceous follicles less adherent and easier to remove. May help restore sun-damaged skin. Long-term, low-dose therapy may be suitable for selected patients.
Inhibits microcomedo formation and eliminates lesions present. Available as 0.025%, 0.05%, and 0.1% creams. Available also as 0.01% and 0.025% gels.
|
|---|
| Adult Dose | Apply to eyelid margins qd/bid |
|---|
| Pediatric Dose | <12 years: Not recommended
>12 years: Apply as in adults |
|---|
| Contraindications | Documented hypersensitivity; use with other retinoids; use with other topical acne medications or astringents |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Discontinue if severe burning, stinging, or erythema develops; avoid unnecessary sun exposure; use of medication may worsen telangiectasias; exhibits cross-sensitivity to other vitamin A derivatives |
|---|
Drug Category: Steroids
Topical steroids occasionally are needed to help suppress inflammatory changes in the cornea.
| Drug Name | Prednisolone acetate (Pred Forte, Econopred) |
|---|
| Description | Decreases inflammation and corneal neovascularization. Suppresses migration of polymorphonuclear leukocytes and reverses increased capillary permeability. |
|---|
| Adult Dose | 1 gtt OU q1-12h based on severity of inflammation |
|---|
| Pediatric Dose | Administer as in adults |
|---|
| Contraindications | Documented hypersensitivity; viral, fungal, or tubercular infections |
|---|
| Interactions | None reported |
|---|
| Pregnancy | C - Safety for use during pregnancy has not been established.
|
|---|
| Precautions | Can increase corneal thinning and melting and lead to globe perforation; monitor IOP carefully, and discontinue topical steroids if an acute rise in pressure noted; discontinue steroids at first sign of active ocular surface infection |
|---|
Further Inpatient Care
- Inpatient care is rarely necessary, except in some cases of corneal perforations or severe secondary corneal infections.
Further Outpatient Care
- Long-term management by both dermatology and ophthalmology is necessary to control this disease. Visits may be frequent in the beginning to gain control over symptoms or to protect an endangered cornea.
In/Out Patient Meds
- Lid hygiene
-
- Artificial tears
-
- Oral antibiotics - Doxycycline, tetracycline, clarithromycin, or metronidazole
-
- Consider erythromycin ointment.
-
- Consider topical metronidazole.
-
- Consider topical steroids.
-
Deterrence/Prevention
- Patients should avoid trigger foods and situations.
-
- For some patients avoidance of sunlight can minimize flare-ups.
-
Complications
- Complications include corneal vascularization, ulceration, perforations, secondary bacterial infections, and, ultimately, decreased vision.
-
- Eyes undergoing penetrating keratoplasty are more likely to experience graft rejection than eyes without rosacea because of the increased inflammatory response and relatively increased corneal vasculature.
-
Prognosis
- Rosacea can be controlled symptomatically but is generally a chronic condition, which requires long-term care and follow-up care.
-
Patient Education
- Informing patients of the chronic, relapsing nature of this disease is important so that patient expectation matches available therapy and patient follow-up care is maximized. Additionally, ophthalmologists probably underdiagnose rosacea due to a lack of familiarity with the dermatologic manifestations of the disease.
Medical/Legal Pitfalls
- Failure to recognize, diagnose, and treat rosacea can compromise the integrity of the ocular surface.
-
Special Concerns
- Because rosacea is a chronic, often progressive disease, patients are likely to become increasingly symptomatic as they age.
- Patients need to understand that rosacea is a chronic condition, requiring long-term treatment.
| Media file 1:
Typical dermatologic findings of rosacea, including midfacial papules, pustules, and rhinophyma. |
 |  View Full Size Image | |
Media type: Photo
|
| Media file 2:
Typical findings of rosacea, including papules, pustules, and rhinophyma. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 3:
Ocular rosacea. Eyelid telangiectasias with inspissated meibomian glands. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 5:
Ocular rosacea. Extensive corneal pannus with thinning. |
 | View Full Size Image | |
Media type: Photo
|
| Media file 6:
Ocular rosacea. Extensive corneal neovascularization and opacification. |
 | View Full Size Image | |
Media type: Photo
|
- Frucht-Pery J, Sagi E, Hemo I, Ever-Hadani P. Efficacy of doxycycline and tetracycline in ocular rosacea. Am J Ophthalmol. Jul 15 1993;116(1):88-92. [Medline].
- Torresani C. Clarithromycin: a new perspective in rosacea treatment. Int J Dermatol. May 1998;37(5):347-9. [Medline].
- Barnhorst DA Jr, Foster JA, Chern KC, Meisler DM. The efficacy of topical metronidazole in the treatment of ocular rosacea. Ophthalmology. Nov 1996;103(11):1880-3. [Medline].
- Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. Nov 1997;104(11):1863-7. [Medline].
- Browning DJ, Proia AD. Ocular rosacea. Surv Ophthalmol. Nov-Dec 1986;31(3):145-58. [Medline].
- Buechner SA. Rosacea: an update. Dermatology. 2005;210(2):100-8. [Medline].
- Knox CM, Smolin G. Rosacea. Int Ophthalmol Clin. 1997;37(2):29-40. [Medline].
- Powell FC. Clinical practice. Rosacea. N Engl J Med. Feb 24 2005;352(8):793-803. [Medline].
- Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol. Apr 2002;46(4):584-7. [Medline].
- Wilkin JK. Rosacea. Pathophysiology and treatment. Arch Dermatol. Mar 1994;130(3):359-62. [Medline].
Ocular Rosacea excerpt Article Last Updated: May 14, 2007
|
