Rosacea and Dry Eyes Part 8
Treatment continues to point back to the immune system, starting at a genetic level and then to the gut…
Woo YR, Han YJ, Kim HS, Cho SH, Lee JD. Updates on the Risk of Neuropsychiatric and Gastrointestinal Comorbidities in Rosacea and Its Possible Relationship with the Gut-Brain-Skin Axis. Int J Mol Sci. 2020 Nov 10;21(22):8427. doi: 10.3390/ijms21228427. PMID: 33182618; PMCID: PMC7696644.
Treatment of Rosacea- Johns Hopkins Review Article
Historically, rosacea was treated by bloodlettings and application of leeches on rosacea-affected skin.67 Rosacea therapy has changed since then, but a curative treatment approach has not yet been developed. Thomas Bateman's quote holds true to date: “The perfect cure of [acne] rosacea is, in fact, never
accomplished” (from Delineations of cutaneous diseases, 1812).
Most current guidelines are based on the identification of the rosacea subtype to select the appropriate therapy. However, in reality there is often an overlap of clinical features across rosacea subtypes in each patient, requiring several therapeutic strategies for optimal outcome. Thus, there is no single best way to treat all rosacea patients.68-70
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
I think it is clear that until we can manipulate the genes responsible for Rosacea and reorganize the gut flora around an individual’s immune system, that Mr. Bateman’s quote is likely to remain true. Fortunately, there have been many headways made into the treatment of Rosacea since 1812!
I believe this review article applies well to the ocular rosacea I see in my practice - particularly in regards to the “life-long treatment intervention.” For most, this is pretty simple - but for some, it can get quite complex. The simplest can be practicing ample lid hygiene, including control of the stubborn mites called Demodex. (see my earlier posts on these topics, here: https://www.eyethera.com/blog/demodex-the-tiny-mite-with-a-big-effect-on-dry-eye-disease and https://www.eyethera.com/blog/why-do-some-people-produce-pasty-meibum-part-4 (among others in earlier posts). Continuing in our review of this article, I’ve pulled some general recommendations as follows, below:
Treatment of Rosacea- Johns Hopkins Review Article
General recommendations include a gentle skin care regimen to maintain skin hydration and barrier function, and photoprotection (sun exposure avoidance and sunscreen with a sun protection factor of 30 or greater).
Additionally, cover-up or color-correcting powders can be helpful to mitigate the psychosocial impact of rosacea. Since the psychosocial impact of rosacea tends to be underestimated by physicians, this issue should be raised with every patient and considered in the therapeutic plan.
Several topical drugs including topical metronidazole, azelaic acid, ivermectin, and brimonidine tartrate are approved for rosacea by the United States Food and Drug Administration (FDA).
The only (FDA) approved oral drug for rosacea is low-dose doxycycline. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
Treatment of Rosacea- Johns Hopkins Review Article
- ...the only oral agent approved by the FDA to treat inflammatory rosacea lesions is a modified-release doxycycline (40 mg once-daily), which was approved in 2006.75 This once-daily 40 mg doxycycline dosing (30 mg immediate-release and 10 mg delayed-release beads) provides anti- inflammatory, without antimicrobial effects; in vivo microbiological studies demonstrated no long-term effects on bacterial flora of the oral cavity, skin, intestinal tract, and vagina.92-95
- Based on most current evidence, oral tetracycline (moderate quality evidence) and doxycycline (high quality evidence) were both associated with improvements in papulopustular rosacea compared with placebo.76 There was no difference in effectiveness between 100 mg and 40 mg doxycycline, but there was evidence of fewer adverse events with the lower dose (RR 0.25, 95% CI 0.11 to 0.54) (low quality evidence).76,94
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003
In my practice, I find that there has been little difference between the 40mg dose noted above and the (much) cheaper 50mg dose (without the different absorption profile). In my estimation, this difference in dosage and absorption is not significant for most, as doxycycline is largely absorbed through the liver pathway and has a lasting effect in oil glands (so that in some cases, even 50mg every other day can still have treatment value for rosacea patients). Azithromycin can have similar benefits for some rosacea patients (and can be available as a topical eye-drop preparation), so choice of which antibiotic (and by which route) can be customized by the physician for their patient.
For those who don’t do well with longer-term antibiotics (due to allergies, side effects, or as a preference), IPL can be a great option and can be used with or without antibiotics. Cost is often an issue, as most insurance programs will cover the antibiotics but will not cover IPL treatments. I’’ve posted extensively on IPL and will summarize this with some references, in my next posting (and can cover some of the other dermatological treatments recommended in the above review article). For more on doxycycline please also see my earlier post in this series, here: https://www.eyethera.com/blog/rosacea-and-dry-eyes-part-6 ).
To schedule an appointment with Dr. Jaccoma, call Excellent Vision at either of these two dry eye offices:
(1) 155 Griffin Rd, Portsmouth, NH 03801 (603) 574-2020
(2) 3 Woodland Rd, STE 112 Stoneham, MA 02180 (near Boston) (781) 321-6463