Rosacea and Dry Eyes Part 9

As this is a focus on dry eye disease, it is necessary to include more on the Treatment of Ocular Rosacea- (with another nod to the J. Hopkins Review Article https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5821167/#cit0003 ) *(I’ve put my comments in parenthesis with a leading asterisk to help annotate the actual published reporting. The bold faced type is my emphasis and not from the published articles).

• Patients with mild ocular rosacea often present with a dry gritty feeling in the eyes; they can usually be treated by lid hygiene and lubricating eye drops. Patients with more severe ocular rosacea present with burning or stinging of the eyes, crusting of the lid margins, or formation of chalazia and hordeola. They frequently need topical or systemic antibiotics, or cyclosporine.

• Topical cyclosporine 0.05% ophthalmic emulsion *(Restasis, with now a variety of compounded and more generic formulations available) has been shown to be more beneficial than artificial tears in the treatment of ocular rosacea (low quality evidence).76,100 For the more severe ocular rosacea, referral to an ophthalmologist is prudent.

Physical Treatment of Rosacea - above referenced J. Hopkins Article

• Telangiectasia *(I discussed these fine, red, “spider lines” caused by dilated superficial blood vessels in the lead blog of this series, with photos that demonstrate them).

• Reduction in telangiectasia is not to be expected with any of the currently available topical agents for rosacea. However, these features frequently become a psychological burden and can substantially impact rosacea patients' quality of life.

• Destruction of dilated vessels by vascular lasers or intense pulse light is the primary therapy to reduce telangiectasia. Light energy is absorbed by hemoglobin in cutaneous vessels, leading to vessel heating and coagulation.

• Most commonly used for the treatment of erythema and telangiectasia in rosacea patients are the pulsed dye laser (PDL, pulsed dye laser, 585–595 nm) and intense pulse light (IPL) devices.101,102

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According to the latest Cochrane Systematic Review, pulsed dye

laser and intense pulsed light therapy were each associated with erythema and

telangiectasia improvement, but without difference between treatments (moderate

quality evidence).76

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Drawing from published data and discussions in Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ko HS, Suh YJ, Byun JW, Choi GS, Shin J. Pulsed Dye Laser Treatment Combined with Oral Minocycline Reduces Recurrence Rate of Rosacea. Ann Dermatol. 2017 Oct;29(5):543-547. doi: 10.5021/ad.2017.29.5.543. Epub 2017 Aug 25. PMID: 28966509; PMCID: PMC5597646.

• The recurrence rate of rosacea was not known very well, but has been reported as 60% in 6 months after withdrawal of the drug *(minocycline - which is a tetracycline-derivative similar to doxycycline). It is not known which treatment can reduce relapses of rosacea effectively.

• The objective *(of this study) was to identify whether 595 nm-pulsed dye laser (PDL) treatment reduced recurrence rate among rosacea patients who were treated with oral minocycline.

One hundred and seven Korean patients with rosacea who started treatment with oral minocycline (100 mg/d) with or without PDL (2∼4 sessions) were evaluated retrospectively.

• Cox proportional hazards model showed that the combined use of PDL with oral minocycline appeared to be a significant protective factor for the hazard of recurrence of rosacea (hazard ratio, 0.492; 95% CI, 0.257∼0.941; p=0.032).

• Patients were categorized into 2 groups according to the treatment modality:

• – Group 1: Oral minocycline (100 mg per day) alone

• – Group 2: Oral minocycline (100 mg per day) plus 595 nm-PDL (total 2∼4 sessions)

The PDL (Pulsed Dye Laser) (595 nm, VBeam; Candela/Syneron, Wayland, MA, USA) settings were: fluence, 10.0 J/cm2; spot size, 7 mm; pulse duration, 10 milliseconds; and passes, 2 with 10% overlap of treatment spots. The settings were standard subpurpuragenic settings, including published guidelines and company-recommended ones at the time of the study7. *(Important to note from the above quoted, earlier J. Hopkins report, that PDL was found equal to IPL - or Intense Pulsed Light. As a provider who owned and operated a VBeam PDL prior to switching to a Lumenis M22 IPL system, my general sense is that IPL is likely safer over and around eyelids - but is also similar in results to PDL at the common treatment levels for rosacea. It is worth another look at my earlier post on IPL here https://www.eyethera.com/blog/do-results-of-ipl-treatment-vary-by-technique-and-by-the-filters-used-amp-does-it-regenerate-withered-glands ).

• Pulsed dye laser (PDL) has been suggested to be used adjunctively with oral and topical rosacea regimens for more complete symptom resolution6. PDL shows a therapeutic effect by photo-thermolysis targeting oxyhemoglobins within cutaneous vasculature7,8. PDL is effective for erythema, flushing, telangiectasia and even inflammatory lesions in patients with rosacea6,7,8. Biopsy specimens which were taken from patients with rosacea 3 months after PDL therapy showed that nerve fiber density and number of substance P immunoreactive nerve fibers were decreased9,10. However, exact relationship between this and the therapeutic effect of PDL has not been demonstrated yet.

The multiple Cox proportional hazards model showed that PDL treatment added to oral minocycline was an important protective factor for a hazard of the recurrence of rosacea (HR, 0.492; 95% CI,
0.257∼0.941; p=0.032). The treatment duration with oral minocycline was not a significant prognostic factor for the recurrence of rosacea (p>0.05).

This study showed that the 1 month-recurrence rate after oral minocycline alone was 17.2% and the 6 month- recurrence rate was 66.8%, which is similar to the results of previous report.

In the present study, the 1 month-recurrence rate was 3.2% and the 6 month-recurrence rate was 49.2% after PDL in combination with oral minocycline therapy.

Generally, two to four laser treatments are required to achieve best outcomes for rosacea6. Patients with total 2∼4 sessions of PDL were only included in this study. When we evaluated data including patients with a single session of PDL, the recurrence rates between groups were not significantly different (data not shown). It means a single laser session is not enough to see the therapeutic effect.

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*(My personal take on this mirrors my clinical observations. 4 IPL treatment sessions are generally required for optimal control of rosacea. Adding Doxycycline - or any Tetracycline-derived oral antibiotic such as Minocycline - can enhance the treatment value. This appears to lead to a higher level of improvement in some cases, but to a more lasting benefit in most cases. It also speaks to my general recommendation for “maintenance” IPL treatments every 6-12 months regardless of whether a tetracycline is used adjunctively - and some may benefit from even more. I’ll cover a little more on Rosacea treatments in the next blog posting!)

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