Dry Eye Dx and Tx: Rosacea: From Skin to Eye

Cutaneous rosacea and dry eye disease exhibit overlapping characteristics, raising the need for improved diagnosis and treatment strategies, especially for ocular manifestations.

By
Roxanna Potter, OD
July 1, 2025
4 min

Contact Lens Spectrum

At a Glance

Category	Detail
Condition	Rosacea and ocular rosacea associated with dry eye disease
Key Mechanisms	Multifactorial inflammatory, autoimmune, and neurological mechanisms; involvement of hormones, environment, microbes including Demodex mites and bacteria
Target Population	Adults (5.5% global prevalence), including fair-skinned and underdiagnosed darker-skinned populations; also pediatric cases
Care Setting	Dermatology and eyecare clinical settings with interdisciplinary collaboration

Key Highlights

Rosacea presents with overlapping phenotypes including facial erythema, papules, pustules, vascular abnormalities, and ocular manifestations such as blepharitis, conjunctivitis, dry eye, and meibomian gland dysfunction.
Ocular rosacea occurs in 10-15% of cutaneous rosacea cases and can present without skin involvement; severe ocular disease may lead to keratitis, corneal neovascularization, scarring, ulceration, and anterior uveitis.
Treatment ranges from lifestyle modifications and omega-3 supplementation to topical and oral therapies, with emerging use of light and thermal therapies; evidence-based guidelines for dosing and duration are lacking.

Guideline-Based Recommendations

Diagnosis

Identify rosacea based on patient-specific phenotypic expression rather than rigid subtypes.
Look for facial signs such as erythema, telangiectasias, papules, pustules, and phymatous changes.
Assess ocular signs including blepharitis, conjunctivitis, dry eye symptoms, meibomian gland dysfunction, and lid telangiectasias.
Consider ocular rosacea even in absence of skin involvement.
Be aware of underdiagnosis in darker-skinned patients due to pigment masking.

Management

Recommend omega-3 fatty acid supplementation and avoidance of known triggers (heat, exercise, spicy foods, UV exposure, chemical irritants, alcohol).
Use preservative-free artificial tears and lid hygiene for mild ocular involvement.
Employ topical immunomodulators (cyclosporine, lifitegrast, steroids) for moderate to severe ocular disease.
Consider oral antibiotics (doxycycline, minocycline, azithromycin) for moderate to advanced cases.
Utilize light-based therapies (intense pulsed light, thermal pulsation) as adjunctive treatments for skin and eyelids.
Collaborate with dermatology for comprehensive management.

Monitoring & Follow-up

Regularly evaluate ocular and cutaneous signs and symptoms to assess treatment response.
Monitor for progression to severe ocular complications such as keratitis and corneal scarring.
Adjust therapies based on clinical severity and patient tolerance.

Risks

Potential underdiagnosis leading to delayed treatment and progression of ocular complications.
Lack of consensus on dosing and duration of oral and light-based therapies may affect treatment efficacy and safety.
Severe ocular rosacea can cause vision-threatening complications if untreated.

Patient & Prescribing Data

Patients with cutaneous and/or ocular rosacea including those with mild to severe ocular involvement

Mild cases benefit from lifestyle changes and topical therapies; moderate to severe cases often require systemic antibiotics and immunomodulators; light and thermal therapies are promising but lack standardized protocols.

Clinical Best Practices

Screen for ocular rosacea in patients presenting with dry eye symptoms and facial rosacea signs.
Perform thorough ocular surface and adnexal examination including lid margin evaluation.
Educate patients on trigger avoidance and importance of adherence to therapy.
Coordinate care with dermatologists to optimize management of both skin and ocular manifestations.
Stay updated on emerging evidence and evolving treatment guidelines.