CASE REPORT Pediatric Dermatology 1–4, 2014
Ophthalmic Rosacea: Case Report in a Child and Treatment Recommendations Christiane Potz-Biedermann, M.D.,* Tarun Mehra, M.D.,† Christoph Deuter, M.D.,‡ Manfred Zierhut, M.D.,‡ and Martin Schaller, M.D.* *Department of Dermatology, Eberhard-Karls-University, T€ ubingen, Germany, †Medical Directorate, University Hospital of Z€ urich, Z€ urich, Switzerland, ‡Department of Ophthalmology, Eberhard-Karls-University, T€ ubingen, Germany
Abstract: We report a rare case of rosacea with ocular involvement in a child that remitted with prolonged anti-inflammatory oral tetracycline therapy and provide general expert recommendations. A 14-year-old girl presented with discrete papules and pustules on both cheeks with blepharitis and conjunctivitis. Ophthalmologic examination confirmed bilateral severe blepharitis, as well as a corneal infiltrate in the right eye with additional neovascularization. The diagnosis of rosacea with ocular involvement was made. In addition to the existing antibiotic and antiinflammatory topical eye therapy, systemic treatment with minocycline 50 mg twice a day was started. After marked improvement, the dose was reduced to 50 mg once a day. After further amelioration, treatment was switched to maintenance therapy with 40 mg of prolonged-release doxycycline. Three years after a 12-month course of anti-inflammatory therapy, the patient remained recurrence free.
Ocular involvement in rosacea occurs in approximately 30% to 50% of patients (1) presenting with blepharitis and keratitis. Symptoms include foreign body sensation in the eyes, light sensitivity, and tearing. Visual impairment is not uncommon, especially in severely affected children (1,2), but ocular involvement is not necessarily associated with inflammatory cutaneous rosacea, often delaying appropriate anti-inflammatory therapy. Because of the low prevalence of rosacea in childhood, as well as frequently missing cutaneous
stigmata, the diagnosis of ocular rosacea in this age group is frequently delayed. We report a rare case of rosacea with severe ocular involvement in a child. CASE REPORT Colleagues in the Department of Ophthalmology referred a 14-year-old girl with recurrent blepharoconjunctivitis to the Department of Dermatology, University of T€ ubingen. She had discrete papules and pustules on both cheeks and clearly visible blepharitis
Address correspondence to Martin Schaller, M.D., Department of Dermatology, Eberhard-Karls-University, Liebermeisterstr. 25, D-72076 T€ ubingen, Germany, or e-mail: martin.schaller@med. uni-tuebingen.de. DOI: 10.1111/pde.12419
© 2014 Wiley Periodicals, Inc.
1
2 Pediatric Dermatology 2014
and conjunctivitis (Fig. 1A). She had a 2- to 3-year history of recurrent red eyes that had been treated with a variety of topical agents, most recently with ofloxacin eye drops. The patient complained of painful foreign body sensation in the eyes, photophobia, and tearing. Ophthalmologic examination confirmed bilateral severe blepharitis and a corneal infiltrate in the right eye with additional neovascularization. Because of the presence of severe blepharitis and keratoconjunctivitis, immediate treatment with antibiotic eye drops (moxifloxacin) was started. Antibiotic and steroidal ointment (gentamycin and dexamethasone) was used on the lower lid and artificial tears (sodium hyaluronate) were started. After exclusion of herpes simplex virus infection using polymerase chain reaction, we made the diagnosis of rosacea with ocular involvement and, in addition to the existing topical therapy of the eye, initiated systemic treatment with minocycline 50 mg twice a day. This led to marked improvement of her skin lesions and the ocular involvement after several weeks. She continued to improve, and after 3 months we reduced the dose of minocycline to 50 mg once daily. Her disease remained stable, so we switched to 40 mg of prolonged-release doxycycline as maintenance therapy. She was treated for an additional 6 months with anti-inflammatory therapy (Fig. 1B). Three years after a 12-month course of anti-inflammatory therapy, the patient remained recurrence free. DISCUSSION The reported prevalence of ocular involvement in rosacea varies from 30% to 50% (1) in adults. In A
approximatley 20% of these individuals, ocular complaints precede cutaneous findings (3). In children, cutaneous rosacea is often characterized by papules and pustules but sometimes tends to be discrete and similar to perioral dermatitis (2). Ocular symptoms may be present, especially in girls with cutaneous rosacea, and are associated with a significantly higher rate of complications than in adults; corneal involvement is not uncommon (4) (Table 1). There is no correlation between the severity of ocular rosacea and inflammatory cutaneous rosacea (3). Although rosacea in children, especially before puberty, is uncommon, ocular symptoms are often present at diagnosis. During puberty, the diagnosis of rosacea is challenging, because of the clinical overlap between rosacea and acne. The hallmarks of rosacea in children are facial erythema, telangiectases, flushing, and papules and pustules restricted to the cheeks, chin, forehead, and nasolabial fold (5). The therapeutic approach in adults depends on the severity. Treatment of mild ocular rosacea with blepharoconjunctivits should include regular lid and eye hygiene consisting of warm compresses, cleaning of the lid margin, and the use of lipid-containing artificial tears. Persistent blepharitis, corneal neovascularization, or marginal infiltration require topical antibiotics and at least 6 months of systemic antiinflammatory antibiotic therapy. In patients with keratitis or scarring, steroid eye drops are important, and if anti-inflammatory maintenance therapy is necessary, topical cyclosporine A may be a useful alternative. The literature includes few reports about therapy of ocular rosacea in very young patients (Table 2).
B
TABLE 1. Common Symptoms and Findings in Ocular Rosacea Symptoms
Findings
Blepharitis with
Chronic redness
Figure 1. (A) Perioral papules and pustules and blepharitis before therapy with (B) complete healing after minocycline 50 mg twice a day and 40 mg of prolongedrelease doxycycline.
blocked meibomian glands Conjunctival hyperemia Keratitis with infiltrates Neovascularization of the cornea Ulceration of the cornea with scarring
of the eyes Burning, tearing,
foreign body sensation Sensitivity to light
Potz-Biedermann et al: Pediatric Ocular Rosacea 3
TABLE 2. Overview of Systemic Medications for Ocular Rosacea in Childhood Patients and symptoms
Therapy
Outcome/follow-up
4 girls, 2 boys, 3–12 yrs old Corneal ulcers (n = 3) Nazir et al (4)
Erythromycin 30–50 mg/kg/day for 4–6 wks (for children < 8 yrs) Doxycycline 50–100 mg twice daily for 1 mo, then 50–100 mg/day for 1–2 mos before further tapering Erythromycin 20 mg/kg/day for 12 mos than 5–10 mg/kg/day for 6 mos Doxycycline 100–200 mg for 12 mos Clarithromycin 250 mg/day for 3 mos
Strong improvement but relapse observed (25% after1 mos, 66% after 6 mos)
Erythromycin 200–600 mg/day for 5 days Doxycycline 100–200 mg/day Azithromycin 500 mg/day Doxycycline >12 yrs Metronidazole 20–30 mg/kg/day for 3–6 mos for
Ophthalmic Rosacea: Case Report in a Child and Treatment Recommendations Christiane Potz-Biedermann, M.D.,* Tarun Mehra, M.D.,† Christoph Deuter, M.D.,‡ Manfred Zierhut, M.D.,‡ and Martin Schaller, M.D.* *Department of Dermatology, Eberhard-Karls-University, T€ ubingen, Germany, †Medical Directorate, University Hospital of Z€ urich, Z€ urich, Switzerland, ‡Department of Ophthalmology, Eberhard-Karls-University, T€ ubingen, Germany
Abstract: We report a rare case of rosacea with ocular involvement in a child that remitted with prolonged anti-inflammatory oral tetracycline therapy and provide general expert recommendations. A 14-year-old girl presented with discrete papules and pustules on both cheeks with blepharitis and conjunctivitis. Ophthalmologic examination confirmed bilateral severe blepharitis, as well as a corneal infiltrate in the right eye with additional neovascularization. The diagnosis of rosacea with ocular involvement was made. In addition to the existing antibiotic and antiinflammatory topical eye therapy, systemic treatment with minocycline 50 mg twice a day was started. After marked improvement, the dose was reduced to 50 mg once a day. After further amelioration, treatment was switched to maintenance therapy with 40 mg of prolonged-release doxycycline. Three years after a 12-month course of anti-inflammatory therapy, the patient remained recurrence free.
Ocular involvement in rosacea occurs in approximately 30% to 50% of patients (1) presenting with blepharitis and keratitis. Symptoms include foreign body sensation in the eyes, light sensitivity, and tearing. Visual impairment is not uncommon, especially in severely affected children (1,2), but ocular involvement is not necessarily associated with inflammatory cutaneous rosacea, often delaying appropriate anti-inflammatory therapy. Because of the low prevalence of rosacea in childhood, as well as frequently missing cutaneous
stigmata, the diagnosis of ocular rosacea in this age group is frequently delayed. We report a rare case of rosacea with severe ocular involvement in a child. CASE REPORT Colleagues in the Department of Ophthalmology referred a 14-year-old girl with recurrent blepharoconjunctivitis to the Department of Dermatology, University of T€ ubingen. She had discrete papules and pustules on both cheeks and clearly visible blepharitis
Address correspondence to Martin Schaller, M.D., Department of Dermatology, Eberhard-Karls-University, Liebermeisterstr. 25, D-72076 T€ ubingen, Germany, or e-mail: martin.schaller@med. uni-tuebingen.de. DOI: 10.1111/pde.12419
© 2014 Wiley Periodicals, Inc.
1
2 Pediatric Dermatology 2014
and conjunctivitis (Fig. 1A). She had a 2- to 3-year history of recurrent red eyes that had been treated with a variety of topical agents, most recently with ofloxacin eye drops. The patient complained of painful foreign body sensation in the eyes, photophobia, and tearing. Ophthalmologic examination confirmed bilateral severe blepharitis and a corneal infiltrate in the right eye with additional neovascularization. Because of the presence of severe blepharitis and keratoconjunctivitis, immediate treatment with antibiotic eye drops (moxifloxacin) was started. Antibiotic and steroidal ointment (gentamycin and dexamethasone) was used on the lower lid and artificial tears (sodium hyaluronate) were started. After exclusion of herpes simplex virus infection using polymerase chain reaction, we made the diagnosis of rosacea with ocular involvement and, in addition to the existing topical therapy of the eye, initiated systemic treatment with minocycline 50 mg twice a day. This led to marked improvement of her skin lesions and the ocular involvement after several weeks. She continued to improve, and after 3 months we reduced the dose of minocycline to 50 mg once daily. Her disease remained stable, so we switched to 40 mg of prolonged-release doxycycline as maintenance therapy. She was treated for an additional 6 months with anti-inflammatory therapy (Fig. 1B). Three years after a 12-month course of anti-inflammatory therapy, the patient remained recurrence free. DISCUSSION The reported prevalence of ocular involvement in rosacea varies from 30% to 50% (1) in adults. In A
approximatley 20% of these individuals, ocular complaints precede cutaneous findings (3). In children, cutaneous rosacea is often characterized by papules and pustules but sometimes tends to be discrete and similar to perioral dermatitis (2). Ocular symptoms may be present, especially in girls with cutaneous rosacea, and are associated with a significantly higher rate of complications than in adults; corneal involvement is not uncommon (4) (Table 1). There is no correlation between the severity of ocular rosacea and inflammatory cutaneous rosacea (3). Although rosacea in children, especially before puberty, is uncommon, ocular symptoms are often present at diagnosis. During puberty, the diagnosis of rosacea is challenging, because of the clinical overlap between rosacea and acne. The hallmarks of rosacea in children are facial erythema, telangiectases, flushing, and papules and pustules restricted to the cheeks, chin, forehead, and nasolabial fold (5). The therapeutic approach in adults depends on the severity. Treatment of mild ocular rosacea with blepharoconjunctivits should include regular lid and eye hygiene consisting of warm compresses, cleaning of the lid margin, and the use of lipid-containing artificial tears. Persistent blepharitis, corneal neovascularization, or marginal infiltration require topical antibiotics and at least 6 months of systemic antiinflammatory antibiotic therapy. In patients with keratitis or scarring, steroid eye drops are important, and if anti-inflammatory maintenance therapy is necessary, topical cyclosporine A may be a useful alternative. The literature includes few reports about therapy of ocular rosacea in very young patients (Table 2).
B
TABLE 1. Common Symptoms and Findings in Ocular Rosacea Symptoms
Findings
Blepharitis with
Chronic redness
Figure 1. (A) Perioral papules and pustules and blepharitis before therapy with (B) complete healing after minocycline 50 mg twice a day and 40 mg of prolongedrelease doxycycline.
blocked meibomian glands Conjunctival hyperemia Keratitis with infiltrates Neovascularization of the cornea Ulceration of the cornea with scarring
of the eyes Burning, tearing,
foreign body sensation Sensitivity to light
Potz-Biedermann et al: Pediatric Ocular Rosacea 3
TABLE 2. Overview of Systemic Medications for Ocular Rosacea in Childhood Patients and symptoms
Therapy
Outcome/follow-up
4 girls, 2 boys, 3–12 yrs old Corneal ulcers (n = 3) Nazir et al (4)
Erythromycin 30–50 mg/kg/day for 4–6 wks (for children < 8 yrs) Doxycycline 50–100 mg twice daily for 1 mo, then 50–100 mg/day for 1–2 mos before further tapering Erythromycin 20 mg/kg/day for 12 mos than 5–10 mg/kg/day for 6 mos Doxycycline 100–200 mg for 12 mos Clarithromycin 250 mg/day for 3 mos
Strong improvement but relapse observed (25% after1 mos, 66% after 6 mos)
Erythromycin 200–600 mg/day for 5 days Doxycycline 100–200 mg/day Azithromycin 500 mg/day Doxycycline >12 yrs Metronidazole 20–30 mg/kg/day for 3–6 mos for
