Figure 1A
Figure 1B
The etiology of rosacea is unknown. However, a genetic predisposition, changes in vascular mediating mechanisms, abnormal vascular reactivity, Helicobacter (H.) pylori infection, Demodex folliculorum, hypertension, sunlight, seborrhea, and psychogenic factors have all been incriminated. The diagnosis is based on clinical findings. Ocular rosacea, now defined as a specific subset of the disease by the National Rosacea Society, includes a wide variety of manifestations such as meibomian gland dysfunction, staphylococcal lid disease, recurrent chalazia, chronic conjunctivitis, peripheral corneal neovascularization, marginal corneal infiltrates, episcleritis, and iritis. Rosacea-associated conjunctivitis accounts for 3% of all chronic conjunctivitis cases. Ocular findings may precede skin involvement. The complications are ei6:
PAN-AMERICA
ther non-sight-threatening minor or major. Symptoms often begin with foreign body sensation, pain, and burning.19 The most common ocular finding is blepharoconjunctivitis. There is commonly a history of recurrent hordeolum and chalazion. Up to 55% of patients undergoing chalazion surgery have been reported to have signs of cutaneous rosacea.20 Conjunctival findings include interpalpebral hyperemia with congestion of the bulbar conjunctival vessels. Keratoconjunctivitis sicca has been reported in up to 40% of patients.21 Corneal findings commonly involve the inferior cornea and include mild to moderate punctuate epithelial keratitis. More advanced disease leads to corneal vascularization, “spade shaped� peripheral corneal infiltrates, and even ulceration and perforation. As such, more advanced cases of ocular rosacea may be vision threatening. Management focuses on control rather than cure of the disease. Patients should avoid recognized stimuli of the disease – prolonged sun exposure, spicy foods, excessively hot beverages, and alcohol consumption among others. The management of roseatic eye disease is based on the clinical manifestations. Systemic antibiotics are the primary form of therapy, chiefly tetracycline and doxycycline.22. Aggressive lid hygiene is employed to manage the blepharitis. Blepharoconjunctivitis may also be treated with topical metronidazole 2% gel, although an ophthalmic preparation is not commercially available. With close monitoring, topical corticosteroids may be useful in severe inflammatory cases. 23 The tetracyclines in combination with corticosteroid eye drops and artificial tears exert a strong anti-inflammatory effect in the treatment of ocular rosacea. In cases of severe keratitis with corneal melting or scarring, surgical intervention may be the only option. Surface disease, however, predisposes these patients to a higher risk of post-keratoplasty surface disease and immune graft rejection.
Seborrheic Dermatitis Seborrheic dermatitis is another very common condition that tends to have a bimodal distribution. The two types, by time of occurrence are infantile and adult. The infantile form typically occurs in the first
few months of life, while the adult from generally begins during and after puberty and may persist well on into life. The pathophysiology of this condition is still not entirely clear. In the past, investigators have entertained relationships with Malassezia (previously pityrosporum) and an immune response to yeasts, while others have hypothesized a hyperproliferative state.26 Seborrheic dermatitis may affect the scalp, the central part of the face, the anterior portion of the chest, as well as the flexural creases of the arms, legs, and groin.27 Mild cases present with erythema or scaling of the involved areas. These areas may appear oily or dry. The proliferation of scales often begins as a small patch and may extend to have a well demarcated area and may be associated with itching. Ocular involvement includes erythema and hyperemia of the lid margin associated with irritation and itching. The posterior lamella of the lid will appear red and irregular. The lid margin often demonstrates thick inspissation or oil capping of the meibomian gland orifices. (Fig. 2) Madarosis, (loss of lashes) may be present in more severe cases. The tear film may be oily and often evaporates more rapidly because of the abnormal lipid layer. Symptoms may include dry eye symptoms, photophobia, burning, itching, irritation, and blurred vision. Chalazia, keratoconjunctivitis sicca, punctate epithelial erosions, and occasional marginal ulcers may be observed.28 The treatment of seborrheic dermatitis includes regular lid hygiene. The dermatitis is commonly treated topically with steroid creams, selenium, salicylic acid, coal tar preparations, and occasionally pyrithione zinc. Recent reports have demonstrated success with topical immunomodulators such as tacrolimus and pimecrolimus. Lubrication is important if it is associated with evaporative dry eye. It is important, when treating patients, that they be aware of the chronic nature of the problem and the need for long-term treatment.
Contact Dermatitis Contact dermatitis is the most common eruption of the eyelid. It is seen most often in women. The allergic type is the result of an immune reaction to an allergen. Pruritis