Reconsidering Ocular Rosacea Treatment

 
Capriotti

The “closed lid” perspective takes a different approach for treatment. 

Results from a small clinical trial on the efficacy of a novel treatment method conducted by Kara Capriotti, MD, and colleagues could change the way dermatologists and ophthalmologists treat ocular rosacea.1 

Currently, overlap between dermatology and ophthalmology is a major challenge for the diagnosis and treatment of rosacea, according to Dr Capriotti, who is in practice in Philadelphia, Pennsylvania. 

“Dermatologists are great at looking at the skin and making a diagnosis of rosacea based on physical exam but are not as proficient when performing an ocular exam; for ophthalmologists the reverse is true,” she said. “We must be comfortable looking at the eyelids and ruling out anything that could be masquerading as rosacea, and we have a big disadvantage in dermatology because we don’t use slit-lamp biomicroscopy. The treatment algorithm is relatively straightforward for cutaneous rosacea and we all feel comfortable using both topical and oral regimens to manage the skin, but for ocular manifestations the treatment armamentarium we are trained with is quite limited to oral doxycycline.”

Dr Capriotti added that in severe cases or cases where the eyes are the only thing involved or the ocular symptoms maybe seem out-of-proportion to the lid signs, it is imperative to be sure a primary ocular inflammatory process is not present. Referral might be necessary.

“In the future, especially if there is a good topical therapy with low risk profile (ie, steroid-free, nonirritating, etc.) there will be more collaboration between dermatology, ophthalmology, and primary care to manage these cases. The eyelid is a modified skin structure, like hair or nails, and routine diseases can be treated as such with better understanding of the pathophysiology,” she said.

Ocular Rosacea

“I now tend to think of ocular rosacea as being more of a broad, nonspecific lid disease, multifactorial in nature, encompassing a range of pathologies that are often difficult to distinguish,” said Dr Capriotti, noting that the more general umbrella term commonly used in ophthalmology, “blepharitis,” best captures the variety of this condition. 

She says the notion of marrying dermatology and ophthalmology for the treatment of rosacea/blepharitis settled in when she began to think of the condition as a collective “lid” disease. “The symptoms are usually thought of as ocular surface symptoms—itching, watery eyes; grittiness; foreign body sensation; photophobia—but a lot of the signs of the disease when you look at them actually are lid and skin signs—erythematous eyelid margin; crusting, flaking, or matting at the lash line; madarosis; desquamation of lid skin. A lot of the pathology with this chronic and complicated condition stems from infectious and inflammatory mechanisms,” she said.

The treatment approaches from the specialties vary. For example, almost all of the ophthalmology approaches to the disease start at the ocular surface and these surface treatments are always a little bit (or a lot) toxic to the ocular surface, whereas dermatology approaches everything from the cutaneous side, she said. “Herein lies the psaradigm shift; looking at this as a group from both sides—from the ocular surface side and from the skin side. If we can eliminate the lid signs—can we get remission of the ocular surface symptoms?” she said.

According to Dr Capriotti, by treating the lid signs first via a topical approach through the closed lid, much of the ocular surface symptoms can be eliminated without ever touching the ocular surface, thus preventing a lot of the associated toxicity and side effects commonly seen with topical ophthalmic products. This outside in, “closed-eye” approach may change the way dermatologists and especially ophthalmologist manage this common, often chronic condition. The ability to deliver treatment to lid structures via the cutaneous rather than ocular surface is optimal in preventing toxicity. It also may spare the patient from well-known potential side effects associated with lengthy oral doxycycline treatments.

The Study

In their study, Dr Capriotti and colleagues sought to determine if eliminating the lid signs of ocular rosacea would result in remission of the ocular surface symptoms.1 They assessed the efficacy of 0.5% (w/w) povidone-iodine (PVP-I) in dimethyl sulfoxide (DMSO) gel (PVP-I in DMSO) among 3 participants with ocular rosacea that was recalcitrant to topical and/or oral conventional treatments. Participants applied the gel once a day for 4 weeks to the cutaneous eyelid and lid margins. The 3 participants reported major improvements in both the signs and symptoms of ocular rosacea. While gritty and foreign body sensations were fully resolved in only 2 participants, all 3 participants experienced resolution of erythema of eyelid margin, crusting, and flaking. None of the participants discontinued treatment. 

Dr Capriotti and her colleagues—including ophthalmologists and chemists—intend to continue assessing the safety and efficacy of this and other topical therapies for a variety of skin and nail diseases with Veloce BioPharma. 

Reference

1. Capriotti K, Pelletier J, Stewart K, Barone S, Capriotti J. A paradigm shift in the treatment of ocular rosacea: a transdermal approach. Presented at: American Academy of Dermatology 2018 Annual Meeting; February 16-20, 2018; San Diego, CA.