rosacea ocular

CASE SERIES

Childhood ocular rosacea: Considerations for diagnosisand treatmentajd_557 272..275

Esther Hong1 and Gayle Fischer1,2

1Dermatology Department, Royal North Shore Hospital, and 2Northern Clinical School, Faculty of Medicine,University of Sydney, Sydney, New South Wales, Australia

ABSTRACT

Rosacea in children is not as well described as it is inadults. Ocular signs may be a dominant feature andsome children with what has previously been calledperiorificial dermatitis may in fact have rosacea. Wereport three cases of paediatric ocular rosacearesponding to prolonged treatment with oral erythro-mycin. Our cases demonstrate the close association ofperiorificial dermatitis with childhood rosacea, andhighlight the importance of eye signs in its diagnosticcriteria.

Key words: chalazion, child, ocular, periorificialdermatitis, rosacea.

INTRODUCTION

Childhood rosacea is considered to be rare and descriptionsin the paediatric age group rely on small case studies. Thesestudies emphasise the association of recurrent chalaziawith rosacea in children. Periorificial dermatitis is notuncommon in children and, while some consider it to be aseparate entity to and differential diagnosis for rosacea,1,2

some studies have found close associations linking perior-ificial dermatitis to childhood rosacea3 and, in particular,ocular signs of rosacea.4

There are no clear guidelines for first-line therapy inchildhood rosacea. Treatment has historically paralleledadult regimens, using systemic and topical antibiotics suchas tetracyclines, erythromycin and metronidazole.We herein report three children aged 12 months,

18 months and 3 years of age with rosacea who presentedinitially with a diagnosis of periorificial dermatitis, but in

whom ocular disease was a significant element. All threecases responded to long-term monotherapy with oral eryth-romycin (3050 mg/kg/day).

CASE REPORTS

Case 1

An 18-month-old girl presented to the paediatric dermatol-ogy clinic with a 3-month history of facial pustules. A con-current pustular eruption on the dorsum of her hands wasswabbed and subsequently grew Staphylococcus aureus.This was treated with mupirocin ointment. She had anuneventful past medical history.Examination revealed perioral and paranasal micropap-

ules. Initially there was no evidence of ocular lesions ortelangiectasia.A diagnosis of periorificial dermatitis was made. The

facial rash responded well to oral erythromycin 50 mg/kgdaily for 2 weeks, followed by 30 mg/kg daily for 4 weeks.One month after the patient completed her 6-week course

of erythromycin, the pustular periorificial rash recurred.Another skin swab revealed S. aureus. She was commencedon oral cephalexin and bleach baths. The patients familymembers were treated with mupirocin intranasal ointment.The patient presented 6 months later with persistent peri-

orificial dermatitis and additionally significant bilateral ble-pharitis with recurrent chalazia (Fig. 1). The patientsmother and grandmother were also noted to have clinicalfeatures of rosacea. A diagnosis of ocular and facial rosaceawas made and oral erythromycin therapy was reinstated at30 mg/kg daily for 12 weeks. At ophthalmic review, she wasnoted to have mild blepharoconjunctivitis. The rest of theeye examination was normal.There was complete resolution of skin and eye signs after

3 months. No adverse effects were noted with treatment.Because of the severity of her previous eye disease, a deci-sion was made to keep her on therapy (30 mg/kg/day oralerythromycin) for another 3 months.

Case 2

A 3-year-old boy presented with a 7-month history of apapular facial eruption in association with recurrent

Correspondence: Dr Esther Hong, Dermatology Department,Level 11, Royal North Shore Hospital, St Leonards, NSW 2065,Australia. Email: [email protected] Hong, MB BS. Gayle Fischer, FACD.Submitted 27 April 2009; accepted 15 June 2009.

Australasian Journal of Dermatology (2009) 50, 272275 doi: 10.1111/j.1440-0960.2009.00557.x

2009 The AuthorsJournal compilation 2009 The Australasian College of Dermatologists

chalazia of the upper and lower lids. Topical antibiotics andtopical corticosteroids prescribed by his general practitio-ner had yielded no improvement. He was on regular pre-ventive inhalers for asthma. There was a family history ofatopy, but not of rosacea. On examination there werepapules involving perioral, paranasal and periorbital skin(Fig. 2). Chalazia, telangiectasia and erythema were notedon both eyelids. Photophobia was also present on examina-tion. Oral erythromycin 30 mg/kg daily was commencedand ophthalmic review revealed normal intraocular pres-sure, corneal and fundal examination.Over the next 3 months on erythromycin, there were no

further chalazia and the facial eruption resolved almostcompletely. At 1 month follow up he has ceased treatmentand remains asymptomatic.

Case 3

A 12-month-old girl presented with a 2-month history of apersistent, asymptomatic micropapular facial eruption,associated with lesions of the upper eyelids. Previous topicalantibiotic treatment had been ineffective. She was other-wise healthy with no other skin disease. Her uncle andmother both had adult-onset rosacea.Examination revealed a micropapular eruption on the

cheeks, perioral and infra-orbital skin. No ocular lesionswere present at that time. Management was commencedwith 30 mg/kg/day oral erythromycin. There was an excel-lent response to treatment with resolution of the eruption in3 days and no further ocular lesions. Treatment was contin-ued for 6 weeks and at the time of writing has been ceased.

DISCUSSION

Rosacea is considered a rare disease in children; however,periorificial dermatitis is not uncommon. Although thelatter is usually precipitated by the use of topical corticos-teroids on the face in adults, in children the condition is

usually idiopathic. It typically responds promptly to oralerythromycin over a 612-week period, although it mayrecur, requiring repeated courses of antibiotic.In 2008, Chamaillard et al. reported a boy with perioral

dermatitis occurring with ocular signs who responded tooral metronidazole, and suggested perioral dermatitis andocular rosacea should be merged.4

We observed three paediatric cases of idiopathic perior-ificial dermatitis (pustules around the mouth, nose andeyes, not precipitated by topical corticosteroids) in whomocular signs (mainly recurrent chalazia and blepharitis)were also present. Our cases support the conclusion ofChamaillard et al. that periorificial dermatitis may in fact bea cutaneous feature in childhood ocular rosacea, ratherthan a differential diagnosis, as previous classifications hadsuggested.1,2 It is also of interest that in two of our threecases there was a family history of rosacea. This has beenpreviously noted.5

Previous studies have reported that children with styesand blepharitis were more likely to have rosacea in adultlife.6 This study made the point that ocular signs in rosaceamay precede skin signs and needs to be considered asocular rosacea so that appropriate management could beinstituted.Recently it has been proposed that the diagnostic criteria

for childhood rosacea are the same as those used for

Figure 1 Case 1 (right) at 6 months from initial presentation withperiorificial dermatitis, bilateral blepharitis and chalazion of lefteyelid. The patients mother (left) was noted to have facial papulesand telangiectasia of the cheeks.

Figure 2 Case 2 at initial presentation with perioral and paranasalpapules, bilateral chalazia and eyelid erythema. Photophobia waspresent on examination.

Childhood ocular rosacea 273


adults,46 except that diagnosis in childhood requires at leasttwo of the primary features. We propose that diagnosis ofchildhood rosacea be made on the basis of at least onepresenting primary feature, including ocular signs asshown in Table 1. It has previously been suggested thatperiorificial dermatitis can be differentiated from paediatricpapulopustular rosacea by the absence of ocular signs in theformer and a predilection of the latter to involve the centralface, while tending to spare periocular skin.8

We agree that the presence of ocular signs is a key featureby which to diagnose rosacea in a child. Case 1 presentedinitially with a periorificial pustular eruption and was diag-nosed as having periorificial dermatitis. However, whenocular signs developed a revised diagnosis of childhoodrosacea was made. Cases 2 and 3 had ocular manifestationsin addition to periorificial dermatitis at initial presentation,enabling an immediate diagnosis. Cases 1 and 3 had afamily history of rosacea, which we believe may alsosupport the diagnosis.The histopathological changes seen in both conditions

are comparable, showing perifollicular infiltrates consistingof lymphohistiocytes, epithelioid and giant cells.3 Whiletopical corticosteroids play a part in adult perioral derma-titis, they usually do not in children, adding support fordifferentiating between adult and childhood disease. Peri-orificial dermatitis in adults is in most cases precipitated bythe use of topical corticosteroids on the face. In children,although topical corticosteroids almost always exacerbatethe disease, they rarely precipitate it.Treatment for both periorificial dermatitis and rosacea in

children uses oral erythromycin and topical metronidazole.Treatment with oral metronidazole has been reported, butis inadvisable because of the risk of peripheral neuropathy.9

Tetracyclines are considered to be the best systemic therapyfor ocular rosacea in adults; however, tetracyclines areassociated with staining and weakening of tooth enameland are contraindicated in young children.8

In our cases erythromycin at 3050 mg for at least3 months was a safe and effective treatment. We proposethat it can be used as a first-line monotherapy.In 2006, Cetinkaya and Akova used doxycycline success-

fully in two ocular rosacea cases, and suggested it to besuperior to erythromycin due to flare ups with the latter.10

However, it should be noted that they used 20 mg/kg/day

then tapered to 10 mg/kg/day, which was probably sub-therapeutic. Likewise, in 2008 Chamaillard et al. suggestedthat erythromycin was inferior to metronidazole due toweaker response and early relapses, but did not specifywhat dose of erythromycin was trialled.4 Relapse has alsobeen reported in ocular rosacea treated with doxycycline ifnot given for long enough periods.11

Children with isolated ocular manifestations seen in ter-tiary ophthalmic centres have been successfully treatedwith systemic erythromycin associated with topical ocu-lar antibiotic and steroid preparations.12,13 The studies sug-gest that such signs as blepharokeratoconjunctivitis are acommon ocular presentation in children,12 and prompttreatment may be important in preventing further progres-sion of disease.13 Topical ocular antibiotics can be difficult toadminister to children and were not needed in our threecases, as systemic erythromycin was sufficient treatment forboth skin and ocular signs.Our cases suggest that erythromycin is an effective first-

line monotherapeutic agent when used at adequate thera-peutic doses of 3050 mg/kg/day on a long-term basis,which caused no side-effects and induced remission. Moredefinitive studies are needed to determine the treatment ofchoice and duration of treatment for this condition.

CONCLUSION

We propose that childhood rosacea may not be as uncom-mon as was previously thought and that some children withperiorificial dermatitis may in fact have childhood rosacea.We believe that childhood periorificial dermatitis may bebetter classified as a form of childhood rosacea particularlywhere there has been no precipitant, where there areocular signs, where the condition has relapsed rapidly aftercessation of oral antibiotics and where there is a familyhistory of rosacea.The criteria for diagnosing childhood rosacea are the

same as for adults, but with added emphasis on ocularsigns as a primary feature. In children, ocular signsmay dominate the clinical picture and should be enquiredabout in all children with perioral dermatitis. Ophthalmicreview is essential in children with ocular signs to preventserious sequelae such as corneal ulcers, scarring andperforation.11,13

Table 1 Diagnostic features of rosacea in adults and children4,7

Primary features Secondary features

Adults Children Adults Children

FlushingNon-transient erythemaPapules and pustulesTelangiectases

FlushingNon-transient erythemaPapules and pustulesTelangiectasesOcular signs (chalazia,blepharoconjunctivitis, conjunctivalhyperaemia, keratitis, corneal ulcers)

Facial burning, stinging, plaques,oedemaDry appearancePhymaOcular signs (chalazia,blepharoconjunctivitis, conjunctivalhyperaemia, keratitis, corneal ulcers)

Facial burning, stinging,plaques, oedemaDry appearancePhyma

Adult rosacea: one or more primary features predominantly on the facial convexities. Childhood rosacea: one or more primary featureson the facial convexities.

274 E Hong and G Fischer


Childhood rosacea responds well to treatment with oralerythromycin and may require prolonged treatment oflonger than 3 months.

REFERENCES

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3. Laude TA, Salvemini JN. Perioral dermatitis in children.Semin. Cutan. Med. Surg. 1999; 18: 2069.

4. Chamaillard M, Mortemousque B, Boralevi F, Marques daCosta C, Aitali F, Taieb A, Leaute-Labreze C. Cutaneous andocular signs of childhood rosacea. Arch. Dermatol. 2008; 144:16771.

5. Leaute-Labreze C, Chamaillard M. [Paediatric rosacea]. Ann.Dermatol. Venereol. 2007; 134: 78892. (In French.)

6. Bamford JT, Gessert CE, Renier CM, Jackson MM, Laabs SB,Dahl MV, Rogers RS. Childhood stye and adult rosacea. J. Am.Acad. Dermatol. 2006; 55: 9515.

7. Wilken J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R,Powell F. Standard classification of rosacea: report of thenational rosacea society expert committee on the classificationand staging of rosacea. J. Am. Acad. Dermatol. 2002; 46: 5847.

8. Kroshinsky D, Glick SA. Pediatric rosacea. Dermatol. Ther.2006; 19: 196201.

9. Kapoor K, Chandra M, Nag D, Paliwal JK, Gupta RC, SaxenaRC. Evaluation of metronidazole toxicity: a prospective study.Int. J. Clin. Pharmacol. Res. 1999; 19: 838.

10. Cetinkaya A, Akova YA. Pediatric ocular acne rosacea: long-term treatment with systemic antibiotics. Am. J. Ophthalmol.2006; 142: 81621.

11. Nazir SA, Murphy S, Siatkowski RM, Chodosh J, Siatkowski RL.Ocular rosacea in childhood. A. J. Ophthalmol. 2004; 137: 13844.

12. ViswalingamM, Rauz S, Morlet N, Dart JK. Blepharokeratocon-junctivitis in children: diagnosis and treatment. Br. J. Ophthal-mol. 2005; 89: 4003.

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