Although ocular disease commonly occurs in people with rosacea, ocular rosacea remains underrecognized by dermatologists and even eye specialists, according to experts. Fortunately, an ophthalmologist told Medscape Medical News that ocular rosacea responds to largely the same treatments as other rosacea types, and research continues to produce therapeutic advances for ocular symptoms.

“One of the most overlooked components of rosacea is involvement of the eye,” said Christopher G. Bunick, MD, PhD, associate professor of dermatology and a faculty member with the Program in Translational Biomedicine at Yale University School of Medicine, New Haven, Connecticut. In a recently published meta-analysis, the prevalence of ocular involvement in patients with cutaneous rosacea was about 44%.

Once or twice a month, Bunick added, someone with moderate-to-severe rosacea presents to him, and despite their having seen another physician, the patient’s dry eyes may not have been diagnosed as rosacea even in the context of skin symptoms such as redness, edema, itching, and pain. Additional ocular rosacea findings range from eyelid margin telangiectasias, unstable tear film, and eyelid crusting to vision changes, photophobia, and foreign-body sensations. 

Resolving rosacea requires a systemic approach, said Bunick, and patients often suffer if doctors fail to address both ocular and skin symptoms.

However, added Jonathan S. Weiss, MD, it remains unclear to him whether many ophthalmologists or optometrists fully understand ocular rosacea and its optimal treatment. Up to half the patients he sees with ocular rosacea who present at his practice are on topical steroid eye drops prescribed by their ophthalmologists, he said, and these patients experience rebound symptoms upon withdrawal of the eye drops. Weiss is an adjunct assistant professor of dermatology at Emory University School of Medicine, Atlanta.

“Unfortunately,” said Edward J. Wladis, MD, professor and chair of ophthalmology at Lions Eye Institute of Albany Medical College in Albany, New York, “there are a million causes of the ocular surface disease we see in rosacea, and many of our medications are not deployed in the proper manner.”

Normally, Wladis told Medscape Medical News, oil produced by the meibomian gland stabilizes tear films. But when rosacea clogs this gland, tears evaporate too quickly. And often, he said, ophthalmologists prescribe medications, such as cyclosporine, which only improve tear output. Steroid drops can effectively treat ocular rosacea symptoms, Wladis added, but because their nonspecific mechanism does not address the underlying disease process, “it’s no surprise that patients get frustrated and turn to other clinicians.”

Dermatologists’ Comfort Zone?

But how effectively does the average dermatologist treat ocular rosacea? Neal Bhatia, MD, director of clinical dermatology at Therapeutics Clinical Research in San Diego, said that dermatologists are handcuffed by the fact that no topical treatment they commonly prescribe for rosacea has an eye-friendly vehicle. So rather than diagnosing and treating ocular rosacea themselves, he told Medscape Medical News, “Many dermatologists give it up to the ophthalmologists. Or they don’t know which treatments to give because dermatologists typically do not prescribe suspensions or eye drops.” “That’s where we’re running into trouble,” he said, “and many rosacea patients fall through the cracks.”

Part of the problem, said Benjamin Ungar, MD, is that because ocular rosacea is neither a purely dermatologic nor purely ophthalmologic disease, it has been underappreciated from the dermatologic perspective. Ungar is an assistant professor of dermatology and director of the Rosacea & Seborrheic Dermatitis Clinic in the Icahn School of Medicine at Mount Sinai in New York.

Most dermatologists have not received training in the thorough evaluation of eye issues and disease, Ungar said in an interview. “To diagnose ocular rosacea confidently,” he said, “you also have to confidently diagnose other possible etiologies of ocular disease. And as dermatologists, that’s very difficult.”

Accordingly, he said that many dermatologists — if they’re even thinking about ocular rosacea — take the approach that if a patient with rosacea potentially has ocular involvement or a high suspicion thereof, “the dermatologist will involve ophthalmology colleagues to guide that evaluation, diagnosis, and treatment. Having ophthalmology involvement is going to make everyone feel more comfortable that we’re treating the right thing and treating it appropriately.”

Wladis said that, although dermatologists are probably very interested in helping patients with ocular rosacea, its impact occurs at the ocular surface, and the risk for vision can be substantial. “As a result,” he said, “ophthalmologists are more likely to have the examination tools to track the health of the cornea and surface of the eye, so referral from the dermatologist to the ophthalmologist makes sense.”

Treatment Strategies

Based on the National Rosacea Society (NRS)’s rethinking of rosacea subtypes, published in 2018, said Wladis, “we should consider all forms of rosacea to be related.” And because rosacea pathology is fundamentally identical regardless of location, he said, many therapies that address skin symptoms also affect the eye.

Updated rosacea treatment guidelines from the NRS and the American Acne & Rosacea Society take a stepwise approach that matches intervention intensity with individual patient presentation. Treatments for ocular rosacea include warm compresses and cleaning the eyelashes with baby shampoo “on a wet washcloth rubbed onto the eyelashes of the closed eyes,” according to the NRS. Additionally, lubricating eye drops can soothe dry, gritty eyes while reducing inflammation, according to a review published in April 2025.

For moderate ocular rosacea affecting the inner eyelid, tear secretion, and/or ocular surface, NRS guidelines suggest applying topical treatments such as ophthalmic azithromycin, cyclosporine drops, or tacrolimus ointment to the eyelashes. Oral treatments for reducing inflammation include cyclosporine and subantimicrobial-dose antibiotics, according to the NRS. For example, Bunick prescribes tetracyclines in anti-inflammatory doses, typically for 30 days. “This is where the extended-release forms of doxycycline (Oracea) and minocycline (Emrosi) are very valuable,” he said, “as patients who suffer from significant ocular rosacea probably will need a long-term antibiotic for its anti-inflammatory properties.” 

In a case that Bunick published in 2022, off-label sarecycline (Seysara) provided safe, effective treatment for a patient with ocular rosacea. This third-generation, narrow-spectrum tetracycline is the safest tetracycline and minimizes harm to Gram-negative bacteria and the gut microbiome, he said. “It also has the least risk for creating drug resistance in bacteria,” Bunick said. “And one of the best places to use it is in rosacea, particularly with older patients who have rosacea flares or styes on the eyelids. Instead of putting them on broad-spectrum doxycycline or minocycline that could cause gut dysbiosis, a narrow-spectrum medicine could be very beneficial.” 

Bunick added that it would surprise him if most dermatologists avoid treating ocular rosacea because every dermatologist is comfortable with tetracycline antibiotics and is trained to recognize the ocular symptoms. Moreover, he said, dermatologists are the leading rosacea experts. “It’s part of our job in treating the entire patient to address whether or not there’s ocular involvement.” Just as dermatologists ask patients with psoriasis about joint pains, said Bunick, he suspects that most dermatologists ask patients with rosacea about ocular symptoms and manage such symptoms when they occur.

Even without skin findings, Bunick said, dry, gritty eyes are enough to diagnose ocular rosacea. Additional diagnostic questions include whether patients sometimes find their eyes very dry and painful upon opening in the morning or blinking, he said. The eyes can be so dry, Bunick explained, that moving the eyelids “almost feels like ripping the conjunctival cells right off the ocular surface.”

Among additional treatments for moderate ocular rosacea, intense pulsed light may improve ocular surface symptoms and meibomian gland function, according to NRS guidelines. Ocular rosacea also may respond to topical ivermectin, as suggested by a case published in 2018 and a 10-patient series published in 2020. Recalcitrant ocular rosacea also may benefit from omega-3 fatty acid supplementation, which has been shown to improve dry eye and ocular rosacea.

Severe, nonresponsive ocular rosacea requires referral to ophthalmology for treatments that may include topical steroids, alternative agents, and, where indicated, surgery, according to NRS guidelines.

Although the stepwise approach recommended above may be helpful for dermatologists, added Bunick, he believes that moderate-to-severe ocular rosacea requires an all-out blitz. “The goal is to get the patient better quickly,” he said, “because it can be a disfiguring disease and affects quality of life.”

Productive Pipeline

During the last few years, said Wladis, improved understanding of ocular rosacea biology has driven exciting developments that enable clinicians to target the disease much more effectively. Lotilaner ophthalmic solution 0.25% (Xdemvy), for example, earned FDA approval for Demodex blepharitis in 2023. “I believe that patients and clinicians have tremendous enthusiasm for new therapies,” said Wladis, “so the market will likely be very robust.”

Unmet Needs

To better address ocular rosacea in dermatology, Bunick said, “The biggest unmet need is greater recognition.” Ocular rosacea is very easy to diagnose clinically, said Wladis, “but you have to look for it.” Considering the inconsistent distribution of symptoms that may selectively affect the eyes, he added, dermatologists stand on the front lines, as patients with rosacea frequently present to them first. “Often,” said Wladis, “they are the gatekeepers who can adequately refer patients for very targeted ophthalmic care.”

Dermatologists also should feel comfortable prescribing ocular rosacea therapies, Bunick said. Having more therapies would help greatly as well, he added. “We need to understand the pathophysiology of ocular rosacea and have more targeted therapies that are not always systemic antibiotics or eye ointments,” said Bunick. “There’s a lot of room for innovation there, and a huge unmet need.”

Wladis reported holding equity in Praxis Biotechnology. Bunick reported having received basic science research grants from Almirall. Ungar reported being a consultant, researcher, and/or speaker for AbbVie, Arcutis Biotherapeutics, Bristol Myers Squibb, Botanix Pharmaceuticals, Castle Biosciences, Fresenius Kabi, Galderma, Incyte, Johnson & Johnson, LEO Pharma, Eli Lilly, Pfizer, Primus Pharmaceuticals, RAPT Therapeutics, Sanofi, Sun Pharma, UCB, Veradermics, and VRG Therapeutics. Bhatia reported affiliations with AbbVie, Advanced Derm Solutions, Almirall, Arcutis Biotherapeutics, Beiersdorf, Galderma, Journey, La Roche-Posay, LEO Pharma, Ortho Dermatologics, Sagimet Biosciences, Skinfix, and Sun Pharma. Weiss reported being a researcher, consultant, and/or speaker for AbbVie, Arcutis Biotherapeutics, Aslan, Bausch, Biofrontera, Bristol Myers Squibb, Cutera, Dermavant/Organon, Galderma, Incyte, LEO Pharma, Novartis, Ortho Dermatologics, Pfizer, Regeneron, Sanofi, Sun Pharma, UCB, and Verrica.

John Jesitus is a Denver-based freelance medical writer and editor.