Topical Ivermectin Among Rx Options for Ocular Rosacea

LAS VEGAS — In the clinical experience of Julie C. Harper, MD, patients with ocular rosacea don’t always present with telltale signs like red or bloodshot eyes.

“Sometimes they just have a dry, gritty feel to their eye and only the lid margin is red,” Harper, who practices dermatology in Birmingham, Alabama, said at the annual fall meeting of the Society of Dermatology Physician Associates.

Ocular rosacea and associated meibomian gland dysfunction (MGD) affects between 8% and 85% of patients with rosacea, according to one review. Typical clinical findings include the presence of a foreign-body sensation in the eye, burning, photophobia, blurred vision, redness, and tearing.

In 2011, The International Workshop on Meibomian Gland Dysfunction published recommendations for the treatment and management of MGD, including the use of warm compresses up to four times per day for 15 minutes, eyelid massage tweezers, artificial tears, topical azithromycin, topical emollient lubricant or liposomal spray, oral doxycycline, topical cyclosporine, and in severe cases, topical steroids.

“You can also use a no-tears shampoo,” added Harper, who was not involved with the published recommendations. “What you’re trying to do is release that clogged sebaceous gland so that you can remoisturize the surface of the eye. I do not use any topical steroid drops on the eye, just because of the increased risk of glaucoma. If patients want that, they’re going to have to get it from their eye doctor.”

Topical ivermectin 1% is another treatment option for ocular rosacea. In 2018, German dermatologists published the case of a 50-year old man with papulopustular rosacea and blepharoconjunctivitis. The man applied ivermectin 1% cream every night — a total of five pea-sized amounts spread over the entire face, “which is a lot; I don’t use this much,” Harper commented. A half pea-sized amount of ivermectin 1% cream was also applied to the closed upper lid and lid edge. At week 35, both the skin and the ocular Investigator’s Global Assessment were completely clear, and no relapse was evident 20 months after the end of treatment.

“The take-home message is that patients can apply topical ivermectin on their eyelids,” Harper said. “It works pretty well.”

If symptoms persist after all options are used, Harper said, there is evidence suggesting that omega-3 fatty acids may help treat ocular rosacea and dry eye, either in the form of flaxseed oil or fish oil. One study found an improvement in the Ocular Surface Disease Index of patients with blepharitis and MGD taking flaxseed oil (1000 mg/d) as compared with similar patients receiving olive oil placebo. Natural omega-3 sources include cold-water fish. 

Harper disclosed ties with Almirall, Cutera, Galderma, Journey, Ortho Dermatologics, and Sun Pharmaceutical Industries.