CASE SERIES

Childhood ocular rosacea: Considerations for diagnosis

and treatmentajd_557 272..275
Esther Hong
1
and Gayle Fischer
1,2
1
Dermatology Department, Royal North Shore Hospital, and
2
Northern 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 in
adults. Ocular signs may be a dominant feature and
some children with what has previously been called
perioricial dermatitis may in fact have rosacea. We
report three cases of paediatric ocular rosacea
responding to prolonged treatment with oral erythro-
mycin. Our cases demonstrate the close association of
perioricial dermatitis with childhood rosacea, and
highlight the importance of eye signs in its diagnostic
criteria.
Key words: chalazion, child, ocular, perioricial
dermatitis, rosacea.
INTRODUCTION
Childhood rosacea is considered to be rare and descriptions
in the paediatric age group rely on small case studies. These
studies emphasise the association of recurrent chalazia
with rosacea in children. Perioricial dermatitis is not
uncommon in children and, while some consider it to be a
separate entity to and differential diagnosis for rosacea,
1,2
some studies have found close associations linking perior-
icial dermatitis to childhood rosacea
3
and, in particular,
ocular signs of rosacea.
4
There are no clear guidelines for rst-line therapy in
childhood rosacea. Treatment has historically paralleled
adult regimens, using systemic and topical antibiotics such
as tetracyclines, erythromycin and metronidazole.
We herein report three children aged 12 months,
18 months and 3 years of age with rosacea who presented
initially with a diagnosis of perioricial dermatitis, but in
whom ocular disease was a signicant element. All three
cases 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 was
swabbed and subsequently grew Staphylococcus aureus.
This was treated with mupirocin ointment. She had an
uneventful past medical history.
Examination revealed perioral and paranasal micropap-
ules. Initially there was no evidence of ocular lesions or
telangiectasia.
A diagnosis of perioricial dermatitis was made. The
facial rash responded well to oral erythromycin 50 mg/kg
daily 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 perioricial rash recurred.
Another skin swab revealed S. aureus. She was commenced
on oral cephalexin and bleach baths. The patients family
members were treated with mupirocin intranasal ointment.
The patient presented 6 months later with persistent peri-
oricial dermatitis and additionally signicant bilateral ble-
pharitis with recurrent chalazia (Fig. 1). The patients
mother and grandmother were also noted to have clinical
features of rosacea. A diagnosis of ocular and facial rosacea
was made and oral erythromycin therapy was reinstated at
30 mg/kg daily for 12 weeks. At ophthalmic review, she was
noted to have mild blepharoconjunctivitis. The rest of the
eye 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 oral
erythromycin) for another 3 months.
Case 2
A 3-year-old boy presented with a 7-month history of a
papular facial eruption in association with recurrent
Correspondence: Dr Esther Hong, Dermatology Department,
Level 11, Royal North Shore Hospital, St Leonards, NSW 2065,
Australia. Email: ehon8261@med.usyd.edu.au
Esther 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 Authors
Journal compilation 2009 The Australasian College of Dermatologists
chalazia of the upper and lower lids. Topical antibiotics and
topical 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 of
atopy, but not of rosacea. On examination there were
papules involving perioral, paranasal and periorbital skin
(Fig. 2). Chalazia, telangiectasia and erythema were noted
on both eyelids. Photophobia was also present on examina-
tion. Oral erythromycin 30 mg/kg daily was commenced
and 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 almost
completely. At 1 month follow up he has ceased treatment
and remains asymptomatic.
Case 3
A 12-month-old girl presented with a 2-month history of a
persistent, asymptomatic micropapular facial eruption,
associated with lesions of the upper eyelids. Previous topical
antibiotic treatment had been ineffective. She was other-
wise healthy with no other skin disease. Her uncle and
mother both had adult-onset rosacea.
Examination revealed a micropapular eruption on the
cheeks, perioral and infra-orbital skin. No ocular lesions
were present at that time. Management was commenced
with 30 mg/kg/day oral erythromycin. There was an excel-
lent response to treatment with resolution of the eruption in
3 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,
perioricial dermatitis is not uncommon. Although the
latter 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 oral
erythromycin over a 612-week period, although it may
recur, requiring repeated courses of antibiotic.
In 2008, Chamaillard et al. reported a boy with perioral
dermatitis occurring with ocular signs who responded to
oral metronidazole, and suggested perioral dermatitis and
ocular rosacea should be merged.
4
We observed three paediatric cases of idiopathic perior-
icial dermatitis (pustules around the mouth, nose and
eyes, not precipitated by topical corticosteroids) in whom
ocular signs (mainly recurrent chalazia and blepharitis)
were also present. Our cases support the conclusion of
Chamaillard et al. that perioricial dermatitis may in fact be
a cutaneous feature in childhood ocular rosacea, rather
than a differential diagnosis, as previous classications had
suggested.
1,2
It is also of interest that in two of our three
cases there was a family history of rosacea. This has been
previously noted.
5
Previous studies have reported that children with styes
and blepharitis were more likely to have rosacea in adult
life.
6
This study made the point that ocular signs in rosacea
may precede skin signs and needs to be considered as
ocular rosacea so that appropriate management could be
instituted.
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 with
perioricial dermatitis, bilateral blepharitis and chalazion of left
eyelid. The patients mother (left) was noted to have facial papules
and telangiectasia of the cheeks.
Figure 2 Case 2 at initial presentation with perioral and paranasal
papules, bilateral chalazia and eyelid erythema. Photophobia was
present on examination.
Childhood ocular rosacea 273
2009 The Authors
Journal compilation 2009 The Australasian College of Dermatologists
adults,
46
except that diagnosis in childhood requires at least
two of the primary features. We propose that diagnosis of
childhood rosacea be made on the basis of at least one
presenting primary feature, including ocular signs as
shown in Table 1. It has previously been suggested that
perioricial dermatitis can be differentiated from paediatric
papulopustular rosacea by the absence of ocular signs in the
former and a predilection of the latter to involve the central
face, while tending to spare periocular skin.
8
We agree that the presence of ocular signs is a key feature
by which to diagnose rosacea in a child. Case 1 presented
initially with a perioricial pustular eruption and was diag-
nosed as having perioricial dermatitis. However, when
ocular signs developed a revised diagnosis of childhood
rosacea was made. Cases 2 and 3 had ocular manifestations
in addition to perioricial dermatitis at initial presentation,
enabling an immediate diagnosis. Cases 1 and 3 had a
family history of rosacea, which we believe may also
support the diagnosis.
The histopathological changes seen in both conditions
are comparable, showing perifollicular inltrates consisting
of lymphohistiocytes, epithelioid and giant cells.
3
While
topical corticosteroids play a part in adult perioral derma-
titis, they usually do not in children, adding support for
differentiating between adult and childhood disease. Peri-
oricial dermatitis in adults is in most cases precipitated by
the use of topical corticosteroids on the face. In children,
although topical corticosteroids almost always exacerbate
the disease, they rarely precipitate it.
Treatment for both perioricial dermatitis and rosacea in
children uses oral erythromycin and topical metronidazole.
Treatment with oral metronidazole has been reported, but
is inadvisable because of the risk of peripheral neuropathy.
9
Tetracyclines are considered to be the best systemic therapy
for ocular rosacea in adults; however, tetracyclines are
associated with staining and weakening of tooth enamel
and are contraindicated in young children.
8
In our cases erythromycin at 3050 mg for at least
3 months was a safe and effective treatment. We propose
that it can be used as a rst-line monotherapy.
In 2006, Cetinkaya and Akova used doxycycline success-
fully in two ocular rosacea cases, and suggested it to be
superior to erythromycin due to are 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. suggested
that erythromycin was inferior to metronidazole due to
weaker response and early relapses, but did not specify
what dose of erythromycin was trialled.
4
Relapse has also
been reported in ocular rosacea treated with doxycycline if
not given for long enough periods.
11
Children with isolated ocular manifestations seen in ter-
tiary ophthalmic centres have been successfully treated
with systemic erythromycin associated with topical ocu-
lar antibiotic and steroid preparations.
12,13
The studies sug-
gest that such signs as blepharokeratoconjunctivitis are a
common ocular presentation in children,
12
and prompt
treatment may be important in preventing further progres-
sion of disease.
13
Topical ocular antibiotics can be difcult to
administer to children and were not needed in our three
cases, as systemic erythromycin was sufcient treatment for
both skin and ocular signs.
Our cases suggest that erythromycin is an effective rst-
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. More
denitive studies are needed to determine the treatment of
choice 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 with
perioricial dermatitis may in fact have childhood rosacea.
We believe that childhood perioricial dermatitis may be
better classied as a form of childhood rosacea particularly
where there has been no precipitant, where there are
ocular signs, where the condition has relapsed rapidly after
cessation of oral antibiotics and where there is a family
history of rosacea.
The criteria for diagnosing childhood rosacea are the
same as for adults, but with added emphasis on ocular
signs as a primary feature. In children, ocular signs
may dominate the clinical picture and should be enquired
about in all children with perioral dermatitis. Ophthalmic
review is essential in children with ocular signs to prevent
serious sequelae such as corneal ulcers, scarring and
perforation.
11,13
Table 1 Diagnostic features of rosacea in adults and children
4,7
Primary features Secondary features
Adults

Children

Adults Children
Flushing
Non-transient erythema
Papules and pustules
Telangiectases
Flushing
Non-transient erythema
Papules and pustules
Telangiectases
Ocular signs (chalazia,
blepharoconjunctivitis, conjunctival
hyperaemia, keratitis, corneal ulcers)
Facial burning, stinging, plaques,
oedema
Dry appearance
Phyma
Ocular signs (chalazia,
blepharoconjunctivitis, conjunctival
hyperaemia, keratitis, corneal ulcers)
Facial burning, stinging,
plaques, oedema
Dry appearance
Phyma

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

Childhood rosacea: one or more primary features
on the facial convexities.
274 E Hong and G Fischer
2009 The Authors
Journal compilation 2009 The Australasian College of Dermatologists
Childhood rosacea responds well to treatment with oral
erythromycin and may require prolonged treatment of
longer than 3 months.
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Childhood ocular rosacea 275
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