Treatment of Rosacea in Children

Introduction to Pediatric Rosacea

The American Academy of Ophthalmology recommends initiating treatment with topical metronidazole or azelaic acid for mild cases of pediatric rosacea, and adding oral erythromycin for moderate to severe disease, as tetracyclines are contraindicated under age 8 due to tooth staining 1

Ocular symptoms often precede cutaneous manifestations in children with rosacea, leading to chronic recurrent blepharokeratoconjunctivitis, punctate erosions, peripheral keratitis, meibomian gland disease, or recurrent chalazia before facial findings appear 2, 3
Children with rosacea typically present with corneal involvement and asymmetric ocular disease, with potential for sight-threatening visual impairment including corneal melting/perforation 3
Facial rosacea is less frequent in children, and associated atopy is common 3

For mild disease, the American Academy of Ophthalmology recommends first-line topical therapy with topical metronidazole 0.75% or 1.0% once daily 1
For moderate to severe disease or ocular involvement, combination therapy with a topical agent (ivermectin, metronidazole, or azelaic acid) and oral erythromycin is required 1
Oral erythromycin is the systemic antibiotic of choice in children under 8 years, as tetracyclines cause permanent tooth staining 1

A stepwise approach based on severity is recommended for ocular rosacea management, with mild cases treated with lid hygiene measures 4
Moderate to severe cases require oral erythromycin (or doxycycline if ≥8 years) combined with lid hygiene 1, 4
A high index of suspicion is critical, as ocular involvement can lead to corneal scarring and vision loss 2, 3

Tetracyclines (doxycycline, minocycline, tetracycline) should never be used in children under 8 years due to permanent tooth staining and enamel impairment 1
Ocular involvement should always be examined for, as it may be the presenting feature of rosacea in children 2, 3

Long-term maintenance with topical agents is essential to prevent relapses in children with rosacea 4, 5
Identifying and avoiding personal triggers, such as spicy foods and extreme temperatures, can help manage rosacea in children, although evidence is limited 4
Sun protection with SPF 30+ and gentle cleansers are essential adjuncts in the management of pediatric rosacea 5