Ocular Rosacea: Treatment with Rifaximin, a Non Systemic Antibiotic

Abstract

Leonard B Weinstock and Trisha L Myers

Background: Rosacea is associated with Crohn’s disease, liver disease, chronic pancreatitis, achlorhydria, Helicobacter pylori and recently with idiopathic small intestinal bacterial overgrowth (SIBO). Two publications demonstrated that rifaximin, a non-absorbed, gut-directed antibiotic for SIBO led to improvement in facial rosacea. Ocular manifestations occur in up to 58% of rosacea patients and include dry eyes, foreign body sensation, photosensitivity, eyelid inflammation, neovascularization and corneal ulcers. Methods: Patients who had been diagnosed with ocular rosacea by four ophthalmologists were referred for SIBO testing using the lactulose breath test (LBT). All were refractory to rosacea therapy. An open-label, IRBapproved trial of rifaximin 550 mg/3x/day for 10-14 days was performed in LBT-positive subjects. Ten and twenty days after ending rifaximin, subjects were queried if their eye symptoms had marked, moderate or mild improvement or if they were unchanged.
Results: Twenty four patients (21F/3M), mean age 59 with facial involvement in 4 were tested. The LBT was positive in 9/24 (38%). LBT-positive subjects had chronic gastrointestinal symptoms in 63% vs., 33% in LBTnegative subjects. Rifaximin was prescribed to 9 LBT-positive subjects. Insurance denied the prescription in one subject. One subject was lost was to follow up. Improvement in ocular rosacea symptoms was marked (4), moderate (1) and mild (2).
Conclusions: Rifaximin therapy led to improvement in ocular rosacea in the setting of SIBO. Dysregulation of the innate immune system as a result of gastrointestinal inflammation could lead to an increase in systemic cytokines and microbial antigens/antibodies in the skin and eyelids leading to activation of rosacea.

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