At the 2026 SECO meeting, Janelle Davison, OD, discussed the characteristics and treatment requirements of ocular rosacea in varying skin tones, according to the Fitzpatrick classifications. She also outlined customized treatment protocols for diverse skin tones while maintaining safety in dry eye disease and meibomian gland dysfunction (MGD) treatment.

Rosacea in darker skin tones is underrepresented in epidemiologic studies and clinical trials, which perpetuates knowledge gaps and underrecognition when patients present for diagnosis and treatment, Dr. Davison said. However, the Skin of Color Society is working to address these gaps.

Signs in Dark and Light Skin Tones

Erythema and telangiectasia—which are indicative of rosacea—are easily visible on lighter skin tones (Fitzpatrick classifications I to III), but are more subtle or masked on darker skin tones (Fitzpatrick classifications IV to VI). However, telangiectatic blood vessels in the eyelid can present in darker skin tones. According to one study Dr. Davison cited, “Ocular rosacea in dark skinned females is a common presentation and is comparable to that reported for fair skin, with eyelid telangiectasia and MGD.”¹

Rosacea on darker skin tones is also likely to present with postinflammation hyperpigmentation, granulomatous papules, and prominent ocular manifestations with minimal visible redness, Dr. Davison described. On lighter skin tones, rosacea presents with inflammatory papules and pustules, as well as tissue thickening.

Half of patients with rosacea have comorbid facial and ocular rosacea, and 20% present with ocular rosacea first, she said, “particularly in darker skin tones where facial signs may be subtle or overlooked.”

Treatment Pearls

Intense pulsed light (IPL), laser, and low-level light therapy (LLLT) are all possible treatment options, though their distinctions should be considered thoroughly for the spectrum of skin tones. IPL is polychromatic; targets hemoglobin, melanin, and water; and treats diffuse redness whereas laser is monochromatic; targets hemoglobin; and treats individual blood vessels, among other differences. LLLT has minimal side effects, is safe for all skin types, and has anti-inflammatory effects, but it cannot close off telangiectasia, whereas IPL destroys inflammatory blood vessels, includes 3 targets in a single treatment, and has anti-inflammatory effects, but parameters must be selected carefully.

Patients who are treatment resistant but motivated are good fits for IPL, Dr. Davison said. They should complete a standardized form to determine their Fitzpatrick skin type to be sure that their parameters are set appropriately. Conduction gel, eye protection, and a wavelength filter are all included in the protocol.

Dr. Davison also provided a treatment outline for IPL energy settings for darker skin tones. 

“In my clinic,” she added, “conservative settings minimize the risk of adverse events while still providing therapeutic benefit.” Waiting 4 weeks between sessions for the first 4 treatments in the Toyos protocol may be beneficial as well, rather than waiting 2 weeks between treatments, she said. Maintenance treatments along with meibomian gland expression can then occur every 6 to 12 months.

“Studies show that IPL combined with meibomian gland expression produces superior results compared to either treatment alone, regardless of skin type,” Dr. Davison said.

After-treatment care includes sun protection for 2 weeks to prevent hyperpigmentation, though patients should avoid sunscreens with a white cast to ensure consistent use, she added. If patients experience hyperpigmentation, they can be treated with topical hydroquinone, tranexamic acid, or vitamin C. Burns can be treated with immediate cooling, topical steroids, and would care, and all adverse events should be documented thoroughly to adjust future session treatment protocols.

Finally, Dr. Davison reviewed how to integrate IPL into practices, from staff training and setting up treatment rooms and documentation, to patient education. Staff members should understand IPL procedures, patient selection criteria, and pretreatment and posttreatment protocols, especially for diverse skin types. Treatment rooms should be comfortable for patients with proper lighting, and include all necessary supplies (ie, eye protection and cooling options), while documentation should include comprehensive consent forms, treatment logs, and photographic documentation systems. Patient education materials should show diverse representation and clearly address concerns that are specific to patients with darker skin tones.

Reference

1. Al-Balbeesi AO, Almukhadeb EA, Halawani MR, Bin Saif GA, Al Mansouri SM. Manifestations of ocular rosacea in females with dark skin types. Saudi J Ophthalmol. 2019 Apr-Jun;33(2):135-141. doi:10.1016/j.sjopt.2019.01.006