Rosacea
Also called acne rosacea
Chronic facial flushing with persistent centrofacial erythema, telangiectasia, and papulopustules, but no comedones. Triggers: heat, alcohol, spice, sun.
How it looks
Persistent centrofacial erythema with telangiectasia and scattered papulopustules over the cheeks and nose, sparing the periocular skin.
Rose is the lesion, grey the pattern the lesions make, green where on the body it lives.
Across skin tones
Rosacea is underdiagnosed in deeply pigmented skin because the erythema is hard to see, look for the symptom triad (flushing, burning, triggers), papulopustules, and a violaceous hue.
Forms & variants
Erythematotelangiectatic rosacea
Persistent centrofacial redness with flushing and telangiectasia; the earliest and commonest pattern.
Papulopustular rosacea
Dome-shaped papules and pustules over a red background with no comedones, the feature that separates it from acne.
Phymatous (rhinophymatous) rosacea
Sebaceous and fibrous overgrowth thickening the nose (rhinophyma), chin, or forehead, mostly in older men.
Ocular rosacea
Gritty red lid margins, blepharitis, and recurrent chalazia; it can precede the skin disease and threaten vision, so the eyes are asked about every time.
Symptoms & course
- Flushing and burning
- Ocular grittiness in ocular rosacea
Diagnostic approach
- Clinical diagnosis
- Consider lupus workup if photosensitive malar erythema without papulopustules
Differential, and how to separate them
- Acne vulgaris
Favours it: Comedones present, younger patient, truncal lesions
Against it: Rosacea never has comedones and flushes with triggers
- Seborrheic dermatitis
Favours it: Greasy scale in the folds
Against it: Rosacea affects convexities and does not scale
Management principles
- Trigger avoidance and daily sunscreen
- Topical metronidazole, azelaic acid, or ivermectin for papulopustular disease
- Oral tetracyclines for moderate disease; refer ocular involvement
Clinical pearl: Malar erythema that crosses the nasolabial folds and carries pustules is rosacea; lupus spares the folds and never makes pustules.
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