A 55-Year-Old Woman With Bumps on Her Face

Amin Esfahani, MD; Mary E. Lohman, BA; Anne Laumann, MBChB, MRCP(UK)


October 11, 2017


The case described presents a common dermatosis in an atypical skin type for this disease. Rosacea is a chronic skin condition that is characterized by wide range of signs and symptoms. Four types of rosacea are recognized: erythematotelangiectatic, papulopustular, phymatous, and ocular.[1] Rosacea is most common in women older than 30 years, with the exception of phymatous rosacea, which is more common in men. Given the diverse presentation, prevalence is not well defined. Studies, however, show that it is found more frequently in Caucasians and in those with fair, sun-sensitive (phototypes 1 and 2) skin, with a prevalence of approximately 10%.[1–3] Rosacea can affect patients with darker skin tones, but this is uncommon and, as in this case, represents a diagnostic challenge.[4]

The pathogenesis of rosacea is not well understood. Current evidence suggests an interplay of immune dysfunction (eg, abnormal cathelicidin, kallikrein 5), microorganisms (eg, Demodex folliculorumBacillus oleroniusHelicobacter pylori), ultraviolet radiation, and vascular hyperactivity. Genetic susceptibility has also been demonstrated in some studies.[1,5,6]

Each of the four types of rosacea is associated with its own unique features, although overlap between types is common. The hallmarks of erythematotelangiectatic rosacea include centrofacial erythema, flushing, and telangiectasia (enlarged cutaneous blood vessels). An example is shown in Figure 3. Other features include sensitivity to the sun, fine flaking, and, in some individuals, stinging and burning in affected areas. The clinical diagnosis of erythematotelangiectatic rosacea can be a challenge, given that the appearance is similar to chronic actinically (sun) damaged skin. The diagnosis is a challenge in patients with darker skin tones, in particular, because erythema is more violaceous in quality.[1]

Papulopustular rosacea is distinguished by a centrofacial eruption of small, dome-shaped, erythematous papules and pustules (as in this case). An example is shown in Figure 4. Each individual lesion generally lasts 2 weeks and heals without scarring (unless manipulated by the individual). Unlike acne, comedones are not present. Patients can be asymptomatic or have a range of symptoms, such as tenderness and/or pruritus.[1]

Figure 4.

Phymatous rosacea is characterized by tissue hypertrophy, including the sebaceous unit, leading to thickened skin. An example is shown in Figure 5. It is the only type of rosacea that is more common in men. It typically occurs on the nose (rhinophyma), but can also be found on the chin (gnathophyma), ears (otophyma), central forehead (metophyma), and eyelids (blepharophyma). Phymatous rosacea can occur de novo or in the setting of mild rosacea, acne, or chronic sun damage. Its presence does not correlate with the severity of other types of rosacea.[1,7]

Figure 5.

Ocular rosacea occurs in more than 50% of patients with cutaneous rosacea. Ocular symptoms precede cutaneous findings in approximately 20% of these patients (as in this case), and occur after cutaneous presentation in about 50%. The clinical findings are diverse and nonspecific. They include blepharitis, conjunctival injection, conical dandruff (tiny concretions at the bases of the cilia), scurf (scaling at eyelid margins), keratitis, abnormal tearing, cicatricial conjunctivitis, and chalazion or hordeolum (stye) formation. Symptoms include photophobia, blurry vision, itching, tearing, dryness, and a gritty or foreign-body sensation. A detailed review of ocular symptoms and patient awareness about ocular rosacea are important for early detection. Referral to an ophthalmologist is recommended if a patient exhibits signs or symptoms of ocular rosacea.[1,8,9]


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