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

Treatment for rosacea depends on the type of clinical signs and symptoms and their severity. In general, behavioral modifications are necessary to lessen flares. Patients should avoid triggers (if they exist), undertake gentle skin care—with the frequent use of emollients (which help protect skin barrier and minimize symptoms of irritation) and with lukewarm water and mild cleansers—and avoid irritating topical products, such as toners, astringents, and chemical exfoliating agents. Sun protection is important because it can help minimize flares of facial redness.[1]

The initial approach for the treatment of erythematotelangiectatic rosacea includes the aforementioned behavioral modifications. However, for patients who fail to improve or who have more severe involvement, pharmacologic and laser/light therapy are options. Laser and light therapy target the vascular features of rosacea. The most commonly used devices are pulsed dye and potassium titanyl phosphate (KTP) lasers and intense pulsed light. Retreatment with lasers might be required. Currently, evidence supporting the pharmacologic treatment of facial erythema in rosacea is limited. Topical brimonidine, a vasoconstrictive alpha-2 adrenergic receptor agonist, has shown benefit in a small percentage of patients. However, some patients have reported severe rebound erythema several hours after application.[1,10,11] Topically applied oxymetazoline cream is another option to treat erythema.

In addition to behavioral modifications, papulopustular rosacea requires topical and systemic medications. For mild to moderate disease, first-line therapy includes topical metronidazole, azelaic acid, or ivermectin. Topical metronidazole once daily has been shown to be effective because of a combination of antimicrobial, anti-inflammatory, and antioxidant properties. The efficacy of treatment appears to be similar for different vehicles and strengths (0.75% vs 1%). Azelaic acid is a naturally occurring dicarboxylic acid with antioxidant and anti-inflammatory properties. Recommended dosing is twice daily, but evidence suggests that once-daily use can be effective. Ivermectin 1% cream once daily has been shown to be effective in the management of papulopustular rosacea. Topical ivermectin has both antiparasitic and anti-inflammatory properties.

In addition to the aforementioned agents, sulfacetamide–sulfur wash is often recommended, although the mechanism of action is not known. For moderate to severe disease, first-line therapy is an oral tetracycline. Traditionally, the most common treatment has been doxycycline or minocycline 100 mg twice daily. Response time is generally 4-12 weeks. Sub-antimicrobial dosing, such as doxycycline 20 mg twice daily, can be effective. Macrolide antibiotics have also been used, albeit less frequently.

For those with refractive disease, isotretinoin is an option. However, given the chronic nature of rosacea, relapse is frequent, necessitating maintenance therapy. This is usually achieved with topical or systemic therapy (either sub-antimicrobial doses of tetracyclines or short full-dose bursts during flares). Similarly, ocular rosacea can be treated with a combination of topical and systemic antibiotics.[1,12,13]

Treatment of phymatous rosacea includes ablative laser or surgical debulking.[1]

Rosacea is not considered to be a cutaneous manifestation of a systemic disorder. A few studies have linked rosacea to systemic disorders, such as dyslipidemia, hypertension, migraines and other central nervous system disorders, and autoimmune disease. However, the current evidence is not strong enough to recommend further workups in patients with rosacea.

This case was a diagnostic challenge because rosacea is rarely seen in skin of color and is, therefore, often overlooked. This can lead to unnecessary workups and referrals. In this patient, a diagnosis of lupus was unlikely due to a lack of associated signs and the presence of papules and pustules. Although seborrheic dermatitis is commonly seen in skin of color, this patient did not have the typical greasy, yellow scale or perinasal, retroauricular, scalp, or eyebrow involvement. Similarly, the history and location of the lesions did not support periorificial dermatitis. One diagnosis that should not be overlooked in a middle-aged African-American patient presenting with facial papules is sarcoidosis. But the pustules, the relapsing and superficial nature of lesions, and the history contradict this diagnosis.


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