Red facial rash with "granitos"

Journal of Family Practice, Sept, 2005 by Tricia Punsalan, Richard P. Usatine

A 56-year-old Hispanic woman came to the office distraught about the red rash on her face. The rash has been on her cheeks and nose for 5 years, but over the past 2 weeks she has developed red, mildly pruritic, and very tender papules that she calls granitos (the Spanish term for pimples). Foods do not make the rash better or worse, but it gets redder with sun exposure. She had not tried any lotions or sought medical attention until now, when she noticed that the papules were increasing in number but not size.

A few years ago she first noticed small blood vessels becoming more prominent, especially on her cheeks. The lesions have not bled or ulcerated. Her health has been generally good within the past year, with no recent infections. Review of systems indicated no changes in vision, upper respiratory illness, or systemic conditions. She is being treated for type 2 diabetes and hypertension. She does not have a family history of the same rash. FIGURES 1 AND 2 show erythema and telangiectasias distributed symmetrically on both cheeks and nose. A cluster of smooth papules were seen under the nose. No scales were noted.

[FIGURES 1-2 OMITTED]

* What is the diagnosis?

* How would you treat this condition?

* Diagnosis: Rosacea

The patient has rosacea. Rosacea is a common inflammatory skin condition characterized by erythema, edema, papules, pustules, or telangiectasias, most notably found on the concave portions of the cheeks, forehead, chin, and nose. (1) Its peak incidence is between the ages of 30 and 50 years.

Because of the marked flushing due to inflammation and capillary hyperreactivity and dilation, the rash has brought a certain degree of social embarrassment for some patients. Moreover, some equate rosacea with excessive alcohol consumption, but this is simply not true.

Although rosacea is a chronic disorder, it does alternate between periods of flare-up and remission. Flares may be triggered by stress, sun exposure, heat, hot drinks and spicy foods, alcohol, exercise, wind, and hot baths. In 50% of all rosacea patients, there are some ocular symptoms, ranging from mild dryness and grittiness to blepharitis, conjunctivitis, and even keratitis. (2)

* Differential diagnosis

Although the differential diagnosis of rosacea is wide--acne, folliculitis, sarcoid, seborrheic dermatitis, and systemic lupus erythematosus [SLE]--there are unique characteristics that can help distinguish these from rosacea.

For example, the age of onset for rosacea tends to be 30 to 50 years, much later than the onset for acne vulgaris. Similarly, in acne vulgaris comedones are often present, but they are absent in rosacea.

Seborrheic dermatitis tends to produce scales while rosacea does not. Moreover, while both seborrheic dermatitis and rosacea can affect the central facial area, papules and telangiectasias are absent in the former while present with the latter.

SLE can be scarring, does not produce papules or pustules, and it spares the nasolabial folds and nose. Whereas rosacea has a more central face distribution, folliculitis typically presents with pustules visibly surrounding hair follicles and has associated tenderness to palpation and sometimes severe pruritus.

* Causes and pathophysiology of rosacea

Although the cause of rosacea is unknown, its mechanism is understood to be nonspecific inflammation followed by dilation around follicles and hyperreactive capillaries. Oftentimes these dilated capillaries present as telangiectasias, which collectively exacerbate the red flushing. As the disorder progresses, diffuse hypertrophy of the connective tissue and sebaceous glands ensues.

Rosacea is more common in women than men (FIGURE 3). Men are typically more prone to the extreme forms of hyperplasia, which causes rhinophymatous rosacea (FIGURE 4)--eg, W C Fields's nose.

[FIGURES 3-4 OMITTED]

Alcohol may accentuate erythema, but does not cause the disease. Sun exposure may precipitate an acute rosacea flare, but flare-ups can happen without sun exposure.

A significant increase in the hair follicle mite Demadex folliculorum is sometimes found in rosacea. It is theorized that these mites play a role because they incite an inflammatory or allergic reaction by mechanical blockage of follicles.

* Stages of rosacea

There are 4 stages or subtypes of rosacea.

* Subtype 1: Erythematotelangiectatic rosacea. This stage is characterized by frequent mild to severe blushing with trace persistent central facial erythema in an individual.

* Subtype 2: Papulopustular rosacea (seen in FIGURES 1, 2, AND 3). This is a highly vascular stage that involves longer periods of flushing than the first stage--often lasting from days to weeks. Minute telangiectasias and papules start to form by this stage, and some patients begin having very mild ocular complaints such as ocular grittiness or conjunctivitis.

Subtype 3: Phymatous rosacea. The third stage is also called the rhinophymatous stage. It is characterized by deepening shades of erythema and more papules and pustules. In the chronic forms of rosacea, hyperplasia of the sebaceous glands occurs, which forms a thickened confluent plaque of erythema at the tip of the nose known as rhinophyma. This hyperplasia can cause significant disfigurement to the forehead, eyelids, chin, and nose. The nasal disfiguration is seen more commonly in men than women (FIGURE 4).