Wednesday, July 11, 2018

Granulomatous Rosacea

A 34-year-old sociologist presented for evaluation of forehead lesions, which have been present for about 2 years.  These began about a year after her daughter's birth.  Before that, she was on oral contraceptives and was fine, but she has not been on any hormonal birth control since then.  She saw another dermatologist and was treated with topicals, a SilkPeel, Tretinoin.  She also took doxycycline for 2 – 4 weeks. Nothing helped.  She is anxious about her appearance. 

O/E:   The examination shows a pleasant, outgoing woman.  She has a somewhat pebbly appearance to the forehead with many, mostly not inflammatory discrete and confluent submillimeter papules.  There were a few erythematous papules.

Clinical Photos:

Initial Diagnosis:  I considered an acneiform eruption.  A 4 mm punch biopsy was performed.

Pathology:  Thanks to Assistant Professor Hye Jin Chung, MD from Boston University Skin Pathology for kindly providing these beautiful photomicrographs.
There is a moderate and superficial perivascular and perifollicular infiltrat.  Focal granulomas formation is noted.

Presumptive Final Diagnosis: Granulomaous Rosacea
Discussion:  Is this really a subset of rosacea, or is it an acneiform disease sui generis? Clinically, it does not look like rosacea and it appears to be defined by dermatopathologists who only see small plugs of skin.  Similarly, perioral dermatitis is an acneiform disorder of uncertain etiology, but the diagnosis is strictly clinical.

1. Lee GL, Zirwas MJ. Granulomatous Rosacea and Periorificial Dermatitis: Controversies and Review of Management and Treatment. Dermatol Clin. 2015 Jul;33(3):447-55.
Abstract: Granulomatous rosacea and periorificial dermatitis are common skin conditions affecting the face. This article examines the historical origin, causes, clinical presentation, and management strategies for these entities.  Link to Full Text.

Omar Khokhar and Amor Khachemoune. A Case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affects the face. Dermatology Online Journal 2004 10 (1): 6  Free Full Text.
Abstract: Granulomatous rosacea is a variant of rosacea that may present similar to other granulomatous diseases. We present the case of a 45-year-old woman with a 2-year history of facial erythema with multiple papules and pustules on the cheeks, chin, and glabella. The patient responded to minocycline, resulting in healing 6 months without residual scarring. This patient's clinical and histological presentation and treatment outcome are to our assessment consistent with granulomatous rosacea. However, other clinically and histologically related entities will be discussed. These entities include, but are not limited to, perioral dermatitis, granulomatous periorificial dermatitis, lupus miliaris disseminatus faciei, facial afro-caribbean eruption syndrome, and sarcoidosis.


  1. from Krystal Jones, Fellow in Pediatric Dermatology, Boston: I have only seen a few cases of granulomatous rosacea in residency - they typically required extended courses of mino/doxy (if they failed that, we went to isotretinoin). Dapsone has been reported to help?

    The localization limited to just the forehead and not central face makes me think of a few other things - While it isn't as pustular/inflammatory as one would expect, I would also scrape to make sure it isn't demodex, in which case it may respond to Soolantra or oral ivermectin. Final thought is a granulomatous reaction/contact dermatitis to a hair product? Seems far fetched, I don't see much literature on it with the exception of after micro needling, but is it itchy at all?

  2. from Dr. Cheng Leng, Malaysia: She has very numerous isomorphic closed comedones clinically, especially at the forehead. We have to go back to history taking to ensure she doesn’t in fact have pomade acne. As to the granulomatous histology, can it be due to the foreign body reaction to the seepage of whatever is blocking the ducts?

  3. from Khalifa Sharquie, Baghdad, Iraq: Granulomatous rosacea is not uncommon problem seen in clinical practice where the patient seen with shiny monomorphous red papules with no pustules.Its management needs oral steroid like 10mg prednisone together with oral septrin 4tab day for 2weeks then reduced to 2tab together with flagyl 500 mg a day with topical combination of ivermectin with mometazone cream until remission for about one month then to taper all elements of therapy according to response


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