Treatment Refractory Facial Dermatitis

History This 62 yo woman has had a facial dermatitis for 18 months. It has persisted despite treatment with triamcinalone cream, mupirocin ointment, metronidazole gel and oral doxycycline.  Her medications include atorvastin, bupropoin, citalopram and antiprzoale.  

Clinical: There is an erythematous papular eruption of the perioral region with some extension to the nasolabial folds and left lower lid.  Scraping for Demodex mites showed only one or two mites.

Clinical Image:

 

Photomicrographs: Courtesy of Dr. David Jones, Berkshire Medical Center

There are well formed granulomas localized to the upper and mid dermis predominantly,

 associated with follicular elements. Giant cells are present and there is a cuff of bland lymphocytes as well as a rare focus of central fibrinous debris. 

 

 

 

 

                                         

Diagnosis:  Granulomatous Rosacea is the best fit. 
In the differential diagnosis are Lupus milliaris dissemanituts faciei and rosacea. 

 References: 

1. K F Helm  1 , J Menz, L E Gibson, C H Dicken A clinical and histopathologic study of granulomatous rosacea.  J Am Acad Dermatol 1991 Dec;25(6 Pt 1):1038-43.

Abstract: A retrospective clinical and histopathologic study of 53 patients with granulomatous rosacea was undertaken. The patients had a broad clinical spectrum of lesions that ranged from primarily erythema to papulonodular lesions. Extrafacial lesions occurred in 15% of patients. Histologic examination showed mixed lymphohistiocytic inflammation (primarily lymphocytic inflammation in 40% of patients and primarily histiocytic with a few giant cells in 34%), epithelioid granulomas in 11% of patients, and epithelioid granulomas with caseation necrosis in 11%. Most patients had a good response to oral antibiotic therapy. Granulomatous rosacea is not a distinct disease but can be regarded and treated as a subtype of rosacea.

2. Efstathios Rallis and Chrysovalantis Korfitis. Isotretinoin for the Treatment of Granulomatous Rosacea: Case Report and Review of the Literature.
Abstract: Granulomatous rosacea is considered a clinical variant of rosacea and is characterized by hard yellow, brown, red or flesh-colored cutaneous papules or nodules that may be severe and may lead to scarring. The lesions typically appear on the cheeks and periorificial lesions; they are monomorphic in each patient and sit on relatively normal-appearing skin. The diagnosis should be established by excluding other granulomatous disorders and rosacea-like eruptions such as sarcoidosis, tuberculosis, and lupus miliaris disseminatus faciei. The clinical course is chronic and unpredictable, and management can be very difficult. 

3. Mitchell Brady, Vera Wang, Francesca Kartono, Lynn Sikorski. Granulomatous rosacea treated with tapinarof. JAAD Case Rep. 2025 Jul 11:64:1-2.  PMC Full Text