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Home , Folliculitis, Malassezia folliculitis, Rhinophyma, Rosacea

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Spot Mimickers that Can Complicate Diagnosis and Treatment Dermatologists are generally adept at diagnosing the various “red face” conditions, but sometimes mimickers are mistaken for rosacea.

By Joseph Bikowski, MD

ccording to the National Rosacea Society dermatitis will respond to permethrin, (NRS, rosacea.org), up to 16 million crotaminton, or therapy, any of which Americans have rosacea, a chronic potential- is effective against the . Standard dosing for Aly progressive disease demonstrated to nega- Permethrin (Elimite, Allergan) or Crotamiton tively impact an individual’s quality of life (QOL). (Eurax, Novartis) is twice daily for four weeks. Though no cure is yet available, several effective Alternatively, ivermectin 3mg orally in a single therapies are marketed for rosacea, and treatment dose may be effective. is shown to improve QOL.1 Nonetheless, some cases of rosacea are challenging. Complicating patient management is the possibility of a misdiag- Perioral dermatitis is an inflammatory eruption nosis. Several common and uncommon cutaneous focused about the mouth, nasolabial folds, and chin conditions can mimic rosacea, leading clinicians to and is distinguished from other dermatoses by the implement an ineffective treatment regimen for sparing of a clear area between the eruption and the the patient. Below is a summary of rosacea mimic- vermillion border.4 It has been suggested that perio- kers with an emphasis on treatment for each.

Demodex Dermatitis Take-Home Tips. Several common and uncommon cutaneous Perhaps the most controversial of the rosacea mim- conditions can mimic rosacea, leading clinicians to implement an ickers, Demodex dermatitis refers to a distinct con- ineffective treatment regimen for the patient. Demodex dermatitis dition that is separate from but that could overlap refers to a distinct condition that is separate from but that could with rosacea.2 Although there is evidence for an overlap with rosacea. Perioral dermatitis is an inflammatory eruption association between rosacea and the Demodex fol- focused about the mouth, nasolabial folds, and chin and is liculorum mite, there is no sound evidence to sug- distinguished from other dermatoses by the sparing of a clear area gest that Demodex are causative in rosacea.3 between the eruption and the vermillion border. , possibly Demodex dermatitis (Fig. 1) is characterized by mediated by various different contributors, may mimic rosacea. facial , dryness, scaling, and roughness Pseudorhinophyma describes a condition that has the appearance of with or without /pustules. The diagnosis is but is in actuality mechanical in nature. The condition is typically caused by swelling of the nose due to pressure from tight- generally confirmed through successful response fitting eyeglasses. ● to anti-infective therapy.

December 2011 | Practical | 35 Rosacea Mimickers All images courtesy of Joseph Bikowski, MD/DermEdOnline.com

Fig. 2. -induced dermatitis.

prescription or OTC to the face.5 Withdrawal of corticosteroids is curative, typically with immediate cessation of drug application. In Fig. 1a. Demodex dermatitis (top) certain cases, tapered withdrawal is indicated to Fig. 1b. Demodex mite from infected . prevent a flare. ral dermatitis may present in association with Folliculitis rosacea, though this has not been well studied. Folliculitis, possibly mediated by various different Nonetheless, topical antimicrobials, including contributors, may mimic rosacea. , erythromycin, and clindamycin, as Sycosis Barbae. Sycosis barbae is characterized well as topical , have all been suggested by follicular pustules with a surrounding halo of as effective for perioral dermatitis and are all used erythema and is localized to the beard area of men for the treatment of rosacea, as well.4 Alternatively, only. This is also called anti-inflammatory dose (Oracea, or Barber's . ) once daily for four weeks has been effec- folliculitis. Malassezia folliculitus tive for perioral dermatitis in my practice. (previously called pityrosporum follicultius, Fig. 3) Steroid-induced dermatitis (Fig. 2) generally is characterized by papulopustules in a follicular presents with a distribution of that is simi- pattern on the back, chest, upper arms, and, occa- lar to that for perioral dermatitis; A key difference sionally the neck, and face into the scalp.6 is involvement of the skin adjacent to the vermil- Monomorphous erythematoid papulpustules that lion border. To identify steroid-induced dermatitis, measure 1-2mm in diameter also mimic vul- or what I term steroid use/abuse/misuse dermati- garis. Treatment is ketoconazole 200mg ii once tis, question patients about topical application of daily for two to four weeks.

36 | Practical Dermatology | December 2011 Rosacea Mimickers

Fig. 3. Malassezia folliculitus (left). Fig. 4. folliculitis (center). All images courtesy of Joseph Bikowski, MD/DermEdOnline.com Fig. 5. Pseudofolliculitis barbae (above).

Herpes simplex folliculitis. Herpes simplex fol- can now be provided safely and effectively in liculitis (Fig. 4) is a very rare presentation, affect- these patients.8 Laser and light therapy is shown to ing only about four in 76,500 individuals. Patients permanently destroy root, thus eliminating may or may not have a history of HSV infection at the that mediate the inflammatory papules. the time of presentation. The condition affects . Sometimes called ringworm of men and women equally and, unlike sycosis bar- the beard, tinea barbae (Fig. 6) is a very uncom- bae or psuedofolliculitis barbae, is not localized to the beard area. Patients who are HIV positive may be at increased risk for developing herpes simplex folliculitis. Oral antiviral therapy is effective for treating acute herpes simplex folliculitis. Pseudofolliculitis barbae. Pseudofolliculitis bar- bae or PFB (Fig. 5) may be described by patients as “razor bumps” or “ingrown hairs.” The papular, pustular, follicular-based disorder is not mediated by any infectious organism, rather it is an inflam- matory response. The condition is most common in black males, where highly curved and flattened hairs fail to emerge from the follicle but instead become convoluted within the follicle. Oral doxy- cycline or may be instituted as treat- ment for their anti-inflammatory effects, as may topical calcineurin inhibitors. Topical benzoyl per- oxide/clindamycin applied twice daily for two to 10 weeks has been shown effective.7 Laser hair removal may be used adjunctively to treat PFB and reduce the risk for recurrence. The treatment had been contraindicated in patients with skin phototypes IV-VI or sun-tanned skin but Fig. 6. Tinea barbae

December 2011 | Practical Dermatology | 37 Rosacea Mimickers All images courtesy of Joseph Bikowski, MD/DermEdOnline.com

Fig. 7a. Pseudorhinophyma. Fig. 7b. Eyeglasses implicated in causing pressure and swelling. Dr. Bikowski has served on the speaker's bureau or advi- mon superficial infection of the sory board or is a shareholder or consultant to Allergan, beard.9 It may be very localized with intense Coria, Galderma, Stiefel/GlaxoSmithKline, Intendis, Medicis, or more diffuse with a somewhat Promius, Quinnova, Ranbaxy, and Warner-Chilcott. reduced inflammatory component, similar in appearance to .8 Systemic antifungal Joseph Bikowski, MD, FAAD is Clinical therapy is preferred. Assistant Professor of Dermatology, Ohio State University, Columbus, OH and Director, Bikowski Skin Care Center, Sewickley, PA. Pseudorhinophyma Phymatous rosacea (Subtype 3), characterized by thickened skin, nodules, and anatomical enlarge- 1. Aksoy B, Altaykan-Hapa A, Egemen D, Karagöz F, Atakan N. The impact of rosacea on quality of life: effects of demographic and clinical characteristics ment, is far more common in men than women. and various treatment modalities. Br J Dermatol. 2010 Oct;163(4):719-25. Rhinophyma or enlargement of the nose is likely 2. Bikowski JB, Del Rosso JQ. Demodex dermatitis: a retrospective analysis of the most common presentation of phymatous clinical diagnosis and successful treatment with topical crotamiton. J Clin rosacea. However, not all tissue swelling of the Aesthet Dermatol. 2009;2:20-5. nose is attributable to rosacea. I use the term 3. Zhao YE, Wu LP, Peng Y, Cheng H. Retrospective analysis of the association between Demodex infestation and rosacea. Arch Dermatol. 2010;146:896-902. pseudorhinophyma (Fig. 7) to describe a condition 4. Lipozencic J, Ljubojevic S. Perioral dermatitis. Clin Dermatol. 2011 Mar- that has the appearance of rhinophyma but is in Apr;29(2):157-61. actuality mechanical in nature. The condition is 5. Ljubojeviae S, Basta-Juzbasiae A, Lipozenèiae J. Steroid dermatitis resem- typically caused by swelling of the nose due to bling rosacea: aetiopathogenesis and treatment. J Eur Acad Dermatol pressure from tight-fitting eyeglasses. Venereol. 2002;16:121-6. Suspicion for pseudorhinophyma is suggested 6. http://emedicine.medscape.com/article/1091037-overview any time a patient with no history of rosacea pres- 7. Cook-Bolden FE, Barba A, Halder R, Taylor S. Twice-daily applications of 5%/clindamycin 1% gel versus vehicle in the treatment of ents with apparent rhinophyma. In the patient pseudofolliculitis barbae. Cutis. 2004 Jun;73(6 Suppl):18-24. with a history of rosacea and even the patient with 8. Battle EF Jr. Advances in laser hair removal in skin of color. J Drugs a diagnosis of rhinophyma, it may be wise to Dermatol. 2011 Nov 1;10(11):1235-9. assess for proper fit of eyeglasses, which may be 9. Xavier MH, Torturella DM, Rehfeldt FV, Alvariño CR, Gaspar NN, Rochael MC, exacerbating the underlying phyma. ■ Cunha Fde S. Sycosiform tinea barbae caused by rubrum. Dermatol Online J. 2008 Nov 15;14(11):10.

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