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The Great Mimickers of Rosacea

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The Great Mimickers of Rosacea Jeannette Olazagasti, BS; Peter Lynch, MD; Nasim Fazel, MD, DDS Practice Points Rosacea is characterized by frequent flushing; persistent erythema (ie, lasting for at least 3 months); telangiectasia; and interspersed episodes of inflammation with swelling, papules, and pustules. Rosacea is most commonly seen in adults older than 30 years and is considered to have a strong hereditary component, as it is more commonly seen in individuals of Celtic and Northern European descent as well as those with fair skin. Although rosacea is one of the most common Rosacea Characteristics conditions treated by dermatologists, it also is Rosacea is a chroniccopy disorder affecting the central one of the most misunderstood. It is a chronic dis- parts of the face that is characterized by frequent order affecting the central parts of the face and flushing; persistent erythema (ie, lasting for at least is characterized by frequent flushing; persistent 3 months); telangiectasia; and interspersed epi- erythema (ie, lasting for at least 3 months); tel- sodes of inflammation with swelling, papules, and angiectasia; and interspersed episodes of inflam- pustules.not2 It is most commonly seen in adults older mation with swelling, papules, and pustules. than 30 years and is considered to have a strong Understanding the clinical variants and disease hereditary component, as it is more commonly seen course of rosacea is important to differentiateDo in individuals of Celtic and Northern European this entity from other conditions that can mimic descent as well as those with fair skin. Furthermore, rosacea. Herein we present several mimickers of approximately 30% to 40% of patients report a fam- rosacea that physicians should consider when ily member with the condition.2 diagnosing this condition. Rosacea Subtypes—In a 2002 meeting held to Cutis. 2014;94:39-45. standardize the diagnostic criteria for rosacea, the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea described lthough rosacea is oneCUTIS of the most common 4 broad clinical subtypes of rosacea: erythematotel- conditions treated by dermatologists, it also is angiectatic, papulopustular, phymatous, and ocular.3 Aone of the most misunderstood. Historically, More than 1 subtype may present in the same patient. large noses due to rhinomegaly were associated with A progression from one subtype to another can occur indulgence in wine and wealth.1 The term rosacea is in cases of severe papulopustular or glandular rosacea derived from the Latin adjective meaning “like roses.” that eventuate into the phymatous form.2 Moreover, Rosacea was first medically described in French as not all of the disease features are present in every goutterose (pink droplet) and pustule de vin (pimples patient. Secondary features of rosacea include burn- of wine).1 This article reviews the characteristics of ing or stinging, edema, plaques, dry appearance rosacea compared to several mimickers of rosacea that of the skin, ocular manifestations, peripheral site physicians should consider. involvement, and phymatous changes. In erythematotelangiectatic rosacea, epi- Ms. Olazagasti is from the University of Puerto Rico School of sodic flushing occurs, which can last longer than Medicine, San Juan. Drs. Lynch and Fazel are from the University of 10 minutes with the central face exhibiting the most California, Davis School of Medicine, Sacramento. intense color. The redness also may involve the The authors report no conflict of interest. Correspondence: Nasim Fazel, MD, DDS, Department of Dermatology, peripheral portion of the face as well as extrafacial University of California, Davis School of Medicine, 3301 C St, #1300, areas (eg, ears, scalp, neck, chest). Periocular skin Sacramento, CA 95816 ([email protected]). is spared. The stimuli that may bring on flushing WWW.CUTIS.COM VOLUME 94, JULY 2014 39 Copyright Cutis 2014. No part of this publication may be reproduced, stored, or transmitted without the prior written permission of the Publisher. Mimickers of Rosacea include short-term emotional stress, hot drinks, or simply an inhabitant of follicles in rosacea-prone alcohol, spicy foods, exercise, cold or hot weather, skin remains a subject for future investigation. and hot water.3 Demodicosis occurs mainly in immunosuppressed Patients with papulopustular rosacea generally patients because immunosuppression influences present with redness of the central portion of the face the number of Demodex mites and the treatment along with persistent or intermittent flares character- response. Multiple patients with AIDS and/or those ized by small papules and pinpoint pustules. There with a CD4 lymphocyte count below 200/mm3 have also is an almost universal sparing of the periocular been reported to have demodicosis.5-11 In immuno- skin, and a history of flushing often is present; how- competent patients, pruritic papular, papulopustu- ever, flushing usually is milder than in the erythema- lar, and nodular lesions occur on the face, but in totelangiectatic subtype. The constant inflammation immunocompromised patients, the eruption may be may lead to chronic edema and phymatous changes, more diffuse, affecting the back, presternal area, and which occur more commonly in men than in women.3 upper limbs.6 A correct diagnosis relies on suggestive Phymatous rosacea is characterized by marked clinical signs, the presence of numerous parasites on skin thickening and irregular surface nodularities, direct examination, and a good clinical response to most commonly involving the nose (rhinophyma), acaricide treatment. though the chin (gnathophyma), forehead (meto- Helicobacter pylori seropositivity has been associ- phyma), ears (otophyma), and eyelids (blepharo- ated with various dermatologic disorders, includ- phyma) also are occasionally affected. There are ing rosacea.12 However, robust support for a causal 4 variants of rhinophyma with distinct histopatho- association between H pylori and rosacea does logic features: glandular, fibrous, fibroangiomatous, not exist. Several studies have demonstrated high and actinic.3 The glandular variant is most often seen prevalence rates of H pylori in rosacea patients, some in men who have thick sebaceous skin. Edematous even in comparisoncopy with age- and sex-matched papules and pustules often are large and may be controls.13,14 Moreover, treatments aimed at eradicat- accompanied by nodulocystic lesions. Frequently, ing H pylori also beneficially influence the clinical affected patients will have a history of adolescent outcome of rosacea; for instance, metronidazole, a acne with scarring. commonnot treatment of roscea, is an effective agent Ocular rosacea may precede cutaneous findings against H pylori. by many years; however, in most cases the ocular Understanding the clinical variants and disease findings occur concurrently or develop later on in course of rosacea is important to differentiate this the disease course. The most consistent findingsDo in entity from other conditions that can mimic rosacea. ocular rosacea are blepharitis and conjunctivitis. Laboratory studies and histopathologic examina- Symptoms of burning or stinging, itching, light sen- tion via skin biopsy may be needed to differentiate sitivity, and a foreign body sensation are common in between rosacea and rosacealike conditions. these patients.3 Pathogenesis—Several investigators have proposed Common Rosacealike Conditions that Demodex folliculorum may play a pathogenic role Systemic Lupus Erythematosus—Systemic lupus in rosacea. Demodex is a CUTIScommon inhabitant of erythematosus (SLE) is a chronic inflammatory dis- normal human skin, and its role in human disease ease that has protean clinical manifestations and fol- is a matter of controversy.3 Demodex has a predilec- lows a relapsing and remitting course. Characteristic tion for the regions of the skin that are most often malar erythema appears in approximately 50% of affected by rosacea, such as the nose and cheeks. patients and may accompany or precede other symp- The clinical manifestations of rosacea tend to appear toms of lupus. The affected skin generally feels warm later in life, which parallels the increase in the den- and appears slightly edematous. The erythema may sity of Demodex mites that occurs with age.4 It has last for hours to days and often recurs, particularly been hypothesized that beneficial effects of metroni- with sun exposure. The malar erythema of SLE can dazole in the treatment of rosacea may be related to be confused with the redness of erythematotelangi- an antiparasitic effect on Demodex; however, these ectatic rosacea. Nevertheless, the color of the skin in mites can survive high concentrations of the drug.3 SLE has a violaceous quality and may show a more Moreover, modern techniques that employ cyanoac- abrupt cutoff, especially at its most lateral margins. rylate surface biopsies, which are extremely sensitive, Marzano et al15 reported 4 cases in which lupus estimate that the prevalence of Demodex in healthy erythematosus was misdiagnosed as rosacea. All skin approaches 100%.4 Consequently, the simple 4 patients presented with erythema that was local- identification of Demodex is by no means proof of ized to the central face along with a few raised, pathogenesis. Whether Demodex is truly pathogenic smooth, round, erythematous to violaceous papules 40 CUTIS® WWW.CUTIS.COM Copyright Cutis 2014. No part of this publication may be reproduced, stored, or transmitted
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