Pictorial case study

A 26-year-old woman presented complaining of a red rash over her cheeks.

The rash was burning and not itchy. Red papules were distributed over her cheeks, forehead and chin. There were a few pustules and she had nasal telangiectasia. She had noticed that heat, stress and sunlight made her face redder. What is the diagnosis, management and differential diagnoses?

Diagnosis and management

She has rosacea, a chronic condition that affects the skin, usually the face. It is more common in women, especially during the menopause. It is more apparent on people with fair skin.

Common triggers of rosacea include alcohol, caffeinated drinks, spicy foods, sunlight, wind, extremes of temperature, irritant topical products, menopausal flushing and drugs that cause vasodilation. Sometimes there are ocular manifestations such as blepharitis and conjunctivitis as well as oedema, burning or stinging.

This patient’s rosacea responded to oral tetracycline. She could have been treated with topical metronidazole. Isotretinoin is occasionally used in severe inflammatory forms of rosacea. More recently, lasers have been used to reduce erythema and telangiectasia.

Possible different diagnoses

Acne vulgaris.

Seborrhoeic dermatitis.

Systemic lupus erythematosus.

Tuberous sclerosis.

Perioral dermatitis.

Differential diagnosis

Acne vulgaris

Erythematous papules.

Comedones, pustules and nodules may be seen.

Neck, back, chest, shoulder and upper trunk can be affected.

Anti-comedonal and anti-inflammatory agents should be used.

Other treatment options: oral antibiotics, isotretinoin, antiandrogens.

Advise that it may take months to see an improvement.

Contributed by Dr Vasa Gnanapragasam, a GP in Sutton, Surrey

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