Download Spot Rosacea Mimickers that Can Complicate Diagnosis

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Spot Rosacea 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
A
ccording to the National Rosacea Society
(NRS, rosacea.org), up to 16 million
Americans have rosacea, a chronic potentially progressive disease demonstrated to negatively impact an individual’s quality of life (QOL).
Though no cure is yet available, several effective
therapies are marketed for rosacea, and treatment
is shown to improve QOL.1 Nonetheless, some
cases of rosacea are challenging. Complicating
patient management is the possibility of a misdiagnosis. Several common and uncommon cutaneous
conditions can mimic rosacea, leading clinicians to
implement an ineffective treatment regimen for
the patient. Below is a summary of rosacea mimickers with an emphasis on treatment for each.
Demodex dermatitis will respond to permethrin,
crotaminton, or ivermectin therapy, any of which
is effective against the mite. Standard dosing for
Permethrin (Elimite, Allergan) or Crotamiton
(Eurax, Novartis) is twice daily for four weeks.
Alternatively, ivermectin 3mg orally in a single
dose may be effective.
Perioral Dermatitis
Perioral dermatitis is an inflammatory eruption
focused about the mouth, nasolabial folds, and chin
and is distinguished from other dermatoses by the
sparing of a clear area between the eruption and the
vermillion border.4 It has been suggested that perio-
Demodex Dermatitis
Take-Home Tips. Several common and uncommon cutaneous
Perhaps the most controversial of the rosacea mimickers, Demodex dermatitis refers to a distinct condition that is separate from but that could overlap
with rosacea.2 Although there is evidence for an
association between rosacea and the Demodex folliculorum mite, there is no sound evidence to suggest that Demodex are causative in rosacea.3
Demodex dermatitis (Fig. 1) is characterized by
facial erythema, dryness, scaling, and roughness
with or without papules/pustules. The diagnosis is
generally confirmed through successful response
to anti-infective therapy.
conditions can mimic rosacea, leading clinicians to implement an
ineffective treatment regimen for the patient. Demodex dermatitis
refers to a distinct condition that is separate from but that could
overlap with rosacea. Perioral dermatitis is an inflammatory eruption
focused about the mouth, nasolabial folds, and chin and is
distinguished from other dermatoses by the sparing of a clear area
between the eruption and the vermillion border. Folliculitis, possibly
mediated by various different contributors, may mimic rosacea.
Pseudorhinophyma describes a condition that has the appearance of
rhinophyma but is in actuality mechanical in nature. The condition is
typically caused by swelling of the nose due to pressure from tightfitting eyeglasses. ●
December 2011 |
Practical Dermatology | 35
All images courtesy of Joseph Bikowski, MD/DermEdOnline.com
Rosacea Mimickers
Fig. 2. Steroid-induced dermatitis.
Fig. 1a. Demodex dermatitis (top)
Fig. 1b. Demodex mite from infected skin.
ral dermatitis may present in association with
rosacea, though this has not been well studied.
Nonetheless, topical antimicrobials, including
metronidazole, erythromycin, and clindamycin, as
well as topical azelaic acid, have all been suggested
as effective for perioral dermatitis and are all used
for the treatment of rosacea, as well.4 Alternatively,
anti-inflammatory dose doxycycline (Oracea,
Galderma) once daily for four weeks has been effective for perioral dermatitis in my practice.
Steroid-induced dermatitis (Fig. 2) generally
presents with a distribution of lesions that is similar to that for perioral dermatitis; A key difference
is involvement of the skin adjacent to the vermillion border. To identify steroid-induced dermatitis,
or what I term steroid use/abuse/misuse dermatitis, question patients about topical application of
36 | Practical Dermatology
| December 2011
prescription or OTC corticosteroids to the face.5
Withdrawal of corticosteroids is curative, typically
with immediate cessation of drug application. In
certain cases, tapered withdrawal is indicated to
prevent a flare.
Folliculitis
Folliculitis, possibly mediated by various different
contributors, may mimic rosacea.
Sycosis Barbae. Sycosis barbae is characterized
by follicular pustules with a surrounding halo of
erythema and is localized to the beard area of men
only. This staphylococcal infection is also called
sycosis vulgaris or Barber's itch.
Malassezia folliculitis. Malassezia folliculitus
(previously called pityrosporum follicultius, Fig. 3)
is characterized by papulopustules in a follicular
pattern on the back, chest, upper arms, and, occasionally the neck, and face into the scalp.6
Monomorphous erythematoid papulpustules that
measure 1-2mm in diameter also mimic acne vulgaris. Treatment is ketoconazole 200mg ii once
daily for two to four weeks.
Fig. 3. Malassezia folliculitus (left).
Fig. 4. Herpes simplex folliculitis (center).
Fig. 5. Pseudofolliculitis barbae (above).
Herpes simplex folliculitis. Herpes simplex folliculitis (Fig. 4) is a very rare presentation, affecting only about four in 76,500 individuals. Patients
may or may not have a history of HSV infection at
the time of presentation. The condition affects
men and women equally and, unlike sycosis barbae 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 barbae 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 inflammatory 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 doxycycline or minocycline may be instituted as treatment for their anti-inflammatory effects, as may
topical calcineurin inhibitors. Topical benzoyl peroxide/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
can now be provided safely and effectively in
these patients.8 Laser and light therapy is shown to
permanently destroy hair root, thus eliminating
the hairs that mediate the inflammatory papules.
Tinea barbae. Sometimes called ringworm of
the beard, tinea barbae (Fig. 6) is a very uncom-
Fig. 6. Tinea barbae
December 2011 |
Practical Dermatology | 37
All images courtesy of Joseph Bikowski, MD/DermEdOnline.com
Rosacea Mimickers
All images courtesy of Joseph Bikowski, MD/DermEdOnline.com
Rosacea Mimickers
Fig. 7a. Pseudorhinophyma. Fig. 7b. Eyeglasses implicated in causing pressure and swelling.
mon superficial dermatophyte infection of the
beard.9 It may be very localized with intense
inflammation or more diffuse with a somewhat
reduced inflammatory component, similar in
appearance to tinea corporis.8 Systemic antifungal
therapy is preferred.
Pseudorhinophyma
Phymatous rosacea (Subtype 3), characterized by
thickened skin, nodules, and anatomical enlargement, is far more common in men than women.
Rhinophyma or enlargement of the nose is likely
the most common presentation of phymatous
rosacea. However, not all tissue swelling of the
nose is attributable to rosacea. I use the term
pseudorhinophyma (Fig. 7) to describe a condition
that has the appearance of rhinophyma but is in
actuality mechanical in nature. The condition is
typically caused by swelling of the nose due to
pressure from tight-fitting eyeglasses.
Suspicion for pseudorhinophyma is suggested
any time a patient with no history of rosacea presents with apparent rhinophyma. In the patient
with a history of rosacea and even the patient with
a diagnosis of rhinophyma, it may be wise to
assess for proper fit of eyeglasses, which may be
exacerbating the underlying phyma. ■
38 | Practical Dermatology
| December 2011
Dr. Bikowski has served on the speaker's bureau or advisory board or is a shareholder or consultant to Allergan,
Coria, Galderma, Stiefel/GlaxoSmithKline, Intendis, Medicis,
Promius, Quinnova, Ranbaxy, and Warner-Chilcott.
Joseph Bikowski, MD, FAAD is Clinical
Assistant Professor of Dermatology, Ohio State
University, Columbus, OH and Director, Bikowski
Skin Care Center, Sewickley, PA.
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
and various treatment modalities. Br J Dermatol. 2010 Oct;163(4):719-25.
2. Bikowski JB, Del Rosso JQ. Demodex dermatitis: a retrospective analysis of
clinical diagnosis and successful treatment with topical crotamiton. J Clin
Aesthet Dermatol. 2009;2:20-5.
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.
4. Lipozencic J, Ljubojevic S. Perioral dermatitis. Clin Dermatol. 2011 MarApr;29(2):157-61.
5. Ljubojeviae S, Basta-Juzbasiae A, Lipozenèiae J. Steroid dermatitis resembling rosacea: aetiopathogenesis and treatment. J Eur Acad Dermatol
Venereol. 2002;16:121-6.
6. http://emedicine.medscape.com/article/1091037-overview
7. Cook-Bolden FE, Barba A, Halder R, Taylor S. Twice-daily applications of
benzoyl peroxide 5%/clindamycin 1% gel versus vehicle in the treatment of
pseudofolliculitis barbae. Cutis. 2004 Jun;73(6 Suppl):18-24.
8. Battle EF Jr. Advances in laser hair removal in skin of color. J Drugs
Dermatol. 2011 Nov 1;10(11):1235-9.
9. Xavier MH, Torturella DM, Rehfeldt FV, Alvariño CR, Gaspar NN, Rochael MC,
Cunha Fde S. Sycosiform tinea barbae caused by Trichophyton rubrum.
Dermatol Online J. 2008 Nov 15;14(11):10.