ROSACEA FULMINANS

By Gary M. White, MD

Rosacea fulminans also known as pyoderma faciale Courtesy Michael O. Murphy, MD


Rosacea fulminans (RF), also known as pyoderma faciale, is an explosive inflammatory condition of the face. Some consider it a rosacea variant and others consider it more akin to acne vulgaris. In contrast to acne vulgaris however, comedones are absent. In two cases of supposed pyoderma faciale, gram-negative bacteria (Klebsiella and Enterobacter) were found through needle aspiration [Cutis 2002;69;261]. This fact should be treated with some skepticism however, as neither patient responded to ciprofloxicillin. Both needed isotretinoin and improved over months.

Clinical

The patient, usually a young woman, presents with multiple inflammatory pustules, nodules, and plaques on the face. Onset is acute. Bacterial cultures are negative.

Treatment

A bacterial culture should be taken to rule out infection. Prednisone should be started to calm the inflammation, e.g., 0.5-1.0 mg/kg/day, along with an oral tetracycline, e.g., doxycycline or minocycline 100 mg BID. In the US, this may be done for the first month while the 30-day waiting period for isotretinoin imposed by the pledge system passes. Then, the antibiotic is stopped, isotretinoin is begun, (e.g., 0.2-0.5 mg/kg/day) and the prednisone is tapered over 2-3 weeks. The isotretinoin dose is increased as tolerated to 1 mg/kg/day and continued until resolution occurs. This usually works out to the standard 4-5 month isotretinoin course.

Warm compresses and a high-potency topical steroid ointment may be used during the first 1-2 weeks to help calm the inflammation. Incision and drainage should not be done as this will add to any scarring.

There is a significant risk of an initial flare when the isotretinoin is begun. This is true for all severe acne or rosacea at the initiation of isotretinoin therapy. Thus, prednisone calms down the inflammation and the tetracycline reduces the bacterial load, all in preparation for isotretinoin.

Pregnancy

Occasionally, RF will occur in pregnancy, possibly related to hormonal changes. Prednisone may be used in consultation with Obstetrics. Oral antibiotics that have been used successfully include azithromycin and amoxicillin. Topical sulfur and intralesional steroid injections may be considered.

Additional Pictures

Courtesy Michael O. Murphy, MD
Rosacea fulminans also known as pyoderma faciale Rosacea fulminans also known as pyoderma faciale Rosacea fulminans also known as pyoderma faciale

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