Granulomatous rosacea (GR) is a papular, inflammatory condition of the face. Various names have been used for this condition including lupus miliaris disseminatus faciei, granulomatous perioral dermatitis and acne agminata. Steroid rosacea is similar as well. Although the conditions are quite similar, patients with LMDF lack flushing and telangiectasia, have eyelid involvement, and heal with scarring. Thus, many now view LMDF as its own distinct rosacea-like syndrome. I however have chosen to group them mostly together as they seem, in my experience, to represent the same condition.
Multiple papules occur on the face. The papules are small, monomorphous, "juicy" and red to pink. The distribution is usually symmetric and prefers the perioral and periocular areas. The histology resembles tuberculosis, but no mycobacterial infection is found. Topical tacrolimus has induced a similar condition [AD 2003;139;229]. It may also occur in the axilla.
Patients should be asked about any steroid use, particularly topical, although inhaled steroids, e.g. as a treatment in a child for asthma may be found. Any steroid or TCI (topical calcineurin inhibitor) use should be stopped if possible.
Oral tetracycline therapy should be started and given over several months (e.g., tetracycline 500 mg BID, doxycycline 100 mg BID or minocycline 100 mg BID). Topical metronidazole (e.g. Metrogel) or ivermetin (Soolantra) should be given as well. GR condition is slower to respond than standard rosacea. Several months are usually needed. The patient may be seen in 1-2 months follow up and any improvement should give encouragement to the patient. If after 2 months, there is no improvement, therapy should be changed.
Isotretinoin and dapsone have been reported helpful. Untreated, spontaneous resolution over 1-3 years is common, but scarring may result.
Other therapies that have been utilized include oral and intramuscular corticosteroids, tranilast, clofazimine, oral metronidazole combined with topical tacrolimus ointment, and laser therapy (non-ablative fractionated 1,565 nm laser and a 1,450 nm diode laser).
Oral (single dose of 200-250 ug/kg) or topical (1%) ivermectin resulted in either complete or almost complete clearance in 14/15 children [JAAD 2017;76;567] with either periorificial dermatitis or papulopustular rosacea. The only side effect was mild desquamation in 5 patients. Of note, Soolantra is ivermectin 1%.
Acne agminata of the axilla. JAMA Derm 2015;151;893
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