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 and the chest and back are usually spared. Bacterial culture of pustules should always be done, but even if positive, oral antibiotics may not clear as secondary infection may occur.
The patient, usually a young woman, presents with multiple inflammatory pustules, nodules, and plaques on the face. Onset is acute. Bacterial cultures are negative.
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.
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 (e.g. 250 mg daily) and amoxicillin. Topical sulfur and intralesional steroid injections may be considered. Post partum, isotretinoin may be used if appropriate.
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