Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor
2014:80:3;272-274
doi: 10.4103/0378-6323.132267
PMID: 24823417

Rosacea fulminans

Hong Yi Koh, See Ket Ng, Wee Ping Tan
 Department of Dermatology, National Skin Centre, Singapore,

Correspondence Address:
Hong Yi Koh
National Skin Centre(s) Pte Ltd., 1 Mandalay Road, Singapore 308205, Republic of Singapore

How to cite this article:
Koh HY, Ng SK, Tan WP. Rosacea fulminans. Indian J Dermatol Venereol Leprol 2014;80:272-274
Copyright: (C)2014 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Rosacea fulminans is an intensely inflammatory facial eruption that affects young women. It can be mistaken for cutaneous infections and inappropriately treated with surgery or short courses of antibiotics. Accurate diagnosis and treatment reduces the potential for scarring.

A 32-year-old woman presented with a painful facial eruption which started 2 years ago as a carbuncle. The first culture from pus grew Enterobacter but the rash responded only partially to incision and drainage and various antibiotics including cephalexin, cloxacillin, co-amoxiclav and ciprofloxacin. The patient was then suspected to have nodulocystic acne vulgaris and isotretinoin at 15 mg daily initially led to resolution, but she relapsed after 7 months of treatment. She was afebrile and had no relevant medical or drug history. Physical examination showed erythema, edema and multiple pustules over most of the face [Figure - 1]. The total white cell count was 10.9 × 10 9 /L with neutrophilia (81.3%). Erythrocyte sedimentation rate was 59 mm/h. Repeat cultures for bacteria, fungi and mycobacteria were negative and serum antinuclear antibody was non-reactive. Skin biopsy from a pustule on an erythematous, edematous plaque on the cheek showed a folliculo-centric infiltrate of neutrophils within the upper to mid-dermis with a ruptured hair follicle, upper dermal edema and superficial and mid-dermal perivascular lymphocytic infiltrate [Figure - 2]. Rosacea fulminans was diagnosed and she was treated with doxycycline 100 mg twice a day, topical metronidazole gel and 2 weeks of indomethacin. The facial erythema and edema improved with cessation of new pustule formation. After 5 months of doxycycline and topical metronidazole, she achieved complete resolution [Figure - 3].

Figure 1: Erythematous, edematous plaques with pustules and crusts over the whole face
Figure 2: Folliculocentric infi ltrate of neutrophils in the upper to mid-dermis with ruptured hair follicle, upper dermal edema and superfi cial and mid-dermal perivascular lymphocytic infi ltrate
Figure 3: Complete resolution with mild scarring after 5 months of treatment with doxycycline, non-steroidal anti-infl ammatory drugs and topical metronidazole

Rosacea fulminans (synonym: pyoderma faciale) is a rare, inflammatory dermatosis that predominantly afflicts women in the 2 nd to 3 rd decades of life. A recent review found about 60 published articles since 1978. [1] It presents as an acute facial eruption of coalescing nodules, pustules and draining sinuses with pronounced erythema and edema. Men are uncommonly affected and extra-facial involvement is rare. [1],[2] A history of seborrhea or sudden increase in oiliness prior to eruption may be elicited. Notwithstanding the fulminant nature of the outbreak, systemic symptoms are uncommon. The etiopathogenesis of rosacea fulminans remains unknown. Plewig et al. in their study classified it as a severe form of rosacea on morphologic and histologic grounds and a history of flushing in their patients, though this classification is not universally accepted. [3],[4] Recently, Kim et al. reported a case of male rosacea fulminans associated with ocular rosacea and a history of papulo-pustular rosacea. [2] Most patients, however, have no prior history of rosacea and the disease usually does not recur after resolution. Significant associations have been reported with inflammatory bowel disease and pregnancy. Less common associations include rheumatoid arthritis, thyroid and liver diseases, oral contraceptive pills, pegylated interferon alpha-2b and ribavirin therapy and high dose vitamins B6 and B12. [3],[5] Some patients recall major emotional experiences before onset of disease. [5]

Histological examination shows extensive dermal and perifollicular inflammatory infiltrates of neutrophils, lymphocytes, histiocytes and occasional eosinophils, giant cells and granulomas. Cultures are either sterile or grow skin commensals, e.g., Staphylococcus epidermidis, Staphylococcus aureus, Corynebacterium or Propionibacterium species. Gram-negative organisms are rarely isolated.

The differential diagnosis includes acne fulminans which generally afflicts adolescent men with a history of acne vulgaris. Acne fulminans has more comedones, hemorrhagic ulcerations, a more extensive distribution on neck and trunk and prominent systemic symptoms including fever, arthralgia, myalgia and osteolytic bone changes. Gram-negative folliculitis usually presents as a flare of follicular pustules after prolonged antibiotic therapy for acne vulgaris. Other considerations include Sweet′s syndrome, halogenoderma, androluteoma and granulomatous infections.

Systemic prednisolone (0.5-1.0 mg/kg/day) is rapidly effective for rosacea fulminans though relapses are common when it is tapered. Isotretinoin may be started concurrently at low dose, or later after inflammation has abated, to maintain remission. A dose of 0.5-1.0 mg/kg/day over 6-12 months is generally required. Oral tetracycline, erythromycin, dapsone and azithromycin have also been used successfully, the latter often employed in pregnancy where alternatives are limited. Topical therapies include compresses, topical steroids and topical antibiotics. While most reports cite isotretinoin as the most effective treatment, our patient relapsed while on the drug and responded instead to a combination of doxycycline, non-steroidal anti-inflammatory agents and topical metronidazole. Most patients achieve remission within 1 year and relapses are uncommon. Scarring is a significant sequelae. [5]

References
1.
Ribeiro LB, Ramos-e-Silva M. Rosacea fulminans. Cutis 2013;92:29-32.
[Google Scholar]
2.
Kim TG, Noh SM, Do JE, Lee MG, Oh SH. Rosacea fulminans with ocular involvement. Br J Dermatol 2010;163:877-9.
[Google Scholar]
3.
Plewig G, Jansen T, Kligman AM. Pyoderma faciale. A review and report of 20 additional cases: Is it rosacea? Arch Dermatol 1992;128:1611-7.
[Google Scholar]
4.
Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, et al. Standard classification of rosacea: Report of the National Rosacea Society Expert Committee on the Classification and Staging of Rosacea. J Am Acad Dermatol 2002;46:584-7.
[Google Scholar]
5.
Massa MC, Su WP. Pyoderma faciale: A clinical study of twenty-nine patients. J Am Acad Dermatol 1982;6:84-91.
[Google Scholar]

Fulltext Views
828

PDF downloads
305
Show Sections