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FA L L C L I N I C A L D E R M AT O L O G Y C O N F E R E N C E P R O C E E D I N G S
IS IT REALLY ROSACEA?
A DISCUSSION OF DIFFERENTIAL DIAGNOSES, TREATMENTS
AND ADVANCES IN RESEARCH
BY JOSEPH BIKOWSKI, M.D.
BIKOWSKI SKIN CARE CENTER
SEWICKLEY, PA
There have been few, if
any, new systemic or topical
medications developed
in the last few years for the
treatment of rosacea, so oftentimes,
advancement in therapy
relies upon the correct diagnosis.
The right medicine will not work
with the wrong diagnosis. For
Joseph Bikowski, M.D. every individual who pre s e n t s
with a red, scaly face, the dermatologist
will consider the differential diagnoses: rosacea, seborrheic
dermatitis, irritant contact dermatitis, allergic contact
dermatitis, etc. Is it really rosacea? Are there other things that
can look like rosacea?
D I F F E R E N T I A L DIAGNOSES AND UNUSUAL
FACES OF ROSACEA
D e m o d ex d e r m a t i t i s . When patients present with red, scaly
faces, the first consideration is whether there is an “infectious”
component or an infestation that can be cured or suppre s s e d
for a prolonged period of time. Cases of D e m o d e x d e r m a t i t i s
can be treated with permethrin (Elimite) or crotamiton (Eurax)
twice daily, morning and night, for 2 to 4 weeks.
Case 1. A patient had been treated for almost 2 years for
rosacea and then seborrheic dermatitis without improvement
(Figure 1). A potassium hydroxide (KOH) preparation revealed
Demodex. Because no other treatment had been effective,
the patient was started on Elimite twice daily, and within 2
weeks, his face cleared. The red, scaly rash over his forehead,
nose and malar eminence disappeared. The patient
remained clear at 1-year follow-up.
Rosacea, seborrheic dermatitis and D e m o d e x d e r m a t i t i s
can exist separately or together. Oftentimes, the red scaling
is not seborrheic dermatitis with rosacea or seborrheic
dermatitis alone. Rather, it may be D e m o d e x d e r m a t i t i s .
Patients in whom the diagnosis of rosacea is suspected
should have KOH preparations performed on scrapings of
the scales from their faces and empirical treatment with
either Elimite or Eurax twice daily, morning and night, for 2
weeks. Individuals who are not improving with anti-ro s a c e a
therapy or anti-seborrheic dermatitis therapy who still have
red, scaly faces should receive one of these topicals twice
daily for 2 to 4 weeks.
Steroid use/abuse/misuse dermatitis. Another unusual
p resentation that may resemble rosacea is stero i d
use/abuse/misuse dermatitis. Any cortisone molecule used
frequently over a long period of time in a susceptible individual
can produce steroid use/abuse/misuse dermatitis.
Case 2. A 26-year-old woman presented with an
intensely pruritic, erythematous, scaly, papular eruption of 6
months’ duration on her face (F i g u re 2). For that period of
time, she had been applying a topical corticosteroid to her
face 4 times daily. The steroid responsible for this was
0.5% hydrocortisone cream.
PATIENTS IN WHOM THE DIAGNOSIS
OF ROSACEA IS SUSPECTED SHOULD
HAVE KOH PREPARATIONS
PERFORMED ON SCRAPINGS OF THE
SCALES FROM THEIR FACES.
Plaque ro s a c e a . The usual presentation for rosacea is erythema,
papules and pustules on the central third of the face.
H o w e v e r, there is a presentation called plaque rosacea in which
erythema, edema, papules and pustules appear only in one isolated
area, ie, on one cheek (F i g u re 3). These patients re s p o n d
to rosacea therapy, especially systemic therapies.
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