Case Study : Infection and Sepsis
23. Pustular eruption on face
A 30-YEAR-OLD WOMAN came into our clinic for treatment of a facial rash. She said that she first noticed the rash (FIGURE) about 2 months earlier. Over the previous month, the eruption had worsened. Interestingly, the patient noted that she had started Bikram yoga (an intensive form of yoga performed in a room heated, in this case, to 105°F) 5 weeks prior to the onset of symptoms.
She was taking the yoga classes 2 to 4 times a week and said that she experienced an exacerbation of her symptoms after each 1-hour session.
Our patient had rosacea, an inflammatory condition of the skin that typically affects the convex portions of the central face. This chronic cutaneous disorder usually starts after age 30 in both men and women, and is more prevalent in those with fairer skin.(1).
In fact, an epidemiologic study showed the prevalence to be as high as 10% in the Swedish population.(2).
The condition, which is not life threatening, can be controlled, although not cured.
Its effect on appearance may have a negative impact on a patient’s quality of life.
The etiology and pathogenesis of rosacea are unknown.
However, different pathogenic mechanisms have been discussed in the literature, including vasculature reactivity, dermal matrix degeneration, microbial organisms, and activities that cause flushing or blushing, such as spicy food, alcohol consumption, or emotional stressors.
Rosacea flare-ups have also been linked to extremes in temperature, as was the case with our patient.
Due to the varied clinical manifestations, it is likely that genetics may also play a role in the development of rosacea.(3,4).
The differential. Rosacea can be confused with acne, systemic lupus erythematosus, and sarcoidosis.
A standardized approach to diagnosing rosacea
In 2002, an expert committee assembled by the National Rosacea Society established primary and secondary criteria for diagnosing rosacea.(5). Diagnosis is based on the presence of 1 or more of the following signs in a central face distribution:
flushing (transient erythema)
papules and pustules
Additionally, 1 or more of the following secondary features may also be present:
burning or stinging
elevated red inflammatory papules or plaques
phymatous changes (most commonly on the nose).
Rosacea comes in many forms
According to the expert committee assembled by the National Rosacea Society, the primary and secondary features (above) can be used to designate specific subtypes of rosacea.
Erythematotelangiectatic rosacea is generally characterized by flushing and persistent central facial erythema.
However, a history of flushing alone is common among these patients.(5).
Flushing episodes usually last longer than 10 minutes (3) and can be triggered by any vasodilating stimulus, like exercise, cold, heat, sunlight, hot beverages, or alcohol.(6-8).
Papulopustular rosacea is the form of rosacea that our patient had, and is known as classic rosacea or pink papular rosacea.
It is characterized by persistent erythema in the central portion of the face with persistent or episodic papules and/or pustules. These inflammatory papules and pustules may also occur in the perioral, perinasal, or periocular areas (5).
Edema may accompany inflammatory episodes, but is frequently subtle.(9)
This subtype may be confused with acne vulgaris.
The key to differentiation is looking for comedones; they are present in acne vulgaris, but absent in papulopustular rosacea. However, both rosacea and acne may be present in the same patient, making diagnosis and treatment more difficult.
Phymatous rosacea usually involves the nose (rhinophyma), but can also affect the forehead, chin, cheeks, and ears.
The distinct appearance of this subtype comes from enlargement, thickened skin, and irregular surface nodularities.(5) Historically, rhinophyma has been associated with alcoholism, but there is no clear evidence of this association.(10).
Ocular rosacea affects the eyelids, conjunctiva, and cornea.
Consider this diagnosis when there is 1 of more of the following findings: foreign body sensation, burning or stinging, dryness, itching, photosensitivity, blurred vision, conjunctival telangiectases, or periorbital edema.(5).
Corneal involvement can threaten sight, and up to 58% of rosacea patients may experience ocular manifestations.(11) Therefore, it is imperative that you ask patients with rosacea if they’ve had any problems with their eyes, and that you examine the conjunctivae and eyelids.
Tx hinges on oral, topical agents—as well as avoidance
Erythematotelangiectatic and papulopustular rosacea have common therapies that include a long list of oral and topical agents. Agents that are most commonly used include oral tetracyclines, topical sodium sulfacetamide, azelaic acid, and metronidazole.(12).
Another approach to treatment is called the “avoidance policy,” where triggers for blushing and facial erythema are identified and then avoided.
One survey by the National Rosacea Society study found that 78% of patients felt that avoiding triggers was at least somewhat effective in controlling their rosacea.(13).
Time for a different form of yoga?
Because our patient developed papulopustular rosacea after taking Bikram yoga classes, we advised her to avoid this particular form of exercise because of the heat.
We told her that she could, however, participate in other forms of yoga, as long as they were not done in a hot environment.
Due to the severity and severe inflammatory nature of her eruption, we started the patient on oral minocycline 100 mg twice daily, and 3 topical medicines including sodium sulfacetamide/sulfur 10%/5% wash, followed by azelaic acid 20% cream every night, and metronidazole 1% gel every morning to the affected areas.
Our patient’s condition responded to treatment. The erythema on her face improved and the number of papules and pustules declined.
CORRESPONDENCE: Heather W. Wickless, MD, MPH, Durango Dermatology, 523-B South Camino del Rio, Durango, CO 81303;
1. Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Dermatol Venereol. 2005;19:273-285.
2. Berg M, Liden S. An epidemiological study of rosacea. Acta Derm Venereol. 1989;69:419-423.
3. Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis, and subtype classification. J Am Acad Dermatol. 2004;51:327-341.
4. Diamantis S, Waldorf HA. Rosacea: clinical presentation and pathophysiology. J Drugs Dermatol. 2006;5:8-12.
5. Wilkin J, Dahl M, Detmar M, 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;46:584-587.
6. Wilkin JK. Oral thermal-induced flushing in erythematotelangiectatic rosacea. J Invest Dermatol. 1981;76:15-18.
7. Wilkin JK. Flushing reactions: consequences and mechanisms. Ann Intern Med. 1981;95:468-476.
8. Dupont C. The role of sunshine in rosacea. J Am Acad Dermatol. 1986;15:713-714.
9. Chen DM, Crosby DL. Periorbital edema as an initial presentation of rosacea. J Am Acad Dermatol. 1997;37:346-348.
10. Curnier A, Choudhary S. Rhinophyma: dispelling the myths. Plast Reconstr Surg. 2004;114:351-354.
11. Akpek EK, Merchant A, Pinar V, Foster CS. Ocular rosacea: patient characteristics and follow-up. Ophthalmology. 1997;104:1863-1867.
12. Gupta AK, Chaudhry MM. Rosacea and its management: an overview. J Eur Acad Dermatol Venereol. 2005;19:273-285.
13. National Rosacea Society. Survey finds that rosacea flare-ups are common but can be controlled. Spring 1999. Rosacea Rev. Available at: Accessed March 19, 2009.
Sodium sulfacetamide/sulfur 10%/5% wash is N/A in Ireland.
Azelaic acid 20% cream is available in Ireland as Skinoren 15% gel
Metronidazole 1% gel is available in Ireland as Rozex 0,75% aqu. gel , and Rosex 0,75 cream
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