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Granulomatous Rosacea

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Rosacea Variant:
Granulomatous Rosacea [also known as Lupoid rosacea]

This is the only variant as of this date recognized by the NRS 'expert committee' who first classified rosacea into subtypes and variants. This variant of rosacea is characterized by firm, yellow, brownish or redish, cutaneous papules or nodules. These lesions are less inflammatory and frequently sit upon relatively normal-appearing skin but sometimes it is diffusely red and thickened. Typically, they are monomorphic in each individual patient affecting the cheeks and the periorifical areas. For diagnosing this form of rosacea, other signs and symptoms of rosacea are not necessary. Diascopy with a glass spatula reveals the lupoid character of the infiltrations. Lupoid or granulomatous rosacea may lead to scarring of the skin. [1]

"Granulomatous rosacea is a rare chronic inflammatory skin disease with an unknown origin. The role of Demodex follicularum in its pathogenesis is currently proved." [9]

Granulomatous rosacea Image Dermatology Online Journal

One source describes granulomatous rosacea:

"A rare caseating granulomatous variant of rosacea (acne agminata/lupus miliaris disseminatus faciei) can manifest with inflammatory erythematous or flesh-colored papules distributed symmetrically across the upper part of the face, particularly around the eyes and the nose. The lesions tend to be discrete, and surrounding erythema is not a marked feature but may be present. This pattern of rosacea is sometimes associated with scarring and may be resistant to conventional treatment." [1]

"...Although usually considered a non-pathogenic parasite in parasitological textbooks, Demodex folliculorum has been implicated as a causative agent for some dermatological conditions, such as rosacea-like eruptions and some types of blepharitis. Several anecdotal reports have demonstrated unequivocal tissue damage directly related to the presence of the parasite. However, this seems to be exceedingly rare, in contrast with the marked prevalence of this infestation. We have had the opportunity to observe one of such cases. A 38-year-old woman presented with rosacea-like papular lesions in her right cheek. Histopathological examination revealed granulomatous dermal inflammation with a well-preserved mite phagocytized by a multinucleated giant cell. This finding may be taken as an evidence for the pathogenicity of the parasite, inasmuch as it does not explain how such a common parasite is able to produce such a rare disease." It is associated with demodex. [2]

"Histological investigation revealed follicular cysts and a chronic granulomatous perifolliculitis with many of Demodex folliculorum." [3] Another report had a similar finding. [4]

A report by Neri, et. al., suggested that Idiopathic Facial Aseptic Granuloma (IFAG), or pyodermite froide du visage be "considered the possibility that IFAG might be included in the spectrum of granulomatous rosacea (GR)." [5]

Treatment

Dapsone [6]

Isotretinoin (10-20 mg daily) [7]

"The aetiopathogenetic role of Helicobacter pylori in rosacea remains controversial. We report a 27-year-old man with a 4-year history of intractable rosacea. Histopathology showed epithelioid granulomas. H. pylori infection was proven directly on gastroscopy and by serological testing. Treatment with clarithromycin, metronidazole and pantoprazole eradicated H. pylori. Skin changes were markedly improved by the end of this therapy and had resolved completely 2 months later. The patient has been followed up, and has remained free of symptoms for 3 years. We suggest that H. pylori may be involved in the aetiopathogenesis of granulomatous rosacea." [8]

elmonxito says he is convinced that removing some of his infected teeth improved his granulomatous rosacea. [10]

End Notes

[1] rosacea.dermis.net

[2] Granulomatous rosacea associated with Demodex folliculorum.
Amichai B, Grunwald MH, Avinoach I, Halevy S.
Int J Dermatol. 1992 Oct;31(10):718-9.

[3] Tubero-pustular demodicosis
Grossmann B, Jung K, Linse R.
Hautarzt. 1999 Jul;50(7):491-4.

[4] Demodex folliculorum and the histogenesis of granulomatous rosacea
Grosshans EM, Kremer M, Maleville J.
Hautarzt. 1974 Apr;25(4):166-77.

[5] Should Idiopathic Facial Aseptic Granuloma Be Considered Granulomatous Rosacea? Report of Three Pediatric Cases.
Neri I, Raone B, Dondi A, Misciali C, Patrizi A.
Pediatr Dermatol. 2012 Feb 16. doi: 10.1111/j.1525-1470.2011.01689.x.

[6] Hautarzt. 2013 Apr;64(4):226-8. doi: 10.1007/s00105-013-2556-7.
Successful treatment of granulomatous rosacea with dapsone.
Ehmann LM, Meller S, Homey B.
Hautklinik des Universitätsklinikums Düsseldorf, Moorenstr. 5, 40225, Düsseldorf, Deutschland.

[7] Hautarzt. 2013 Nov 1.
Lupoid rosacea as a special form of rosacea : Review of pathogenesis and therapeutic options.
Vanstreels L, Megahed M.
Source
Klinik für Dermatologie und Allergologie, Universitätsklinikum der RWTH Aachen, Pauwelsstr. 30, 52074, Aachen, Deutschland

[8] Eur J Gastroenterol Hepatol. 2001 Nov;13(11):1379-83.
Resolution of granulomatous rosacea after eradication of Helicobacter pylori with clarithromycin, metronidazole and pantoprazole.
Mayr-Kanhäuser S1, Kränke B, Kaddu S, Müllegger RR.

[9] J Med Case Rep. 2017; 11: 230.
Published online 2017 Aug 20. doi:  10.1186/s13256-017-1401-5 PMCID: PMC5563383
Granulomatous rosacea: a case report
A. Kelaticorresponding author and F. Z. Mernissi

[10] Demodex follicularum connected to Granulomatous rosacea, post no 4 by elmonxito

Other Sources

A case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affect the face.
Omar Khokhar MD, and Amor Khachemoune MD CWS
Dermatology Online Journal 10 (1): 6

Granulomatous rosacea.
Sánchez JL, Berlingeri-Ramos AC, Dueño DV.
Am J Dermatopathol. 2008 Feb;30(1):6-9.

J Cutan Med Surg. 2012 Dec 1;16(6):438-441.
Isotretinoin for the Treatment of Granulomatous Rosacea: Case Report and Review of the Literature.
Rallis E, Korfitis C.

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