Recognizing Rosacea: Tips on Differential Diagnosis

September 2019 | Volume 18 | Issue 9 | Original Article | 888 | Copyright © September 2019

Sandra Marchese Johnson MD FAAD,a Andrew Berg PA,b Chelsea Barr MPAS PA-Cc

ªJohnson Dermatology, Fort Smith, AR

BBerg Consulting and Investments, Inc, Lee’s Summit, MO

cHouston Skin Associates, Houston, TX

signs and symptoms vary from patient to patient.6 It is important for clinicians to be aware of lesion/redness patterns and nuances in order to effectively evaluate patients.

Primarily Lesional Presentation
Acne vulgaris
Acne may be mistaken for rosacea, particularly in adults with late-onset acne (Figure 4).6 Comedones are often present with acne vulgaris and absent with rosacea. Telangectasias are often present with rosacea and absent with acne vulgaris. (Table 2).6 The presence of eye symptoms also tilts the diagnosis toward rosacea.6,18 Rosacea rarely affects children and adolescents, whereas acne is more common in young people than old.10 Acne patients may be less likely to report suffering from flushing compared with rosacea patients.10 Finally, involvement of non-facial areas (chest and back) is common in acne, and rare with rosacea.10 Rosacea affects mainly the central face (cheeks, nose, and forehead). Acne can appear anywhere on the face with hormonal acne more concentrated on the chin, jawline, and neck.

Steroid-induced acne/rosacea/perioral dermatitis
The use of topical or inhaled corticosteroids can result in an acneiform eruption that looks similar to papulopustular rosacea (Figure 5). However, steroid-induced acne usually is seen in a perioral distribution, comedones are absent, and the patient may be older than the typical acne sufferer.6 Lesions resolve when steroid use is discontinued. During history taking, patients should be asked about recent steroid use. As shown in Figure 6, this type of dermatitis manifests as a scaly or red rash around the mouth – sparing the vermillion border – with small papules and scaling. It can also be seen in patients with a history of overuse of heavy face creams and moisturizers. It is most common in young women, but can occur in children and men as well.19

Demodicidosis (Demodex folliculitis) presents as numerous inflammatory papules on the face and occurs when Demodex mites infest the pilosebaceous unit or penetrate dermal tissue.20 Clinically, there can be varying degrees of skin roughness,