Acne Rosacea in Skin of Color
A 41-year-old black female presents with an 8-month history of worsening hyperpigmented patches and erythema on her bilateral cheeks as well as years of cystic papules. She has tried over-the-counter products, including benzoyl peroxide creams and bleaching agents, which have only worsened her symptoms. She denies fever, joint pain, photosensitivity, eye discomfort, mucosal lesions, or any other skin lesions.
Physical examination. The exam revealed a Fitzpatrick skin type VI with papules and pustules on a violet erythematous background located on bilateral cheeks. There was slight induration with overlying hyperpigmented patches(Figure 1).
Differential diagnosis included contact and irritant dermatitis, polymorphous light eruption, systemic lupus erythematosus, dermatomyositis, and sarcoidosis.
Laboratory tests. Punch biopsy of left malar cheek on hematoxylin and eosin stain revealed a mild, superficial, perivascular lymphohistiocytic infiltrate, sebaceous hyperplasia with telangiectasias consistent with rosacea (Figure 2). Direct immunofluorescence and patch testing were both negative.
Treatment. The patient was started on a course of oral doxycycline 100 mg PO daily as well as topical metronidazole gel. Her follow-up visit showed improved symptoms.
Discussion. Rosacea is a chronic, relapsing inflammatory disorder that primarily involves the central face and more commonly affects Caucasians of Northern and Eastern European descent.1,2 Clinically there are 4 distinct forms: telangiectatic, papulopustular type, granulomatous rosacea, and hyperplastic glandular type, which is associated with rhinophyma. Ocular rosacea is an extracutaneous form of the disease that does not require cutaneous manifestations for diagnosis.3,4
Presentation. Typically, this disorder manifests with flushing in an individual in their 20s and eventually becomes more problematic after age 30, when there may be central facial edema, telangiectasia, persistent facial erythema, as well as papules and pustules. It has predominance for women, except the rhinophymatous type which is more commonly seen in men. This type is characterized by dilated follicles, tissue hypertrophy, and irregular nodules, which most commonly affect the nose, but can also be seen on the chin, ears, and cheeks.3 In patients of color, yellow-brown nodules and papules with or without post-inflammatory pigmentation changes in the malar, perioral, and periocular regions may present instead of erythematous, inflamed typical papules. Clinically, the granulomatous form of rosacea may present more commonly in African Americans.1,2 Clinically, patients will have varying degrees of erythema depending on the constitutive skin pigmentation.2,3
These patients usually present frustrated and confused that they have developed acne so late in their lives, which seems resistant to all acne treatments. Additionally, they report that past treatments were irritating and likely triggered typical rosacea symptoms.2
Diagnosis. In fair-skinned individuals, thorough history and clinical assessment is usually sufficient for diagnosis. In patients of color, the diagnosis may be more challenging and biopsy may prove to be quite useful. Differential diagnosis in this patient population includes acute and chronic cutaneous lesions of lupus erythematosus, which presents in a photo-distributed area with variable inflammation and lesions that that tend to be better circumscribed. There may even be evidence of scarring and atrophy. Sarcoidosis, which can present with flat-topped reddish brown papules on the face, should also be regarded in the differential diagnosis as this disease has potentially serious systemic manifestations and complications. Other connective tissue diseases, such as dermatomyositis with periorbital violaceous erythema, may also be considered. Additionally, rosacea, which has more centrofacial distribution and lack of comedones, may be difficult to distinguish from acne vulgaris.
Treatment. Treatment should always begin with nonpharmacologic interventions, such as avoidance of triggers of flushing (eg, extremes of temperature, sunlight, spicy foods, alcohol, exercise, acute psychological stressors, and medications). Daily routine should consist of washing the face with a nonsoap, gentle cleanser and twice-a-day skin moisturization, which may be associated with reduction in skin sensitivity. Sunscreen protection (at least SPF 30) and avoiding midday sun exposure is recommended.5 Chemical, as well as manual exfoliation, toners, and astringents, should be avoided.3,6 Aside from behavioral modifications, management with oral tetracyclines, topicals including metronidazole, benzoyl peroxide, sulfa-based products, azaleic acid, and/or retinoic acid remain the mainstay of therapy.7
References:
1.Culp B, Scheinfeld N. Rosacea: a review. PT. 2009;34(1):38-45.
2.Alexis AF. Rosacea in patients with skin of color: uncommon but not rare. Cutis. 2010;86(2):60-62.
3.Crawford GH, Pelle MT, James WD. Rosacea: I. Etiology, pathogenesis and subtype classification. J Am Acad Dermatol. 2004;51(3):327-341.
4.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(4):584-587.
5.Pelle MT, Crawford GH, James WD. Rosacea II. Therapy. J Am Acad Dermatol. 2004;51(4):499-512.
6.Draelos ZD. Facial hygiene and comprehensive management of rosacea. Cutis. 2004;73(3):183-187.
7.Rosen T, Stone MS. Acne rosacea in blacks. J Am Acad Dermatol. 1987;17(1):70-73.