Rosacea lupoid L71.8

Special form of rosacea with development of chronic, therapy-resistant, follicular, brown-reddish (lupoid) or red nodules. Diascopy shows a follicle-bound so-called lupoid (yellow-brown) infiltrate, which indicates a granulomatous follicular reaction.

S.a. Rosacea. Furthermore, neurovascular dysregulation and neuroinflammation(!), a disturbed cytokine and chemokine network, misactivation of the antimicrobial peptide cathelicidin, a pathological reaction to colonization by Demodex folliculorum are discussed.

The occurrence of lupoid rosacea under therapy with Infliximab or Etanercept was described sporadically.

m:w=1:1; age of manifestation: 30-60 years

Nose, cheeks (centrofacial parts), upper and lower eyelids.

Disseminated, centrofacially localized, chronic clinical picture with 0.2-0.3 cm follicular and non follicular, red or brown-red (lupoid), smooth but also scaly or scaly-crusted papules, which can also (untreated) confluent to larger (granulomatous) plaques and nodules (could then be called rosacea granulomatosa; see also rosacea conglobata). There are clinically and histologically fluid transitions to "lupoid" perioral dermatitis.

Spotted dense, predominantly follicular, more rarely perivascular infiltrates from lymphocytes, neutrophil granulocytes, epithelial cells with giant cells, lymphocytes and plasma cells. Dilated blood and lymph vessels, edema of the dermis. Often also actinic elastosis. There is a tendency for inflammatory infiltration of the follicular epithelium. The epithelial cell character of the perifollicular granulomas may be in the foreground of the histological picture. Melting is absent. The follicles themselves may be dilated and contain (sometimes numerous) follicular mites.

Histological pattern: Perifollicular and perivascular dermatitis with epithelioid cell granulomas in the middle and deep dermis, lymphocytes and plasma cells. Frequent detection of demodex mites.

• See below Rosacea.
• Tetracyclines (e.g. Tetracycline Kps.) in a low dosage of 50 mg/day p.o. or minocycline (e.g. Klinomycin) 50 mg/day p.o. should be used as first-step therapy. The therapy should initially be designed for a period of 2-3 months.
• Clinical experience with systemic isotretinoin is sufficiently large for this indication. The therapeutic success has been proven in double-blind studies at doses of 0.3.g/kgKG p.o.. However, experience has shown that lower initial doses of 0.1-0.2 mg/kgkg p.o. and 10 mg p.o. every second day as long-term therapy are sufficient.
• Other therapy options are of much less value:
  • Alternative with limited clinical benefit: metronidazole (e.g. Clont) 1-1.5 g/day, isoniazid (e.g. Isozid Tbl.) 5 mg/kg bw/day or dapsone(DADPS) in a dosage of 50-100 mg/day p.o..
  • Alternative: In case of theapieresistance a therapy with an antiscabiosum for several days is recommended (e.g. 5% permethrin cream).

It is doubtful to what extent a differentiation from granulomatous rosacea is necessary. Probably it is an identical symptom complex with different expressiveness. To what extent lupoid rosacea can be distinguished from lupus miliaris disseminatus faciei is uncertain.

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2. Hafeez ZH (2003) Perioral dermatitis: an update. Int J Dermatol 42: 514-517
3. Lewandowsky F, Lutz W (1922) A case of a previously undescribed skin disease (epidermodysplasia verruciformis). Arch Dermatol Syphil (Berlin) 141: 193-202.
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5. Snapp RH (1949) Lewandowsky's rosacea-like eruption. A clinical study. J Invest Derm 13: 175-190
6. Urbatsch AJ et al (2002) Extrafacial and generalized granulomatous periorificial dermatitis. Arch Dermatol 138: 1354-1358
7. Vanstreels L et al (2013) Lupoid rosacea as a special form of rosacea. Dermatologist 64: 886-888
8. Winter UM et al (2008) A case of granulomatous rosacea temporally associated with etanercept. Dermatologist 59: 724-727