What is the diagnosis and treatment for a 54-year-old man with recurrent episodes of erythema, telangiectasia, and ectasia on the cheeks, nose, and ears, exacerbated by exercise and prolonged outdoor exposure, with symptoms including a stinging sensation but no itchiness or discharge?

Diagnosis: Rosacea (Erythematotelangiectatic Subtype)

This patient has rosacea, diagnosed by the presence of persistent centrofacial erythema with telangiectasia and ectasia, exacerbated by exercise and outdoor exposure, accompanied by a stinging sensation. 1

Diagnostic Rationale

The diagnosis is established based on the following features:

• Persistent centrofacial erythema with periodic intensification by trigger factors (exercise, outdoor exposure) meets the minimum diagnostic criteria for rosacea 1, 2
• Telangiectasia and ectasia on the cheeks, nose, and ears represent major features of rosacea, though not independently diagnostic 1
• Stinging sensation is a recognized minor feature of rosacea 1
• Centrofacial distribution (cheeks, nose) is essential for rosacea diagnosis 1
• Absence of itching or discharge helps distinguish this from other inflammatory dermatoses 1

The phenotype-based classification identifies this as erythematotelangiectatic rosacea, characterized by persistent erythema and visible blood vessels without inflammatory papules or pustules 1, 3

Treatment Approach

First-Line Management

Begin with trigger avoidance and topical brimonidine 0.5% gel once daily for persistent erythema. 4, 5

• Trigger avoidance: Identify and minimize exposure to heat, exercise-induced flushing, prolonged sun exposure, hot beverages, spicy foods, and alcohol 3, 5
• Photoprotection: Use broad-spectrum sunscreen (minimum SPF 30) and wide-brimmed hats, as UV radiation activates inflammatory pathways 1, 5
• Gentle skin care: Use mild, non-irritating cleansers and fragrance-free moisturizers to avoid exacerbating symptoms 5

Pharmacologic Treatment for Erythema

Topical brimonidine 0.5% gel is the most effective agent for reducing persistent erythema through alpha-adrenergic receptor agonism causing vasoconstriction 6, 4, 5

• Apply once daily to affected areas 5
• Onset of action within 30 minutes, lasting up to 12 hours 4
• Alternative: Topical oxymetazoline is another vasoconstrictor option 4

Treatment for Telangiectasia

Intense pulsed light (IPL) or pulsed dye laser therapy is the definitive treatment for telangiectasia and persistent erythema. 6, 4, 7

• IPL and laser therapies target hemoglobin in dilated vessels, providing long-term reduction of visible blood vessels 6, 4
• Multiple sessions (typically 3-5) are usually required for optimal results 4
• Combination therapy: Brimonidine gel plus IPL provides superior outcomes compared to either treatment alone 6

Additional Topical Options

If inflammatory features develop or for additional symptom control:

• Topical metronidazole (0.75% or 1%) or azelaic acid (15% gel or 20% cream) can be added for anti-inflammatory effects 4, 5
• Topical ivermectin 1% addresses potential Demodex mite involvement, which may contribute to inflammation 4, 7

Important Clinical Considerations

Ocular Screening

Evaluate for ocular rosacea, as it commonly accompanies cutaneous disease and can lead to sight-threatening complications if untreated 1, 2

• Ask about eye symptoms: burning, stinging, dryness, foreign body sensation, or recurrent styes 1
• Examine for blepharitis, meibomian gland dysfunction, conjunctival injection, or corneal involvement 1
• If ocular symptoms are present, refer to ophthalmology for lid hygiene instruction, topical cyclosporine, or systemic antibiotics 1, 5

Common Pitfalls to Avoid

• Do not use topical corticosteroids on the face, as they can cause steroid-induced rosacea and worsen the condition long-term 3
• Avoid harsh or abrasive skin care products that can disrupt the skin barrier and trigger flares 5
• Screen for systemic medications that may exacerbate symptoms (antihistamines, vasodilators) 1
• Consider Demodex infestation if symptoms are refractory to standard treatment, particularly in older patients with cylindrical dandruff at lash bases 8

Monitoring and Follow-up

• Assess treatment response at 4-6 weeks 4
• Evaluate each phenotypic feature (erythema, telangiectasia, symptoms) independently rather than using subtype classification 1
• Treatment goals include reducing erythema intensity, decreasing flush frequency, improving patient-reported symptoms, and enhancing quality of life 1