Diagnosis: Rosacea (Papulopustular Subtype)
The clinical presentation of facial redness and pustules that does not spare the nasal folds is diagnostic of rosacea, specifically papulopustular rosacea, and should be treated initially with topical metronidazole or azelaic acid, with consideration of systemic doxycycline for more extensive disease. 1, 2
Key Diagnostic Features
The involvement of the nasal folds is the critical distinguishing feature here:
- Rosacea characteristically affects the nasal folds, involving the central face including cheeks, nose, chin, and forehead 1, 3
- This contrasts with seborrheic dermatitis, which typically spares the nasal folds
- The presence of pustules on an erythematous background is characteristic of papulopustular rosacea (Stage III) 4, 2
- Rosacea most commonly presents between ages 30-60 years 1, 5
Initial Treatment Algorithm
First-Line Topical Therapy
Start with topical metronidazole or azelaic acid for inflammatory lesions and erythema 1, 2:
- Metronidazole 0.75% or 1% gel/cream applied once or twice daily 6
- Azelaic acid 15% gel or foam applied twice daily 6
- Ivermectin 1% cream is also effective for papules and pustules 6, 2
Adjunctive Therapy for Erythema
- Brimonidine 0.33% gel once daily for persistent facial redness 6, 1
- Oxymetazoline HCl 1% cream for erythema 6
Systemic Therapy Indications
Add oral doxycycline if topical therapy alone is insufficient or disease is extensive 1, 2:
- Low-dose doxycycline 40 mg modified-release capsules once daily (subantimicrobial dose) 6, 1
- This formulation provides anti-inflammatory effects without antimicrobial resistance concerns
- Standard-dose tetracyclines (doxycycline 100 mg twice daily or tetracycline 500 mg twice daily) for more severe cases 5
Emerging Options
- Encapsulated benzoyl peroxide 5% (E-BPO) shows rapid onset by Week 2 with excellent tolerability and sustained results up to 52 weeks 6
- Minocycline foam 1.5% is a newer topical option approved in 2020 6
Essential Maintenance Measures
All patients require trigger avoidance and gentle skin care regardless of pharmacologic treatment 1, 2:
- Daily broad-spectrum sunscreen (minimum SPF 30) 1
- Mild, non-irritating cleansers and moisturizers 1, 2
- Avoid triggers: alcohol, spicy foods, hot beverages, temperature extremes, stress 5
Critical Pitfalls to Avoid
Do not use topical corticosteroids on the face - this can cause steroid rosacea, a severe complication characterized by worsening papules, pustules, and erythema 4
Screen for ocular involvement - ocular rosacea occurs commonly and includes conjunctivitis, blepharitis, burning, and grittiness 1, 5. Refer to ophthalmology if present, as this requires specific management with lid hygiene, topical cyclosporine, and potentially systemic antibiotics 1
Consider quality of life impact - rosacea significantly affects emotional health, self-esteem, and social functioning due to its facial location 3, 2. Address psychological impact and consider referral for mental health support if needed.
When to Refer
- Fixed phymatous changes (skin thickening, especially rhinophyma) require laser, light-based therapies, or surgical intervention 1, 2
- Ocular rosacea with significant symptoms warrants ophthalmology consultation 1, 2
- Refractory disease not responding to standard topical and systemic therapy 2
Special Considerations
In patients with skin of color, diagnosis may be delayed because erythema and telangiectasia are more difficult to visualize 2. Look for other features including papules, pustules, skin texture changes, and patient-reported flushing or burning sensations.
The phenotype-based approach endorsed by international consensus prioritizes treating the specific features most troubling to the patient rather than following a rigid algorithm 6, 3. Tailor therapy to whether inflammatory lesions, erythema, or both predominate.