Diagnosis: Rosacea
The diagnosis is A. Rosacea—the triad of facial telangiectasia, flushing, and papules in a new-onset presentation is characteristic of this chronic inflammatory dermatosis. 1, 2
Why This is Rosacea
The patient's presentation meets the diagnostic criteria established by the British Journal of Dermatology:
- Persistent centrofacial erythema with telangiectasia represents the minimum diagnostic feature when combined with periodic intensification by trigger factors 1, 2
- Papules are a major feature that, when combined with the persistent erythema and telangiectasia, confirms the diagnosis 1
- Flushing (transient erythema) is a major feature characterized by intensity, frequency, and duration 1
The centrofacial distribution is essential for diagnosis—rosacea characteristically affects the malar and nasal areas of the face 2, 3
Why Not the Other Options
Acne vulgaris (Option B) is excluded because:
- Acne presents with comedones (blackheads and whiteheads), which are absent in this presentation 4
- Acne lacks the characteristic flushing and telangiectasia seen here 4
- Acne typically affects adolescents and young adults, while rosacea typically presents between ages 30-60 5, 4
Systemic lupus erythematosus (Option C) is excluded because:
- SLE presents with a malar "butterfly" rash that spares the nasolabial folds, whereas rosacea involves the entire central face including the nose 2
- SLE lacks the papulopustular component and telangiectasia characteristic of rosacea 1
- SLE would present with systemic symptoms (fever, arthritis, fatigue) and laboratory abnormalities (ANA, anti-dsDNA) 2
Critical Next Steps
Evaluate for ocular involvement immediately—ocular rosacea commonly accompanies cutaneous disease and can lead to sight-threatening complications if untreated 2:
- Ask about burning, stinging, dryness, foreign body sensation, or recurrent styes 2
- Examine for blepharitis, meibomian gland dysfunction, conjunctival injection, or corneal involvement 6, 2
- Children with ocular rosacea may present with corneal involvement and potential for visual impairment including corneal melting/perforation 6
Important Clinical Pitfalls
In patients with darker skin tones (phototypes V and VI), diagnosis is challenging because erythema and telangiectasia may not be visible 1, 7:
- Emphasize hyperpigmentation and symptoms of irritation (burning and stinging) in these patients 7
- Do not dismiss the diagnosis simply because classic erythema is not apparent 1
Do not overlook subtle presentations—many patients exhibit only mild signs such as telangiectasia and a history of easy facial flushing, leading to missed diagnoses 6