Rosacea: The Daily PANCE Blueprint
A 46-year-old woman has two years of central facial redness across her cheeks and nose that flares with hot drinks, spicy food, sunlight, and red wine. She now has a few small papules and pustules in the same area, with visible telangiectasias. She reports gritty, burning eyes. On examination there are no comedones anywhere on her face. Which of the following is the most likely diagnosis?
A. Acne vulgaris
B. Seborrheic dermatitis
C. Rosacea
D. Systemic lupus erythematosus
E. Contact dermatitis
Answer and topic summary
The answer is C. Rosacea
Central facial erythema with telangiectasias, flushing triggered by heat, alcohol, spicy food, and sun, and inflammatory papules and pustules WITHOUT comedones is rosacea. The absence of comedones is the single most useful discriminator from acne vulgaris — comedones are the defining lesion of acne and are never a feature of rosacea. Her gritty, burning eyes point to ocular rosacea, which affects up to half of patients and is easy to miss. Management starts with trigger avoidance, gentle skin care, and daily broad-spectrum sunscreen; topical metronidazole, azelaic acid, or ivermectin treat the papulopustular component, brimonidine reduces persistent erythema, and oral doxycycline is added for more severe or ocular disease. Longstanding untreated disease can progress to rhinophyma, the bulbous sebaceous overgrowth of the nose seen mostly in men. Seborrheic dermatitis produces greasy scale in the nasolabial folds and scalp rather than telangiectasias, and the malar rash of lupus characteristically spares the nasolabial folds and comes with systemic findings.
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