Middle-aged Man Who Claims He Is Not a Drinker

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HISTORY

A 41-year-old man is seen for routine physical examination. Apart from mildly elevated cholesterol 2 years ago and a bout of bacterial bronchitis last winter, he has been healthy. Says he has had “bad acne” since age 21. Has applied drying agents that worsened it and that sting; has “sensitive skin” problems from creams. Now prefers to ignore his facial skin.

PHYSICAL EXAMINATION

Moderately unkempt-appearing but well-spoken man. Vital signs normal. Face and skin as shown. No lesions seen elsewhere on skin or in mucous membranes of his mouth.

WHAT’S YOUR DIAGNOSIS?

(answer on next page)

What’sYour Diagnosis?
ANSWER: ROSACEA

This man’s red, papulopustular, inflamed central and lower face permit a diagnosis of rosacea,¹ a condition of unknown cause that affects nose, cheeks, chin, and sometimes adjacent skin. His overgrown nose constitutes rhinophyma, a subtype of rosacea that chiefly afflicts men. There is no diagnostic test for rosacea, no pathognomonic feature, and even the histopathology on skin biopsy is not unique; so the diagnosis is made clinically, ideally long before rhinophyma can supervene.

The patient’s prominent beard stubble, along with the exposed mesh undershirt, and bits of white material on beard and cheeks, make an impression of carelessness about his appearance in public. We need to be wary of drawing such a conclusion: his uneven skin surface may make shaving painful or bloody, and the white debris could be something applied topically to relieve misery.

Minimal injection of the conjunctivae and some crusting of his lower eyelids could represent ophthalmic rosacea.

The forehead shows just a single papule and a suggestion of thickened skin. Scalp hair and eyebrows appear normal.

SUBTYPES I AND II

Figure 1 – In a young girl with corticosteroid-induced rosacea, central facial predilection is particularly prominent. Erythema is punctuated by papules, some topped by pustules that produce pinpoint white spots. Forehead shows what appears to be ordinary steroid acne, while eyes and periocular skin are spared.

Classification of rosacea brings order to a plethora of red faces and prominent blood vessels on the skin of the nose.^1-5 After onset, often in early to mid-adulthood, progression can occur over decades.

Subtype I ^rosacea usually includes recurrent facial flushing and blushing, more severe than in the general population. For predisposed persons, alcohol triggers or worsens attacks. Inappropriate or excessive vasodilation of facial vessels is part of the problem, but the cause of this vasodilation is unclear. Recognized triggers vary from patient to patient: alcohol, emotional upset, excess sunlight, heat, hot drinks, foods, certain medicines, even menses.

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