Rational Management of Papulopustular Rosacea With Concomitant Facial Seborrheic Dermatitis-A Case Report

Wendy L. McFalda, DO; Heather L. Roebuck, BS, MSN, FNP-BC
Clarkston Dermatology, Clarkston, Michigan

Objective: To report a case of papulopustular rosacea with concomitant seborrheic dermatitis and discuss how signs and symptoms were ameliorated using a rational therapeutic approach. Design: Patient case report. Setting: Clinical practice. Participant: One male patient with rosacea, seborrheic dermatitis, and actinic keratoses. Measurements: Change in signs and symptoms over time. Results: Improved skin care practices and treatment with azelaic acid 15% gel twice daily in combination with low-dosage oral isotretinoin resulted in improvement in symptoms of both rosacea and seborrheic dermatitis. Conclusion: In patients with multiple skin disorders, use of medications with benefits for more than one of the skin conditions may, in some cases, reduce the overall number of medications needed, thus simplifying treatment.  (J Clin Aesthet Dermatol. 2011;4(1):40–42.)

Rosacea is a common inflammatory skin disorder characterized by facial erythema, papules, and pustules; it is reported to affect approximately 16 million Americans.[1] As there are many common facial dermatoses, rosacea often coexists in a given patient with other facial skin disorders, such as actinic keratosis, acne vulgaris, and/or seborrheic dermatitis.[2] The presence of these concomitant conditions can confound diagnosis. Acne vulgaris and rosacea, for example, often appear to be quite similar, although rosacea lacks the comedones of acne and is often associated with confluence of erythema and presence of inflammatory papules and pustules on the central face.

Beyond confounding diagnosis, the presence of concomitant skin disorders may complicate treatment, in some cases necessitating the use of different therapeutic agents. There is often, however, an opportunity to use treatments that, due to their multiple mechanisms of action, are beneficial not only for rosacea, but also for other coexisting skin conditions. The authors report here a case of papulopustular rosacea with concomitant seborrheic dermatitis as well as actinic keratoses and discuss how therapy was carried out with a single topical agent that addressed more than one concomitant facial dermatosis, in combination with intermittent systemic therapy. The importance of recommending a gentle skin care regimen in patients with rosacea is also emphasized.

Case Report
A 78-year-old Caucasian man with Fitzpatrick skin type 2 presented with papulopustular and phymatous rosacea. He had concomitant seborrheic dermatitis of 15 years’ duration and a history of actinic keratoses on the forehead and right ear, which had previously been treated with cryosurgery.

The patient’s rosacea was first diagnosed in 1960 when he was 29 years old. Between 1994 and 2004, he managed his rosacea with the brand formulation of metronidazole gel 0.75% twice daily. In 2004, he was switched to the generic metronidazole gel 0.75%, which he used through 2006. At presentation, his skin care regimen consisted of a common brand sensitive skin cleanser.

In February 2009, the patient presented with erythema, papules, pustules, and rhinophyma (Figure 1). He reported concerns regarding the progression of phymatous changes on his nose and expressed interest in a new treatment regimen to more effectively manage his rosacea. He was initiated on azelaic acid (AzA) 15% gel twice daily in combination with isotretinoin 40mg twice weekly. In addition, the importance of a good skin care regimen as an integral component of rosacea therapy was discussed with him, and the patient was instructed to use a ceramide-based hydrating cleanser (CeraVeTM, Coria Laboratories, Fort Worth, Texas) and moisturizing lotion (CeraVeTM) and Neutrogena Healthy Defense® SPF 45 Daily Moisturizer with Helioplex® (Neutrogena, Los Angeles, California).

In March 2009, the patient returned for management of actinic keratoses, which were successfully treated with cryosurgery. He remained motivated and adhered to the prescribed treatment plan for rosacea and seborrheic dermatitis. He continued to be monitored monthly in accordance with the iPLEDGE program requirements through his Veterans Affairs health services.

In May 2009, the patient returned for follow up. Papules, pustules, and erythema were reduced, and his nose appeared less phymatous (Figure 2). Significant improvement was noted in his inflammatory papules and facial scaling, and sebaceous hyperplasia lesions decreased in number and size. His treatment is ongoing.

AzA is a naturally occurring dicarboxylic acid with anti-inflammatory, antimicrobial, antikeratinizing, antioxidant, and antityrosinase mechanisms of action.[3,4] Indicated for the treatment of rosacea, the multiple mechanisms of action of AzA gel 15% would suggest utility in other skin conditions as well, including seborrheic dermatitis. A recent pilot study conducted in patients who had mild-to-moderate facial seborrheic dermatitis found that six weeks of treatment with AzA 15% gel twice daily resulted in a more rapid onset of therapeutic effect and a greater improvement in scaling, erythema, and pruritus than vehicle alone.[5]

Isotretinoin, an oral retinoid, is most commonly used for the treatment of severe, refractory, inflammatory acne. It has also been used to treat rosacea in patients who experienced insufficient or transient effects with the use of conventional topical and systemic therapies.[6] Treatment with oral isotretinoin 10mg/day for 16 weeks resulted in significant decreases in papules, pustules, erythema, and telangiectasias. The risk of potential side effects associated with systemic isotretinoin therapy and its lack of an approved indication for rosacea treatment may limit its utilization to treat papulopustular rosacea that has truly failed to respond to other options.[7]
Isotretinoin, by reducing sebum production, can also improve the symptoms of seborrheic dermatitis. In a small study, 10 men with seborrheic dermatitis were treated with isotretinoin 1mg/kg/day for six weeks. All showed significant improvement in symptoms.[8] In the case presented here, the choice of isotretinoin 40mg was influenced by the limitations of the patient’s insurance, which would only cover isotretinoin 40mg. A twice-weekly dosing schedule was used to achieve an overall lower dose of isotretinoin more similar to that typically used for rosacea.

This case clearly illustrates the importance of sunblock in a skin care regimen. The development of actinic keratoses increases with greater ultraviolet light exposure, which also exacerbates signs and symptoms of rosacea.[9,10] Photoprotection is an important component of therapy for both rosacea and actinic keratoses.[11]

Here the authors report on a case in which a patient with papulopustular rosacea and facial seborrheic dermatitis was successfully treated with a single topical medication, an oral medication, and the incorporation of a gentle skin care regimen. AzA gel 15% twice daily was used in conjunction with isotretinoin 40mg twice a week, skin-care education, a gentle skin-care regimen, and photo-protection. In patients with multiple skin disorders, use of medications that can yield therapeutic benefits for more than one of their conditions may reduce the overall number of medications needed, thus simplifying treatment and reducing cost of therapy. Isotretinoin, indicated for the treatment of severe recalcitrant nodular acne, in this case was used for its benefits for both the patient’s rosacea and seborrheic dermatitis. AzA 15% gel, a medication approved for treatment of papulopustular rosacea, exhibits multiple properties, including anti-inflammatory, antimicrobial, anti-keratinizing, comedolytic, antioxidant, and antityrosinase effects, some of which may be operative in the treatment of both papulopustular rosacea and seborrheic dermatitis. Other potentially concurrent common facial disorders for which AzA may be of therapeutic benefit include acne vulgaris and hyperpigmentation.

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