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Abstract

Granulomatous rosacea is a chronic inflammatory condition and a rare variant of rosacea, typically seen in middle-aged females. Granulomatous rosacea presenting in children is exceptionally rare, herein we present one such case. An 8-year-old male presented to the clinic with a 2-year duration of papules on his nose that worsened with sun exposure and were resistant to topical treatment with clobetasol, pimecrolimus, tacrolimus, mupirocin and oral treatment with cefadroxil and griseofulvin. On exam, there was a hypertrophic erythematous plaque with sebaceous hyperplasia, cobblestoning, scaling, and milia within the nasojugal folds. A 4mm punch biopsy was performed on the nasal ala. Laboratory evaluation revealed a negative ANA. Microscopic examination demonstrated a dense superficial and deep perifollicular and perivascular inflammatory infiltrate composed of lymphocytes, plasma cells, histiocytes with non-caseating granulomas, and giant cell formation. Gram stain highlighted gram-positive cocci within the stratum corneum, while GMS special stain was negative for fungal organisms, and AFB (Fite) stain was negative for mycobacteria. Previous bacterial and fungal cultures were negative. Based on the clinical and histopathologic findings, the diagnosis of granulomatous rosacea was favored.

The diagnosis of granulomatous rosacea relies on histopathologic evaluation due to its varied clinical presentation and overlap with mimickers such as sarcoidosis, periorificial dermatitis, cutaneous lupus, lupus miliaris disseminates faciei, and granuloma faciale. Within the pediatric population this is a challenging diagnosis considering the rarity of rosacea let alone this rare variant. Greater awareness and early diagnosis are critical to initiating appropriate management and minimizing the risk of long-term scarring.