Rosacea Fulminans: Causes And Treatments

Rosacea fulminans or pyoderma faciale is a rare cutaneous disorder that usually affects women between the ages of 15-46. The disease is characterized by sudden onset of papules, pustules, cysts, and painful coalescing nodules with red-cyanotic centrofacial erythema. Although its etiology remains unknown, hormonal, immunological, and vascular factors have been reported. Early diagnosis and prompt treatment should minimize unsightly scars.

Pyoderma faciale presents as unsightly and painful large red bumps (nodules), pustules, and sores on very red areas of the cheeks, chin, and/or forehead. The lesions may leave scars. Despite the severity of the inflammation, there are no internal symptoms. No infective organisms are found in bacterial cultures of the affected skin.

As this condition is rare, it is not certain which is the best medication to use. The following oral medications may help:

Antibiotics are commonly used to treat acne. They are available as topical preparations for mild acne, and as tablets, capsules, and elixirs for oral use in moderate and severe acne. A doctor's prescription is required to obtain antibiotics. Antibiotics or brand names are available on prescription. Antibiotics have two main effects on acne:

• They reduce the number of bacteria on the skin surface and in the follicles, including Cutibacterium acnes (also known as Propionibacterium acnes)

• They have an anti-inflammatory action.

Isotretinoin (13-cis retinoic acid) is a vitamin-A derivative (retinoid). The liver naturally makes small quantities of isotretinoin from vitamin A, but the drug we prescribe is made synthetically. 

Isotretinoin was developed in the 1950s but only started being used in the mid-1970s. The original brand names were Accutane® and Roaccutane®, but there are now many generic versions on the market, of varying potency. In New Zealand, oral isotretinoin is available in 5 mg, 10 mg, and 20 mg capsules.

A corticosteroid taken by mouth or given by intramuscular injection is often called a systemic steroid. Systemic steroids are synthetic derivatives of the natural steroid, cortisol, produced by the adrenal glands, and have profound anti-inflammatory effects. Systemic (cortico)steroids are also called glucocorticoids or cortisones. They include: Prednisone, Prednisolone, Methylprednisolone And Beclomethasone Prednisone and prednisolone are equivalent and are the most prescribed oral corticosteroids for inflammatory skin diseases. Oral prednisone is the most prescribed systemic steroid in New Zealand. Fludrocortisone is predominantly a mineralocorticoid and its anti-inflammatory effects are minimal. Systemic steroids differ in dose, mineralocorticoid potency, half-life (duration of action), and how effectively they suppress the hypothalamic-pituitary-adrenal (HPA) axis (suppression leads to reduced production of natural cortisol).

Most cases can be expected to clear up with a combination of these medications taken for 3 to 6 months. Treatment for less than one month is considered short-term treatment. Corticosteroids for a few days or weeks are relatively safe when prescribed for acute dermatitis. Treatment continuing for more than 3 months is regarded as long-term and results in the majority of undesirable side effects.

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