These Experts share problem-solving insights about their most challenging acne/rosacea cases.

A 39-year-old man presents with a 1-year history of “bumps” on his scalp. He has a history of flushing and blushing on his face and neck, as well as a history of similar “bumps” of his face, neck and torso. On examination multiple erythematous-based, painful papules and pustules were found on his scalp (see figures 1 and 2). Similar lesions were on his face, neck, chest, shoulders and back. The patient was placed on doxycycline 100 mg per day and was clear of all inflammatory lesions at his 1 month follow-up visit. The dose was then tapered down over the course of the next 2 months to 100 mg every third day. He has remained disease free on this low-dose suppressive therapy. Diagnosing the Condition This patient has rosacea, which classically presents with flushing/blushing and erythematous 1 mm to 4 mm papules and pustules on the central third of the face. It’s most frequently seen in middle-aged females with fair complexions, but men may be more affected than previously recognized. Extra-cutaneous inflammatory lesions (papules and pustules) may also frequently be missed on casual examination unless the neck, scalp and torso are examined. Consider the following conditions in the differential diagnosis: bacterial folliculitis, pityrosporum folliculitis, drug eruption, cutaneous artifactual disease and external trauma. Treatment Topical medications are of little value in the treatment of rosacea scalp disease because it’s difficult to apply the medication directly to the scalp on a regular basis and in a consistent manner. Therefore, a systemic antibiotic is the treatment of choice, preferably doxycycline or minocycline because the once a day dosing schedule facilitates compliance.