Rosacea fulminans in pregnancy: successful treatment with azithromycin

Rosacea fulminans (RF) is an uncommon condition, mainly affecting women, usually several years after adolescence. It is characterized by the sudden onset of papules, pustules and nodules strictly located on the face. It is rarely accompanied by systemic symptoms, and is often (but not necessarily) preceded by seborrhoea, chronic acne vulgaris or rosacea. Although the aetiology is unknown, immunological, hormonal and vascular factors have been suggested. The differential diagnosis includes acne conglobata, acne fulminans, Gram-negative folliculitis, bromoderma, iododerma and androluteoma (luteoma of pregnancy that produces an excessive amount of male sex hormones). We describe a case of RF presenting in pregnancy. A 33-year-old woman presented with a 3-week history of facial eruption, within the 11th week of her first pregnancy. She had no history of dermatological disease. On physical examination, papules, pustules and nodules were seen on the patient s face, without comedones or systemic symptoms (Fig. 1a). There were no acneiform lesions on the chest or back. The patient had previously used topical fusidic acid, mupirocin and topical erythromycin on the facial lesions, without improvement. Cultures for bacterial pathogens were negative, and all blood test parameters were normal. Serology for rubella, toxoplasma, syphilis, hepatitis B and C viruses, and human immunodeficiency were negative. The patient was started on azithromycin 500 mg ⁄ day for three consecutive days (days 1, 2 and 3) each week for the first 4 weeks, then 250 mg ⁄ day on the same days for the next 4 weeks, and 500 mg ⁄ week on day 1 for a further 4 weeks, with topical metronidazole in all 12 weeks. After this treatment, the patient continued with topical metronidazole and topical clindamycin until the seventh month of pregnancy. On one specific inflammatory nodule located on the left cheek, the patient used a topical combination of fusidic acid and 0.1% betamethasone. A rapid therapeutic response to the treatment was seen. By the sixth month of pregnancy, the patient had no skin lesions on her face (Fig. 1b). The usual ultrasonographic gestational controls and blood tests were normal. Pregnancy ended with normal spontaneous vaginal delivery at full term. RF has previously been reported in a few cases associated with pregnancy (Table 1), and in women taking oral contraceptives. As a result, hormonal triggering factors have been suggested. Corticoids and isotretinoin are regarded as the two main therapeutic agents, although isotretinoin is absolutely contraindicated in pregnancy, and the use of systemic steroids in pregnancy can be justified only if the benefits outweigh the risks. Systemic steroids can produce intrauterine growth retardation, maternal diabetes mellitus and hypertension. Tetracyclines, antiandrogenic contraceptives and dapsone are also contraindicated in pregnancy. Azithromycin has recently been found to be an effective alternative for the treatment of inflammatory acne and rosacea. It is better tolerated than erythromycin, and does not pose an increased risk of congenital malformation or miscarriage. We used the treatment guideline proposed by Bakar et al., with a successful response. To our knowledge, this is the fifteenth reported case of rosacea fulminans associated with pregnancy, thus contributing further evidence that pregnancy can exacerbate this condition.