Granulomatous rosacea is considered to be the only true variant of rosacea. Diascopy of larger lesions often reveals apple-jelly nodules, indicating their granulomatous histology. Other signs and symptoms of rosacea are not required to make a diagnosis of granulomatous rosacea. The response to treatment may be slow, which must be the most important consideration for both the clinician and the patient. We present an otherwise healthy 62-year-old non-atopic woman with a 15-year history of episodic facial flushing, often accompanied by a burning sensation without sweating. Exclusively affecting the face, lesions had a high tendency to spread each year. The patient was a lifelong non-smoker. A seller on the local market, she spent most of her time outdoors. She had no positive family history of rosacea. At the time of presentation, she was not taking any medications, except for topical neutral creams. Multiple reddish-brown papules without comedones, associated with telangiectasia were scattered over the erythematous background on the chin, forehead, cheeks, nose, glabella and eyelids, while small pustules clustered over the eyelids. The nasolabial folds, neck and ears were not affected. There was neither lymphadenopathy, nor ocular involvement. Based on the history, physical, laboratory and other relevant investigations including histopathology, the diagnosis of granulomatous rosacea was established. The therapy was conducted with topical azelaic acid 20% cream, twice daily for six months. Clinical evaluation was done every 14 days during the first month, and once monthly during the next five months. Affter two weeks, there was a significant decrease in the mean inflammatory lesion count. At the end of the therapy, telangiectasia and facial erythema almost disappeared. There were no side effects. Apart from several short episodes of erythema, during the five-year-long follow-up, there were no other signs of the disease. In conclusion, azelaic acid 20% cream may be an effective and safe treatment option for some patients with granulomatous rosacea.
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