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SHORT COMMUNICATION
Year : 2021  |  Volume : 66  |  Issue : 4  |  Page : 401-404
Unusual Spurts of Rosacea Like Dermatoses, Posing a Diagnostic Dilemma During Covid-19 Pandemic: A Cross-Sectional, Observational Study From a Tertiary Care Centre


1 Department of Dermatology, Base Hospital Delhi Cantt, New Delhi, India
2 Department of Pediatrics, Base Hospital Delhi Cantt, New Delhi, India
3 Department of Dermatology, Command Hospital Air Force, Bangalore, Karnataka, India
4 Department of Dermatology, Jorhat Medical College and Hospital, Jorhat, Assam, India
5 Department of Dermatology, Venereology and Leprosy, Command Hospital Air Force, Bangalore, Karnataka, India
6 Department of Dermatology, Venereology and Leprosy, Affiliated Faculty, Armed Forces Medical College, Military Hospital, Kirkee, Pune, Maharashtra, India

Date of Web Publication17-Sep-2021

Correspondence Address:
Barnali Mitra
Department of Pediatrics, Base Hospital Delhi Cantt, New Delhi - 110 010
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijd.IJD_759_20

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   Abstract 


Background: The gradual opening of healthcare system since second week of May 2020 following lockdown imposed due to corona virus pandemic saw spurts of cases of unexplained central facial dermatoses in subset of previously healthy people. The aim of the study was to find out the cause and establish the definitive diagnosis of unusual occurrence of facial dermatoses on previously healthy people so that an appropriate management can be offered to the patients. Materials and Methods: It was a cross-sectional, observational study carried during May 15 to July 15, 2020 at a tertiary dermatology center. All cases presented with erythema on face and papular or pustular lesions on central facial area of not more than 2 months of duration were included in the study. Results: Total 81 patients visited skin OPD with facial dermatoses of various types during this period, out of which 21 patients fulfilled the inclusion criteria. This was 0.72% (21/2900) of total skin OPD of the 2 months. All the patients had been using face masks during this period of symptoms due to the ongoing coronavirus situation. Dermatological examination revealed only erythema on the central area of face (n = 10), erythema and few papules (n = 3), erythmatous papules and pustules (n = 5), and erythematous papules, pustules, and telengiectasia (n = 3). All the skin biopsies showed predominantly epithelioid cells, noncaseating granuloma with a variable degree of infiltrate. Conclusion: There has been a definite change in the lifestyle due to the current Covid-19 pandemic. People are compulsorily using face masks to avoid the spread of Covid-19 infection. This change in behavior has brought out a surge of rosacea like lesions on the covered area of face. Partly, it can be explained by change in innate immunity due to excessive sweating and change in microenvironment of skin.


Keywords: Covid-19, face mask, rosacea


How to cite this article:
Singh GK, Mitra B, Bhatnagar A, Mitra D, Talukdar K, Das P, Patil C, Sandhu S, Sinha A, Singh T. Unusual Spurts of Rosacea Like Dermatoses, Posing a Diagnostic Dilemma During Covid-19 Pandemic: A Cross-Sectional, Observational Study From a Tertiary Care Centre. Indian J Dermatol 2021;66:401-4

How to cite this URL:
Singh GK, Mitra B, Bhatnagar A, Mitra D, Talukdar K, Das P, Patil C, Sandhu S, Sinha A, Singh T. Unusual Spurts of Rosacea Like Dermatoses, Posing a Diagnostic Dilemma During Covid-19 Pandemic: A Cross-Sectional, Observational Study From a Tertiary Care Centre. Indian J Dermatol [serial online] 2021 [cited 2021 Dec 3];66:401-4. Available from: https://www.e-ijd.org/text.asp?2021/66/4/401/326143





   Background Top


The World Health Organization declared Covid-19 a pandemic on March 11, 2020.[1] This created unprecedented lockdown in the movement, and people have been advised to use face masks along with mandatory social distancing to prevent the spread of deadly coronavirus infection. The gradual opening of the healthcare system since second week of May 2020 saw spurts of cases of unexplained central facial dermatoses in a subset of previously healthy people. There are various dermatoses that can present as erythema on the face or papulopustular lesions on the central area of face, e.g. acne, rosacea, topical steroid misuse, photosensitive dermatitis, allergic contact dermatitis, cutaneous sarcoidosis, lupus miliaris disseminatous faciei, facial Afro-Caribbean eruption, and cutaneous tuberculosis.[2],[3],[4]

The only common finding was that the use of a face mask was noted in all the patients. The aim of this study was to find out the cause and establish the definitive diagnosis of an unusual occurrence of facial dermatoses on previously healthy people so that appropriate management can be offered to the patients.


   Materials and Method Top


It was a cross-sectional, observational study carried during May 15 to July 15, 2020 at a tertiary dermatology center in North India. All cases that presented erythema on face and papular or pustular lesions on the central facial area of not more than 2 months of duration were included in the study. Patients who were on treatment for facial dermatoses, have cases of acne, applied any drugs/cosmetic products before the appearance of these lesions, have a history suggestive of previous photosensitivity, and who performed any procedures on the face were excluded from the study. Patients who had a past history of skin lesions on the central facial area but asymptomatic and not on any drugs from last 3 months were also included in the study. The routine tests like hemogram with erythrocyte sedimentation rate (ESR), renal and liver function test, and urine analysis and blood sugar random, potassium hydroxide (KOH) mount, serum calcium, and chest X-ray PA view were performed in each patient and 4-mm skin biopsy was done from the skin lesion for histopathological examination (HPE) where clinical doubts existed.


   Results Top


Total 81 patients visited skin OPD with the problem of facial dermatoses of various types during this period, out of which 21 patients fulfilled the inclusion criteria. This was 0.72% (21/2900) of total skin OPD of the two months. Total 21 patients, 16 males (76%) and 5 females (24%) with the mean age of 37 years (range 18–64 years), were included in the study. The details of patients with their history, clinical examination, and past history were statistically analyzed. Last three consecutive years for the same period, the number of patients with central facial dermatoses was 7 (0.07% of total OPD, i.e. (7/9600)), 6 (0.06% of total OPD, i.e. (06/9400)), and 7 (0.07% of total OPD, i.e. (07/9700)), for 2017, 2018, and 2019, respectively. The differences in the rate of facial dermatoses in comparison to the previous three years were statistically significant with a P value less than 0.005; this is depicted in [Table 1].
Table 1: Facial dermatoses in last 4 years at tertiary center between mid May to mid July

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All the patients had been using face masks during this period of symptoms due to the ongoing coronavirus situation. No patient had itching on the lesions or associated fever, weight loss, rhinitis, cough, or breathlessness. None of the patients were diagnosed to have coronavirus infection. Dermatological examination revealed only erythema on the central area of face (n = 10), erythema and few papules (n = 3), erythmatous papules and pustules (n = 5), and erythematous papules, pustules, and telengiectasia (n = 3). The clinical images of different types of facial dermatoses are illustrated in [Figure 1] and [Figure 2] with [Figure 1] demonstrating a diffuse erythematous centrofacial rash and [Figure 2] showing patients with papulopustular lesions.
Figure 1: Patients with central facial erythema

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Figure 2: Patients with centrofacial papulopustular lesions

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Details of representative HPE are illustrated in [Figure 3]. The histopathological features in seven out of ten patients were opined as granulomatous roseacea. All the skin biopsies showed predominantly epithelioid cells, noncaseating granuloma with a variable degree of infiltrate. The epidermis was unremarkable in all of the cases except one case that showed mild acanthosis and spongiosis. The granulomas in all cases were predominantly tuberculoid type and perifollicular in location. They were composed of epithelioid histiocytes, Langhans giant cells, and foreign body-type giant cells without central caseous necrosis. The granulomas were small, ill-formed to well-formed with peripheral lymphoid infiltrate. The presence of Demodex folliculorum mites or any excessive eosinophil or plasma cell deposition was not seen in any of the biopsy samples. Three samples showed superficial dermal elastotic degeneration along with dilated vascular channels. Apart from the routine hematoxylin and eosin staining, special staining methods, such as Giemsa, Fite–Faraco, periodic acid–Schiff, and Ziehl–Neelsen, were performed to exclude the infective etiology for granulomatous inflammation in all cases. Gene Xpert test for Mycobacterium tuberculosis was performed in all the skin biopsy samples, which did not reveal any positive finding.
Figure 3: Photomicrograph of granluomatous rosacea. (a) Nodular pattern of inflammation, with the presence of tiny epithelioid cell granulomas with occasional giant cells (HPE, ×100). (b) Perifollicular pattern of granulomatous inflammation (HPE, ×400)

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   Discussion Top


With gradual relaxation in lockdown, the opening of healthcare facilities for outdoor patients consultation from the first week of May 2020, department of dermatology witnessed unusual cases of rosacea like facial erythema and papular and pustular lesions mainly distributed over the central area of face. Our analysis of results showed that the rate of such cases was more than ten times in comparison to the previous 3 years', which was statistically significant. Those who developed such facial dermatoses were using facial masks of various manufacturing qualities. Why a certain subset of people developed facial dermatoses mainly confined to the mask area, which gradually progressed even to surrounding area, cannot be explained with certainty at this stage. Probably they had excessive sweating and occlusion of the sebaceous gland, which may have altered the microenvironment of skin and change the innate immunity leading to inflammatory changes and eruption of acne and rosacea like lesions on the affected areas.

Out of 21 total patients, only 5 were female (24%). This difference in gender was significant. This can be explained by the facts that ladies keep mostly house bound and they were not using compulsory masks for long period unlike their male counterparts who go out for their respective works.

Our subset of patients had features of granulomatous rosacea on HPE. Ten out of twenty-one patients had only erythema of central facial areas, whereas eight had features typical of rosacea. These data were correlated with the various histopathological features of various facial dermatoses.[5]

Classically, facial lesions having chronic and relapsing course with erythema, papules, pustules, and telangiectasia with or without ocular lesions are considered rosacea.[6] Granulomatous rosacea's (GR) precise nosology is uncertain, but it has been accepted as a variant of rosacea by the National Rosacea Society Expert Committee.[6] It is clinically characterized by monomorphic discrete, yellowish facial papules along with erythema on the central facial area.[7] On HPE, it shows noncaseating epithelioid cell granulomas with or without follicular involvement. Differentiating clinically and histopathologically with other similar granulomatous facial conditions like lupus miliaris disseminatus faciei, micropapular sarcoidosis, and tuberculosis is really intriguing at times.[8]

The exact etiopathogenesis of GR is not certain. Demodex folliculorum was detected within the central dilated follicular infundibula or in the center of the granuloma in few of the case reports.[9],[10] However, in our study, none of the hisopathological slides showed Demodex. Current molecular studies suggest that GR is associated with altered innate immune responses.[11] There is excess cathelicidin peptides in the epidermis and increased serine protease kallikrein 5 activity in the granular and cornified layers which may play certain roles in the pathophysiology.[12]

There is no standard treatment guideline for GR. Oral antibiotics, such as tetracycline or doxycycline and systemic steroid for a short duration, have been used with success. Topically azelaic acid, benzoyl peroxide, metronidazole, corticosteroids, and pimecrolimus have been used with varied efficacy.[5] Isotretinoin has been found effective for recalcitrant GR.[13] Brimonidine gel, an alpha-adrenergic vasoconstrictor, is a newly approved treatment for erythema in rosacea.[14] We also prescribed cap doxycycline, clindamycin lotion, and metronidazole gel as first line therapies. But 7 patients out of 21 did not respond to first line therapies where isotretinoin was added resulting in mild benefit. Thirteen out of twenty one patients continue to have mild skin lesions even after 2 months of therapies. This is most probably due to continuation of wearing masks due to the ongoing pandemic.

Techasatian et al.[15] reported acne and acneiform facial eruptions as the commonest presentation along with itching as the most common symptom. No other study mentioned and increased incidence of granulomatous facial lesions secondary to wearing face masks, hence this study highlights a unique observation that may be reported frequently in future.


   Conclusion Top


There has been definite change in the lifestyle due to ongoing Covid-19 pandemic. People are compulsorily using face masks for long hours to avoid the spread of Covid-19 infection. This change in behavior has brought out a surge of rosacea like lesions on the covered area of face. Partly, it can be explained by the change in innate immunity due to excessive sweating and the change in microenvironment of skin. However, a larger, multicentric, prospective, and controlled study is required to confirm these findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Manchanda Y, Das S, De A. Coronavirus disease of 2019 (COVID-19) facts and figures: What every dermatologist should know in this hour of need. Indian J Dermatol 2020;65:251-8.  Back to cited text no. 1
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2.
Tempark T, Shwayder TA. Perioral dermatitis: A review of the condition with special attention to treatment options. Am J Clin Dermatol 2014;15:101-13.  Back to cited text no. 2
    
3.
Mullanax MG, Kierland RR. Granulomatous rosacea. Arch Dermatol 1970;101:206-11.  Back to cited text no. 3
    
4.
Hatch LA, Laurain D, Messina J, Seminario-Vidal L. An erythematous facial rash. J Fam Pract 2019;68:E9-11.  Back to cited text no. 4
    
5.
Lee GL, Zirwas MJ. Granulomatous rosacea and periorificial dermatitis: Controversies and review of management and treatment. Dermatol Clin 2015;33:447-55.  Back to cited text no. 5
    
6.
Wilkin J, Dahl M, Detmar M, Drake L, Feinstein A, Odom R, et al. Standard classification of rosacea: Report of the National Rosacea society expert committee on the classification and staging of rosacea. J Am Acad Dermatol 2002;46:584-7.  Back to cited text no. 6
    
7.
Khokhar O, Khachemoune A. A case of granulomatous rosacea: Sorting granulomatous rosacea from other granulomatous diseases that affect the face. Dermatol Online J 2004;10:6.  Back to cited text no. 7
    
8.
Chougule A, Chatterjee D, Yadav R, Sethi S, De D, Saikia UN. Granulomatous rosacea versus lupus miliaris disseminatus Faciei-2 faces of facial granulomatous disorder: A clinicohistological and molecular study. Am J Dermatopathol 2018;40:819-23.  Back to cited text no. 8
    
9.
Hsu CK, Hsu MM, Lee JY. Demodicosis: A clinicopathological study. J Am Acad Dermatol 2009;60:453-62.  Back to cited text no. 9
    
10.
Amichai B, Grunwald MH, Avinoach I, Halevy S. Granulomatous rosacea associated with Demodex folliculorum. Int J Dermatol 1992;31:718-9.  Back to cited text no. 10
    
11.
Casas C, Paul C, Lahfa M, Livideanu B, Lejeune O, Alvarez-Georges S, et al. Quantification of demodex folliculorum by PCR in rosacea and its relationship to skin innate immune activation. Exp Dermatol 2012;21:906-10.  Back to cited text no. 11
    
12.
Coda AB, Hata T, Miller J, Audish D, Kotol P, Two A, et al. Cathelicidin, kallikrein 5, and serine protease activity is inhibited during treatment of rosacea with azelaic acid 15% gel. J Am Acad Dermatol 2013;69:570-7.  Back to cited text no. 12
    
13.
Rallis E, Korfitis C. Isotretinoin for the treatment of granulomatous rosacea: Case report and review of the literature. J Cutan Med Surg 2012;16:438-41.  Back to cited text no. 13
    
14.
Buddenkotte J, Steinhoff M. Recent advances in understanding and managing rosacea. F1000Res 2018;7:F1000 Faculty Rev-1885.  Back to cited text no. 14
    
15.
Techasatian L, Lebsing S, Uppala R, Thaowandee W, Chaiyarit J, Supakunpinyo C, et al. The effects of the face mask on the skin underneath: A prospective survey during the COVID-19 pandemic. J Prim Care Community Health 2020;11:2150132720966167.  Back to cited text no. 15
    


    Figures

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