A case of rosacea fulminans during pregnancy with review of the literature.

Dear Editors, Rosacea fulminans (RF) is a rare facial dermatosis defined by an abrupt eruption of papulopustules, coalescent purplish nodules to plaques and abscesses that mainly affect the central face; its relationship to rosacea is uncertain and its pathogenesis is not fully understood. RF occurs more frequently in post-adolescent women, with hormonal changes such as pregnancy being well-known triggers. In this case, therapeutic options are limited. We report a case of RF during pregnancy successfully treated with a combination of oral antibiotics and oral corticosteroids, which we present along with a review of the literature. A 31-year-old woman in the 12th week of her second pregnancy presented with a five-day history of facial eruption. Physical examination showed painful erythematous papules and pustules with honey-colored crusts on both cheeks and chin (Figure 1a). She had no history of rosacea or acne, and no systemic symptoms except mild androgenetic alopecia. Her previous pregnancy had been uneventful. Suspecting impetigo, we prescribed topical fusidic acid and amoxicillin/clavulanate 3 g/daily. However, after 1 week, new papules and coalescing nodules and pustules appeared. No comedones were seen (Figure 1b). Histopathological examination confirmed a diagnosis of RF during pregnancy, and the patient was treated with oral azithromycin 500 mg once daily for three consecutive days each week from week 16 to week 21 of pregnancy, and with prednisone 20 mg once daily, with a slow tapering and discontinuation at week 31. Thereafter, the skin lesions improved significantly with only mild erythema remaining at week 32 (Figure 1c). Her pregnancy progressed uneventfully, resulting in the delivery of a healthy girl at full term. After the postpartum period, new facial papules flared, and the erythema intensified (Figure 1d). Treatment with isotretinoin 0.5 mg/kg/day was started 3 months after delivery, with the clearance of the lesions within one month (Figure 1e). Isotretinoin was discontinued after 4 months, and no relapses occurred during 6 months of follow-up. Including our case, 27 cases of RF during pregnancy have been reported to date1-9 (Table 1): Median age at diagnosis was 31 years (range: 26–33) and 54% of the patients developed RF during the first trimester. Of those whose medical history was investigated, 58% had a history of acne or rosacea and 45% of the patients had RF during their first pregnancy. Only 11% of the patients had a fever. The most commonly administered therapy was oral antibiotics (74%) with macrolides being the most prescribed (70%). Topical antibiotics, including fusidic acid, mupirocin, erythromycin, metronidazole, and clindamycin, were used in 70% of the cases. Topical permethrin 5% was effective in only one case. Almost half of the patients (46%) received oral corticosteroids and nearly one-third needed isotretinoin after delivery. Complications, potentially steroid-induced, included one case of pre-term birth, intrauterine growth retardation, three cases of gestational diabetes mellitus and two cases of fetal death. Additionally, two cases of ocular rosacea were reported. The review suggests that pregnancy remains a significant trigger for RF, especially during the first trimester and in patients with a history of acne or rosacea. Treatment of RF during pregnancy is challenging, and therapeutic decisions must be taken carefully. Topical antibiotics or corticosteroids, in monotherapy or combination, often do not control the condition. In one case, topical permethrin 5% twice daily led to complete clearing of the lesions, but further experiences are necessary to confirm its effectiveness. Systemic beta-lactam antibiotics, alone or in combination with topical drugs, may not be sufficient, and macrolides, primarily oral azithromycin, are preferred due to their efficacy. Further therapy may include systemic corticosteroids: we started prednisone at a dose of 0.18 mg/kg/daily; indeed, systemic corticosteroids are justified when the benefits outweigh the risk of fetal complications. Nine cases, including the author's, have reported an improvement with oral corticosteroids, with an initial average prednisone dose of 35.5 mg daily (standard deviation [SD]: 8). However, clear dosing recommendations for RF during pregnancy are lacking in the literature and the weight-based dosage was not standardized.10 In two cases, a maintenance dose of prednisone 20 mg daily was used due to continued relapses at lower doses, which may have led to fatal outcomes for the fetuses. In other medical specialties, studies have investigated the use of oral corticosteroids in pregnancy, with recommendations to keep daily prednisone to less than 20 mg for treating simultaneous rheumatic diseases, but higher doses are acceptable if required.11 Prednisone is preferred over other molecules due to its low risk of placental passage. In conclusion, a combination of systemic steroids and macrolides is a first choice for treating complicated cases. Early diagnosis and prompt management, while avoiding ineffective treatments, are important for reducing the lesion's extension and sequelae. None.