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[CASE REPORT]

Rational Management of Papulopustular

Rosacea With Concomitant
Facial Seborrheic Dermatitis
A Case Report
WENDY L. McFALDA, DO; HEATHER L. ROEBUCK, BS, MSN, FNP-BC
Clarkston Dermatology, Clarkston, Michigan

ABSTRACT
Objective: To report a case of papulopustular rosacea with concomitant seborrheic dermatitis and discuss how signs
and symptoms were ameliorated using a rational therapeutic approach. Design: Patient case report. Setting: Clinical
practice. Participant: One male patient with rosacea, seborrheic dermatitis, and actinic keratoses. Measurements:
Change in signs and symptoms over time. Results: Improved skin care practices and treatment with azelaic acid 15% gel
twice daily in combination with low-dosage oral isotretinoin resulted in improvement in symptoms of both rosacea and
seborrheic dermatitis. Conclusion: In patients with multiple skin disorders, use of medications with benefits for more
than one of the skin conditions may, in some cases, reduce the overall number of medications needed, thus simplifying
treatment. (J Clin Aesthet Dermatol. 2011;4(1):40–42.)

R
osacea is a common inflammatory skin disorder
characterized by facial erythema, papules, and
pustules; it is reported to affect approximately 16
million Americans.1 As there are many common facial
dermatoses, rosacea often coexists in a given patient with
other facial skin disorders, such as actinic keratosis, acne
vulgaris, and/or seborrheic dermatitis.2 The presence of
these concomitant conditions can confound diagnosis.
Acne vulgaris and rosacea, for example, often appear to be
quite similar, although rosacea lacks the comedones of
acne and is often associated with confluence of erythema
and presence of inflammatory papules and pustules on the
central face.
Beyond confounding diagnosis, the presence of
concomitant skin disorders may complicate treatment, in
some cases necessitating the use of different therapeutic
agents. There is often, however, an opportunity to use
treatments that, due to their multiple mechanisms of
action, are beneficial not only for rosacea, but also for
other coexisting skin conditions. The authors report here a
case of papulopustular rosacea with concomitant
seborrheic dermatitis as well as actinic keratoses and
discuss how therapy was carried out with a single topical
agent that addressed more than one concomitant facial
dermatosis, in combination with intermittent systemic
therapy. The importance of recommending a gentle skin
care regimen in patients with rosacea is also emphasized.
CASE REPORT
A 78-year-old Caucasian man with Fitzpatrick skin type
2 presented with papulopustular and phymatous rosacea.
He had concomitant seborrheic dermatitis of 15 years’
duration and a history of actinic keratoses on the forehead
and right ear, which had previously been treated with
cryosurgery.
The patient’s rosacea was first diagnosed in 1960 when
he was 29 years old. Between 1994 and 2004, he managed
his rosacea with the brand formulation of metronidazole

DISCLOSURE: Dr. McFalda is a speaker for Allergan, Astellas, and Medicis. Ms. Roebuck is a consultant for Intendis and a consultant and speaker for
Amgen, Abbott, and Ortho Neutrogena.
ADDRESS CORRESPONDENCE TO: Heather L. Roebuck, BS, MSN, FNP-BC, Clarkston Dermatology, 5701 Bow Pointe Drive, Suite 217, Clarkston,
MI 48346; E-mail: hroebuck@hotmail.com

40 [January 2011 • Volume 4 • Number 1] 40

Roebuck.qxp 12/28/10 12:11 PM Page 41
Figure 1. A 78-year-old Caucasian man with
papulopustular and phymatous rosacea,
seborrheic dermatitis, and a history of actinic
keratoses on the forehead and right ear, at the
initial visit
gel 0.75% twice daily. In 2004, he was switched to the
generic metronidazole gel 0.75%, which he used through
2006. At presentation, his skin care regimen consisted of a
common brand sensitive skin cleanser.
In February 2009, the patient presented with erythema,
papules, pustules, and rhinophyma (Figure 1). He reported
concerns regarding the progression of phymatous changes
on his nose and expressed interest in a new treatment
regimen to more effectively manage his rosacea. He was
initiated on azelaic acid (AzA) 15% gel twice daily in
combination with isotretinoin 40mg twice weekly. In
addition, the importance of a good skin care regimen as an
integral component of rosacea therapy was discussed with
him, and the patient was instructed to use a ceramide-
based hydrating cleanser (CeraVeTM, Coria Laboratories,
Fort Worth, Texas) and moisturizing lotion (CeraVeTM) and
Neutrogena Healthy Defense® SPF 45 Daily Moisturizer
with Helioplex® (Neutrogena, Los Angeles, California).
In March 2009, the patient returned for management of
actinic keratoses, which were successfully treated with
cryosurgery. He remained motivated and adhered to the
prescribed treatment plan for rosacea and seborrheic
dermatitis. He continued to be monitored monthly in
accordance with the iPLEDGE program requirements
through his Veterans Affairs health services.
In May 2009, the patient returned for follow up. Papules,
pustules, and erythema were reduced, and his nose
appeared less phymatous (Figure 2). Significant
improvement was noted in his inflammatory papules and
41 [ January 2011 • Volume 4 • Number 1]
Figure 2. The patient at two months’ follow up
after treatment with azelaic acid 15% gel twice
daily in combination with isotretinoin 40mg
twice weekly
facial scaling, and sebaceous hyperplasia lesions decreased
in number and size. His treatment is ongoing.
DISCUSSION
AzA is a naturally occurring dicarboxylic acid with anti-
inflammatory, antimicrobial, antikeratinizing, antioxidant,
and antityrosinase mechanisms of action.3,4 Indicated for
the treatment of rosacea, the multiple mechanisms of
action of AzA gel 15% would suggest utility in other skin
conditions as well, including seborrheic dermatitis. A
recent pilot study conducted in patients who had mild-to-
moderate facial seborrheic dermatitis found that six weeks
of treatment with AzA 15% gel twice daily resulted in a
more rapid onset of therapeutic effect and a greater
improvement in scaling, erythema, and pruritus than
vehicle alone.5
Isotretinoin, an oral retinoid, is most commonly used for
the treatment of severe, refractory, inflammatory acne. It
has also been used to treat rosacea in patients who
experienced insufficient or transient effects with the use of
conventional topical and systemic therapies.6 Treatment
with oral isotretinoin 10mg/day for 16 weeks resulted in
significant decreases in papules, pustules, erythema, and
telangiectasias. The risk of potential side effects associated
with systemic isotretinoin therapy and its lack of an
approved indication for rosacea treatment may limit its
utilization to treat papulopustular rosacea that has truly
failed to respond to other options.7
Isotretinoin, by reducing sebum production, can also
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improve the symptoms of seborrheic dermatitis. In a small October 1–10, 2007; Buenos Aires, Argentina.
study, 10 men with seborrheic dermatitis were treated with 6. Erdogan FG, Yurtsever P, Aksoy D, Eskioglu F. Efficacy of
isotretinoin 1mg/kg/day for six weeks. All showed significant low-dose isotretinoin in patients with treatment-resistant
improvement in symptoms.8 In the case presented here, the rosacea. Arch Dermatol. 1998;134(7):884–885.
choice of isotretinoin 40mg was influenced by the limitations 7. Roche discontinues and plans to delist Accutane in the US.
of the patient’s insurance, which would only cover Nutley, NJ: Roche Pharmaceuticals; June 29, 2009. Roche
isotretinoin 40mg. A twice-weekly dosing schedule was used website. http://www.rocheusa.com/newsroom/current/
to achieve an overall lower dose of isotretinoin more similar 2009/ pr200906201. Accessed on October 31, 2009.
to that typically used for rosacea. 8. Cowley NC, Farr PM, Shuster S. The permissive effect of
This case clearly illustrates the importance of sunblock sebum in seborrhoeic dermatitis: an explanation of the rash in
in a skin care regimen. The development of actinic neurological disorders. Br J Dermatol. 1990;122(1):71–76.
keratoses increases with greater ultraviolet light exposure, 9. Engel A, Johnson M-L, Haynes SG. Health effects of
which also exacerbates signs and symptoms of rosacea.9,10 sunlight exposure in the United States. Results from the
Photoprotection is an important component of therapy for first National Health and Nutrition Examination Survey,
both rosacea and actinic keratoses.11 1971–1974. Arch Dermatol. 1988;124(1):72–79.
10. Hensen P, Müller ML, Haschemi R, et al. Predisposing
CONCLUSION factors of actinic keratosis in a North-West German
Here the authors report on a case in which a patient population. Eur J Dermatol. 2009;19(4):345–354.
with papulopustular rosacea and facial seborrheic 11. Maietta G, Rongioletti F, Rebora A. Seborrheic dermatitis
dermatitis was successfully treated with a single topical and daylight. Acta Derm Venereol. 1991;71(6):538–539.
medication, an oral medication, and the incorporation of a
gentle skin care regimen. AzA gel 15% twice daily was used
in conjunction with isotretinoin 40mg twice a week, skin-
care education, a gentle skin-care regimen, and photo-
protection. In patients with multiple skin disorders, use of
medications that can yield therapeutic benefits for more
than one of their conditions may reduce the overall number
of medications needed, thus simplifying treatment and
reducing cost of therapy. Isotretinoin, indicated for the
treatment of severe recalcitrant nodular acne, in this case
was used for its benefits for both the patient’s rosacea and
seborrheic dermatitis. AzA 15% gel, a medication approved
for treatment of papulopustular rosacea, exhibits multiple
properties, including anti-inflammatory, antimicrobial, anti-
keratinizing, comedolytic, antioxidant, and antityrosinase
effects, some of which may be operative in the treatment of
both papulopustular rosacea and seborrheic dermatitis.
Other potentially concurrent common facial disorders for
which AzA may be of therapeutic benefit include acne
vulgaris and hyperpigmentation.

REFERENCES
1. National Rosacea Society. Information for patients.
http://www.rosacea.org/patients/index.php. Accessed on
May 11, 2010.
2. Feldman SR, Hollar CB, Gupta AK, Fleischer AB. Women
commonly seek care for rosacea: dermatologists frequently
provide the care. Cutis. 2001;68(2):156–160.
3. Draelos Z, Kayne AL. Implications of azelaic acid’s multiple
mechanisms of action: therapeutic versatility. Presented at:
American Academy of Dermatology 66th Annual Meeting;
February 1–5, 2008; San Antonio, Texas.
4. Passi S. Pharmacology and pharmacokinetics of azelaic
acid. Rev Contemp Pharmacother. 1993;4:441–447.
5. Reich K, Friedrich M, Graupe K. A double-blind, vehicle-
controlled study of the efficacy and safety of azelaic acid
(AzA) 15% gel in mild-to-moderate seborrheic dermatitis.
Presented at: the 21st World Congress of Dermatology;

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