Photo Rounds

Red rash on cheeks

A 55-year-old man sought care for the red rash on both cheeks that had worsened over the past year. He denied any pain or itching in the area. His hypertension was under control and he was otherwise in good health. He denied starting any new medications, but acknowledged that he didn’t use sunscreen or a hat for sun protection.

What's your diagnosis?


The FP diagnosed erythematotelangiectatic rosacea in this patient. This stage of rosacea is characterized by frequent episodes of mild to severe flushing with persistent central facial erythema. As its name suggests, there are many telangiectasias along with the erythema.

The standard therapy for papulopustular rosacea—oral doxycycline and topical metronidazole—is less effective for erythematotelangiectatic rosacea. There is, however, a new FDA-approved medication (brimonidine gel) that treats the erythema of rosacea. There have been numerous studies that show this gel is better than a placebo gel for reducing the erythema of erythematotelangiectatic rosacea. However, if the new gel is too costly for the patient, an alternative is to use over-the-counter oxymetazoline and have the patient apply this directly to the skin on a daily basis.

In this case, the FP suggested that the patient avoid food, drink, and activities that exacerbate his flushing. The patient was also given a prescription for brimonidine gel with an explanation about the optional use of over-the-counter oxymetazoline.

Photo and text for Photo Rounds Friday courtesy of Richard P. Usatine, MD. This case was adapted from: Usatine R. Rosacea. In: Usatine R, Smith M, Mayeaux EJ, et al, eds. Color Atlas of Family Medicine. 2nd ed. New York, NY: McGraw-Hill; 2013:659-664.

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